Pouchitis and pouch dysfunction

Dual arterial blood supply D-pouch in a patient with ulcerative colitis undergoing proctocolectomy and ileal pouch-anal anastomosis: A case report

INTRODUCTION

Pouchitis is the most common complication in Ulcerative colitis (UC) patients after restorative proctocolectomy with ileal pouch-anal anastomosis (RP-IPAA) and ischemia may be a significant contributing factor. Tension and blood supply are the primary concerns while performing the procedure. A dual arterial blood supply technique is designed to decrease tension while ensuring sufficient blood perfusion.

PATIENT CONCERNS

A 61-year-old female patient with 14 years history of UC wanted to seek surgical treatment.

DIAGNOSES

Ulcerative colitis.

INTERVENTIONS

After physical examination and treatment of parenteral nutrition, the patient underwent a D-pouch with dual arterial blood supply after total proctocoloectomy.

OUTCOMES

The patient recovered well and was discharged 10 days after her procedure. Postoperatively dual arterial blood supply to the D-pouch was demonstrated by computed tomography angiography (CTA).

CONCLUSION

D-pouch with dual arterial blood supply is feasible and safe in patients with UC undergoing RP-IPAA.

Pharmacodynamic assessment of vedolizumab for the treatment of ulcerative colitis

INTRODUCTION

Vedolizumab is an anti-integrin approved for the treatment of Crohn's disease and ulcerative colitis. By binding the α4β7-integrin heterodimer, vedolizumab blocks leukocyte translocation into gastrointestinal tissue.

AREAS COVERED

This review discusses the chemistry, pharmacologic properties, clinical efficacy, and safety of vedolizumab in ulcerative colitis. Other medications available for the treatment of ulcerative colitis are also discussed.

EXPERT OPINION

Vedolizumab is a promising new agent for the treatment of ulcerative colitis. Its mechanism of action differs from TNF-α inhibitors and immune suppressants, allowing it to be used in cases of TNF-α inhibitor failure or non-response, or as a first-line biologic drug. Available safety data suggests that vedolizumab is not associated with an increased risk of infection or malignancy; however, additional post-marketing data are required to confirm these initial reports. Vedolizumab is likely to be used in growing numbers of patients over the coming years.

Antibodies against glycoprotein 2 are novel markers of intestinal inflammation in patients with an ileal pouch

BACKGROUND AND AIMS

The Crohn's disease (CD)-specific pancreatic auto-antibodies (PAB), have been recently identified to target glycoprotein 2 (GP2). Pouchitis is an inflammation of the small bowel developing in up to 60% of ulcerative colitis patients undergoing proctocolectomy and ileal pouch anal anastomosis. Occurrence of CD-specific antibodies was reported to be a predictor of pouchitis. We aimed to assess the prevalence of anti-GP2 antibodies (anti-GP2) in the serum and feces of pouch patients and to correlate them with clinical parameters. Furthermore, we examined mucosal expression of the GP2 protein in the pouch.

METHODS

Pouch patients were prospectively recruited and checked for clinical, endoscopic, and laboratory markers of inflammation. IgG and IgA anti-GP2 levels in serum and fecal samples were determined using ELISA. GP2 protein was assessed by immunohistochemistry.

RESULTS

Anti-GP2 was elevated in both serum and fecal samples of patients with inflamed compared to those with non-inflamed pouches and patients with familial-adenomatous polyposis after surgery (p<0.05, respectively). Moreover, patients with CD-like complications exhibited significantly higher anti-GP2 titers than those without CD-like complications (p≤0.01). High levels of anti-GP2 correlated with more frequent bowel movements per day and with the presence of at least one anti-glycan antibody (p≤0.05). GP2 itself was more abundant in the mucosa of patients with chronic pouchitis.

CONCLUSIONS

Anti-GP2 exists in the serum and feces of pouch patients and correlates with pouch inflammation, and presence of other serological markers. Thus, anti-GP2 may contribute to better stratification of pouchitis, more-so when the inflammation exhibits CD-like complications.

The pediatric pouch in inflammatory bowel disease: a primer for the gastroenterologist

Pediatric severe ulcerative colitis that is resistant to current medical treatment can successfully be managed surgically with a colectomy, ileal pouch creation and pouch-anal anastomosis. Key issues that should be considered and discussed before the pouch option can be offered include alternative surgical procedures, pouch function expectations, risk of surgical leak, pelvic sepsis, anastomotic strictures, acute and chronic pouch inflammation, Crohn's disease of the pouch and risk of reduced fertility for females. A long-term risk is malignancy of the residual colonic tissue. The decision to proceed with a pouch or not poses a substantial emotional burden to the child and family. Despite the risk of surgical complications and pouch inflammatory and functional challenges, the overwhelming majority of children and their families are satisfied with their pouch surgery outcomes. Further study is needed to assess preoperative risk predictors, prevention and treatment of complications.

Clinical significance of indefinite for dysplasia on pouch biopsy in patients with underlying inflammatory bowel disease

BACKGROUND

"Indefinite for dysplasia" (IND) on pouch mucosal biopsy is occasionally reported during routine histopathological evaluation. The natural history and implication of this histologic entity in ileal pouch-anal anastomosis (IPAA) has not been studied.

AIM

The aim of this study is to characterize cumulative probability, natural history, and clinical outcome of pouch IND in a cohort of patients with inflammatory bowel disease (IBD).

METHODS

All 932 patients with restorative proctocolectomy and IPAA for IBD were included. Patients with or without IND were classified into the study and control groups. Demographic, clinical, endoscopic, and histologic variables were analyzed.

RESULTS

The mean duration from IBD diagnosis to colectomy and from pouch construction to data entry was 8.4 ± 8.5 and 9.7 ± 6.2 years, respectively. A total of 2,250 surveillance or diagnostic pouchoscopies with biopsies were performed for the cohort. Twenty-one patients (2.3%) were diagnosed with anal transitional zone and/or pouch IND, for whom subsequent pouchoscopies were performed with the mean procedure number being 3.4 ± 2.2 per patient during a mean of follow-up of 19.3 ± 16.1 months. One patient with IND developed low-grade dysplasia and one had high-grade dysplasia in a separate endoscopy. Cox model showed the presence of primary sclerosing cholangitis was an independent risk factor for pouch IND [hazard ratio = 6.76 (95% CI 2.56-17.88)]. Interobserver agreement (kappa score) for diagnosing pouch IND between GI pathologists ranged from 0.67 to 0.76.

CONCLUSIONS

Subsequent dysplasia was uncommon in pouch patients with IND. Natural history of pouch IND warrants further long-term investigation.

Impact of capsule endoscopy on management of inflammatory bowel disease: a single tertiary care center experience

BACKGROUND

Capsule endoscopy (CE) is performed to assess inflammatory bowel disease (IBD). We aimed to define the results of CE in subtypes of IBD and to determine whether CE results in management changes.

METHODS

A retrospective cohort study was performed of all CEs for IBD at a tertiary care center from 2003-2009. Descriptive statistics were used to compare IBD-specific medications, surgeries, and imaging studies in the 3 months prior and 3 months after CE.

RESULTS

Of 907 CEs performed from 2003-2009, 128 were for an indication of symptomatic IBD and 124 capsules left the stomach (86 for Crohn's disease [CD], 15 for indeterminate colitis [IC], 23 for pouchitis). Only 22.1% of CEs done for CD were normal, as compared to 53.3% for IC and 34.8% for pouchitis. Severe findings in CD consisted of multiple aphthae/ulcers (22.1%), stenosis (8.1%), and stenosis with immediate retention (17.4%). In CD, 61.6% had a change in medication in the 3 months after the CE, with 39.5% initiating a new IBD medication, most commonly budesonide or corticosteroids. In the 3 months following CE, 12.8% of patients with CD underwent surgery. Severe findings on CE in patients with CD, as compared to no/minimal findings, resulted in significant differences in medication changes (73.2% versus 51.1%, P = 0.04), addition of medications (58.5% versus 22.2%, P < 0.01), and surgeries (21.9% versus 4.4%, P = 0.01).

CONCLUSIONS

CE results in management changes in the majority of cases of symptomatic IBD, regardless of the subtype of IBD.

Simple score to identify colectomy risk in ulcerative colitis hospitalizations

BACKGROUND

Patients hospitalized for ulcerative colitis (UC) are at high risk for colectomy. Despite growing interest in research using administrative data in inflammatory bowel disease, there is no available tool in such research to stratify disease severity or identify patients at high risk for colectomy.

METHODS

Using the Nationwide Inpatient Sample (NIS) 2004, we identified patients hospitalized for UC flare through appropriate ICD-9-CM discharge diagnosis codes (556.x). Our primary outcome of interest was undergoing total colectomy (45.8). Multivariate logistic regression models were constructed to identify independent predictors of colectomy. From this, a cumulative risk score was developed. Hospitalizations were divided into 3 strata (low, intermediate, high) based on the odds of colectomy.

RESULTS

There were a total of 15,142 hospitalizations with a discharge diagnosis of UC included in our study among whom 366 patients underwent total colectomy (2.4%). Anemia (odds ratio [OR] 2.13), requirement for blood transfusion (OR 2.22), malnutrition (OR 4.53), and total parenteral nutrition (OR 4.30) were independent predictors of colectomy as were transfer in from another hospital (OR 2.06) and admission to a teaching hospital (OR 1.73). The cumulative colectomy risk score ranged from 0-8, with significantly higher risk of colectomy in the high-risk stratum (13.7%) compared to the intermediate-risk (4.2%, P < 0.001) and low-risk (1.3%, P < 0.001) strata. The risk score performed well in its discriminative ability with an area under the curve of 0.70.

CONCLUSIONS

We propose a simple and novel risk score to stratify the severity of UC hospitalizations and predict colectomy in this population.