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Akiyama S, Barnes EL, Onoda T, Ishikawa N, Shiroyama M, Ito Y, Rubin DT, Tsuchiya K. Endoscopic assessment of the J pouch in ulcerative colitis: A narrative review. DEN OPEN 2025; 5:e373. [PMID: 38694540 PMCID: PMC11058686 DOI: 10.1002/deo2.373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 04/08/2024] [Indexed: 05/04/2024]
Abstract
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.
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Affiliation(s)
- Shintaro Akiyama
- Department of GastroenterologyInstitute of MedicineUniversity of TsukubaTsukubaIbarakiJapan
| | - Edward L Barnes
- Division of Gastroenterology and HepatologyUniversity of North Carolina at Chapel HillChapel HillUSA
| | - Tsubasa Onoda
- Department of GastroenterologyNHO Mito Medical CenterIbarakiJapan
- Doctoral Program in Medical SciencesGraduate School of Comprehensive Human SciencesUniversity of TsukubaTsukubaIbarakiJapan
| | - Naoki Ishikawa
- Department of GastroenterologyInstitute of MedicineUniversity of TsukubaTsukubaIbarakiJapan
- Doctoral Program in Medical SciencesGraduate School of Comprehensive Human SciencesUniversity of TsukubaTsukubaIbarakiJapan
| | - Mamiko Shiroyama
- Department of GastroenterologyInstitute of MedicineUniversity of TsukubaTsukubaIbarakiJapan
- Doctoral Program in Medical SciencesGraduate School of Comprehensive Human SciencesUniversity of TsukubaTsukubaIbarakiJapan
| | - Yuka Ito
- Department of GastroenterologyNHO Mito Medical CenterIbarakiJapan
| | - David T Rubin
- University of Chicago Medicine Inflammatory Bowel Disease CenterChicagoUSA
| | - Kiichiro Tsuchiya
- Department of GastroenterologyInstitute of MedicineUniversity of TsukubaTsukubaIbarakiJapan
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Holubar SD. Unraveling Twisted Pouch Syndrome: A Narrative Review of Classification, Diagnosis, Treatment, and Prevention. Inflamm Bowel Dis 2024:izae161. [PMID: 39096527 DOI: 10.1093/ibd/izae161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Indexed: 08/05/2024]
Abstract
BACKGROUND We recently described a cluster of symptoms known as twisted pouch syndrome that rarely affects patients with ileoanal pouches. Herein, we present a narrative review in which we describe the diagnosis, treatment, and prevention of twisted pouch syndrome, with a focus on a simple classification schema. METHODS Diagnostic signs from endoscopic and radiological examinations, treatment, and prevention strategies are presented. RESULTS Patients with twisted pouch syndrome suffer from a triad of obstructive symptoms, erratic bowel habits, and pain which may be severe, debilitating visceral pain, all in the setting of a mechanical pouch abnormality. Diagnostic modalities include imaging, careful pouchoscopy, functional testing, diagnostic laparoscopy or laparotomy, and recently 3-dimensional pouchography. Classification of twisted pouch syndrome is based on the location and degree of rotation of the pouch and its mesentery. Outlet twists may result when the distal pouch rotates >90° to 360° clockwise inadvertently during anastomosis; when only the distal most pouch is twisted, it results in an iris-like deformity of the pouch outlet, or when the distal half of the pouch is twisted, a mid-pouch stenosis and an hourglass-shaped pouch may result. Inlet twists are either a full 360° (mesentery posterior), unintentional 180° (mesentery anterior), or 90° counterclockwise twists. Both inlet and outlet twists are fixed deformities and may only be reduced by disconnecting the entire pouch from the anus. If they result in twisted pouch syndrome, a redo pouch procedure or pouch excision is required to reduce the twist; 90° counterclockwise twists may undergo pouch inlet transposition. Adhesive twists result when the pouch becomes fixed in the pelvis in an abnormal configuration, such as when the efferent limb becomes twisted underneath the afferent limb secondary to an occult tip of the J leak, and may be reduced by pelvic adhesiolysis with or without pouch revision. CONCLUSIONS Pouches may rarely be inadvertently twisted during construction or twisted owing to adhesive disease or leaks. A high index of suspicion is needed to establish the diagnosis. We present a simple classification of twisted pouch syndrome that may aid in the prevention and recognition of these often difficult to diagnose postoperative complications.
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Affiliation(s)
- Stefan D Holubar
- Dept. of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic, Cleveland OH, USA
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Barnes EL, Esckilsen S, Ashburn J, Barto A, Bloomfeld R, Cairns A, Mehta K, Patel P, Dziwis J, Dunn MS, Rahbar R, Sadiq TS, Hanson JS, Herfarth HH. Extensive Colitis and Smoking Are Associated With Postoperative Complications Within 30 Days of Ileal Pouch-Anal Anastomosis. Inflamm Bowel Dis 2024; 30:1326-1333. [PMID: 37607334 PMCID: PMC11291612 DOI: 10.1093/ibd/izad177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND Our understanding of outcomes after proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) is largely based on analyses of selected populations. We created a state-level registry to evaluate the epidemiology of IPAA surgery and pouch-related outcomes across the major healthcare systems performing these surgeries in our state. METHODS We created a retrospective cohort of all patients undergoing restorative proctocolectomy with IPAA for UC at 1 of 4 centers between January 1, 2018, and December 31, 2020. The primary outcomes of this study were the rate of complications and all-cause readmissions within the first 30 days of the final stage of IPAA surgery. RESULTS During the study period, 177 patients underwent IPAA surgery with 66 (37%) experiencing a complication within 30 days. After adjusting for the number of stages in IPAA surgery, patients with extensive UC (odds ratio, 3.61; 95% confidence interval, 1.39-9.33) and current or former smokers (odds ratio, 2.98; 95% confidence interval, 1.38-6.45) were more likely to experience a complication. Among all patients, 57 (32%) required readmission within 30 days. The most common reasons for readmission were ileus/small bowel obstruction (22%), peripouch abscess (19%), and dehydration (16%). CONCLUSION In this first state-level examination of the epidemiology of IPAA for UC, we demonstrated that the complication rate after IPAA for UC was 37%, with one-third of patients being readmitted within 30 days. Extensive disease at the time of colectomy appears to be an indicator of more severe disease and may portend a worse prognosis after IPAA.
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Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
- Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, NC, USA
| | - Scott Esckilsen
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Jean Ashburn
- Division of Colon and Rectal Surgery, Atrium Health at Wake Forest Baptist, Winston-Salem, NC, USA
| | - Amy Barto
- Division of Gastroenterology and Hepatology, Duke University, Durham, NC, USA
| | - Richard Bloomfeld
- Section of Gastroenterology, Atrium Health at Wake Forest Baptist, Winston-Salem, NC, USA
| | - Ashley Cairns
- Division of Colon and Rectal Surgery, Atrium Health at Wake Forest Baptist, Winston-Salem, NC, USA
| | - Kurren Mehta
- Department of Medicine, Duke University, Durham, NC, USA
| | - Pooja Patel
- Department of Medicine, Duke University, Durham, NC, USA
| | - Jennifer Dziwis
- Section of Gastroenterology, Atrium Health at Wake Forest Baptist, Winston-Salem, NC, USA
- Department of Medicine, Duke University, Durham, NC, USA
| | - Michael S Dunn
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | | | | | - John S Hanson
- Division of Gastroenterology and Hepatology, Atrium Health, Charlotte, NC, USA
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
- Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, NC, USA
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Abstract
Pouchitis is an acute or chronic inflammatory disease of the ileal reservoir. It is common after restorative proctocolectomy with ileal pouch-anal anastomosis, and treatment of chronic antibiotic-refractory pouchitis has proven challenging. Most cases of acute pouchitis evolve into chronic pouchitis. The aetiology of acute pouchitis is likely to be partly related to the gut microbiota, whereas the pathophysiology of chronic pouchitis involves abnormal interactions between genetic disposition, faecal stasis, the gut microbiota, dysregulated host immunity, surgical techniques, ischaemia and mesentery-related factors. Pouchoscopy with biopsy is the most valuable modality for diagnosis, disease monitoring, assessment of treatment response, dysplasia surveillance and delivery of endoscopic therapy. Triggering or risk factors, such as Clostridioides difficile infection and use of non-steroidal anti-inflammatory drugs, should be modified or eradicated. In terms of treatment, acute pouchitis usually responds to oral antibiotics, whereas chronic antibiotic-refractory pouchitis often requires induction and maintenance therapy with integrin, interleukin or tumour necrosis factor inhibitors. Chronic pouchitis with ischaemic features, fistulae or abscesses can be treated with hyperbaric oxygen therapy.
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Affiliation(s)
- Bo Shen
- Center for Inflammatory Bowel Diseases and the Global Center for Integrated Colorectal Surgery and IBD Interventional Endoscopy, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York, NY, USA.
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Akiyama S, Ollech JE, Cohen NA, Traboulsi C, Rai V, Glick LR, Yi Y, Runde J, Cohen RD, Olortegui KBS, Hurst RD, Umanskiy K, Shogan BD, Hyman NH, Rubin MA, Dalal SR, Sakuraba A, Pekow J, Chang EB, Rubin DT. Endoscopic Normalization and Transition of J-Pouch Phenotypes Over Time in Patients With Inflammatory Bowel Disease. Inflamm Bowel Dis 2024:izae106. [PMID: 38916136 DOI: 10.1093/ibd/izae106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Indexed: 06/26/2024]
Abstract
BACKGROUND Patients with inflammatory bowel disease (IBD) who undergo proctocolectomy with ileal pouch-anal anastomosis may develop pouchitis. We previously proposed a novel endoscopic classification of pouchitis describing 7 phenotypes with differing outcomes. This study assessed phenotype transitions over time. METHODS We classified pouch findings into 7 main phenotypes: (1) normal, (2) afferent limb (AL) involvement, (3) inlet (IL) involvement, (4) diffuse, (5) focal inflammation of the pouch body, (6) cuffitis, and (7) pouch-related fistulas noted more than 6 months after ileostomy takedown. Among 2 endoscopic phenotypes, the phenotype that was first identified was defined as the primary phenotype, and the phenotype observed later was defined as the subsequent phenotype. RESULTS We retrospectively reviewed 1359 pouchoscopies from 426 patients (90% preoperative diagnosis of ulcerative colitis). The frequency of primary phenotype was 31% for AL involvement, 42% for IL involvement, 28% for diffuse inflammation, 72% for focal inflammation, 45% for cuffitis, 18% for pouch-related fistulas, and 28% for normal pouch. The most common subsequent phenotype was focal inflammation (64.8%), followed by IL involvement (38.6%), cuffitis (37.8%), AL involvement (25.6%), diffuse inflammation (23.8%), normal pouch (22.8%), and pouch-related fistulas (11.9%). Subsequent diffuse inflammation, pouch-related fistulas, and AL or IL stenoses significantly increased the pouch excision risk. Patients who achieved subsequent normal pouch were less likely to have pouch excision than those who did not (8.1% vs 15.7%; P = .15). CONCLUSIONS Pouch phenotype and the risk of pouch loss can change over time. In patients with pouch inflammation, subsequent pouch normalization is feasible and associated with favorable outcome.
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Affiliation(s)
- Shintaro Akiyama
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Jacob E Ollech
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Nathaniel A Cohen
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Cindy Traboulsi
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Victoria Rai
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Laura R Glick
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Yangtian Yi
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Joseph Runde
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Russell D Cohen
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | | | - Roger D Hurst
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Konstantin Umanskiy
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Benjamin D Shogan
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Neil H Hyman
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Michele A Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Sushila R Dalal
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Atsushi Sakuraba
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Joel Pekow
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Eugene B Chang
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - David T Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
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Barnes EL, Desai A, Hashash JG, Farraye FA, Kochhar GS. The Natural History After Ileal Pouch-Anal Anastomosis for Ulcerative Colitis: A Population-Based Cohort Study From the United States. Am J Gastroenterol 2024:00000434-990000000-01192. [PMID: 38888231 DOI: 10.14309/ajg.0000000000002891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 06/12/2024] [Indexed: 06/20/2024]
Abstract
INTRODUCTION There are limited data regarding the natural history after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC). The principal objectives of this study were to identify 4 key outcomes in the natural history after IPAA within 1, 3, 5, and 10 years: the incidence of pouchitis, Crohn's-like disease of the pouch, use of advanced therapies after IPAA, and pouch failure requiring excision in a network of electronic health records. METHODS We performed a retrospective cohort study in TriNetX, a research network of electronic health records. In addition to evaluating incidence rates, we also sought to identify factors associated with pouchitis and advanced therapy use within 5 years of IPAA after 1:1 propensity score matching, expressed as adjusted hazard ratios (aHRs). RESULTS Among 1,331 patients who underwent colectomy with IPAA for UC, the incidence of pouchitis increased from 58% in the first year after IPAA to 72% at 10 years after IPAA. After propensity score matching, nicotine dependence (aHR 1.61, 95% confidence interval [CI] 1.19-2.18), antitumor necrosis factor therapy (aHR 1.33, 95% CI 1.13-1.56), and vedolizumab prior to colectomy (aHR 1.44, 95% CI 1.06-1.96) were associated with an increased risk of pouchitis in the first 5 years after IPAA. The incidence of Crohn's-like disease of the pouch increased to 10.3% within 10 years of IPAA while pouch failure increased to 4.1%. The incidence of advanced therapy use peaked at 14.4% at 10 years after IPAA. DISCUSSION The incidence of inflammatory conditions of the pouch remains high in the current era, with 14% of patients requiring advanced therapies after IPAA.
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Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Aakash Desai
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Jana G Hashash
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Francis A Farraye
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Gursimran S Kochhar
- Division of Gastroenterology, Hepatology & Nutrition, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
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Wang Z, Wang J, Yang Z, Li S, Ding C, Gong J. A specific phenotype of pouchitis was associated with worst prognosis in patients with ulcerative colitis according to Chicago classification. Dig Liver Dis 2024; 56:1007-1013. [PMID: 38065699 DOI: 10.1016/j.dld.2023.11.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 11/23/2023] [Accepted: 11/27/2023] [Indexed: 05/28/2024]
Abstract
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.
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Affiliation(s)
- Zhongyuan Wang
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Jiansheng Wang
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Zirui Yang
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Song Li
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Chao Ding
- Department of General Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Jianfeng Gong
- Department of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China.
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Shen B. Endoscopic Evaluation of the Ileal Pouch. Dis Colon Rectum 2024; 67:S52-S69. [PMID: 38276962 DOI: 10.1097/dcr.0000000000003269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
BACKGROUND Structural and inflammatory adverse sequelae are common after restorative proctocolectomy and IPAA. On rare occasions, neoplasia can occur in patients with ileal pouches. Pouchoscopy plays a key role in the diagnosis, differential diagnosis, disease monitoring, assessment of treatment response, surveillance, and delivery of therapy. OBJECTIVE A systematic review of the literature was performed, and principles and techniques of pouchoscopy were described. DATA SOURCES PubMed, Google Scholar, and Cochrane databases. STUDY SELECTION Relevant articles on endoscopy in ileal pouches published between January 2000 and May 2023 were included based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. INTERVENTION Diagnostic, surveillance, and therapeutic endoscopy in ileal pouch disorders were included. MAIN OUTCOME MEASURES Accurate characterization of the ileal pouch in healthy or diseased states. RESULTS The main anatomic structures of a J- or S-pouch are the stoma closure site, prepouch ileum, inlet, tip of the "J," pouch body, anastomosis, cuff, and anal transition zone. Each anatomic location can be prone to the development of structural, inflammatory, or neoplastic disorders. For example, ulcers and strictures are common at the stoma closure site, inlet, and anastomosis. Leaks are commonly detected at the tip of the "J" and anastomosis. Characterization of the anastomotic distribution of inflammation is critical for the differential diagnosis of subtypes of pouchitis and other inflammatory disorders of the pouch. Neoplastic lesions, albeit rare, mainly occur at the cuff, anal transition zone, or anastomosis. LIMITATIONS This is a qualitative, not quantitative, review of mainly case series. CONCLUSIONS Most structural, inflammatory, and neoplastic disorders can be reliably diagnosed with a careful pouchoscopy. The endoscopist and other clinicians taking care of pouch patients should be familiar with the anatomy of the ileal pouch and be able to recognize common abnormalities. See video from symposium.
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Affiliation(s)
- Bo Shen
- The Global Integrated Center for Colorectal Surgery and Interventional Endoscopy and Center for Inflammatory Bowel Diseases, Columbia University Irving Medical Center/NewYork Presbyterian Hospital, New York, New York
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Alenzi M, Schildkraut T, Hartley I, Badiani S, Ding NS, Rao V, Segal JP. The aetiology of pouchitis in patients with inflammatory bowel disease. Therap Adv Gastroenterol 2024; 17:17562848241249449. [PMID: 38812704 PMCID: PMC11135114 DOI: 10.1177/17562848241249449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 04/08/2024] [Indexed: 05/31/2024] Open
Abstract
Restorative proctocolectomy with ileal pouch-anal anastomosis is a treatment option for patients with refractory ulcerative colitis. Pouchitis is the most common complication, representing a spectrum of diseases ranging from acute antibiotic-responsive type to chronic antibiotic-refractory. Early accurate diagnosis using a combined assessment of symptoms, endoscopy and histology is important for both treatment and prognostication. Most patients respond well to antibiotic therapy; however, management of chronic antibiotic-refractory pouchitis remains a challenge, and treatment options are based on small studies. Pouchitis is thought to be driven by the interaction between genetics, the immune system and the environment but as yet a causal relationship has yet to be identified. Further longitudinal assessment of the pouch integrating new technologies may help us understand the factors driving pouchitis. This review outlines the currently understood risk factors and aetiology of pouchitis.
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Affiliation(s)
- Maram Alenzi
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Tamar Schildkraut
- Department of Gastroenterology, St Vincent’s Hospital, Melbourne, VIC, Australia
| | - Imogen Hartley
- Department of Gastroenterology, St Vincent’s Hospital, Melbourne, VIC, Australia
- Department of Gastroenterology, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Sarit Badiani
- Department of Surgery, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Nik Sheng Ding
- Department of Gastroenterology, St Vincent’s Hospital, Melbourne, VIC, Australia
- Department of Gastroenterology, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Vikram Rao
- Department of General Medicine, Western Health, Footscray, VIC, Australia
| | - Jonathan P. Segal
- Department of Gastroenterology, Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Medicine, University of Melbourne, Parkville, VIC, Australia
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Powers JC, Cohen BL, Rieder F, Click BH, Lyu R, Westbrook K, Hull T, Holubar S, Regueiro MD, Qazi T. Preoperative Use of Multiple Advanced Therapies Is Not Associated With Endoscopic Inflammatory Pouch Diseases. Inflamm Bowel Dis 2024; 30:203-212. [PMID: 37061838 DOI: 10.1093/ibd/izad054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Indexed: 04/17/2023]
Abstract
BACKGROUND Patients with an ileal pouch-anal anastomosis (IPAA) can experience pouch inflammation postoperatively. The use of antitumor necrosis factor (anti-TNF) biologics may be associated with pouch inflammation, but limited data exist on the impact of multiple advanced therapies on development of subsequent pouch inflammation. The aim of this study was to assess for an association between preoperative use of multiple advanced therapies and risk of endoscopically detected inflammatory pouch diseases (EIPDs). METHODS We performed a retrospective analysis of ulcerative colitis (UC) and indeterminate colitis (IBDU) patients who underwent an IPAA at a quaternary care center from January 2015 to December 2019. Patients were grouped based on number and type of preoperative drug exposures. The primary outcome was EIPD within 5 years of IPAA. RESULTS Two hundred ninety-eight patients were included in this analysis. Most of these patients had UC (95.0%) and demonstrated pancolonic disease distribution (86.1%). The majority of patients were male (57.4%) and underwent surgery for medically refractory disease (79.2%). The overall median age at surgery was 38.6 years. Preoperatively, 68 patients were biologic/small molecule-naïve, 125 received anti-TNF agents only, and 105 received non-anti-TNF agents only or multiple classes. Ninety-one patients developed EIPD. There was no significant association between type (P = .38) or number (P = .58) of exposures and EIPD, but older individuals had a lower risk of EIPD (P = .001; hazard ratio, 0.972; 95% confidence interval, 0.956-0.989). CONCLUSION Development of EIPD was not associated with number or type of preoperative advanced therapies.
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Affiliation(s)
- Joseph Carter Powers
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Benjamin L Cohen
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Florian Rieder
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Benjamin H Click
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Ruishen Lyu
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland, OH, USA
| | - Katherine Westbrook
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Tracy Hull
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Stefan Holubar
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Miguel D Regueiro
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Taha Qazi
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
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Akiyama S, Onoda T, Moue S, Sakamoto N, Sakamoto T, Suzuki H, Enomoto T, Matsubara D, Oda T, Tsuchiya K. Association of colonic metaplasia of goblet cells and endoscopic phenotypes of the J pouch in patients with ulcerative colitis: a retrospective pilot study. Intest Res 2024; 22:92-103. [PMID: 38327000 PMCID: PMC10850699 DOI: 10.5217/ir.2023.00105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 09/17/2023] [Accepted: 09/21/2023] [Indexed: 02/09/2024] Open
Abstract
BACKGROUND/AIMS Mucosal adaptation of the ileum toward colonic epithelium has been reported in pouchitis in ulcerative colitis (UC); however, the clinical characteristics, endoscopic findings, and outcomes in patients with pouchitis with ileal mucosal adaptation are poorly understood. METHODS This was a single-center retrospective study comprising UC patients treated by proctocolectomy with ileal pouch-anal anastomosis who had undergone pouchoscopy at the University of Tsukuba Hospital between 2005 and 2022. Endoscopic phenotypes were evaluated according to the Chicago classification. High-iron diamine staining (HID) was performed to identify sulfomucin (colon-type mucin)-producing goblet cells (GCs) in pouch biopsies. We compared clinical data between patients with (high HID group) and without > 10% sulfomucin-producing GCs in at least one biopsy (low HID group). RESULTS We reviewed 390 endoscopic examination reports from 50 patients. Focal inflammation was the most common phenotype (78%). Five patients (10%) required diverting ileostomy. Diffuse inflammation and fistula were significant risk factors for diverting ileostomy. The median proportion of sulfomucin-producing GCs on histological analysis of 82 pouch biopsies from 23 patients was 9.9% (range, 0%-93%). The duration of disease was significantly greater in the high HID group compared to the low HID group. The median percentage of sulfomucin-producing GCs was significantly higher in patients with diffuse inflammation or fistula compared to other endoscopic phenotypes (14% vs. 6.0%, P= 0.011). CONCLUSIONS Greater proportions of sulfomucin-producing GCs were observed in endoscopic phenotypes associated with poor outcomes in UC, indicating patients with pouchitis showing colonic metaplasia of GCs may benefit from early interventions.
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Affiliation(s)
- Shintaro Akiyama
- Department of Gastroenterology, Institute of Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Tsubasa Onoda
- Department of Gastroenterology, Institute of Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Shoko Moue
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Institute of Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Noriaki Sakamoto
- Department of Pathology, Institute of Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Taku Sakamoto
- Department of Gastroenterology, Institute of Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Hideo Suzuki
- Department of Gastroenterology, Institute of Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Tsuyoshi Enomoto
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Institute of Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Daisuke Matsubara
- Department of Pathology, Institute of Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Tatsuya Oda
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Institute of Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Kiichiro Tsuchiya
- Department of Gastroenterology, Institute of Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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12
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Barnes EL, Agrawal M, Syal G, Ananthakrishnan AN, Cohen BL, Haydek JP, Al Kazzi ES, Eisenstein S, Hashash JG, Sultan SS, Raffals LE, Singh S. AGA Clinical Practice Guideline on the Management of Pouchitis and Inflammatory Pouch Disorders. Gastroenterology 2024; 166:59-85. [PMID: 38128971 PMCID: PMC11163976 DOI: 10.1053/j.gastro.2023.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
BACKGROUND & AIMS Pouchitis is the most common complication after restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis. This American Gastroenterological Association (AGA) guideline is intended to support practitioners in the management of pouchitis and inflammatory pouch disorders. METHODS A multidisciplinary panel of content experts and guideline methodologists used the Grading of Recommendations Assessment, Development and Evaluation framework to prioritize clinical questions, identify patient-centered outcomes, conduct an evidence synthesis, and develop recommendations for the prevention and treatment of pouchitis, Crohn's-like disease of the pouch, and cuffitis. RESULTS The AGA guideline panel made 9 conditional recommendations. In patients with ulcerative colitis who have undergone ileal pouch-anal anastomosis and experience intermittent symptoms of pouchitis, the AGA suggests using antibiotics for the treatment of pouchitis. In patients who experience recurrent episodes of pouchitis that respond to antibiotics, the AGA suggests using probiotics for the prevention of recurrent pouchitis. In patients who experience recurrent pouchitis that responds to antibiotics but relapses shortly after stopping antibiotics (also known as "chronic antibiotic-dependent pouchitis"), the AGA suggests using chronic antibiotic therapy to prevent recurrent pouchitis; however, in patients who are intolerant to antibiotics or who are concerned about the risks of long-term antibiotic therapy, the AGA suggests using advanced immunosuppressive therapies (eg, biologics and/or oral small molecule drugs) approved for treatment of inflammatory bowel disease. In patients who experience recurrent pouchitis with inadequate response to antibiotics (also known as "chronic antibiotic-refractory pouchitis"), the AGA suggests using advanced immunosuppressive therapies; corticosteroids can also be considered in these patients. In patients who develop symptoms due to Crohn's-like disease of the pouch, the AGA suggests using corticosteroids and advanced immunosuppressive therapies. In patients who experience symptoms due to cuffitis, the AGA suggests using therapies that have been approved for the treatment of ulcerative colitis, starting with topical mesalamine or topical corticosteroids. The panel also proposed key implementation considerations for optimal management of pouchitis and Crohn's-like disease of the pouch and identified several knowledge gaps and areas for future research. CONCLUSIONS This guideline provides a comprehensive, patient-centered approach to the management of patients with pouchitis and other inflammatory conditions of the pouch.
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Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Manasi Agrawal
- The Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York; Center for Molecular Prediction of Inflammatory Bowel Disease, Department of Clinical Medicine, Aalborg University, Copenhagen, Denmark
| | - Gaurav Syal
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Ashwin N Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Benjamin L Cohen
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases Institute, Cleveland Clinic, Cleveland, Ohio
| | - John P Haydek
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Elie S Al Kazzi
- Division of Gastroenterology, Case Western Reserve University, Cleveland, Ohio
| | - Samuel Eisenstein
- Division of Colorectal Surgery, Department of Surgery, University of California San Diego, La Jolla, California
| | - Jana G Hashash
- Inflammatory Bowel Disease Center, Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
| | - Shahnaz S Sultan
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota; Veterans Affairs Healthcare System, Minneapolis, Minnesota
| | - Laura E Raffals
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Siddharth Singh
- Division of Gastroenterology, University of California San Diego, La Jolla, California
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13
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Kayal M, Posner H, Milwidsky HM, Plietz M, Khaitov S, Sylla P, Greenstein A, Dubinsky MC, Mehandru S, Colombel JF. Acute Severe Ulcerative Colitis Is Associated With an Increased Risk of Acute Pouchitis. Inflamm Bowel Dis 2023; 29:1907-1911. [PMID: 36939632 DOI: 10.1093/ibd/izad039] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Indexed: 03/21/2023]
Abstract
BACKGROUND Pouchitis occurs in up to 80% of patients after total proctocolectomy (TPC) with ileal pouch-anal anastomosis (IPAA) and has been associated with microbial and host-related immunological factors. We hypothesized that a more robust immune response at the time of colectomy, manifested by acute severe ulcerative colitis (ASUC), may be associated with subsequent acute pouchitis. METHODS This was a retrospective cohort analysis of all patients with UC or indeterminate colitis complicated by medically refractory disease or dysplasia who underwent TPC with IPAA at Mount Sinai Hospital between 2008 and 2017 and at least 1 subsequent pouchoscopy. Acute pouchitis was defined according to the Pouchitis Disease Activity Index. Cox regression was used to assess unadjusted relationships between hypothesized risk factors and acute pouchitis. RESULTS A total of 416 patients met inclusion criteria. Of the 165 (39.7%) patients who underwent urgent colectomy, 77 (46.7%) were admitted with ASUC. Acute pouchitis occurred in 228 (54.8%) patients a median of 1.3 (interquartile range, 0.6-3.1) years after the final surgical stage. On multivariable analysis, ASUC (hazard ratio [HR], 1.50; 95% confidence interval [CI], 1.04-2.17) and a greater number of biologics precolectomy (HR, 1.57; 95% CI, 1.06-2.31) were associated with an increased probability of acute pouchitis, while older age at colectomy (HR, 0.98; 95% CI, 0.97-0.99) was associated with a decreased probability. Time to pouchitis was significantly less in patients admitted with ASUC compared with those not (P = .002). CONCLUSION A severe UC disease phenotype at the time of colectomy was associated with an increased probability of acute pouchitis.
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Affiliation(s)
- Maia Kayal
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hannah Posner
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hadar Meringer Milwidsky
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michael Plietz
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sergey Khaitov
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Patricia Sylla
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alexander Greenstein
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Marla C Dubinsky
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Saurabh Mehandru
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jean Frederic Colombel
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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14
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Santiago P, Barnes EL, Raffals LE. Classification and Management of Disorders of the J Pouch. Am J Gastroenterol 2023; 118:1931-1939. [PMID: 37252759 DOI: 10.14309/ajg.0000000000002348] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 05/25/2023] [Indexed: 05/31/2023]
Abstract
Total abdominal proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) is associated with substantial complications despite the benefits of managing refractory and/or neoplasia-associated disease. For the purpose of this review, we focused on the diagnosis of some of the most common inflammatory and structural pouch disorders and their respective management. Pouchitis is the most common complication, and it is typically responsive to antibiotics. However, chronic antibiotic refractory pouchitis (CARP) has been increasingly recognized, and biologic therapies have emerged as the mainstay of therapy. Crohn's-like disease of the pouch (CLDP) can affect up to 10% of patients with UC after IPAA. Medical options are similar to CARP therapies, including biologics with immunomodulators. Studies have shown higher efficacy rates of biologics for CLDP when compared with those for CARP. In addition, managing stricturing and fistulizing CLDP is challenging and often requires interventional endoscopy (balloon dilation and/or stricturotomy) and/or surgery. The implementation of standardized diagnostic criteria for inflammatory pouch disorders will help in advancing future therapeutic options. Structural pouch disorders are commonly related to surgical complications after IPAA. We focused on the diagnosis and management of anastomotic leaks, strictures, and floppy pouch complex. Anastomotic leaks and anastomotic strictures occur in approximately 15% and 11% of patients with UC after IPAA, respectively. Further complications from pouch leaks include the development of sinuses, fistulas, and pouch sepsis requiring excision. Novel endoscopic interventions and less invasive surgical procedures have emerged as options for the management of these disorders.
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Affiliation(s)
- Priscila Santiago
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Laura E Raffals
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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15
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Fortuny M, Gutiérrez-Rios L, Vayreda E, Mañosa M, Domènech E. Tofacitinib for the treatment of inflammatory condition of the ileoanal pouch refractory to infliximab. GASTROENTEROLOGIA Y HEPATOLOGIA 2023; 46:629-630. [PMID: 36115629 DOI: 10.1016/j.gastrohep.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/10/2022] [Accepted: 08/27/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Marta Fortuny
- Servicio de Aparato Digestivo, Hospital Universitari Germans Trias i Pujol, Badalona, España
| | - Laura Gutiérrez-Rios
- Servicio de Aparato Digestivo, Hospital Universitari Germans Trias i Pujol, Badalona, España
| | - Eva Vayreda
- Servicio de Aparato Digestivo, Hospital Universitari Germans Trias i Pujol, Badalona, España
| | - Míriam Mañosa
- Servicio de Aparato Digestivo, Hospital Universitari Germans Trias i Pujol, Badalona, España; Centro de Investigación Biomédica En Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), España
| | - Eugeni Domènech
- Servicio de Aparato Digestivo, Hospital Universitari Germans Trias i Pujol, Badalona, España; Centro de Investigación Biomédica En Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), España.
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16
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Akiyama S, Cohen NA, Kayal M, Dubinsky MC, Colombel JF, Rubin DT. Treatment of Chronic Inflammatory Pouch Conditions With Tofacitinib: A Case Series From 2 Tertiary IBD Centers in the United States. Inflamm Bowel Dis 2023; 29:1504-1507. [PMID: 36745039 PMCID: PMC10472733 DOI: 10.1093/ibd/izad011] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Shintaro Akiyama
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Nathaniel A Cohen
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | - Maia Kayal
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Marla C Dubinsky
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jean-Frederic Colombel
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - David T Rubin
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
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17
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Barnes EL, Long MD, Raffals L, Isaacs K, Stidham RW, Herfarth HH. Development of the Endoscopic Pouch Score for Assessment of Inflammatory Conditions of the Pouch. Clin Gastroenterol Hepatol 2023; 21:1663-1666.e3. [PMID: 35568303 PMCID: PMC9652477 DOI: 10.1016/j.cgh.2022.04.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/20/2022] [Accepted: 04/26/2022] [Indexed: 02/07/2023]
Abstract
Pouchoscopy provides a critical objective measure in the evaluation of patients with suspected inflammatory conditions of the pouch; however, there remain significant gaps in the reliability of the endoscopic scales used in the assessment of these conditions.1,2 Reliability and reproducibility in the assessment of patients after ileal pouch-anal anastomosis (IPAA) are critical, as evidenced by recent efforts to improve standardization in the evaluation of patients with pouch-related disorders.3.
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Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, North Carolina.
| | - Millie D Long
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, North Carolina
| | - Laura Raffals
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Kim Isaacs
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, North Carolina
| | - Ryan W Stidham
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan; Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, North Carolina
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18
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Hassan Y, Connell WR, Rawal A, Wright EK. Review of long-term complications and functional outcomes of ileoanal pouch procedures in patients with inflammatory bowel disease. ANZ J Surg 2023. [PMID: 37095321 DOI: 10.1111/ans.18490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 04/12/2023] [Accepted: 04/16/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND In medically refractory Ulcerative Colitis (UC), proctocolectomy with ileoanal pouch procedure (IAPP) is the preferred continence-preserving surgical option. Functional outcomes post-surgery and long-term complication rates in the biologic era remain ambiguous. This review primarily aims to provide an update on these outcomes. Secondarily, risk factors associated with chronic pouchitis and pouch failure are explored. METHODS Two online databases (MEDLINE and EMBASE) were searched on 4 October 2022 for English studies from 2011-present relating to long-term outcomes of IAPP in inflammatory bowel disease (IBD) patients. Adult patients with 12 month follow-up were included. Studies focused on 30-day post-operative outcomes, non-IBD patients or studies including less than 30 patients were excluded. RESULTS Following screening and full-text review of 1094 studies, 49 were included. Median sample size was n = 282 (IQR: 116-519). Median incidences for chronic pouchitis and pouch failure were 17.1% (IQR: 12-23.6%) and 6.9% (IQR: 4.8-10.8%), respectively. Upon multivariate analysis, chronic pouchitis development was most significantly associated with pre-operative steroid use, pancolitis and extra-intestinal IBD manifestations, whilst pouch failure was most significantly associated with pre-operative diagnosis of Crohn's disease (compared to UC), peri-operative pelvic sepsis and anastomotic leak. Overall patient satisfaction was very high with four included studies reporting greater than 90% satisfaction rates. CONCLUSION Long-term complications for IAPP were common. However, despite this, patient satisfaction post-IAPP was high. Up-to-date knowledge of complication rates and their risk factors improves pre-operative counselling, management planning and patient outcomes.
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Affiliation(s)
- Yusuf Hassan
- Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - William R Connell
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, Australia
| | - Alisha Rawal
- General HMO Stream, Grampians Health, Ballarat, Australia
| | - Emily K Wright
- Melbourne Medical School, University of Melbourne, Melbourne, Australia
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, Australia
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19
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Carman N, Picoraro JA. Advances in Endoscopy for Pediatric Inflammatory Bowel Disease. Gastrointest Endosc Clin N Am 2023; 33:447-461. [PMID: 36948755 DOI: 10.1016/j.giec.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
Endoscopic characterization of pediatric inflammatory bowel disease (IBD) has developed in accordance with advances in treatment and improved understanding of disease progression and complications. Reliable and consistent endoscopic reporting practices and tools continue to evolve. The roles of endoscopic ultrasonography, capsule endoscopy, and deep enteroscopy in the care of children and adolescents with IBD are beginning to be clarified. Opportunities for therapeutic intervention with endoscopy in pediatric IBD, including endoscopic balloon dilation and electroincision therapy, require further study. This review discusses the current utility of endoscopic assessment in Pediatric Inflammatory Bowel Disease, as well as emerging and evolving techniques to improve patient care.
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Affiliation(s)
- Nicholas Carman
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, CHEO Inflammatory Bowel Disease Centre, Children's Hospital of Eastern Ontario, University of Ottawa, Ontario, Canada; Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, Sickkids Inflammatory Bowel Disease Centre, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada.
| | - Joseph A Picoraro
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Irving Medical Center, 622 West 168th Street, PH17-105, New York, NY 10032, USA; NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY 10032, USA
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20
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Xu W, Wang Y, Hua Z, Hu H, Chen W, Cai Z, Cui L, Wu X, Lian L, Ding Z, Du P. Risk Factors and Quality of Life in Patients with Diffuse Pouchitis After Ileal Pouch Anal Anastomosis According to the Chicago Classification for J Pouch: a Retrospective Multicenter Cohort Study in China. J Gastrointest Surg 2023; 27:766-776. [PMID: 36596961 DOI: 10.1007/s11605-022-05563-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 12/02/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Pouchitis is a common late complication in patients with ulcerative colitis (UC) who undergo ileal pouch-anal anastomosis (IPAA). The heterogeneous nature of the clinical and endoscopic presentations could affect the evaluation of therapeutic interventions for pouchitis. Thus, identifying the risk factors and clinical outcomes of pouch inflammation at different sites and severity is becoming increasingly important for colorectal surgeons. METHODS Data on patients who underwent IPAA January from 2008 to June 2022 in our three pouch centers affiliated with the China UC Pouch Center Union were retrospectively collected. Pouchitis was categorized as a different phenotype according to the Chicago Classification. J pouches were classified into short (14 ± 2 cm) and long pouches (22 ± 2 cm) according to the distribution of ileal pouch length in our institute. RESULTS Altogether, 143 patients with a median follow-up time of 5.0 years (interquartile range: 2.0-8.0) were enrolled. Among them, 41 patients (28.7%) developed pouchitis and 32 patients (78%) had diffuse inflammation of the pouch. Patients with diffuse pouchitis had a higher pouchitis disease activity index and more seriously impaired improvement of long-term quality of life than those with pouch phenotypes. A short J pouch, recurrent UC, and preoperative high white blood cell count were independent risk factors for diffuse pouchitis. Furthermore, a short J pouch could effectively predict the occurrence of diffuse pouchitis with an area under the receiver-operating characteristic curve of 0.614, a sensitivity of 62.5%, and a specificity of 60.4% (p = 0.049) and significantly decreased the overall diffuse pouchitis-free survival compared to a long J pouch (p = 0.0002). CONCLUSION Diffuse pouchitis is a common phenotype of pouchitis that seriously impairs long-term prognosis. For colorectal surgeons, decision-making regarding pouch construction with an appropriate length should be considered to prevent the development of diffuse pouchitis.
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Affiliation(s)
- Weimin Xu
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 200092, Shanghai, China.,China UC Pouch Center Union, Shanghai, China
| | - Yaosheng Wang
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 200092, Shanghai, China.,China UC Pouch Center Union, Shanghai, China
| | - Zhebin Hua
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 200092, Shanghai, China.,China UC Pouch Center Union, Shanghai, China
| | - Hang Hu
- Department of Colorectal and Anal Surgery, Hubei Key Laboratory of Intestinal and Colorectal Diseases, Zhongnan Hospital of Wuhan University, 430071, Wuhan, China.,China UC Pouch Center Union, Shanghai, China
| | - Wenhao Chen
- Department of Colorectal and Anal Surgery, Hubei Key Laboratory of Intestinal and Colorectal Diseases, Zhongnan Hospital of Wuhan University, 430071, Wuhan, China.,China UC Pouch Center Union, Shanghai, China
| | - Zerong Cai
- Department of Gastrointestinal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, 510655, Guangzhou, China.,China UC Pouch Center Union, Shanghai, China
| | - Long Cui
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 200092, Shanghai, China.,China UC Pouch Center Union, Shanghai, China
| | - Xiaojian Wu
- Department of Gastrointestinal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, 510655, Guangzhou, China.,China UC Pouch Center Union, Shanghai, China
| | - Lei Lian
- Department of Gastrointestinal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, 510655, Guangzhou, China.,China UC Pouch Center Union, Shanghai, China
| | - Zhao Ding
- Department of Colorectal and Anal Surgery, Hubei Key Laboratory of Intestinal and Colorectal Diseases, Zhongnan Hospital of Wuhan University, 430071, Wuhan, China. .,China UC Pouch Center Union, Shanghai, China.
| | - Peng Du
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 200092, Shanghai, China. .,China UC Pouch Center Union, Shanghai, China.
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21
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Abstract
BACKGROUND Patients with ulcerative colitis often develop medically refractory colonic inflammation or colorectal neoplasia, and approximately 10% to 15% of patients require surgery. The most common surgical procedure is a restorative proctocolectomy with IPAA. Even if the preoperative diagnosis is ulcerative colitis, approximately 10% of patients can develop inflammatory pouch conditions resembling a Crohn's disease phenotype. OBJECTIVE This study aimed to review the diagnostic approach, prognosis, and management of IPAA with Crohn's disease-like features. DATA SOURCES The data sources include search in electronic databases. STUDY SELECTION This narrative review included studies focusing on pouches with Crohn's disease-like features. MAIN OUTCOME MEASURES The main topics in this review included the pathogenesis, risk factors, diagnosis, phenotypes, prognosis, and medications of pouches with Crohn's disease-like features. RESULTS A diagnostic approach for the pouch conditions resembling a Crohn's disease phenotype should be based on history-taking to evaluate its risk factors and endoscopic assessment of the pouch. Prior disease history and pathology, location of pouch complications, and timing of complications offer clues for the differential diagnosis of this phenotype. We advocate for the more descriptive term "pouch with Crohn's disease-like features" and reserve the term "Crohn's disease of the pouch" for patients who undergo IPAA and have a precolectomy diagnosis of Crohn's disease or whose colectomy pathology revealed Crohn's disease. Medications, which are often used for traditional Crohn's disease, show efficacy in pouches with Crohn's disease-like features as well. The poor prognosis associated with pouches with Crohn's disease-like features, particularly the fistulizing phenotype, underscores the importance of proactive monitoring and therapeutic intervention. LIMITATIONS The limitations include no explicit criteria for article selection. CONCLUSIONS This review suggests future research should seek to understand the natural history and meaningful shorter and longer term therapeutic targets for these types of pouch phenotypes. Long-term follow-up and prospective preoperative and postoperative interventional trials of treatments and prevention strategies are needed.
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22
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Abstract
BACKGROUND In patients with ulcerative colitis or familial adenomatous polyposis who develop neoplasia or fail medical therapy and require colectomy, restorative proctocolectomy with IPAA is often indicated. Although often well tolerated, IPAA can be complicated by cuffitis or inflammation of the remaining rectal cuff. Although much has been published on this subject, there is no clear and comprehensive synthesis of the literature regarding cuffitis. METHODS Our systematic literature review analyzes 34 articles to assess the frequency, cause, pathogenesis, diagnosis, classification, complications, and treatment of cuffitis. RESULTS Cuffitis occurs in an estimated 10.2% to 30.1% of pouch patients. Purported risk factors include rectal cuff length >2 cm, pouch-rectal anastomosis, stapled anastomosis, J-pouch configuration, 2- or 3-stage IPAA, preoperative Clostridium difficile infection, toxic megacolon, fulminant colitis, preoperative biologic use, medically refractory disease, immunomodulator/steroids use within 3 months of surgery, extraintestinal manifestations of IBD, and BMI <18.5 kg/m2 at the time of colectomy. Adverse consequences associated with cuffitis include decreased quality-of-life scores, increased risk for pouchitis, pouch failure, pouch excision, and pouch neoplasia. CONCLUSIONS Given the similarities between pouchitis and cuffitis, diagnosis and treatment of cuffitis should proceed according to the International Ileal Pouch Consortium guidelines. This review found that the majority of the current literature fails to distinguish between classic cuffitis (a form of reminant ulcerative proctitis) and nonclassic cuffitis (resulting from other causes). Further work is needed to distinguish the unique risk factors and endoscopic characteristics associated with each subtype, and further randomized clinical trials should be conducted to strengthen the evidence for treatment options.
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23
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Barnes EL, Darlington K, Herfarth HH. Disease Monitoring of the Ileoanal Pouch: How to Utilize Biomarkers, Imaging, and Pouchoscopy. Curr Gastroenterol Rep 2022; 24:127-136. [PMID: 36255602 DOI: 10.1007/s11894-022-00850-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2022] [Indexed: 12/04/2022]
Abstract
PURPOSE OF REVIEW Restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis has been associated with multiple short- and long-term complications. In this review, we examine the role of biomarkers, imaging, and pouchoscopy in the assessment of patients after ileal pouch-anal anastomosis, with a particular focus on the emergence of novel biomarkers and techniques for evaluating and risk stratifying patients after this procedure in the hopes of improving outcomes in this specific population. RECENT FINDINGS There are indications that that the incidence of pouchitis may be increasing in recent decades. Calprotectin and other non-invasive imaging tests such as ultrasound may offer advantages in distinguishing patients with inflammatory conditions of the pouch from other etiologies. In the search for other biomarkers that may identify patients at risk for inflammatory conditions of the pouch, the stool microbiota and metabolomics may play a key role in identifying those patients at greatest risk for complications. Advances in biomarkers, imaging, and standardized pouchoscopy scoring offer immediate improvements in clinical care and will prompt future research efforts.
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Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Campus Box #7080 130 Mason Farm Road, 27599-7080, Chapel Hill, NC, USA. .,Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. .,Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Kimberly Darlington
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Campus Box #7080 130 Mason Farm Road, 27599-7080, Chapel Hill, NC, USA
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Campus Box #7080 130 Mason Farm Road, 27599-7080, Chapel Hill, NC, USA.,Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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24
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Runde J, Erondu A, Akiyama S, Traboulsi C, Rai V, Glick LR, Yi Y, Ollech JE, Cohen RD, Skowron KB, Hurst RD, Umanskiy K, Shogan BD, Hyman NH, Rubin MA, Dalal SR, Sakuraba A, Pekow J, Chang EB, Rubin DT. Outcomes of Ileoanal Pouch Anastomosis in Pediatric Ulcerative Colitis Are Worse in the Modern Era: A Time Trend Analysis Outcomes Following Ileal Pouch-Anal Anastomosis in Pediatric Ulcerative Colitis. Inflamm Bowel Dis 2022; 28:1386-1394. [PMID: 35040964 PMCID: PMC9434476 DOI: 10.1093/ibd/izab319] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Despite significant differences in surgical outcomes between pediatric and adult patients with ulcerative colitis (UC) undergoing colectomy, counseling on pediatric outcomes has largely been guided by data from adults. We compared differences in pouch survival between pediatric and adult patients who underwent total proctocolectomy with ileal pouch-anal anastomosis (IPAA). METHODS This was a retrospective single-center study of patients with UC treated with IPAA who subsequently underwent pouchoscopy between 1980 and 2019. Data were collected via electronic medical records. We stratified the study population based on age at IPAA. Differences between groups were assessed using t tests and chi-square tests. Kaplan-Meier curves were used to compare survival probabilities. Differences between groups were assessed using a log-rank test. RESULTS We identified 53 patients with UC who underwent IPAA before 19 years of age and 329 patients with UC who underwent IPAA at or after 19 years of age. Subjects who underwent IPAA as children were more likely to require anti-tumor nerosis factor (TNF) postcolectomy compared with adults (41.5% vs 25.8%; P < .05). Kaplan-Meier estimates revealed that pediatric patients who underwent IPAA in the last 10 years had a 5-year pouch survival probability that was 28% lower than that of those who underwent surgery in the 1990s or 2000s (72% vs 100%; P < .001). Further, children who underwent IPAA and received anti-TNF therapies precolectomy had the most rapid progression to pouch failure when compared with anti-TNF-naive children and with adults who were either exposed or naive precolectomy (P < .05). CONCLUSIONS There are lower rates of pouch survival for children with UC who underwent IPAA following the uptake of anti-TNF therapy compared with both historical pediatric control subjects and contemporary adults.
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Affiliation(s)
- Joseph Runde
- Section of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Comer Children’s Hospital, Chicago, IL, USA
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Amarachi Erondu
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Shintaro Akiyama
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Cindy Traboulsi
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Victoria Rai
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Laura R Glick
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Yangtian Yi
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Jacob E Ollech
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Russell D Cohen
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Kinga B Skowron
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Roger D Hurst
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Konstatin Umanskiy
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Benjamin D Shogan
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Neil H Hyman
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Michele A Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Sushila R Dalal
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Atsushi Sakuraba
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Joel Pekow
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Eugene B Chang
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - David T Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
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25
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Akiyama S, Ollech JE, Traboulsi C, Rai V, Glick LR, Yi Y, Runde J, Olivas AD, Weber CR, Cohen RD, Olortegui KBS, Hurst RD, Umanskiy K, Shogan BD, Rubin MA, Dalal SR, Sakuraba A, Pekow J, Chang EB, Hart J, Hyman NH, Rubin DT. Histopathology of Colectomy Specimens Predicts Endoscopic Pouch Phenotype in Patients with Ulcerative Colitis. Dig Dis Sci 2022; 67:4020-4031. [PMID: 35288827 PMCID: PMC10966959 DOI: 10.1007/s10620-022-07405-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 11/29/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The endoscopic appearance in patients with "pouchitis" after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) can be quite heterogenous. Patients with an endoscopic phenotype resembling Crohn's disease (CD) are at high risk of pouch loss. AIMS We aimed to assess how the histopathology of colectomy specimens predicts endoscopic pouch phenotypes in UC. METHODS We retrospectively assessed pouchoscopies from patients with UC who underwent IPAA and classified pouch findings into 7 main phenotypes: (1) normal, (2) afferent limb involvement, (3) inlet involvement, (4) diffuse, (5) focal inflammation of the pouch body, (6) cuffitis, and (7) pouch with fistulas noted ≥ 6 months from ileostomy takedown. We assessed the clinical and pathological data including deep, focal inflammation, granulomas, and terminal ileal involvement in the colectomy specimens. Logistic regression analysis was performed to identify contributing factors to each phenotype. RESULTS This study included 1,203 pouchoscopies from 382 patients with UC. On multivariable analysis, deep inflammation was significantly associated with pouch fistulas (Odds ratio 3.27; 95% confidence interval 1.65-6.47; P = 0.0007). Of the 75 patients with deep inflammation, only two patients (2.7%) were diagnosed with CD based on pathology review. Terminal ileal involvement significantly increased the risk of afferent limb involvement (Odds ratio 2.96; 95% confidence interval 1.04-8.47; P = 0.04). There were no significant associations between other microscopic features and phenotypes. CONCLUSIONS We identify histologic features of colectomy specimens in UC that predict subsequent pouch phenotypes. Particularly, deep inflammation in the resected colon was significantly associated with pouch fistulas, a pouch phenotype with poor prognosis.
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Affiliation(s)
- Shintaro Akiyama
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Jacob E Ollech
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Cindy Traboulsi
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Victoria Rai
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Laura R Glick
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Yangtian Yi
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Joseph Runde
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Andrea D Olivas
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Christopher R Weber
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Russell D Cohen
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Kinga B Skowron Olortegui
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Roger D Hurst
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Konstantin Umanskiy
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Benjamin D Shogan
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Michele A Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Sushila R Dalal
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Atsushi Sakuraba
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Joel Pekow
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Eugene B Chang
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - John Hart
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - Neil H Hyman
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA
| | - David T Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Avenue, MC 4076, Chicago, IL, 60637, USA.
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26
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Barnes EL. Reply. Clin Gastroenterol Hepatol 2022; 20:1621-1622. [PMID: 34555520 DOI: 10.1016/j.cgh.2021.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 09/15/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, Multidisciplinary Center for Inflammatory Bowel Diseases, Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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27
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Akiyama S, Rodriguez TG, Rubin DT. Stratifying Risks of Ileal Pouch Outcomes. Clin Gastroenterol Hepatol 2022; 20:1620-1621. [PMID: 34481959 DOI: 10.1016/j.cgh.2021.08.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 08/26/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Shintaro Akiyama
- University of Chicago Medicine, Inflammatory Bowel Disease Center, Chicago, Illinois
| | - Tina G Rodriguez
- University of Chicago Medicine, Inflammatory Bowel Disease Center, Chicago, Illinois
| | - David T Rubin
- University of Chicago Medicine, Inflammatory Bowel Disease Center, Chicago, Illinois
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28
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Kayal M, Ungaro RC, Colombel JF. The Chicago Classification of Pouchitis: An Important Step Toward a Needed Consensus. Clin Gastroenterol Hepatol 2022; 20:281-282. [PMID: 33753242 DOI: 10.1016/j.cgh.2021.03.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 03/17/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Maia Kayal
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ryan C Ungaro
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jean-Frederic Colombel
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
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29
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Shen B, Kochhar GS, Rubin DT, Kane SV, Navaneethan U, Bernstein CN, Cross RK, Sugita A, Schairer J, Kiran RP, Fleshner P, McCormick JT, D'Hoore A, Shah SA, Farraye FA, Kariv R, Liu X, Rosh J, Chang S, Scherl E, Schwartz DA, Kotze PG, Bruining DH, Philpott J, Abraham B, Segal J, Sedano R, Kayal M, Bentley-Hibbert S, Tarabar D, El-Hachem S, Sehgal P, Picoraro JA, Vermeire S, Sandborn WJ, Silverberg MS, Pardi DS. Treatment of pouchitis, Crohn's disease, cuffitis, and other inflammatory disorders of the pouch: consensus guidelines from the International Ileal Pouch Consortium. Lancet Gastroenterol Hepatol 2022; 7:69-95. [PMID: 34774224 DOI: 10.1016/s2468-1253(21)00214-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 05/29/2021] [Accepted: 06/01/2021] [Indexed: 02/06/2023]
Abstract
Pouchitis, Crohn's disease of the pouch, cuffitis, polyps, and extraintestinal manifestations of inflammatory bowel disease are common inflammatory disorders of the ileal pouch. Acute pouchitis is treated with oral antibiotics and chronic pouchitis often requires anti-inflammatory therapy, including the use of biologics. Aetiological factors for secondary pouchitis should be evaluated and managed accordingly. Crohn's disease of the pouch is usually treated with biologics and its stricturing and fistulising complications can be treated with endoscopy or surgery. The underlying cause of cuffitis determines treatment strategies. Endoscopic polypectomy is recommended for large, symptomatic inflammatory polyps and polyps in the cuff. The management principles of extraintestinal manifestations of inflammatory bowel disease in patients with pouches are similar to those in patients without pouches.
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Affiliation(s)
- Bo Shen
- Center for Interventional Inflammatory Bowel Disease, Columbia University Irving Medical Center, NewYork Presbyterian Hospital, New York, NY, USA.
| | - Gursimran S Kochhar
- Division of Gastroenterology, Hepatology, and Nutrition, Allegheny Health Network, Pittsburgh, PA, USA
| | - David T Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Udayakumar Navaneethan
- Center for IBD and Interventional IBD Unit, Digestive Health Institute, Orlando Health, Orlando, FL, USA
| | - Charles N Bernstein
- Inflammatory Bowel Disease Clinical and Research Centre, University of Manitoba, Winnipeg, MB, Canada
| | - Raymond K Cross
- Inflammatory Bowel Disease Program, University of Maryland School of Medicine, Maryland, MD, USA
| | - Akira Sugita
- Department of Clinical Research and Department of inflammatory Bowel Disease, Yokohama Municipal Citizens Hospital, Yokohama, Japan
| | - Jason Schairer
- Department of Gastroenterology, Henry Ford Health System, Detroit, MI, USA
| | - Ravi P Kiran
- Division of Colorectal Surgery, Columbia University Irving Medical Center, NewYork Presbyterian Hospital, New York, NY, USA
| | - Philip Fleshner
- Division of Colorectal Surgery, University of California-Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - James T McCormick
- Division of Colon and Rectal Surgery, Allegheny Health Network, Pittsburgh, PA, USA
| | - André D'Hoore
- Department of Abdominal Surgery, University Hospital Leuven, Leuven, Belgium
| | - Samir A Shah
- Alpert Medical School of Brown University and Miriam Hospital, Gastroenterology Associates, Providence, RI, USA
| | - Francis A Farraye
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Revital Kariv
- Department of Gastroenterology, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Xiuli Liu
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, Gainsville, FL, USA
| | - Joel Rosh
- Department of Pediatric Gastroenterology, Goryeb Children's Hospital/Atlantic Health, Morristown, NJ, USA
| | - Shannon Chang
- Division of Gastroenterology, New York University Langone Health, New York, NY, USA
| | - Ellen Scherl
- Jill Roberts Center for IBD, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, NewYork Presbytarian Hospital, New York, NY, USA
| | - David A Schwartz
- Department of Gastroenterology, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - David H Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Jessica Philpott
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Bincy Abraham
- Houston Methodist and Weill Cornell Medical College, Houston, TX, USA
| | - Jonathan Segal
- Department of Gastroenterology and Hepatology, Hillingdon Hospital, Uxbridge, UK
| | - Rocio Sedano
- Department of Medicine, Division of Gastroenterology, Western University, London, ON, Canada
| | - Maia Kayal
- Department of Gastroenterology, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Stuart Bentley-Hibbert
- Department of Radiology, Columbia University Irving Medical Center, NewYork Presbyterian Hospital, New York, NY, USA
| | - Dino Tarabar
- IBD Clinical Center, University Hospital Center Dr Dragiša Mišović, Belgrade, Serbia
| | - Sandra El-Hachem
- Division of Gastroenterology, Hepatology, and Nutrition, Allegheny Health Network, Pittsburgh, PA, USA
| | - Priya Sehgal
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, NewYork Presbyterian Hospital, New York, NY, USA
| | - Joseph A Picoraro
- Department of Pediatrics, Columbia University Irving Medical Center-Morgan Stanley Children's Hospital, New York, NY, USA
| | - Séverine Vermeire
- Department of Gastroenterology, University Hospitals Leuven, Leuven, Belgium
| | - William J Sandborn
- Department of Gastroenterology, University of California San Diego, San Diego, CA, USA
| | - Mark S Silverberg
- Inflammatory Bowel Disease Centre, Mount Sinai Hospital, Toronto, ON, Canada
| | - Darrell S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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30
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Shen B, Bortlik M, Bruining DH, Coelho-Prabhu N, El-Hachem S, Farraye FA, Iacucci M, Kobayashi T, Kochhar GS, Kotze PG, Lama YG, Levy AN, Liu X, Mao R, Navaneethan U, Schwartz DA, Shergill A, Sood A, Suárez BG. Endoscopic evaluation after surgery in inflammatory bowel disease - Authors' reply. Lancet Gastroenterol Hepatol 2021; 6:691-692. [PMID: 34391522 DOI: 10.1016/s2468-1253(21)00255-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 06/26/2021] [Accepted: 06/29/2021] [Indexed: 12/04/2022]
Affiliation(s)
- Bo Shen
- Center for Interventional Inflammatory Bowel Disease, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY 10032, USA.
| | - Martin Bortlik
- Department of Gastroenterology, Hospital Ceske Budejovice, Ceske Budejovice, Czech Republic
| | | | | | - Sandra El-Hachem
- Division of Gastroenterology, Hepatology, and Nutrition, Allegheny Health Network, Pittsburgh, PA, USA
| | - Francis A Farraye
- Department of Gastroenterology, Mayo Clinic Jacksonville, Jacksonville, FL, USA
| | - Marietta Iacucci
- Institute of Immunology and Immunotherapy, NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, University of Birmingham, Birmingham, UK
| | - Taku Kobayashi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Gursimran S Kochhar
- Division of Gastroenterology, Hepatology, and Nutrition, Allegheny Health Network, Pittsburgh, PA, USA
| | | | - Yago González Lama
- IBD Unit, Gastroenterology and Hepatology Department, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Alexander N Levy
- Division of Gastroenterology and Hepatology, Tufts Medical Center, Boston, MA, USA
| | - Xiuli Liu
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, Gainsville, FL, USA
| | - Ren Mao
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yatsen University, Guangzhou, China
| | - Udayakumar Navaneethan
- IBD Center and IBD Interventional Unit, Digestive Health Institute, Orlando Health, Orlando, FL, USA
| | - David A Schwartz
- IBD Center and IBD Interventional Unit, Digestive Health Institute, Orlando Health, Orlando, FL, USA
| | - Amandeep Shergill
- Department of Gastroenterology, Vanderbilt University Medical Center, Nashville, TN, USA; San Francisco Veterans Affairs Medical Center and Department of Gastroenterology, University of California, San Francisco, CA, USA
| | - Ajit Sood
- Department of Gastroenterology, Dayanand Medical College & Hospital, Ludhiāna, Punjab, India
| | - Begoña Gonzalez Suárez
- Gastroenterology Department, Instituto Clínic de Enfermedades Digestivas y Metabólicas, Hospital Clínic de Barcelona, Barcelona, Spain
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Shen B, Kochhar GS, Kariv R, Liu X, Navaneethan U, Rubin DT, Cross RK, Sugita A, D'Hoore A, Schairer J, Farraye FA, Kiran RP, Fleshner P, Rosh J, Shah SA, Chang S, Scherl E, Pardi DS, Schwartz DA, Kotze PG, Bruining DH, Kane SV, Philpott J, Abraham B, Segal J, Sedano R, Kayal M, Bentley-Hibbert S, Tarabar D, El-Hachem S, Sehgal P, McCormick JT, Picoraro JA, Silverberg MS, Bernstein CN, Sandborn WJ, Vermeire S. Diagnosis and classification of ileal pouch disorders: consensus guidelines from the International Ileal Pouch Consortium. Lancet Gastroenterol Hepatol 2021; 6:826-849. [PMID: 34416186 DOI: 10.1016/s2468-1253(21)00101-1] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/12/2021] [Accepted: 03/15/2021] [Indexed: 12/12/2022]
Abstract
Restorative proctocolectomy with ileal pouch-anal anastomosis is an option for most patients with ulcerative colitis or familial adenomatous polyposis who require colectomy. Although the construction of an ileal pouch substantially improves patients' health-related quality of life, the surgery is, directly or indirectly, associated with various structural, inflammatory, and functional adverse sequelae. Furthermore, the surgical procedure does not completely abolish the risk for neoplasia. Patients with ileal pouches often present with extraintestinal, systemic inflammatory conditions. The International Ileal Pouch Consortium was established to create this consensus document on the diagnosis and classification of ileal pouch disorders using available evidence and the panellists' expertise. In a given individual, the condition of the pouch can change over time. Therefore, close monitoring of the activity and progression of the disease is essential to make accurate modifications in the diagnosis and classification in a timely manner.
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Affiliation(s)
- Bo Shen
- Center for Interventional Inflammatory Bowel Disease, Columbia University Irving Medical Center-New-York Presbyterian Hospital, NY, USA.
| | - Gursimran S Kochhar
- Division of Gastroenterology, Hepatology, and Nutrition, Allegheny Health Network, Pittsburgh, PA, USA
| | - Revital Kariv
- Department of Gastroenterology, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Xiuli Liu
- Department of Pathology and Immunology, Washington University, MO, USA
| | - Udayakumar Navaneethan
- IBD Center and IBD Interventional Unit, Center for Interventional Endoscopy, Orlando Health, Orlando, FL, USA
| | - David T Rubin
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | - Raymond K Cross
- Inflammatory Bowel Disease Program, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Akira Sugita
- Department of Clinical Research and Department of Inflammatory Bowel Disease, Yokohama Municipal Citizens Hospital Yokohama, Japan
| | - André D'Hoore
- Department of Abdominal Surgery, University Hospital Leuven, Belgium
| | - Jason Schairer
- Department of Gastroenterology, Henry Ford Health System, Detroit, MI, USA
| | - Francis A Farraye
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Ravi P Kiran
- Division of Colorectal Surgery, Columbia University Irving Medical Center-New-York Presbyterian Hospital, NY, USA
| | - Philip Fleshner
- Division of Colorectal Surgery, University of California-Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Joel Rosh
- Department of Pediatric Gastroenterology, Goryeb Children's Hospital-Atlantic Health, Morristown, NJ, USA
| | - Samir A Shah
- Alpert Medical School of Brown University and Miriam Hospital, Gastroenterology Associates, Providence, RI, USA
| | - Shannon Chang
- Division of Gastroenterology, New York University Langone Health, New York, NY, USA
| | - Ellen Scherl
- New York Presbyterian Hospital, Jill Roberts Center for IBD, Weill Cornell Medicine, Gastroenterology and Hepatology, New York, NY, USA
| | - Darrell S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - David A Schwartz
- Department of Gastroenterology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Paulo G Kotze
- IBD Outpatients Clinic, Catholic University of Paraná, Curitiba, Brazil
| | - David H Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Jessica Philpott
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Bincy Abraham
- Houston Methodist and Weill Cornell Medical College, Houston, TX, USA
| | - Jonathan Segal
- Department of Gastroenterology and Hepatology, Hillingdon Hospital, Uxbridge, UK
| | - Rocio Sedano
- Department of Medicine, Division of Gastroenterology, Western University, London, ON, Canada
| | - Maia Kayal
- Department of Gastroenterology, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Stuart Bentley-Hibbert
- Department of Radiology, Columbia University Irving Medical Center-New-York Presbyterian Hospital, NY, USA
| | - Dino Tarabar
- IBD Clinical Center, University Hospital Center Dr Dragiša Mišović, Belgrade, Serbia
| | - Sandra El-Hachem
- Division of Gastroenterology, Hepatology, and Nutrition, Allegheny Health Network, Pittsburgh, PA, USA
| | - Priya Sehgal
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center-New-York Presbyterian Hospital, NY, USA
| | - James T McCormick
- Division of Colon and Rectal Surgery, Allegheny Health Network, Pittsburgh, PA, USA
| | - Joseph A Picoraro
- Department of Pediatrics, Columbia University Irving Medical Center-Morgan Stanley Children's Hospital, New York, NY, USA
| | - Mark S Silverberg
- Mount Sinai Hospital Inflammatory Bowel Disease Centre, Toronto, ON, Canada
| | - Charles N Bernstein
- Inflammatory Bowel Disease Clinical and Research Centre, University of Manitoba, Winnipeg, MB, Canada
| | - William J Sandborn
- Department of Gastroenterology, University of California San Diego, San Diego, CA, USA
| | - Séverine Vermeire
- Department of Gastroenterology, University hospitals Leuven, Leuven, Belgium
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