Pouchitis atlas for objective endoscopic diagnosis

Endoscopic assessment of the J pouch in ulcerative colitis: A narrative review

Patients with ulcerative colitis sometimes need a total colectomy with ileal pouch-anal anastomosis due to medically refractory disease or colitis-associated neoplasia. Up to 50% of patients with ulcerative colitis postoperatively develop pouchitis and the rate of chronic inflammatory pouch conditions requiring pouch excision or diverting ileostomy is reported to be 10%. In order to diagnose and monitor pouchitis, pouchoscopy is essential to assess endoscopic inflammatory findings of the J pouch and to survey neoplasia development, particularly in the remnant distal rectum. However, endoscopic protocols for the evaluation of the pouch may not be standardized worldwide and the reliability of existing disease activity indices for pouchitis has been questioned due to the lack of validation. Recently, reliable endoscopic scoring systems based on an observation of the anatomical location of the J pouch were reported and a significant association between the distribution pattern of endoscopic inflammation (i.e., endoscopic phenotype) and pouch outcomes was also uncovered. In this review, we discuss how to survey the J pouch using pouchoscopy, endoscopic indices for pouchitis disease activity, endoscopic phenotypes and classification, and the pathological mechanisms of pouchitis phenotype in patients with ulcerative colitis.

A specific phenotype of pouchitis was associated with worst prognosis in patients with ulcerative colitis according to Chicago classification

BACKGROUND

The impact of different pouch phenotypes on long-term functional outcomes and quality of life (QoL) remains unclear. Our aim is to investigate the association between endoscopic pouchitis phenotypes and patients' long-term prognosis by assessing pouch function and QoL.

METHODS

Pouchitis was classified into distinct phenotypes according to the Chicago Classification. Pouch function was assessed using the Pouch Functional Score (PFS), and QoL was evaluated using the Cleveland Global Quality of Life (CGQL) score.

RESULTS

A total of 252 patients were enrolled in the study, with 78 patients diagnosed with pouchitis. According to the Chicago classification, 42 of these pouchitis patients exhibited an endoscopic phenotype characterized by a combination of diffuse inflammation of the pouch body, inlet involvement, and cuffitis, referred to as the Diffuse-Inlet-Cuffitis phenotype. Patients with pouchitis of the Diffuse-Inlet-Cuffitis phenotype showed significantly higher PFS (11.5 vs 5.5, p = 0.013) and lower CGQL scores (0.67 vs 0.7, p = 0.029) compared to those with other pouch phenotypes. Independent risk factors for this severe phenotype were identified as preoperative disease duration (OR = 1.062, 95% CI: 1.006-1.122, p = 0.030) and disease extent E3 (OR = 2.836, 95% CI: 1.052-7.644, p = 0.036).

CONCLUSIONS

Our study suggested that pouchitis with the Diffuse-Inlet-Cuffitis endoscopic phenotype is common and seriously impairs the long-term prognosis in patients with UC after IPAA. The finding will be beneficial to the stratified management of patients with pouchitis.

Measurement of Disease Activity of Pouchitis

BACKGROUND

Pouchitis is the most common inflammatory complication in ulcerative colitis patients undergoing postoperative construction of an IPAA. Pouchitis refers to a spectrum of diseases, and as such, it lacks a universally accepted definition as well as validated instruments to measure disease activity and treatment response. Assessing pouchitis activity is challenging, and methods for diagnosis and classification of severity of pouchitis are not universally agreed upon.

CLINICAL FEATURES

Pouchitis is characterized by a constellation of clinical symptoms, including increased stool frequency, urgency, incontinence, bleeding, and rarely constitutional symptoms such as malaise and low-grade fever. However, these symptoms are subjective, and similar symptoms can be caused by noninflammatory conditions including anal sphincter dysfunction, anastomotic strictures, occult leaks, pouch inlet obstruction, and cuffitis. Objective scores that include endoscopic and histologic criteria have been developed for subjects with an IPAA. However, these instruments are not validated for measuring pouchitis disease activity and are associated with a number of challenges. In addition, the clinical components of the scores correlate poorly with endoscopic and histologic findings.

CONCLUSION AND FUTURE DIRECTIONS

There is a need for prospective studies to facilitate the development and validation of novel instruments that are valid, reliable, and responsive to change that would facilitate the development of therapeutic agents for the treatment of pouchitis.

The Reliability and Accuracy of Endoscopic Items and Scores Used in the Assessment of the Ileoanal Pouch and Cuff

BACKGROUND AND AIMS

Currently used endoscopic items for the assessment of pouchitis and cuffitis have deficiencies in reliability and validation. We assessed the reliability and accuracy of new endoscopic items for pouchitis and of the Ulcerative Colitis Endoscopic Index of Severity [UCEIS] for cuffitis.

METHODS

Three new endoscopic items were assessed and included in the Monash pouchitis endoscopic subscore: bleeding [absent/contact/spontaneous]; erosions [absent/<10/≥10]; and ulceration [absent/<10%/≥10%]. Three raters evaluated 44 pouchoscopy videos in duplicates, in random order. Intra- and inter-rater reliability of all endoscopic items and UCEIS were assessed. Clinical and histological pouchitis disease activity index [PDAI] subscores were also assessed and faecal calprotectin was measured.

RESULTS

All three Monash endoscopic items had substantial intra-rater reliability with intraclass correlation coefficients [ICCs] >0.61 [95% CI >0.61], compared with only ulcers from the currently used PDAI endoscopic subscore, but inter-rater reliability was only substantial for ulceration and no better than those of the currently used endoscopic items. The Monash endoscopic subscore had a strong positive correlation with the reference standard global endoscopic lesion severity r = 0.80 [95% CI 0.80-0.80] and the reference standard PDAI endoscopic subscore r = 0.70 [95% CI 0.67-0.73], which was higher than the correlation observed for the currently used PDAI endoscopic subscore. The UCEIS had substantial intra-rater reliability, but only fair inter-rater reliability and poor diagnostic performance for cuffitis.

CONCLUSIONS

The Monash endoscopic items, and endoscopic subscore they generate, have enhanced overall performance compared with the currently used PDAI items and subscore. Further validation and responsiveness to change in disease state are indicated.

Increased Quinolone-Resistant Mutations of gyrA and parC Genes after Pouchitis Treatment with Ciprofloxacin

BACKGROUND

Oral antibiotics, such as ciprofloxacin (CFX), are widely used for the treatment of acute and chronic pouchitis. Most bacterial mutations that confer quinolone resistance are at Ser-83 and Asp-87 in the gyrA gene and Ser-80 and Glu-84 in the parC gene.

METHODS

We obtained 51 stool samples from 43 patients who were diagnosed with ulcerative colitis and underwent ileal pouch-anal anastomosis. Patients were divided into 2 groups: 13 patients with CFX treatment of pouchitis and 30 patients without pouchitis. After extraction of fecal DNA, the amount of Escherichia coli 16S rRNA, gyrA, and parC gene DNA were measured using real-time polymerase chain reaction (PCR). Possible mutations at gyrA 83 and 87 and at parC 80 and 84 were investigated by PCR cloning and sequencing, and mutation rates were quantified by rapid PCR-restriction fragment length polymorphism.

RESULTS

Samples from both CFX-treated and -untreated patients had comparable levels of gyrA and parC gene DNA. Nucleic acid and amino acid mutations were identified at gyrA 83 and 87, and at parC 80 and 84. We successfully quantified mutation rates at gyrA 83 and 87, and at parC 84, all of which were significantly higher in samples from CFX-treated patients (70, 84, and 38%) than from CFX-untreated patients (13, 11, and 5%).

CONCLUSION

E. coli in patient pouches may have mutations in their gyrA and parC genes that produce CFX resistance. Mutation rates of these genes were significantly higher in samples from CFX-treated patients. This study contributes to understanding the decrease and loss of CFX effectiveness against pouchitis.

DIAGNOSTIC AND MANAGEMENT APPROACH TO POUCHITIS IN INFLAMMATORY BOWEL DISEASE

In patients with ulcerative colitis refractory to medical therapy, total proctocolectomy and posterior ileal-anal pouch anastomosis is the standard surgical therapy. One of the possible complications is pouchitis. Depending on the duration of the symptoms, it can be classified as acute, recurrent, or chronic. The latter, according to the response to therapy, can be defined as antibiotic-dependent or refractory. The treatment of pouchitis is based on the use of antibiotics and probiotics. Thiopurine and biological therapy have been suggested in patients with refractory pouchitis. Special care should be taken in the endoscopic surveillance of these patients, especially if they present risk factors such as dysplasia or previous colorectal cancer, primary sclerosing cholangitis or ulcerative colitis for more than 10 years.

Pouchitis after ileal pouch-anal anastomosis in ulcerative colitis: Diagnosis, management, risk factors, and incidence

Restorative proctocolectomy with ileal pouch-anal anastomosis has been the surgical treatment of choice for patients with ulcerative colitis who require surgery. Quality of life after this procedure is satisfactory in most cases; however, pouchitis is a troublesome condition involving inflammation of the ileal pouch. When a patient presents with symptoms of pouchitis, such as increased bowel movements, mucous and/or bloody exudates, abdominal cramps, and fever, endoscopy is essential for a precise diagnosis. The proximal ileum and rectal cuff, as well as the ileal pouch, should be endoscopically observed. The reported incidence of pouchitis ranges from 14% to 59%, and antibiotic therapy is the primary treatment for acute pouchitis. Chronic pouchitis includes antibiotic-dependent and refractory pouchitis. Intensive therapy including antitumor necrosis factor antibodies and steroids may be necessary for antibiotic-refractory pouchitis, and pouch failure may occur despite such intensive treatment. Reported risk factors for the development of pouchitis include presence of extraintestinal manifestations, primary sclerosing cholangitis, non-smoking, and postoperative non-steroidal anti-inflammatory drug usage. In the present review, we focus on the diagnosis, endoscopic features, management, incidence, and risk factors of pouchitis in patients with ulcerative colitis who underwent ileal pouch-anal anastomosis.

Outcome after ileal pouch-anal anastomosis in ulcerative colitis patients: experience during a 27-year period

BACKGROUND

No previous study describes the postoperative outcome and functional results after ileal pouch-anal anastomosis (IPAA), performed in ulcerative colitis by the same surgical team with the different anastomotic techniques adopted in a 27-year period.

METHODS

Prospectively, consecutive 333 ulcerative colitis patients operated adopting different IPAA techniques during the open surgery period 1984-2011 were enrolled. IPAA was performed using single stapling (SS) technique in 38 patients, double stapling (DS) technique in 235 patients (TIA stapler 42 patients, Endo-GIA 131 patients, Contour 62 patients) and handsewn IPAA in 60 patients.

RESULTS

Statistically different early and late complications were recorded among the different IPAA techniques. A lower frequency of daily and nocturnal defecations and a higher level of continence were observed in the DS-IPAA compared to handsewn IPAA. The distance between the anastomotic line and the anal verge was significantly lower in DS Endo-GIA or DS Contour groups than in the DS TIA and SS. In SS IPAA group, 31.6% developed cuffitis compared to 14.4% belonging to DS group, at a mean follow-up of 140.4 months.

CONCLUSIONS

Technical improvements changed the IPAA technique. Stapled IPAA is characterized by better functional outcome than handsewn IPAA. DS Endo-GIA and Contour IPAA are followed by lower risk of cuffitis.

Treatment strategy for preventing pouchitis as a postoperative complication of ulcerative colitis: the significance of the management of cuffitis

PURPOSE

The aim of this study was to examine the risk factors for and to evaluate strategies for preventing pouchitis as a postoperative complication of ulcerative colitis (UC).

METHODS

A total of 119 cases of UC in which restorative proctocolectomy with an ileal pouch-anal anastomosis (IPAA) was performed at our institution between 2000 and 2012 was investigated; nine patients in whom it was impossible to close the ileostomy due to an intractable anal fistula or pelvic abscess were excluded.

RESULTS

The cumulative risk of developing pouchitis 5 years after IPAA with stoma closure was 31.0%. Significant relationships with pouchitis were found for the surgical indication (p = 0.0126) and surgical method (p = 0.0214). A significant correlation was found between pouchitis and cuffitis. Pouchitis was significantly more common in the cases with cuffitis than in those without (p = 0.0002). There was also a significantly different cumulative incidence observed between the cases with and without cuffitis (p < 0.0001). In addition, pouchitis had a greater tendency to recur in the cases with cuffitis than in those without (p = 0.2730).

CONCLUSION

The cumulative incidence rate of pouchitis was 10.6% at 1 year, 15.1% at 2 years and 31.0% at 5 years. Controlling cuffitis is important to prevent pouchitis.

Characteristics of extremely early-onset pouchitis after proctocolectomy with ileal pouch-anal anastomosis

OBJECTIVE

This study aims to evaluate the clinical characteristics of patients with postoperative ulcerative colitis developing extremely early-onset pouchitis within 4 weeks of restoration of gastrointestinal continuity.

MATERIAL AND METHODS

This retrospective study involved 225 consecutive patients from January 2000 to May 2011 who underwent ileal pouch-anal anastomosis for ulcerative colitis with a minimum follow-up of 12 months. Extremely early-onset pouchitis was defined as pouchitis developing within 4 weeks of restoration of gastrointestinal continuity. Patients with pouchitis were divided into extremely early-onset pouchitis and non-extremely early-onset pouchitis groups for comparison.

RESULTS

Of 212 patients who met the inclusion criteria, 62 had pouchitis (29.2 %). Eight (3.8 %) patients developed extremely early-onset pouchitis. There was a significant difference in the dosage of steroid per month just before colectomy between the two groups (P = 0.039). The modified Pouchitis Disease Activity Index score for patients with extremely early-onset pouchitis was higher than in patients with non-extremely early-onset pouchitis (P = 0.0009). The occurrence of extremely early-onset pouchitis was associated with the development of chronic pouchitis (P = 0.0056).

CONCLUSION

Extremely early-onset pouchitis may be related to high steroid dosages before colectomy and may be more severe than pouchitis that occurs >4 weeks after restoration of gastrointestinal continuity.

The bacterial pathogenesis and treatment of pouchitis

Restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis is the operation of choice for patients with ulcerative colitis. Pouchitis is the most common cause of pouch dysfunction. Although the pathogenesis of this disease is not well understood, bacteria have been implicated in the disease process. Numerous bacterial studies have been reported over the last 25 years with few unifying findings. In addition, many different treatments for pouchitis have been reported with varying results. Antibiotic treatment remains the most studied and is the mainstay of treatment. In this article we review the aetiology of pouchitis and the evidenced-based treatment options.