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Meianu C, Stroie T, Istratescu D, Preda CM, Diculescu MM. Diagnosis and Medical Treatment of Acute and Chronic Idiopathic Pouchitis in Inflammatory Bowel Disease. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:979. [PMID: 38929596 PMCID: PMC11205934 DOI: 10.3390/medicina60060979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 06/07/2024] [Accepted: 06/10/2024] [Indexed: 06/28/2024]
Abstract
Despite the decreased rates in inflammatory bowel disease (IBD) colectomies due to high advances in therapeutic options, a significant number of patients still require proctocolectomy with ileal pouch-anal anastomosis (IPPA) for ulcerative colitis (UC). Pouchitis is the most common complication in these patients, where up to 60% develop one episode of pouchitis in the first two years after UC surgery with IPAA with severe negative impact on their quality of life. Acute cases usually respond well to antibiotics, but 15% of patients will still develop a refractory disease that requires the initiation of advanced immunosuppressive therapies. For chronic idiopathic pouchitis, current recommendations suggest using the same therapeutic options as for IBD in terms of biologics and small molecules. However, the available data are limited regarding the effectiveness of different biologics or small molecules for the management of this condition, and all evidences arise from case series and small studies. Vedolizumab is the only biologic agent that has received approval for the treatment of adult patients with moderately to severely active chronic refractory pouchitis. Despite the fact that IBD treatment is rapidly evolving with the development of novel molecules, the presence of pouchitis represents an exclusion criterion in these trials. Recommendations for the approach of these conditions range from low to very low certainty of evidence, resulting from small randomized controlled trials and case series studies. The current review focuses on the therapeutic management of idiopathic pouchitis.
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Affiliation(s)
- Corina Meianu
- Gastroenterology Department, Fundeni Clinical Institute, 022328 Bucharest, Romania
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Tudor Stroie
- Gastroenterology Department, Fundeni Clinical Institute, 022328 Bucharest, Romania
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Doina Istratescu
- Gastroenterology Department, Fundeni Clinical Institute, 022328 Bucharest, Romania
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Carmen Monica Preda
- Gastroenterology Department, Fundeni Clinical Institute, 022328 Bucharest, Romania
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Mihai Mircea Diculescu
- Gastroenterology Department, Fundeni Clinical Institute, 022328 Bucharest, Romania
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
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Shen B, Yao Q, Scherl EJ. Management of Primary Sclerosing Cholangitis and Extraintestinal Disorders in Patients With Ileal Pouches: A Systematic Review. Dis Colon Rectum 2024; 67:S106-S114. [PMID: 38411984 DOI: 10.1097/dcr.0000000000003231] [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: 02/28/2024]
Abstract
BACKGROUND Restorative proctocolectomy with IPAA improves the quality of life in patients with ulcerative colitis by the removal of diseased large bowel and preservation of the natural route of defecation. Although the surgery may improve preexisting extraintestinal manifestations in the joints, skin, and eyes, extraintestinal manifestations, particularly primary sclerosing cholangitis, can persist after colectomy. OBJECTIVES A systematic review of diagnosis and treatment of liver, joint, skin, and eye manifestations in patients with restorative proctocolectomy and IPAA for ulcerative colitis. DATA SOURCES PubMed, Google Scholar, and Cochrane database. STUDY SELECTION Relevant articles on primary sclerosing cholangitis and extraintestinal manifestations in ileal pouches published between January 2001 and July 2023 in English were included on the basis of Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. INTERVENTION Diagnosis and treatment of primary sclerosing cholangitis and extraintestinal manifestations in patients with restorative proctocolectomy and IPAA were included. MAIN OUTCOME MEASURES Association between primary sclerosing cholangitis, extraintestinal manifestations, and inflammatory disorders of the pouch and their management. RESULTS Primary sclerosing cholangitis and extraintestinal manifestations are associated with pouchitis, particularly chronic pouchitis. Primary sclerosing cholangitis is associated with chronic pouchitis, enteritis, and possible pouch neoplasia. However, the disease severity and course of primary sclerosing cholangitis and pouchitis do not appear to be parallel. Despite the fact that oral vancomycin or budesonide have been used to treat primary sclerosing cholangitis-associated pouchitis, their impact on the disease course of primary sclerosing cholangitis is not known. Biological therapy for chronic inflammatory disorders of the pouch may also be beneficial for the concurrent extraintestinal manifestations of the joints, skin, and eyes. However, studies on the correlation between the severity of inflammatory pouch disorders and the severity of joint, skin, and eye diseases are lacking. LIMITATIONS This is a qualitative, not quantitative, review of case series and case reports. CONCLUSIONS Primary sclerosing cholangitis and extraintestinal manifestations of the joints, skin, and eyes appear to be associated with inflammatory disorders of the ileal pouch. Although the treatment of pouchitis does not seem to affect the disease course of primary sclerosing cholangitis, effective therapy of inflammatory pouch disorders, particularly with biologics, likely benefits concurrent disorders of the joints, skin, and eyes. See video from the symposium .
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Affiliation(s)
- Bo Shen
- Center for Inflammatory Bowel Disease, Columbia University Irving Medical Center/NewYork Presbyterian Hospital, New York, New York
| | - QingPing Yao
- Division of Rheumatology, Allergy and Immunology, Stony Brook University Renaissance School of Medicine, New York
| | - Ellen J Scherl
- Division of Gastroenterology and Hepatology, Department of Medicine, New York-Presbyterian/Weill Cornell Medical Center, New York, New York
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Anto VP, Ramos AE, Mollen KP. Ouch, my pouch! a clinician's guide to pouchitis. Semin Pediatr Surg 2024; 33:151406. [PMID: 38636151 DOI: 10.1016/j.sempedsurg.2024.151406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
Pouchitis is defined as inflammation of the ileal pouch created during a restorative proctocolectomy with ileal pouch-anal anastomosis. Although the incidence of this inflammatory condition is high, the exact etiology often remains unclear and the management challenging. In this review, we summarize the clinical presentation, pathogenesis, diagnosis, and management of this common complication.
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Affiliation(s)
- Vincent P Anto
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Anna E Ramos
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Kevin P Mollen
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Panganiban RP, Tuan A, Hart M, Pelton M, Mikhail D, Akhtar S, Bogale K, Deiling S, Zhou S, Coates MD, Yochum GS, Koltun W. Pyoderma Gangrenosum Is Associated With Increased Risk of Inflammatory Pouch-Related Complications: A Retrospective Cohort Study. CROHN'S & COLITIS 360 2023; 5:otad024. [PMID: 37663924 PMCID: PMC10474334 DOI: 10.1093/crocol/otad024] [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: 03/07/2023] [Indexed: 09/05/2023] Open
Abstract
Background Pyoderma gangrenosum (PG) is a rare, neutrophilic dermatosis that is a well-established extraintestinal manifestation (EIM) of inflammatory bowel disease. The clinical implications of developing PG in patients with ulcerative colitis (UC) who undergo total proctocolectomy colectomy and ileal pouch anal anastomosis (TPC-IPAA) surgery remain unknown. Methods Study participants were selected from patients enrolled in the Carlino Family Inflammatory Bowel and Colorectal Disease Biobank between 1998 and 2021 with a pre-colectomy diagnosis of UC and who underwent TPC-IPAA surgery. A retrospective study comparing patients with PG and those without PG was performed. The outcomes measured included the development of pouchitis, pouchitis classification, presence of pouch fistula, anal fistula, anal stenosis, and pouch failure. Results In this study, 357 IPAA patients were included, 10 of whom suffered PG. Patients with PG and without PG had similar demographics and clinical characteristics. Both groups had similar rates of pouchitis (80% in PG patients and 64% in patients without PG, P = .504). However, IPAA patients with PG had a higher risk of developing pouch fistula (50% vs 10%, P = .002), anal fistula (40% vs 12%, P = .031), and Crohn's-like disease of the pouch (70% vs 15%, P = .003) compared to patients without PG. Patients who developed PG prior to their first episode of pouchitis were more likely to eventually experience pouch failure (odds ratio: 20.7, 95% confidence interval: 3.9, 110.7, q = 0.003 after false discovery rate adjustment). Conclusions Among UC patients who undergo TPC-IPAA surgery, the development of PG portends poor pouch outcomes and is predictive of pouch failure.
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Affiliation(s)
- Ronaldo Paolo Panganiban
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Penn State Hershey Medical Center, Hershey, PA, USA
- Division of Colorectal Surgery, Department of Surgery, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Alyssa Tuan
- College of Medicine, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Maxwell Hart
- Department of Medicine, The University of Arizona College of Medicine Tucson, Tucson, AZ, USA
| | - Mathew Pelton
- Department of Medicine, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
| | - Daniella Mikhail
- Department of Medicine, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
| | - Sarah Akhtar
- Department of Internal Medicine, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Kaleb Bogale
- Columbia University Irving Medical Center, New York, NY, USA
| | - Susan Deiling
- Division of Colorectal Surgery, Department of Surgery, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Shouhao Zhou
- Division of Biostatistics and Bioinformatics, Department of Public Health Science, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Mathew D Coates
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Gregory S Yochum
- Division of Colorectal Surgery, Department of Surgery, Penn State Hershey Medical Center, Hershey, PA, USA
- Department of Biochemistry and Molecular Biology, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Walter Koltun
- Division of Colorectal Surgery, Department of Surgery, Penn State Hershey Medical Center, Hershey, PA, USA
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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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Bresteau C, Amiot A, Kirchgesner J, de'Angelis N, Lefevre JH, Bouhnik Y, Panis Y, Beaugerie L, Allez M, Brouquet A, Carbonnel F, Meyer A. Chronic pouchitis and Crohn's disease of the pouch after ileal pouch-anal anastomosis: Incidence and risk factors. Dig Liver Dis 2021; 53:1128-1135. [PMID: 33931341 DOI: 10.1016/j.dld.2021.03.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 03/07/2021] [Accepted: 03/24/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Restorative proctocolectomy with ileal-pouch anal-anastomosis (IPAA) is the operation of choice for patients with ulcerative colitis (UC) or with inflammatory bowel diseases unclassified (IBDU). AIMS to assess the incidence and risk factors of chronic pouchitis (CP) and Crohn's disease of the pouch (CDP) in patients with UC or IBDU. METHODS We conducted a retrospective study. We included consecutive patients who underwent IPAA between 2011 and 2019. The main outcome was the occurrence of CP or CDP. We looked for risk factors with multivariable and a least absolute shrinkage and selection operator (LASSO) Cox models. RESULTS 247 patients were included. The 5-year cumulative incidence of CP or CDP was 35.3% (95%CI: 26.2-43.2). In multivariable analysis, diagnosis of IBDU, age less than 35 years at surgery and extra-intestinal manifestations other than articular and primary sclerosing cholangitis were associated with higher incidence. The LASSO analysis identified these three prognostic factors and articular manifestations. In patients with two or more prognostic factors, 5-year cumulative incidence, was 65.2% (95%CI: 41.8-79.2). CONCLUSIONS Five years after IPAA, approximately one-third of patients had either CP or CDP. Risk factors were IBDU, an age less than 35 years at surgery, articular manifestations and other extra-intestinal manifestations.
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Affiliation(s)
- Clément Bresteau
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Université Paris Saclay, CHU Bicêtre, 78, rue du Général Leclerc, Le Kremlin Bicêtre 94270, France
| | - Aurélien Amiot
- Assitance-Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, EA7375, Universite Paris Est Creteil, Créteil, France
| | - Julien Kirchgesner
- Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
| | - Nicola de'Angelis
- Assitance-Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, EA7375, Universite Paris Est Creteil, Créteil, France
| | - Jérémie H Lefevre
- Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
| | - Yoram Bouhnik
- Assistance Publique-Hôpitaux de Paris, Hôpital Beaujon, Université de Paris, Clichy, France
| | - Yves Panis
- Assistance Publique-Hôpitaux de Paris, Hôpital Beaujon, Université de Paris, Clichy, France
| | - Laurent Beaugerie
- Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
| | - Matthieu Allez
- Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Université de Paris, Paris, France
| | - Antoine Brouquet
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Université Paris Saclay, CHU Bicêtre, 78, rue du Général Leclerc, Le Kremlin Bicêtre 94270, France
| | - Franck Carbonnel
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Université Paris Saclay, CHU Bicêtre, 78, rue du Général Leclerc, Le Kremlin Bicêtre 94270, France.
| | - Antoine Meyer
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Université Paris Saclay, CHU Bicêtre, 78, rue du Général Leclerc, Le Kremlin Bicêtre 94270, France
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7
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Roth R, Vavricka S, Scharl M, Schreiner P, Safroneeva E, Greuter T, Zeitz J, Misselwitz B, Schoepfer A, Barry MP, Rogler G, Biedermann L. The impact of colectomy on the course of extraintestinal manifestations in Swiss inflammatory bowel disease cohort study patients. United European Gastroenterol J 2021; 9:773-780. [PMID: 34431613 PMCID: PMC8435245 DOI: 10.1002/ueg2.12125] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 05/13/2021] [Indexed: 12/12/2022] Open
Abstract
Background and Aims Extraintestinal manifestations are reported to occur in up to 45% of inflammatory bowel disease (IBD) patients during the course of disease. It is unknown whether colectomy reduces the rate of de novo extraintestinal manifestations (EIMs) or impacts on severity of EIMs following a parallel versus independent disease course from underlying IBD. Methods Using data from the Swiss Inflammatory Bowel Disease Cohort Study we aimed to analyse the course of EIMs in ulcerative colitis (UC) and Crohn’s disease (CD) patients undergoing colectomy during the cohort’s prospective follow‐up. Results One hundred and twenty‐one IBD patients (33 CD, 81 UC and seven unclassified) underwent colectomy during prospective follow‐up in the Swiss Inflammatory Bowel Disease Cohort Study. Within the 114 patients with UC or CD any EIM was reported in 40 (nine CD and 31 UC) patients. Activity of EIMs ceased entirely after colectomy in 21 patients (52.5%). Complete cessation of EIM after colectomy was higher in patients with UC versus CD with 58.1% versus 33.3%. After colectomy, 29 out of the 114 patients (25.4%) experienced any EIM. Two thirds of these (19 patients) represented persisting EIMs, while in one third (10 patients) EIM represented a de‐novo event after colectomy. Overall, 13.5% of IBD patients developed a de‐novo EIM after colectomy. Conclusions In IBD patients undergoing colectomy, EIMs present prior to surgery will persist in about half of patients. Complete cessation of EIM after colectomy may be less common in CD than in UC. In patients who never experienced EIMs prior to colectomy de‐novo manifestations thereafter should be expected in up to one in seven patients.
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Affiliation(s)
- René Roth
- Department of Gastroenterology, University Hospital Zurich (USZ), University of Zurich, Zurich, Switzerland
| | | | - Michael Scharl
- Department of Gastroenterology, University Hospital Zurich (USZ), University of Zurich, Zurich, Switzerland
| | - Philipp Schreiner
- Department of Gastroenterology, University Hospital Zurich (USZ), University of Zurich, Zurich, Switzerland
| | - Ekaterina Safroneeva
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Thomas Greuter
- Department of Gastroenterology, University Hospital Zurich (USZ), University of Zurich, Zurich, Switzerland
| | - Jonas Zeitz
- Center of Gastroenterology, Clinic Hirslanden, Zurich, Switzerland
| | - Benjamin Misselwitz
- Department of Gastroenterology, University Hospital Zurich (USZ), University of Zurich, Zurich, Switzerland.,Department of Visceral Surgery and Medicine, Inselspital Bern, Bern, Switzerland
| | - Alain Schoepfer
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Mamadou Pathé Barry
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Gerhard Rogler
- Department of Gastroenterology, University Hospital Zurich (USZ), University of Zurich, Zurich, Switzerland
| | - Luc Biedermann
- Department of Gastroenterology, University Hospital Zurich (USZ), University of Zurich, Zurich, Switzerland
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Akiyama S, Rai V, Rubin DT. Pouchitis in inflammatory bowel disease: a review of diagnosis, prognosis, and treatment. Intest Res 2020; 19:1-11. [PMID: 33138344 PMCID: PMC7873408 DOI: 10.5217/ir.2020.00047] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 06/18/2020] [Indexed: 12/11/2022] Open
Abstract
Patients with inflammatory bowel disease (IBD) occasionally need a restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) because of medically refractory colitis or dysplasia/cancer. However, pouchitis may develop in up to 70% of patients after this procedure and significantly impair quality of life, more so if the inflammation becomes a chronic condition. About 10% of patients with IBD who develop pouchitis require pouch excision, and several risk factors of the failure have been reported. A phenotype that has features similar to Crohn’s disease may develop in a subset of ulcerative colitis patients following proctocolectomy with IPAA and is the most frequent reason for pouch failure. In this review, we discuss the diagnosis and prognosis of pouchitis, risk factors for pouchitis development, and treatment options for pouchitis, including the newer biological agents.
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Affiliation(s)
- Shintaro Akiyama
- Inflammatory Bowel Disease Center, The University of Chicago Medicine, Chicago, IL, USA
| | - Victoria Rai
- Inflammatory Bowel Disease Center, The University of Chicago Medicine, Chicago, IL, USA
| | - David T Rubin
- Inflammatory Bowel Disease Center, The University of Chicago Medicine, Chicago, IL, USA
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9
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Koike Y, Uchida K, Inoue M, Nagano Y, Kondo S, Matsushita K, Okita Y, Toiyama Y, Araki T, Kusunoki M. Early first episode of pouchitis after ileal pouch-anal anastomosis for pediatric ulcerative colitis is a risk factor for development of chronic pouchitis. J Pediatr Surg 2019; 54:1788-1793. [PMID: 30446392 DOI: 10.1016/j.jpedsurg.2018.10.056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 09/20/2018] [Accepted: 10/12/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND The predictive factors for chronic pouchitis after ileal pouch-anal anastomosis (IPAA) in pediatric-onset ulcerative colitis (UC) remain unclear. This study evaluated the predictive factors for chronic pouchitis after IPAA in patients with pediatric UC. METHODS The data from 52 patients with pediatric-onset UC who underwent IPAA in Mie University Hospital were retrospectively reviewed. The endoscopy surveillance was performed yearly or at the timing of the symptom. Chronic pouchitis was defined as antibiotic-dependent/-refractory and relapsing cases. Potential predictors of chronic pouchitis were analyzed. RESULTS During the first 5 years after IPAA, pouchitis was identified in 32.7%. Of these patients, 12 (70.6%) developed chronic pouchitis. The predictor of chronic pouchitis was a preoperative history of immunomodulator use before IPAA (p = 0.04). Life table analysis revealed that patients with chronic pouchitis tended to develop pouchitis earlier after IPAA than did patients without chronic pouchitis (p = 0.012). Receiver operating characteristic curve analysis showed that the occurrence of pouchitis within 15 months after IPAA surgery predicted the development of chronic pouchitis (sensitivity, 92%; specificity, 80%). CONCLUSION In pediatric patients with UC, the predictive factors for chronic pouchitis are immunomodulator use and early occurrence of the first episode of pouchitis within 15 months after IPAA. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Yuhki Koike
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan.
| | - Keiichi Uchida
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Mikihiro Inoue
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Yuka Nagano
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Satoru Kondo
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Kohei Matsushita
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Yoshiki Okita
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Yuji Toiyama
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Toshimitsu Araki
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Masato Kusunoki
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
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Cohen S, Padlipsky J, Yerushalmy-Feler A. Risk factors associated with extraintestinal manifestations in children with inflammatory bowel disease. Eur J Clin Nutr 2019; 74:691-697. [PMID: 31395971 DOI: 10.1038/s41430-019-0490-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 07/03/2019] [Accepted: 07/19/2019] [Indexed: 01/06/2023]
Abstract
OBJECTIVES Extraintestinal manifestations (EIM) are common complications of inflammatory bowel disease (IBD) associated with morbidity and reduced quality of life (QOL). The aim of this study was to identify and validate predictors for EIM in children with IBD. METHODS The medical records of children with IBD were retrospectively reviewed, and EIM present before diagnosis and those detected during follow-up, were recorded. RESULTS One-hundred children were included, and their median age (interquartile range) was 13.9 (11.9-15.2) years. Forty-six (46%) children had EIM, including 10 (10%) whose EIM was present before diagnosis and 36 (36%) during follow-up. The most common EIMs were aphthous stomatitis (18%), arthralgia (14%), dermatologic manifestations (8%), and arthritis (6%). A body mass index in the lower or upper quartile (hazard ratio [HR] 9.30 and 23.71, respectively, p < 0.001), moderate-to-severe disease activity (HR 4.43, p < 0.001), extensive Crohn's disease (HR 3.43, p = 0.025), lower hemoglobin level (HR 2.29, p < 0.001), lower albumin level (HR 2.86, p = 0.029), and higher C-reactive protein level (HR 1.04, p < 0.001) at diagnosis were identified as risk factors for EIM during follow-up. CONCLUSIONS Identification of risk factors at IBD diagnosis may help healthcare providers to predict EIM in children with IBD and to improve their management for lessening morbidity and enhancing QOL.
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Affiliation(s)
- Shlomi Cohen
- Pediatric Gastroenterology Unit, "Dana-Dwek" Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | | | - Anat Yerushalmy-Feler
- Pediatric Gastroenterology Unit, "Dana-Dwek" Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Hata K, Okada S, Shinagawa T, Toshiaki T, Kawai K, Nozawa H. Meta-analysis of the association of extraintestinal manifestations with the development of pouchitis in patients with ulcerative colitis. BJS Open 2019; 3:436-444. [PMID: 31463422 PMCID: PMC6706792 DOI: 10.1002/bjs5.50149] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Accepted: 01/18/2019] [Indexed: 12/13/2022] Open
Abstract
Background The presence of extraintestinal manifestations may be associated with the development of pouchitis in patients with ulcerative colitis after ileal pouch–anal anastomosis. The aim of this study was to assess this correlation. Methods A systematic literature search was performed using MEDLINE and the Cochrane Library. Studies published in English up to 22 May 2017 investigating the association between extraintestinal manifestations and development of pouchitis in adults with ulcerative colitis were included. Case reports were excluded. The association of extraintestinal manifestations with the development of overall and chronic pouchitis was investigated using a random‐effects model. Results Of 1010 citations identified, 22 observational studies comprising 5128 patients were selected for analysis. The presence of extraintestinal manifestations was significantly associated with both chronic pouchitis (odds ratio 2·28, 95 per cent c.i. 1·57 to 3·32; P = 0·001) and overall pouchitis (odds ratio 1·96, 1·49 to 2·57; P < 0·001). Conclusion The presence of extraintestinal manifestations is associated with development of pouchitis after ileal pouch–anal anastomosis.
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Affiliation(s)
- K Hata
- Department of Surgical Oncology The University of Tokyo 7-3-1 Hongo, Bunkyo-ku Tokyo, 113-8655 Japan
| | - S Okada
- Department of Surgical Oncology The University of Tokyo 7-3-1 Hongo, Bunkyo-ku Tokyo, 113-8655 Japan
| | - T Shinagawa
- Department of Surgical Oncology The University of Tokyo 7-3-1 Hongo, Bunkyo-ku Tokyo, 113-8655 Japan
| | - T Toshiaki
- Department of Surgical Oncology The University of Tokyo 7-3-1 Hongo, Bunkyo-ku Tokyo, 113-8655 Japan
| | - K Kawai
- Department of Surgical Oncology The University of Tokyo 7-3-1 Hongo, Bunkyo-ku Tokyo, 113-8655 Japan
| | - H Nozawa
- Department of Surgical Oncology The University of Tokyo 7-3-1 Hongo, Bunkyo-ku Tokyo, 113-8655 Japan
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Surveillance Colonoscopy for Ulcerative Colitis-Associated Colorectal Cancer Offers Better Overall Survival in Real-World Surgically Resected Cases. Am J Gastroenterol 2019; 114:483-489. [PMID: 30747769 DOI: 10.14309/ajg.0000000000000117] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To determine the effectiveness of surveillance colonoscopy (SC) and optimize its use by assessing real-world surgically resected cases of ulcerative colitis (UC)-associated colorectal cancer (CRC) and dysplasia. METHODS Clinicopathological data of 406 (238 CRC and 168 dysplasia) patients who underwent surgical resection in 10 UC specialized institutions were retrospectively reviewed. The overall survival (OS) rates were compared between the SC and non-SC groups. The incidence of and risk factors for early-onset CRC (<8 years after UC onset) were identified. The distribution of CRC lesions was also assessed. RESULTS Cancer stages were significantly more advanced in the non-SC group than in the SC group (P < 0.001). The patients in the SC group showed significantly better OS than those in the non-SC group (5-year OS: 89% vs 70%; log-rank test: P = 0.001). Seventeen percent of patients developed CRC within 8 years after UC onset. The age at UC onset was a risk factor and a good predictor of early-onset CRC (<8 years) (P < 0.01; AUC: 0.85). The most common sites of CRC were the rectum (51%) and sigmoid colon (20%). Multiple CRC was identified in 16% of patients. CONCLUSIONS Surveillance colonoscopy was effective and improved the OS in patients with UC. We recommend that patients with late-onset UC (>40 years) undergo SCs earlier because of the high incidence of CRC within 8 years of UC onset. Moreover, the rectum and sigmoid colon should be more thoroughly examined.
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