1
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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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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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3
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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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4
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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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5
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Jillawar N, Bandla V, Galam P, Vajja R, Nirhale D. Study of late complications of restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis operated at a tertiary care center and factors affecting to that. Ann Afr Med 2023; 22:497-500. [PMID: 38358151 PMCID: PMC10775946 DOI: 10.4103/aam.aam_177_22] [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] [Received: 12/18/2022] [Revised: 05/01/2023] [Accepted: 05/03/2023] [Indexed: 02/16/2024] Open
Abstract
Background and Objective Restorative proctocolectomy with ileal pouch-anal anastomosis (RPC-IPAA) is usually preferred surgical treatment for ulcerative colitis (UC). Although treated primarily medically, some refractory and complicated cases of UC may require surgical intervention. It eliminates chronic UC and the risk of colonic cancer. This research aims to study the risk factors associated with the development of postoperative complications. Methodology For this cohort study, we included all the patients who underwent RPC-IPAA in the Department of Gastroenterology, Sheth Vadilal Sarabhai General Hospital, Ahmedabad, over 6 years. Data of the patients were obtained retrospectively from the medical records. We collected the data and analyzed using appropriate statistical tests to look for preoperative patient variables associated with late complications. Late complications were defined as those developed after 1 month. Results Out of 32 patients, 19 were male and 13 were female, with an average age of 32.3 years at the time of operation. Thirteen patients developed complications such as pouchitis (n = 6), incisional hernia (n = 3), bowel obstruction (n = 2), pouch leakage (n = 1), and erectile dysfunction (n = 1). We found serum albumin <3 mg/dl and pancolitis associated with more postoperative late complications with P = 0.007 and 0.04, respectively, which is statistically significant. Conclusion This study demonstrates that low preoperative albumin level and pancolitis are risk factors for late complications of IPAA. Preoperative nutritional support, especially albumin, could reduce late complications.
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Affiliation(s)
- Nikhil Jillawar
- Department of General Surgery, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
| | - Vijetha Bandla
- Department of General Surgery, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
| | - Pushkar Galam
- Department of General Surgery, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
| | - Ramya Vajja
- Department of General Surgery, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
| | - Dakshayani Nirhale
- Department of General Surgery, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
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6
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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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7
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Calvino-Suarez C, Ferreiro-Iglesias R, Baston Rey I, Barreiro-de Acosta M. Managing ulcerative colitis after surgery. Front Med (Lausanne) 2023; 9:1081940. [PMID: 36687422 PMCID: PMC9846502 DOI: 10.3389/fmed.2022.1081940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 12/05/2022] [Indexed: 01/05/2023] Open
Abstract
Management of ulcerative colitis after surgery suggested by guidelines (total proctocolectomy with ileal-pouch anal anastomosis) is a big challenge for physicians because patients who believed that their disease had been cured started experiencing very uncomfortable symptoms repeatedly. A high number of patients develop episodes of pouchitis, which is a non-specific inflammation of the pouch whose etiology is unknown. Antibiotics are the elective treatment for acute pouchitis, but regarding chronic pouchitis, this condition is very complicated to treat due to the absence of well-designed specific studies for this group of patients. Antibiotics, budesonide, and biological therapies are some of the recommended drugs for these patients, but despite their use, some need a permanent ileostomy.
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8
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Abstract
BACKGROUND Restorative proctocolectomy with IPAA is the procedure of choice when colectomy is needed for medically refractory ulcerative colitis. Pouchitis is one of the most common complications among patients who have undergone IPAA and represents a spectrum of disease varying in both phenotype and clinical course. OBJECTIVE This study aimed to assist clinicians and surgeons in the treatment of both acute and chronic pouchitis, including newer therapies and future directions. DIAGNOSIS AND MANAGEMENT Diagnosis is made by endoscopy of the pouch with biopsy because other conditions may produce similar symptoms such as increased stool frequency, abdominal cramps, and urgency. Pouchitis is classified by duration (acute versus chronic), disease pattern (infrequent, relapsing, and continuous), and response to antibiotics (responsive, dependent, and refractory). The Pouchitis Disease Activity Index may be used to measure disease activity. The management of pouchitis is guided by the disease phenotype. Acute episodes are treated with an initial 2-week course of antibiotics (typically ciprofloxacin or metronidazole), although patients with relapsing or chronic pouchitis may require long-term antibiotic treatment or the cycling of different antibiotics. Certain probiotics may also be used for maintenance therapy in those with chronic symptoms. For patients with chronic antibiotic refractory pouchitis, oral budesonide, immunosuppressive agents (azathioprine), or biologic therapy (infliximab, adalimumab, vedolizumab, and ustekinumab) may be required for both induction and maintenance with close monitoring for potential side effects. In rare cases, diverting ileostomy or pouch excision may be required. CONCLUSION Pouchitis represents a spectrum of disease phenotypes, ranging from acute antibiotic responsive pouchitis to chronic antibiotic refractory pouchitis. The management of pouchitis is primarily directed by the disease phenotype.
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9
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Bar N, Avraham Y, Dubinsky V, Cohen NA, Weiss GA, Banon L, Tulchinsky H, Maharshak N, Gophna U, Dotan I. Long-term Antibiotic Treatment in Pouchitis-Patterns of Use and Safety. Inflamm Bowel Dis 2022; 28:1027-1033. [PMID: 34536075 DOI: 10.1093/ibd/izab209] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Pouchitis, often developing after colectomy and ileal pouch-anal anastomosis for ulcerative colitis, is highly responsive to antibiotics. Ciprofloxacin and/or metronidazole are commonly used, often for prolonged periods. We report patterns of antibiotic use, adverse events, and resistant infections in patients with pouchitis with long-term antibiotic treatment. METHODS In a cohort of patients following pouch surgery, a retrospective nested case-control analysis was performed between 2010 and 2017. Ultra-long-term use, defined as the top 10% of users, was compared with the remaining users. Patterns of antibiotic use, adverse events, and resistant infections were analyzed. RESULTS The cohort included 205 patients with UC, of whom 167 (81.5%) used antibiotics for pouchitis, predominantly ciprofloxacin. The long-term antibiotic use rate was 18% and 42% at 5 and 20 years postsurgery, respectively. Mean antibiotic use of at least 1, 3, and 6 months/year was noted in 54 (26.3%), 31 (15.1%), and 14 (6.8%) patients, respectively. Twenty-two (13.2%) and 4 (2.4%) patients reported mild and severe (transient) adverse events, respectively, without mortalities, tendinopathies or arrhythmias. Adverse event rates for ciprofloxacin and metronidazole were 1per 10,000 and 6 per 10,000 use-days, respectively. Longer, but not ultra-long antibiotic use, was associated with mild adverse events. There was no association between antibiotic use and resistant infections. Thirteen (6.3%) patients required ileostomy procedures-more commonly in the ultra-long-term antibiotic users. CONCLUSIONS Patients with pouchitis may require prolonged antibiotic treatment, reflecting clinical benefit and favorable safety profile. Few adverse events and resistant infections were observed with long-term antibiotics use. However, resistant microbial strains selection, which are potentially transmittable, warrants consideration of different therapeutic alternatives.
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Affiliation(s)
- Nir Bar
- Department of Gastroenterology and Hepatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yoav Avraham
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Vadim Dubinsky
- School of Molecular Cell Biology and Biotechnology, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Nathaniel A Cohen
- Department of Gastroenterology and Hepatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Guy A Weiss
- Celiac Disease Program, Vatche and Tamar Manoukian Division of Digestive Diseases, University of California Los Angeles, Los Angeles, California, USA
| | - Lian Banon
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Internal Medicine H, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Hagit Tulchinsky
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Colorectal Unit, Department of Surgery, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Nitsan Maharshak
- Department of Gastroenterology and Hepatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Gophna
- School of Molecular Cell Biology and Biotechnology, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Iris Dotan
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel
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10
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Endoscopic Phenotype of the J Pouch in Patients With Inflammatory Bowel Disease: A New Classification for Pouch Outcomes. Clin Gastroenterol Hepatol 2022; 20:293-302.e9. [PMID: 33549868 PMCID: PMC8339185 DOI: 10.1016/j.cgh.2021.02.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 02/02/2021] [Accepted: 02/02/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Pouchitis is a common complication of ileal pouch-anal anastomosis (IPAA) in patients with ulcerative colitis who have undergone colectomy. Pouchitis has been considered a single entity despite a broad array of clinical and endoscopic patterns. We developed a novel classification system based on the pattern of inflammation observed in pouches and evaluated the contributing factors and prognosis of each phenotype. METHODS We identified 426 patients (384 with ulcerative colitis) treated with proctocolectomy and IPAA who subsequently underwent pouchoscopies at the University of Chicago between June 1997 and December 2019. We retrospectively reviewed 1359 pouchoscopies and classified them into 7 main pouch 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 after ileostomy takedown. Logistic regression analysis was used to assess factors contributing to each phenotype. Pouch survival was estimated by the log-rank test and the Cox proportional hazards model. RESULTS Significant contributing factors for afferent limb involvement were a body mass index of 25 or higher and hand-sewn anastomosis, for inlet involvement the significant contributing factor was male sex; for diffuse inflammation the significant contributing factors were extensive colitis and preoperative use of anti-tumor necrosis factor drugs, for cuffitis the significant contributing factors were stapled anastomosis and preoperative Clostridioides difficile infection. Inlet stenosis, diffuse inflammation, and cuffitis significantly increased the risk of pouch excision. Diffuse inflammation was associated independently with pouch excision (hazard ratio, 2.69; 95% CI, 1.34-5.41; P = .005). CONCLUSIONS We describe 7 unique IPAA phenotypes with different contributing factors and outcomes, and propose a new classification system for pouch management and future interventional studies.
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11
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Frese JP, Gröne J, Lauscher JC, Kreis ME, Weixler B, Beyer K, Seifarth C. Inflammation of the rectal remnant endangers the outcome of ileal pouch-anal anastomosis: a case-control study. Int J Colorectal Dis 2022; 37:1647-1655. [PMID: 35713723 PMCID: PMC9262783 DOI: 10.1007/s00384-022-04195-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/01/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Inflammation of the rectal remnant may affect the postoperative outcome of ileal pouch-anal anastomosis (IPAA) in patients with ulcerative colitis (UC). We aimed to determine the extent of inflammation in the anastomotic area during IPAA and to investigate the impact of proctitis on postoperative complications and long-term outcomes. METHODS Three hundred thirty-four UC patients with primary IPAA were included in this retrospective case-control study. The histopathologic degree of inflammation in the anastomotic area was graded into three stages of no proctitis ("NOP"), mild to medium proctitis ("MIP"), and severe proctitis ("SEP"). Preoperative risk factors, 30-day morbidity, and follow-up data were assessed. Kaplan-Meier analysis was performed in the event of pouch failure. RESULTS The prevalence of proctitis was high (MIP 40.4%, and SEP 42.8%). During follow-up, the incidence of complications was highest among SEP: resulting in re-intervention (n = 40; 28.2%, p = 0.017), pouchitis (n = 36; 25.2%, p < 0.01), and pouch failure (n = 32; 22.4%, p = 0.032). The time interval to pouch failure was 5.0 (4.0-6.9) years among NOP, and 1.2 (0.5-2.3) years in SEP (p = 0.036). ASA 3, pouchitis, and pouch fistula were independent risk factors for pouch failure. CONCLUSION Proctitis at the time of IPAA is common. A high degree of inflammation is associated with poor long-term outcomes, an effect that declines over time. In addition, a higher degree of proctitis leads to earlier pouch failure.
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Affiliation(s)
- Jan P Frese
- Department of General, Visceral, and Vascular Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany.
| | - Jörn Gröne
- Department of General, Visceral, and Vascular Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of General and Visceral Surgery, St. Joseph Krankenhaus, Berlin, Germany
| | - Johannes C Lauscher
- Department of General, Visceral, and Vascular Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Martin E Kreis
- Department of General, Visceral, and Vascular Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Benjamin Weixler
- Department of General, Visceral, and Vascular Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Katharina Beyer
- Department of General, Visceral, and Vascular Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Claudia Seifarth
- Department of General, Visceral, and Vascular Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany
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12
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de Krijger M, Wildenberg ME, Mookhoek A, Verheul S, de Jonge WJ, Ponsioen CY. Expression of MAdCAM-1 and Gut-homing T Cells in Inflamed Pouch Mucosa. J Crohns Colitis 2021; 15:1491-1499. [PMID: 33675360 DOI: 10.1093/ecco-jcc/jjab041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIMS Pouchitis is a common complication following formation of an ileal pouch-anal anastomosis [IPAA] after proctocolectomy for ulcerative colitis [UC]. Gut-specific lymphocyte trafficking mechanisms have been identified as players in the pathogenesis of UC. In the present study, we aimed to characterise the presence of lymphocyte subsets expressing gut-homing molecules in pouches and peripheral blood of UC patients with and without pouchitis. METHODS Biopsy samples and peripheral blood were collected from 29 patients with an IPAA [seven with active inflammation, 22 without inflammation]. Expression of adhesion molecule MAdCAM-1 was assessed using immunohistochemistry, and flow cytometry was used to characterise expression of integrin α4β7, C-chemokine receptor 9 [CCR9], and CD103 on T cell subsets. RESULTS MAdCAM-1 expression was significantly increased in case of active inflammation in the pouch. T cells expressing integrin α4β7 were abundant in the pouch mucosa, but the frequency of integrin α4β7-expressing T cells was decreased on CD4+ lymphocytes during inflammation. Co-expression of gut-homing markers CCR9 and α4β7 was more pronounced in biopsies compared with peripheral blood, but was not enhanced upon active inflammation. CONCLUSIONS Gut-homing T cells are abundant in pouch mucosa, but the classic hypothesis that the chronic inflammatory state is maintained by an accumulation of α4β7-expressing effector T cells is not supported by our data.
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Affiliation(s)
- Manon de Krijger
- Tytgat Institute for Liver and Intestinal Research, Amsterdam UMC, University of Amsterdam, Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands.,Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Manon E Wildenberg
- Tytgat Institute for Liver and Intestinal Research, Amsterdam UMC, University of Amsterdam, Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands.,Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Aart Mookhoek
- Department of Pathology, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Sascha Verheul
- Tytgat Institute for Liver and Intestinal Research, Amsterdam UMC, University of Amsterdam, Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Wouter J de Jonge
- Tytgat Institute for Liver and Intestinal Research, Amsterdam UMC, University of Amsterdam, Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands.,Department of Surgery, University of Bonn, Bonn, Germany
| | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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13
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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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14
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Barnes EL, Holubar SD, Herfarth HH. Systematic Review and Meta-analysis of Outcomes After Ileal Pouch-anal Anastomosis in Primary Sclerosing Cholangitis and Ulcerative Colitis. J Crohns Colitis 2021; 15:1272-1278. [PMID: 33544128 DOI: 10.1093/ecco-jcc/jjab025] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The optimal restorative surgical management of patients with concomitant diagnoses of primary sclerosing cholangitis and ulcerative colitis [PSC-UC] who require colectomy is controversial, given that patients may have an increased risk for pouchitis after ileal pouch-anal anastomosis [IPAA]. We aimed to compare rates of pouchitis and pouch failure among patients with and without PSC by performing a systematic review and meta-analysis. METHODS A systematic search performed through August 18, 2020, identified 12 studies that compared the rates of pouchitis [n = 11] and/or pouch failure [n = 6] among patients with PSC-UC and UC alone. We then performed a meta-analysis using random effects modelling to estimate the odds of developing any episodes of pouchitis or pouch failure. RESULTS A total of 4108 patients underwent an ileal pouch-anal anastomosis after proctocolectomy for UC. Of these, 3799 [92%] were performed for UC alone and 309 [8%] were performed for PSC-UC. In a meta-analysis of 11 studies, patients with PSC-UC compared with UC alone were significantly more likely to develop any pouchitis (63% vs 30%, odds ratio [OR] 4.21, 95% confidence interval [CI] 2.86-6.18), chronic pouchitis [47% vs 15%, OR 6.37, 95% CI 3.41-11.9], and pouch failure [10% vs 7%, OR 1.85, 95% CI 1.08-3.17]. CONCLUSIONS Patients with PSC-UC were more likely to experience pouchitis and pouch failure than patients with UC alone. The risks of inflammatory complications after IPAA must be weighed against the potential complications with other surgical procedures, and future studies comparing outcomes among these procedures may inform decision making in this population.
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Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, 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
| | - Stefan D Holubar
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, 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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15
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Outtier A, Ferrante M. Chronic Antibiotic-Refractory Pouchitis: Management Challenges. Clin Exp Gastroenterol 2021; 14:277-290. [PMID: 34163205 PMCID: PMC8213947 DOI: 10.2147/ceg.s219556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 05/06/2021] [Indexed: 12/12/2022] Open
Abstract
Background Pouchitis is the most common long-term complication in patients with ulcerative colitis who underwent restorative proctocolectomy with ileal pouch-anal anastomosis. The incidence of acute pouchitis is 20% after 1 year and up to 40% after 5 years. Chronic antibiotic-refractory pouchitis develops in approximately 10% of patients. Aim To present a narrative review of published literature regarding the management of chronic antibiotic-refractory pouchitis. Methods Current relevant literature was summarized and critically evaluated. Results Clear definitions should be used to classify pouchitis into acute versus chronic, and responsive versus dependent versus refractory to antibiotics. Before treatment is started for chronic antibiotic-refractory pouchitis, secondary causes should be ruled out. There is a need for validated scoring systems to measure the severity of the disease. Because chronic antibiotic-refractory pouchitis is a rare condition, only small studies with often a poor study design have been performed. Treatments with antibiotics, aminosalicylates, steroids, immunomodulators and biologics have shown to be effective and safe for chronic antibiotic-refractory pouchitis. Also, treatments with AST-120, hyperbaric oxygen therapy, tacrolimus enemas, and granulocyte and monocyte apheresis suggested some efficacy. Conclusion The available data are weak but suggest that therapeutic options for chronic antibiotic-refractory pouchitis are similar to the treatment strategies for inflammatory bowel diseases. However, randomized controlled trials are warranted to further identify the best treatment options in this patient population.
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Affiliation(s)
- An Outtier
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Marc Ferrante
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
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16
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Gonzalez A, Gupta K, Rahman AU, Wadhwa V, Shen B. Risk Factors Associated With Hospital Readmission and Costs for Pouchitis. CROHN'S & COLITIS 360 2021; 3:otab006. [PMID: 36778942 PMCID: PMC9802153 DOI: 10.1093/crocol/otab006] [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: 08/03/2020] [Indexed: 11/14/2022] Open
Abstract
Background Pouchitis is the most common long-term complication in patients with restorative proctocolectomy and ileal pouch-anal anastomosis. This study aimed to identify readmission rates for pouchitis and risk factors associated with readmissions in an extensive national database. Methods We performed a retrospective analysis using the National Readmission Database to determine if patient demographics and clinical characteristics were predictors of hospital readmission within 30 days for adult patients (age >18 years) discharged with a principal diagnosis of pouchitis (ICD-9 code-569.71) from January 2013 to December 2013. Both univariable and multivariable analyses were performed to assess factors associated with 30-day readmission. Results A total of 1538 patients with pouchitis who were discharged alive were identified. 10.2% [95% confidence interval: 7.6, 12.7] of these were readmitted within 30 days of discharge. The average days to readmission were 18.6 ± 1.01. Multivariable analysis of risk factors associated with readmission showed older age as a protective factor for readmission [odds ratio (OR) = 0.88 (0.81, 0.96); P < 0.005]. Sex and the presence of permanent ileostomy were not associated with readmission in patients with pouchitis. The length of stay during readmissions was associated with postoperative wound infection [OR = 7.7 (94.0, 11.30); P < 0.001], ileus [OR = 4.5 (1.6, 7.4); P < 0.002], permanent ileostomy [OR = 3.7 (1.7, 5.7); P < 0.001], and long-term use of nonsteroidal anti-inflammatory drugs [OR = 3.2 (1.06, 5.3); P < 0.003]. Conclusions Readmissions in pouchitis patients are frequent. Long-term use of nonsteroidal anti-inflammatory drugs, ileus, permanent ileostomy, and postoperative wound infection is associated with increased length of stay in readmissions.
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Affiliation(s)
- Adalberto Gonzalez
- Department of Gastroenterology and Hepatology, Cleveland Clinic Florida, Weston, Florida, USA
| | - Kapil Gupta
- Department of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Asad Ur Rahman
- Department of Gastroenterology and Hepatology, Cleveland Clinic Florida, Weston, Florida, USA
| | - Vaibhav Wadhwa
- Center for Advanced Endoscopy, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, USA,Address correspondence to: Vaibhav Wadhwa, MD, Center for Advanced Endoscopy, Beth Israel Deaconess Medical Center/Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA ()
| | - Bo Shen
- Center for Inflammatory Bowel Disease, Columbia University Irving Medical Center-NewYork Presbyterian Hospital, New York, New York, USA
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17
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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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18
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Wasmann KA, van der Does de Willebois EM, Koens L, Duijvestein M, Bemelman WA, Buskens CJ. The Impact of Rectal Stump Inflammation After Subtotal Colectomy on Pouch Outcomes in Ulcerative Colitis Patients. J Crohns Colitis 2020; 15:jjaa157. [PMID: 32901798 PMCID: PMC7904055 DOI: 10.1093/ecco-jcc/jjaa157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Proctitis after subtotal colectomy with ileostomy for ulcerative colitis [UC] is common, but its impact on short- and long-term outcome after pouch surgery is unknown. The aim of this study was to determine the incidence of proctitis after subtotal colectomy and its impact on postoperative morbidity and pouchitis. METHODS The distal margin of the rectal stump of all consecutive patients undergoing completion proctectomy and pouch procedure for UC, between 1999 and 2017, was revised and scored for active inflammation according to the validated Geboes score, and for diversion proctitis. Pathological findings were correlated to complications after pouch surgery and pouchitis [including therapy-refractory] using multivariate analyses. RESULTS Out of 204 included patients, 167 [82%] had active inflammation in the rectal stump and diversion colitis was found in 170 specimens [83%]. Overall postoperative complications and anastomotic leakage rates were not significantly different between patients with and without active inflammation in the rectal stump [34.7% vs 32.4%, p = 0.79, and 10.2% vs 5.4%, p = 0.54, respectively]. Active inflammation of the rectal stump was significantly associated with the development of pouchitis [54.3% vs 25.5%, plog = 0.02], as well as with therapy refractory pouchitis [14% vs 0%, plog = 0.05]. Following multivariate analysis, active inflammation was an independent predictor for the development of pouchitis. Diversion proctitis showed no association with these outcome parameters. CONCLUSIONS Active inflammation in the rectal stump after subtotal colectomy occurs in 80% of UC patients and is a predictor for the development of pouchitis and therapy-refractory pouchitis.
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Affiliation(s)
- Karin A Wasmann
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Lianne Koens
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marjolijn Duijvestein
- Departmen of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Willem A Bemelman
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Christianne J Buskens
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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19
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Outcomes Following Pouch Formation in Paediatric Ulcerative Colitis: A Study From the Porto Group of ESPGHAN. J Pediatr Gastroenterol Nutr 2020; 71:346-353. [PMID: 32541197 DOI: 10.1097/mpg.0000000000002805] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Contemporary pediatric data on pouch outcomes are sparse, especially in the era of laparoscopic surgeries. We aimed to assess outcomes and predictors in children with ulcerative colitis/inflammatory bowel disease (IBD)-unclassified who underwent colectomy and ileal pouch-anal anastomosis. METHODS This was a multicenter retrospective cohort study from 17 IBD centers affiliated with the pediatric IBD Porto group of ESPGHAN. An electronic REDcap system was used to collate baseline characteristics, demographic, clinical, management and surgical data, short- and long-term outcomes, and to identify potential predictors of pouch outcome. RESULTS Of the 129 patients included, 86 (67%) developed pouchitis during follow-up of median 40 months (interquartile range 26-72), of whom 33 (26%) with chronic pouchitis. Patients operated on by surgeons performing <10 pouch surgeries/year had a higher rate of chronic pouchitis (11/27 [41%] vs 8/54 [15%], P = 0.013) on both univariable and multivariable analyses and also associated with time to pouchitis (P = 0.018) and chronic pouchitis (P = 0.020). At last follow-up, overall pouch performance was rated good/excellent in 86 (74%) patients. Time from colectomy to pouch formation was not associated with pouch outcomes. Despite higher rate of nonsevere surgical complications among children undergoing colectomy at <10 years of age (7/16 [44%] vs 10/92 [11%], P = 0.003), functional outcome and pouchitis rate did not differ. CONCLUSIONS Pouchitis rate in children with ulcerative colitis/IBD unclassified is high. Surgeon experience is the major modifiable risk factor for pouch outcome. Our analyses suggest that pouch surgery can also be performed successfully in young children.
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20
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Kitajima T, Okita Y, Kawamura M, Kondo S, Toiyama Y, Uchida K, Kusunoki M. The relationship between preoperative T helper cytokines in the ileal mucosa and the pathogenesis of pouchitis. BMC Gastroenterol 2020; 20:277. [PMID: 32811425 PMCID: PMC7437011 DOI: 10.1186/s12876-020-01421-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 08/11/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Although the etiology of pouchitis remains unknown, inflammatory cytokines are significantly associated with the pathogenesis of pouchitis. The cytokine responses that characterize inflammatory bowel diseases (IBD) are key pathogenic components of the disease. Although cytokine profiles in the colonic mucosa have been investigated in experimental colitis models or IBD patients, cytokine profiles in the ileal mucosa at colectomy have been rarely assessed. AIM To assess the relationship between pouchitis and T helper (Th) cytokines in the ileal mucosa collected at the time of colectomy and pouch construction. METHODS This retrospective study involved 68 consecutive patients from January 2004 to May 2011 who underwent ileal pouch-anal anastomosis for ulcerative colitis. Samples were obtained from the terminal ileum of resected specimens at time of total colectomy or subtotal colectomy. mRNA expression levels of Th cytokines (IFN-γ, IL-23A, IL-5, IL-13 and IL-17A) were determined. RESULTS Forty of 68 patients (58.8%) developed pouchitis. There was no association between IL-23A expression levels and incidence of pouchitis (p = 0.301). Patients with elevated IFN-γ had a significantly higher incidence of pouchitis compared with low IFN-γ patients (p = 0.043). Univariate analysis demonstrated a total dose of prednisolone > 7000 mg administered before colectomy (p = 0.04) and high IFN-γ expression (p = 0.02) were significant risk factors for pouchitis onset. In multivariate analysis, elevated IFN-γ messenger(m)RNA levels were significantly associated with pouchitis onset (p = 0.03). CONCLUSION IFN-γ expression in the normal ileal mucosa at the time of colectomy may be an important factor in the pathophysiology of pouchitis.
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Affiliation(s)
- Takahito Kitajima
- Department of Gastrointestinal and Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Yoshiki Okita
- Department of Gastrointestinal and Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Mikio Kawamura
- Department of Gastrointestinal and Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Satoru Kondo
- Department of Gastrointestinal and Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yuji Toiyama
- Department of Gastrointestinal and Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Keiichi Uchida
- Department of Gastrointestinal and Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Masato Kusunoki
- Department of Gastrointestinal and Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
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21
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Barnes EL, Raffals L, Long MD, Syal G, Kayal M, Ananthakrishnan A, Cohen B, Pekow J, Deepak P, Colombel JF, Herfarth HH, Sandler RS. Disease and Treatment Patterns Among Patients With Pouch-related Conditions in a Cohort of Large Tertiary Care Inflammatory Bowel Disease Centers in the United States. CROHN'S & COLITIS 360 2020; 2:otaa039. [PMID: 32744536 PMCID: PMC7380550 DOI: 10.1093/crocol/otaa039] [Citation(s) in RCA: 5] [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: 03/11/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Gaps exist in our understanding of the clinical course of pouch-related disorders. METHODS We evaluated baseline disease activity and longitudinal treatment patterns among patients with inflammatory conditions of the pouch. RESULTS Among 468 patients with an ileal pouch-anal anastomosis (IPAA), 94 (20%) had acute pouchitis, 96 (21%) had chronic pouchitis, and 192 (41%) had Crohn disease of the pouch. Following an IPAA, 38% of patients were treated with a biologic and 11% underwent inflammatory bowel disease- or bowel-related surgery. CONCLUSIONS Treatment patterns after IPAA indicate that pouch-related disorders have a significant impact on individual patients and the healthcare system.
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Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA.,Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, North Carolina, USA.,Multidisciplinary Inflammatory Bowel Diseases Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Laura Raffals
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Millie D Long
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA.,Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, North Carolina, USA.,Multidisciplinary Inflammatory Bowel Diseases Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Gaurav Syal
- Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Maia Kayal
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ashwin Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Benjamin Cohen
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Joel Pekow
- Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago, Chicago, Illinois, USA
| | - Parakkal Deepak
- Washington University Inflammatory Bowel Diseases Center, St. Louis, Missouri, USA
| | - Jean-Frederic Colombel
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA.,Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, North Carolina, USA.,Multidisciplinary Inflammatory Bowel Diseases Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Robert S Sandler
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA.,Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, North Carolina, USA
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22
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Kayal M, Plietz M, Rizvi A, Radcliffe M, Riggs A, Yzet C, Tixier E, Trivedi P, Ungaro RC, Khaitov S, Sylla P, Greenstein A, Frederic Colombel J, Dubinsky MC. Inflammatory Pouch Conditions Are Common After Ileal Pouch Anal Anastomosis in Ulcerative Colitis Patients. Inflamm Bowel Dis 2020; 26:1079-1086. [PMID: 31587035 PMCID: PMC7456971 DOI: 10.1093/ibd/izz227] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Total proctocolectomy (TPC) with ileal pouch anal anastomosis (IPAA) is the gold standard surgery for ulcerative colitis (UC) patients with medically refractory disease. The aim of this study was to report the rates and risk factors of inflammatory pouch conditions. METHODS This was a retrospective review of UC or IBD unspecified (IBDU) patients who underwent TPC with IPAA for refractory disease or dysplasia between 2008 and 2017. Pouchoscopy data were used to calculate rates of inflammatory pouch conditions. Factors associated with outcomes in univariable analysis were investigated in multivariable analysis. RESULTS Of the 621 patients more than 18 years of age who underwent TPC with IPAA between January 2008 and December 2017, pouchoscopy data were available for 386 patients during a median follow-up period of 4 years. Acute pouchitis occurred in 205 patients (53%), 60 of whom (30%) progressed to chronic pouchitis. Cuffitis and Crohn's disease-like condition (CDLC) of the pouch occurred in 119 (30%) patients and 46 (12%) patients, respectively. In multivariable analysis, female sex was associated with a decreased risk of acute pouchitis, and pre-operative steroid use and medically refractory disease were associated with an increased risk; IBDU was associated with chronic pouchitis; rectal cuff length ≥2 cm and medically refractory disease were associated with cuffitis; age 45-54 at colectomy was associated with CDLC. Rates of pouch failure were similar in chronic pouchitis and CDLC patients treated with biologics and those who were not. CONCLUSIONS Inflammatory pouch conditions are common. Biologic use for chronic pouchitis and CDLC does not impact the rate of pouch failure.
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Affiliation(s)
- Maia Kayal
- Department of Medicine, Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA,Address correspondence to: Maia Kayal, MD The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA. E-mail:
| | - Michael Plietz
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Anam Rizvi
- Department of Medicine, Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Marlana Radcliffe
- Department of Medicine, Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alexa Riggs
- Department of Medicine, Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Clara Yzet
- Department of Medicine, Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Emily Tixier
- Department of Medicine, Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Parth Trivedi
- Department of Medicine, Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ryan C Ungaro
- Department of Medicine, Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sergey Khaitov
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Patricia Sylla
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alexander Greenstein
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jean Frederic Colombel
- Department of Medicine, Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Marla C Dubinsky
- Department of Medicine, Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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23
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Nebbia M, Yassin NA, Spinelli A. Colorectal Cancer in Inflammatory Bowel Disease. Clin Colon Rectal Surg 2020; 33:305-317. [PMID: 32968366 DOI: 10.1055/s-0040-1713748] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Patients with inflammatory bowel disease (IBD) are at an increased risk for developing colorectal cancer (CRC). However, the incidence has declined over the past 30 years, which is probably attributed to raise awareness, successful CRC surveillance programs and improved control of mucosal inflammation through chemoprevention. The risk factors for IBD-related CRC include more severe disease (as reflected by the extent of disease and the duration of poorly controlled disease), family history of CRC, pseudo polyps, primary sclerosing cholangitis, and male sex. The molecular pathogenesis of inflammatory epithelium might play a critical role in the development of CRC. IBD-related CRC is characterized by fewer rectal tumors, more synchronous and poorly differentiated tumors compared with sporadic cancers. There is no significant difference in sex distribution, stage at presentation, or survival. Surveillance is vital for the detection and subsequently management of dysplasia. Most guidelines recommend initiation of surveillance colonoscopy at 8 to 10 years after IBD diagnosis, followed by subsequent surveillance of 1 to 2 yearly intervals. Traditionally, surveillance colonoscopies with random colonic biopsies were used. However, recent data suggest that high definition and chromoendoscopy are better methods of surveillance by improving sensitivity to previously "invisible" flat dysplastic lesions. Management of dysplasia, timing of surveillance, chemoprevention, and the surgical approaches are all areas that stimulate various discussions. The aim of this review is to provide an up-to-date focus on CRC in IBD, from laboratory to bedside.
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Affiliation(s)
- Martina Nebbia
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center IRCCS, Rozzano, Milano, Italy
| | - Nuha A Yassin
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center IRCCS, Rozzano, Milano, Italy
| | - Antonino Spinelli
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center IRCCS, Rozzano, Milano, Italy.,Deparment of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milano, Italy
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24
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25
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Dipasquale V, Mattioli G, Arrigo S, Bramuzzo M, Strisciuglio C, Faraci S, Romeo EF, Contini AC, Ventimiglia M, Zuin G, Felici E, Alvisi P, Romano C. Pouchitis in pediatric ulcerative colitis: A multicenter study on behalf of Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition. Dig Liver Dis 2019; 51:1551-1556. [PMID: 31324473 DOI: 10.1016/j.dld.2019.06.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 06/27/2019] [Accepted: 06/27/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Data on the epidemiology and risk factors for pouchitis following restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA) in pediatric patients with ulcerative colitis (UC) are scarce. AIMS To determine incidence, risk factors and clinical outcome of pouchitis following IPAA in children. METHODS This multicenter, retrospective cohort study, included all pediatric UC patients who underwent colectomy and IPAA from January 2010 to December 2016. RESULTS Eighty-five patients were enrolled. During a median post-surgical period of 24.8 (range: 1.0-72.0) months following IPAA, 38 (44.7%) patients developed pouchitis, including 6 (15.8%) who developed chronic pouchitis. Kaplan-Meier survival estimates of the cumulative probability for pouchitis were 14.6% at 1 year and 27.3% and 51.5% at 2 and 5 years, respectively. Multiple Cox regression model showed that older age at colectomy (hazard ratio, HR: 0.89, p = 0.008) was a protective factor, whereas chronic active colitis as indication for surgery (HR: 4.45, p < 0.001), and a 3-stage IPAA (HR: 2.86, p = 0.028) increased the risk for pouchitis. CONCLUSIONS Long-term risk for pouchitis is significantly high in pediatric-onset UC after IPAA. Younger age at colectomy, chronic active colitis as indication for surgery and 3-stage IPAA may increase the risk for pouchitis.
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Affiliation(s)
- Valeria Dipasquale
- Pediatric Gastroenterology and Cystic Fibrosis Unit, University of Messina, Messina, Italy
| | - Girolamo Mattioli
- Pediatric Surgery Unit, Giannina Research Institute and Children Hospital, Genova, Italy
| | - Serena Arrigo
- Pediatric Surgery Unit, Giannina Research Institute and Children Hospital, Genova, Italy
| | - Matteo Bramuzzo
- Pediatric Department, Gastroenterology, Digestive Endoscopy and Nutrition Unit, Institute for Maternal and Child Health, IRCCS "Burlo Garofalo", Trieste, Italy
| | - Caterina Strisciuglio
- Department of Woman, Child and General and Specialistic Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Simona Faraci
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | | | - Anna Chiara Contini
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Marco Ventimiglia
- Inflammatory Bowel Disease Unit, "Villa Sofia-Cervello" Hospital, Palermo, Italy
| | - Giovanna Zuin
- Pediatric Department, University of Milano Bicocca, FMBBM, San Gerardo Hospital, Monza, Italy
| | - Enrico Felici
- Unit of Pediatrics and "Umberto Bosio" Center for Digestive Diseases, The Children Hospital, AON SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Patrizia Alvisi
- Pediatric Gastroenterology Unit, Maggiore Hospital, Bologna, Italy
| | - Claudio Romano
- Pediatric Gastroenterology and Cystic Fibrosis Unit, University of Messina, Messina, Italy.
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26
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Weaver KN, Kochar B, Hansen JJ, Isaacs KL, Jain A, Sheikh SZ, Fichera A, Chaumont N, Sadiq T, Koruda M, Long MD, Herfarth HH, Barnes EL. Chronic Antibiotic Dependent Pouchitis Is Associated With Older Age at the Time of Ileal Pouch Anal Anastomosis (J-pouch) Surgery. CROHN'S & COLITIS 360 2019; 1:otz029. [PMID: 31667470 PMCID: PMC6798791 DOI: 10.1093/crocol/otz029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Risk factors for the development of chronic antibiotic dependent pouchitis (CADP) are not well understood. METHODS Using multivariable logistic regression, we compared clinical factors between 194 patients with acute antibiotic responsive pouchitis or CADP. RESULTS Individuals with CADP were significantly older (40.9 vs 30.8 years, P < 0.001) and demonstrated a longer disease duration before IPAA (10.3 vs 7.0 years, P = 0.004). Age ≥55 years at the time of IPAA was significantly associated with CADP (adjusted odds ratio = 4.35, 95% confidence interval = 1.01-18.7). CONCLUSIONS Although older age should not represent a barrier to IPAA, further studies evaluating etiologies of this association are warranted.
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Affiliation(s)
- Kimberly N Weaver
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Bharati Kochar
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jonathan J Hansen
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Kim L Isaacs
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Animesh Jain
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Shehzad Z Sheikh
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Alessandro Fichera
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Division of Gastrointestinal Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Nicole Chaumont
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Division of Gastrointestinal Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Tim Sadiq
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Division of Gastrointestinal Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Mark Koruda
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Division of Gastrointestinal Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Millie D Long
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC
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27
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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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28
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Bhattacharya A, Shen B, Regueiro M. Endoscopy in Postoperative Patients with Crohn's Disease or Ulcerative Colitis. Does It Translate to Better Outcomes? Gastrointest Endosc Clin N Am 2019; 29:487-514. [PMID: 31078249 DOI: 10.1016/j.giec.2019.02.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This article discusses the use of endoscopy in patients with Crohn disease and ulcerative colitis in the postoperative setting. Endoscopy is the most sensitive and validated tool available in the diagnosis of recurrence of Crohn disease in the postoperative setting. It is also the most effective diagnostic modality available for evaluating complications of pouch anatomy in patients with ulcerative colitis. In addition to diagnosis, management postoperatively can be determined through endoscopy.
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Affiliation(s)
- Abhik Bhattacharya
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic Foundation, 9500 Euclid Avenue, A30, Cleveland, OH 44195, USA
| | - Bo Shen
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic Foundation, 9500 Euclid Avenue, A30, Cleveland, OH 44195, USA
| | - Miguel Regueiro
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic Foundation, 9500 Euclid Avenue, A30, Cleveland, OH 44195, USA.
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29
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Nishida A, Imaeda H, Inatomi O, Bamba S, Sugimoto M, Andoh A. The efficacy of fecal microbiota transplantation for patients with chronic pouchitis: A case series. Clin Case Rep 2019; 7:782-788. [PMID: 30997086 PMCID: PMC6452488 DOI: 10.1002/ccr3.2096] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 02/21/2019] [Indexed: 01/07/2023] Open
Abstract
Pouchitis is one of the most common complications that develop after restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis. Single fecal microbiota transplantation (FMT) by colonoscopy was performed safely on three patients with pouchitis. However, the efficacy of FMT on pouchitis was limited.
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Affiliation(s)
- Atsushi Nishida
- Department of MedicineShiga University of Medical ScienceOtsuJapan
| | - Hirotsugu Imaeda
- Department of MedicineShiga University of Medical ScienceOtsuJapan
| | - Osamu Inatomi
- Department of MedicineShiga University of Medical ScienceOtsuJapan
| | - Shigeki Bamba
- Division of Clinical NutritionShiga University of Medical ScienceOtsuJapan
| | | | - Akira Andoh
- Department of MedicineShiga University of Medical ScienceOtsuJapan
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30
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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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31
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Ardalan ZS, Sparrow MP. A Personalized Approach to Managing Patients With an Ileal Pouch-Anal Anastomosis. Front Med (Lausanne) 2019; 6:337. [PMID: 32064264 PMCID: PMC7000529 DOI: 10.3389/fmed.2019.00337] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 12/23/2019] [Indexed: 12/11/2022] Open
Abstract
Quality of life after ileal pouch-anal anastomosis (IPAA) surgery is generally good. However, patients can be troubled by pouch-related symptoms and pouch disorders that can be inflammatory, mechanical/surgical, and functional. Management of patients with IPAA begins with measures to maintain a healthy pouch such as optimizing pouch function, providing tailored advice on a healthy diet and lifestyle, screening for and addressing metabolic complications of IPAA, pouch surveillance, and risk stratification for risk of pouchitis and pouch failure. Pouchitis is the most common inflammatory disorder. Primary pouchitis is a spectrum currently classified into three progressive phases-an antibiotic-responsive, an antibiotic-dependent, and an antibiotic-refractory phase. It is predominately microbially mediated in acute antibiotic-responsive pouchitis and predominately immune mediated in chronic antibiotic-refractory pouchitis (CARP). Secondary prophylaxis is recommended for recurrent antibiotic-responsive and for antibiotic-dependent pouchitis. Secondary causes of antibiotic-refractory pouchitis should be ruled out before a diagnosis of CARP is made. CARP is best classified as primary sclerosing cholangitis associated, immunoglobulin G4-associated, and autoimmune. Primary sclerosing cholangitis-associated CARP can be treated with budesonide or oral vancomycin. Early recognition of immunoglobulin G4-associated pouchitis minimizes ineffective antibiotic use. Autoimmune CARP can be managed in a manner similar to UC. The current place of immunosuppressives in the treatment algorithm depends on availability and early access to biological agents. Vedolizumab and ustekinumab are the preferred first- and second-line biologics for autoimmune CARP owing to their efficacy, better side effect profile, and low immunogenicity and need for concomitant immunomodulatory therapy. Antitumor necrosis factor should be reserved for autoimmune CARP failing the above and for CD of the pouch. There are no guidelines for the surveillance of pouches for dysplasia. Incidence varies based on a patient's risk. Since incidence is low, a risk-stratified approach is recommended.
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32
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Noh GT, Han J, Cho MS, Hur H, Min BS, Lee KY, Kim NK. Factors affecting pouch-related outcomes after restorative proctocolectomy. PLoS One 2017; 12:e0186596. [PMID: 29049337 PMCID: PMC5648184 DOI: 10.1371/journal.pone.0186596] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 10/04/2017] [Indexed: 11/18/2022] Open
Abstract
Purposes Restorative proctocolectomy (RPC) with ileal pouch anal anastomosis (IPAA) is the procedure of choice for patients with familial adenomatous polyposis (FAP) and ulcerative colitis (UC) despite morbidities that can lead to pouch failure. We aimed to identify factors associated with pouch-related morbidities. Methods A retrospective analysis of patients who underwent RPC with IPAA was performed. To investigate the factors associated with pouch-related morbidities, patients' preoperative demographic and clinical factors, and intraoperative factors were included in the analysis. Results A total of 49 patients with UC, FAP, and colorectal cancer were included. Twenty patients (40.8%) experienced leakage-related, functional, and/or pouchitis-related morbidities. Patients with American Society of Anesthesiologists (ASA) grade 2 or 3 had a higher risk of functional morbidity than those with grade 1. Intraoperative blood loss exceeding 300.0 mL was associated with an increased risk of pouchitis-related morbidity. Conclusions Our study demonstrated associations of higher ASA grade and increased intraoperative blood loss with poor functional outcomes and pouchitis, respectively.
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Affiliation(s)
- Gyoung Tae Noh
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Jeonghee Han
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Min Soo Cho
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyuk Hur
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Byung Soh Min
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Kang Young Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Nam Kyu Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
- * E-mail:
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33
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Szeto W, Farraye FA. Incidence, prevalence, and risk factors for pouchitis. SEMINARS IN COLON AND RECTAL SURGERY 2017. [DOI: 10.1053/j.scrs.2017.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Yanai H, Ben-Shachar S, Mlynarsky L, Godny L, Leshno M, Tulchinsky H, Dotan I. The outcome of ulcerative colitis patients undergoing pouch surgery is determined by pre-surgical factors. Aliment Pharmacol Ther 2017; 46:508-515. [PMID: 28664992 DOI: 10.1111/apt.14205] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 04/09/2017] [Accepted: 06/04/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pouch surgery, a common intervention for ulcerative colitis (UC) complications, is often associated with the development of pouchitis. AIM To identify predictors of pouch outcome in a cohort of patients with UC. METHODS We conducted a retrospective unmatched case-cohort study in a tertiary IBD referral centre. Adult patients with UC were classified into the worst phenotype throughout follow-up: normal pouch, a form of chronic pouchitis (either chronic pouchitis or Crohn's like disease of pouch [CLDP]), or episodic recurrent acute pouchitis (RAP). Risk factors for pouchitis (chronic forms) were detected using statistical models. RESULTS Two hundred and fifty-three pouch patients were followed up for 13.1±7.3 years. Only 71 patients (28.1%) maintained a favourable outcome of a sustained normal pouch. These patients were older at UC diagnosis (27.8±12.5 vs 23.0±11.4 years), had longer UC duration until surgery (13.4±9.5 vs 8.2±7.9 years), and had higher rates of referral to surgery due to nonrefractory (dysplasia/neoplasia) complications (42.3% vs 16.2%) compared with pouchitis patients. Median survival for sustained normal pouch was 10.8 years (95% CI 8.9-12.7 years), and it was longer in the nonrefractory group (20.3 vs 9.4 years for the refractory group, HR=2.37, 95% CI 1.25-3.52, P=.004). CONCLUSIONS Most patients with UC undergoing pouch surgery will develop pouchitis. Patients operated for nonrefractory indications have a more favourable outcome. These results may contribute to pre- and post-surgical decision-making. The findings imply that the processes determining UC severity may be similar to that causing pouchitis.
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Affiliation(s)
- H Yanai
- IBD Center, Department of Gastroenterology and Liver Diseases, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - S Ben-Shachar
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Genetics Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - L Mlynarsky
- IBD Center, Department of Gastroenterology and Liver Diseases, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - L Godny
- IBD Center, Department of Gastroenterology and Liver Diseases, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - M Leshno
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Coller School of Management, Tel Aviv University, Tel Aviv, Israel
| | - H Tulchinsky
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Colorectal Unit, Division of Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - I Dotan
- IBD Center, Department of Gastroenterology and Liver Diseases, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Predictors of pouchitis after ileal pouch-anal anastomosis in pediatric-onset ulcerative colitis. Eur J Gastroenterol Hepatol 2017; 29:1079-1085. [PMID: 28542114 DOI: 10.1097/meg.0000000000000914] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Few studies have reported on the incidence and risk factors for pouchitis following colectomy and ileal pouch-anal anastomosis (IPAA) in patients with pediatric-onset ulcerative colitis (UC). We aimed to determine clinical predictors for the development of pouchitis following IPAA in this population. PATIENTS AND METHODS We performed a retrospective chart review of all pediatric UC cases that were diagnosed at the Schneider Children's Medical Center of Israel between 1981 and 2013 and who underwent colectomy during disease course. Potential predictors for pouchitis and chronic pouchitis including various demographic, clinical, endoscopic, and histological variables at diagnosis and at the time of surgery were assessed. RESULTS Of 188 patients with pediatric-onset UC, 33 (18%) underwent colectomy and IPAA surgery. During a median postsurgical follow-up of 7.6 (range: 1-21.5) years following IPAA, 20/33 (60%) patients developed pouchitis including 11/33 (33%) patients who developed chronic pouchitis. Kaplan-Meier survival estimates of the cumulative probability for pouchitis were 9% at 1 year and 36 and 55% at 5 and 10 years, respectively. Multivariate Cox models showed that older age at colectomy (hazard ratio: 0.86, P=0.024) was a protective factor, whereas preoperative vitamin-D deficiency (≤20 ng/ml) (hazard ratio: 4.4, P=0.021) increased the risk for pouchitis. Age at diagnosis, sex, disease extent, and preoperative therapeutic regimens did not affect the risk of pouchitis. CONCLUSION Long-term risk for pouchitis is significantly high in pediatric-onset UC after IPAA. Vitamin-D deficiency and younger age at colectomy may increase the risk for pouchitis.
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Cheifetz AS, Gianotti R, Luber R, Gibson PR. Complementary and Alternative Medicines Used by Patients With Inflammatory Bowel Diseases. Gastroenterology 2017; 152:415-429.e15. [PMID: 27743873 DOI: 10.1053/j.gastro.2016.10.004] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 10/03/2016] [Accepted: 10/06/2016] [Indexed: 02/06/2023]
Abstract
Patients and physicians often have many questions regarding the role of complementary and alternative medicines (CAMs), or nonallopathic therapies, for inflammatory bowel diseases (IBDs). CAMs of various forms are used by more than half of patients with IBD during some point in their disease course. We summarize the available evidence for the most commonly used and discussed CAMs. We discuss evidence for the effects of herbs (such as cannabis and curcumin), probiotics, acupuncture, exercise, and mind-body therapy. There have been few controlled studies of these therapies, which have been limited by their small sample sizes; most studies have been uncontrolled. In addition, there has been a lack of quality control for herbal preparations. It has been a challenge to design rigorous, randomized, placebo-controlled trials, in part owing to problems of adequate blinding for psychological interventions, acupuncture, and exercise. These barriers have limited the acceptance of CAMs by physicians. However, such therapies might be used to supplement conventional therapies and help ease patient symptoms. We conclude that physicians should understand the nature of and evidence for CAMs for IBD so that rational advice can be offered to patients who inquire about their use. CAMs have the potential to aid in the treatment of IBD, but further research is needed to validate these approaches.
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Affiliation(s)
- Adam S Cheifetz
- Department of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Robert Gianotti
- Department of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Raphael Luber
- Department of Gastroenterology, Alfred Hospital and Monash University, Melbourne, Australia
| | - Peter R Gibson
- Department of Gastroenterology, Alfred Hospital and Monash University, Melbourne, Australia.
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Schieffer KM, Williams ED, Yochum GS, Koltun WA. Review article: the pathogenesis of pouchitis. Aliment Pharmacol Ther 2016; 44:817-35. [PMID: 27554912 PMCID: PMC5785099 DOI: 10.1111/apt.13780] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 12/03/2015] [Accepted: 08/04/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND A total proctocolectomy followed by ileal pouch-anal anastomosis is a potentially curative surgery for ulcerative colitis or familial adenomatous polyposis. About 5-35% of patients with ulcerative colitis and 0-11% of patients with familial adenomatous polyposis develop subsequent inflammation of the ileal pouch termed pouchitis. AIM To provide a comprehensive analysis of the research studying the possible pathogenesis of pouchitis. The goals were to identify promising areas of investigation, to help focus clinicians, researchers and patients on how to better understand and then potentially manage ileal pouchitis, and to provide avenues for future research investigations. METHODS This review examined manuscripts from 1981 to 2015 that discussed and/or proposed hypotheses with supportive evidence for the potential underlying pathogenic mechanism for pouchitis. RESULTS The pathogenesis of pouchitis is not definitively understood, but various hypotheses have been proposed, including (i) recurrence of ulcerative colitis, (ii) dysbiosis of the ileal pouch microbiota, (iii) deprivation of nutritional short-chain fatty acids, (iv) mucosal ischaemia and oxygen-free radical injury, (v) host genetic susceptibility and (vi) immune dysregulation. However, none of these alone are able to fully explain pouchitis pathogenesis. CONCLUSIONS Pouchitis, similar to inflammatory bowel disease, is a complex disorder that is not caused by any one single factor. More likely, pouchitis occurs through a combination of both dysregulated host inflammatory mechanisms and interaction with luminal microbiota.
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Affiliation(s)
- Kathleen M. Schieffer
- Department of Surgery, Division of Colon and Rectal Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA 17033
| | - Emmanuelle D. Williams
- Department of Medicine, Division of Gastroenterology, The Pennsylvania State University, College of Medicine, Hershey, PA, USA 17033
| | - Gregory S. Yochum
- Department of Surgery, Division of Colon and Rectal Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA 17033,Department of Biochemistry & Molecular Biology, The Pennsylvania State University, College of Medicine, Hershey, PA, USA 17033
| | - Walter A. Koltun
- Department of Surgery, Division of Colon and Rectal Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA 17033
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Abstract
OBJECTIVES Predictive factors for the development of pouchitis after ileal pouch-anal anastomosis (IPAA) in children have not been well studied. In this retrospective study, the incidence and risk factors that predict pouchitis in children with IPAA will be identified. METHODS The records of patients who underwent IPAA surgery at Children's Hospital of Wisconsin between January 2000 and December 2013 were reviewed retrospectively. Patients with clinical, endoscopic, and histological findings consistent with pouchitis were identified. The groups of patients with and without pouchitis or chronic pouchitis were compared to determine which demographic, pathological, or disease characteristics may serve as predictive factors for the development of pouchitis or chronic pouchitis. RESULTS Out of a total of 60 patients who underwent IPAA, preoperative diagnosis was ulcerative colitis (UC) in 43 and familial adenomatous polyposis (FAP) in 17. Pouchitis was identified in 24 (56%) patients with UC and 2 (12%) patients with FAP. Subgroup analysis of patients with UC revealed that chronic pouchitis occurred in 15 (35%) patients. The median follow-up period from construction of the IPAA was 35 months (range 4.59-104.26 months). The study analysis revealed that a higher Pediatric Ulcerative Colitis Activity Index score at the time of diagnosis was a significant predictive factor for both pouchitis (P = 0.001) and chronic pouchitis (P = 0.02). CONCLUSIONS Patients with UC and a higher PUCAI score at the time of diagnosis have a higher risk for developing pouchitis.
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Wu XR, Ashburn J, Remzi FH, Li Y, Fass H, Shen B. Male Gender Is Associated with a High Risk for Chronic Antibiotic-Refractory Pouchitis and Ileal Pouch Anastomotic Sinus. J Gastrointest Surg 2016; 20:631-9. [PMID: 26446071 DOI: 10.1007/s11605-015-2976-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2015] [Accepted: 09/30/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND AIMS The impact of gender on the development of chronic ileal pouch disorders following ileal pouch-anal anastomosis (IPAA) has not been evaluated. This study was aimed to assess the association between gender and pouch outcomes. METHODS Comparisons of long-term pouch outcomes between male and female patients were performed using both univariate and multivariate analyses. RESULTS Of all patients enrolled (n = 1564), 881(56.3 %) were males. Male patients were older at the time of inflammatory bowel disease (IBD) diagnosis and pouch construction. The frequencies of neoplasia as the indication for colectomy and significant comorbidity were higher in males, while fewer male patients had IBD-related extra-intestinal manifestations or concurrent autoimmune disorders. There was no significant difference between the genders in other clinicopathological characteristics. More male patients (n = 144, 16.3 %) developed chronic antibiotic-refractory pouchitis (CARP) than females (n = 73, 10.7 %) (P = 0.001). Seventy-four males (8.4 %) had ileal pouch anastomotic sinus versus 22 female patients (3.2 %) (P < 0.001). Multivariate logistic regression analyses confirmed the association between male gender and CARP (odds ratio (OR) 1.64, 95 % confidence interval (CI) 1.21-2.24, P = 0.002) and male gender and ileal pouch anastomotic sinus (OR 2.85, 95 % CI 1.48-5.47, P = 0.002). After a median follow-up of 9.0 (interquartile range 4.0-14.0) years, pouch failed in a total of 126 patients (8.1 %). No significant difference was identified between male and female patients in pouch failure (P = 0.61). CONCLUSIONS Among the pouch patients referred to our subspecialty Pouch Center, male patients were found to have an increased risk for the CARP and ileal pouch sinus. The pathogenic mechanisms of the association warrant further study.
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Affiliation(s)
- Xian-Rui Wu
- Department of Colorectal Surgery, The Cleveland Clinic Foundation, Cleveland, OH, 44195, USA
| | - Jean Ashburn
- Department of Colorectal Surgery, The Cleveland Clinic Foundation, Cleveland, OH, 44195, USA
| | - Feza H Remzi
- Department of Colorectal Surgery, The Cleveland Clinic Foundation, Cleveland, OH, 44195, USA
| | - Yi Li
- Department of Colorectal Surgery, The Cleveland Clinic Foundation, Cleveland, OH, 44195, USA
| | - Hagar Fass
- Department of Gastroenterology/Hepatology, The Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Bo Shen
- Department of Gastroenterology/Hepatology, The Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44195, USA.
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Serology of Patients with Ulcerative Colitis After Pouch Surgery Is More Comparable with that of Patients with Crohn's Disease. Inflamm Bowel Dis 2015. [PMID: 26197448 DOI: 10.1097/mib.0000000000000487] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND The serologic status of patients with ulcerative colitis (UC) who develop postoperative pouchitis was compared with that of patients with Crohn's disease (CD) and unoperated patients with UC. METHODS Pouch patients were stratified into normal pouch, acute/recurrent acute pouchitis, and chronic pouchitis/Crohn's-like disease of the pouch groups. Antibodies against glycans associated with CD (anti-Saccharomyces cerevisiae, anti-laminaribioside, anti-chitobioside, and anti-mannobioside carbohydrate antibodies [ASCA, ALCA, ACCA, and AMCA, respectively]) were detected and correlated with type of inflammatory bowel disease and pouch behavior. RESULTS A total of 501 patients with inflammatory bowel diseases were recruited: 250 (50%) CD, 124 (24.7%) unoperated UC, and 127 (25.3%) UC-pouch. At least 1 positive antibody was detected in 77.6% CD, 52.0% UC-pouch and 33.1% unoperated UC (P < 0.0001 for all). ACCA and AMCA prevalence in CD, UC-pouch and unoperated patients with UC were 33.2%, 24.4%, and 16.9% (P = 0.003 for all) and 35.2%, 26.8%, and 7.3%, respectively (P < 0.0001 for all). ALCA and ASCA were more prevalent in patients with CD than unoperated UC and UC-pouch patients. A longer interval since pouch surgery was associated with inflammatory pouch behavior: 12.45, 11.39, and 8.5 years for acute/recurrent acute pouchitis, chronic pouchitis/Crohn's-like disease of the pouch, and normal pouch, respectively, P = 0.01 for all. CONCLUSIONS The prevalence of the CD-associated anti-glycan antibodies ACCA and AMCA is significantly increased in UC-pouch patients, suggesting that pouch surgery may trigger differential immune responses to glycans. The finding that the serology of UC-pouch patients shares similarities with that of patients with CD supports the notion that those 2 inflammatory bowel diseases share a common pathogenic pathway.
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Reshef L, Kovacs A, Ofer A, Yahav L, Maharshak N, Keren N, Konikoff FM, Tulchinsky H, Gophna U, Dotan I. Pouch Inflammation Is Associated With a Decrease in Specific Bacterial Taxa. Gastroenterology 2015; 149:718-27. [PMID: 26026389 DOI: 10.1053/j.gastro.2015.05.041] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 05/13/2015] [Accepted: 05/20/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Pouchitis is a common long-term complication in patients with ulcerative colitis (UC) undergoing proctocolectomy with ileal pouch-anal anastomosis. Because the inflammation occurs in a previously normal small bowel, studies of this process might provide information about the development of Crohn's disease. Little is known about the intestinal microbiome of patients with pouchitis. We investigated whether specific bacterial populations correlate with the pouch disease phenotype and inflammatory activity. METHODS We performed a prospective study of patients with UC who underwent pouch surgery (N = 131) from 1981 through 2012 and were followed at Tel Aviv Medical Center. Patients were assigned to groups based on their degree and type of pouch inflammation. Patients with familial adenomatous polyposis after pouch surgery (n = 9), individuals with intact colons undergoing surveillance colonoscopy (n = 10), and patients with UC who did not undergo surgery (n = 9) served as controls. We collected demographic and disease activity data (based on the Pouchitis Disease Activity Index) and measured levels of C-reactive protein. Fecal samples were collected, levels of calprotectin were measured, and microbiota were analyzed by 16S ribosomal RNA gene amplicon pyrosequencing. RESULTS Increased proportions of the Fusobacteriaceae family correlated with increased disease activity and levels of C-reactive protein in patients with UC who underwent pouch surgery. In contrast, proportions of Faecalibacterium were reduced in patients with pouchitis vs controls; there was a negative correlation between proportion of Faecalibacterium and level of C-reactive protein. There was an association between antibiotic treatment, but not biologic or immunomodulatory therapy, with reduced proportions of 11 genera and with increased proportions of Enterococcus and Enterobacteriaceae. CONCLUSIONS Reductions in protective bacteria and increases in inflammatory bacteria are associated with pouch inflammation in patients with UC who underwent pouch surgery. The finding that antibiotics exacerbate dysbiosis indicates that these drugs might not provide long-term benefit for patients with pouchitis. Additional studies of this form of dysbiosis could provide information about the pathogenesis of Crohn's disease.
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Affiliation(s)
- Leah Reshef
- Department of Molecular Microbiology and Biotechnology, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Amir Kovacs
- Department of Molecular Microbiology and Biotechnology, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel; IBD Center, Department of Gastroenterology and Liver Diseases, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Amos Ofer
- IBD Center, Department of Gastroenterology and Liver Diseases, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Lior Yahav
- IBD Center, Department of Gastroenterology and Liver Diseases, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Nitsan Maharshak
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; IBD Center, Department of Gastroenterology and Liver Diseases, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Nirit Keren
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Gastroenterology and Hepatology, Meir Medical Center, Kfar Saba, Israel
| | - Fred M Konikoff
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Gastroenterology and Hepatology, Meir Medical Center, Kfar Saba, Israel
| | - Hagit Tulchinsky
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Colorectal Unit, Department of Surgery, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Uri Gophna
- Department of Molecular Microbiology and Biotechnology, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel.
| | - Iris Dotan
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; IBD Center, Department of Gastroenterology and Liver Diseases, Tel Aviv Medical Center, Tel Aviv, Israel.
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Araki T, Kawamura M, Tanaka K, Okita Y, Fujikawa H, Uchida K, Toiyama Y, Inoue Y, Mohri Y, Kusunoki M. FK506-Binding Protein 5 mRNA Levels in Ileal Mucosa Are Associated with Pouchitis in Patients with Ulcerative Colitis. Dig Dis Sci 2015; 60:1617-23. [PMID: 25596721 DOI: 10.1007/s10620-015-3528-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 01/07/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Although the pathogenesis of pouchitis is incompletely understood, steroid and FK506 therapy are significantly associated with pouchitis. These medical treatments are regulated by the FK506-binding protein (FKBP) 4 and FKBP5 genes. AIM This study aimed to evaluate the relationship between pouchitis and FKBP4 and FKBP5 mRNA expression in ileal mucosa at the time of colectomy. METHODS Ileal mucosa specimens were collected from 71 patients who underwent ileal pouch-anal anastomosis for ulcerative colitis. FKBP4 and FKBP5 mRNA expression was evaluated. The relationship between mRNA expression and clinicopathological factors, including developed pouchitis, was investigated. RESULTS Of these 71 patients, 25 (35.2 %) patients developed pouchitis in a mean duration of 20.2 months (range 0-68 months). FKBP4 mRNA levels in patients who received an immunomodulator were significantly higher than those in untreated patients (0.167 ± 0.060 vs 0.131 ± 0.065, p = 0.009). However, FKBP5 mRNA levels in patients who received a three-stage operation were significantly lower than those in the other patients (1.97 ± 1.15 vs 2.70 ± 1.12, p = 0.02). A total dose of prednisolone >9.4 g (HR 2.84, p = 0.02) before colectomy and FKBP5 mRNA level higher than the median (HR 4.49, p = 0.01) were identified as factors related to pouchitis. CONCLUSIONS FKBP5 mRNA levels in ileal mucosa at the time of colectomy are significantly associated with pouchitis and may be a predictive factor for developing pouchitis.
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Affiliation(s)
- Toshimitsu Araki
- Division of Reparative Medicine, Department of Gastrointestinal and Pediatric Surgery, Institute of Life Sciences, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan,
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Yanai H, Ben-Shachar S, Baram L, Elad H, Gitstein G, Brazowski E, Tulchinsky H, Pasmanik-Chor M, Dotan I. Gene expression alterations in ulcerative colitis patients after restorative proctocolectomy extend to the small bowel proximal to the pouch. Gut 2015; 64:756-64. [PMID: 24982202 DOI: 10.1136/gutjnl-2014-307387] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 06/12/2014] [Indexed: 01/18/2023]
Abstract
OBJECTIVES To evaluate molecular profiles in the small bowel (SB) mucosa proximal to the pouch in ulcerative colitis (UC) patients after pouch surgery. DESIGN Patients were prospectively recruited and stratified according to disease behaviour: normal pouch (NP), chronic pouchitis (CP), and Crohn's-like disease of the pouch (CLDP). Biopsies obtained from the pouch and the normal-appearing proximal SB (40 cm proximal to the anal verge) were compared to ileal biopsies from normal controls (NC). A histopathological score based on the degree of polymorphonuclear and mononuclear infiltrates was used to assess inflammation in the pouch and the proximal SB. Gene expression analysis was performed using microarrays, and validated by real-time PCR. Gene ontology and clustering were evaluated by bioinformatics. RESULTS Thirty-six subjects were recruited (age 18-71 years, 16 males). Histopathology scores demonstrated minimal differences in the normal-appearing proximal SB of all groups. Nonetheless, significant (fold change ≥2, corrected p [FDR] ≤ 0.05) molecular alterations in the proximal SB were detected in all groups (NP n=9; CP n=80; and CLDP n=230) compared with NC. The magnitude of DUOX2 alteration in the proximal SB was highest. An increase of 6.0, 9.8 and 21.7 folds in DUOX2 expression in NP, CP, CLDP, respectively was observed. This was followed by alterations in MMP1, SLC6A14 and PGC. Gene alterations in the proximal SB overlapped with alterations within the pouch (76% and 97% overlap in CP and CLDP, respectively). Gene ontology analysis in the proximal SB and pouch were comparable. CONCLUSIONS Significant gene expression alterations exist in an apparently unaffected proximal SB. Alterations in the pouch and the proximal SB were comparable, suggesting that inflammation may not be limited to the pouch, but that it extends to the proximal SB.
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Affiliation(s)
- Henit Yanai
- Department of Gastroenterology and Liver Diseases, IBD Center, Tel Aviv, Israel
| | | | - Liran Baram
- Department of Gastroenterology and Liver Diseases, IBD Center, Tel Aviv, Israel
| | - Hofit Elad
- Department of Gastroenterology and Liver Diseases, IBD Center, Tel Aviv, Israel
| | - Gilad Gitstein
- Department of Pathology, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Eli Brazowski
- Department of Pathology, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Hagit Tulchinsky
- Colorectal Unit, Division of Surgery, Tel Aviv Medical Center, Tel Aviv, Israel The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Metsada Pasmanik-Chor
- Bioinformatics Unit, G.S.W. Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Iris Dotan
- Department of Gastroenterology and Liver Diseases, IBD Center, Tel Aviv, Israel
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Abstract
Pouchitis is an inflammatory complication after restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA). IPAA is the surgical treatment of choice in patients with ulcerative colitis (UC) who require colectomy. Initial episodes of acute pouchitis generally respond to antibiotics but significant numbers of cases eventually become dependent on or refractory to antibiotics. Management of chronic antibiotic refractory pouchitis is challenging and can ultimately lead to pouch failure. The etiopathogenesis is unknown though recent studies have implicated bacterial dysbiosis of the pouch microbiota, NOD2 polymorphism, and Clostridium difficile infection in the development of severe pouchitis. Early identification of risk factors can help in tailoring therapy and reducing cases of chronic pouchitis.
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Affiliation(s)
- Saleem Chowdhry
- Division of Gastroenterology and Liver Disease, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH, 44106-5066, USA,
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Abstract
Proctitis accounts for a significant proportion of cases of ulcerative colitis (UC), and some patients subsequently develop more extensive disease. However, most patients continue to have limited inflammation, although the changes in the distal colon and rectum can occasionally be severe, and symptoms of increased frequency, rectal bleeding and urgency can be as disabling as they are for patients with more extensive colitis. Furthermore, although symptoms are typically well controlled with standard medications, medically refractory proctitis poses particular problems. Patients generally are not systemically unwell, and there is no added fear of cancer. Therefore, the prospect of colectomy for such limited disease is resisted by patients, physicians and surgeons alike. Unusual therapies, often delivered locally by enema or suppository, have been tested in small case series without definitive outcomes. The pathogenesis of such limited, yet intractable inflammation remains unclear, and the differential diagnosis should be carefully reviewed to ensure that local disease, whether it is infectious, vascular, or a result of injury or degeneration, is not overlooked. Ileo-anal pouch formation is the surgery of choice for about 20% of patients with UC who undergo colectomy. In the majority of cases, this surgery results in an acceptable quality of life and freedom from a stoma. However, in a sizeable minority of cases, pouch dysfunction can cause intractable problems. The causes of pouch dysfunction are varied and must all be considered carefully, particularly in refractory cases. Pouchitis is a common issue and is usually transient and easily treated. However, refractory and chronic pouchitis can be challenging. Ischaemia, injury, infection and Crohn's disease can all cause refractory pouch dysfunction. In a minority of cases, there appears to be no apparent organic pathology, and the presumptive diagnosis is that of a functional pouch disorder. Although it is much rarer, neoplastic changes in the pouch must also be considered, and the risk managed appropriately. The management of both intractable proctitis and the problematic pouch is made more challenging by the wide differential diagnosis that must be considered and by the paucity of high-quality clinical trials to support any one therapy. Key strategies to overcoming these limitations include methodical and systematic investigation and review, and a willingness to tailor therapy to the individual patient. Clinical trials of new treatments should be supported, and data from the experience with small cohorts of patients should be meticulously collected, critically analysed and widely disseminated.
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Affiliation(s)
- Alex Kent
- Translational Gastroenterology Unit, John Radcliffe Hospital and the University of Oxford, Oxford, UK
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46
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Yamamoto T. Risk factors for pouchitis after surgery for ulcerative colitis. Colorectal Dis 2013; 15:759-60. [PMID: 23570620 DOI: 10.1111/codi.12238] [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: 10/08/2012] [Accepted: 10/14/2012] [Indexed: 02/08/2023]
Affiliation(s)
- T. Yamamoto
- Inflammatory Bowel Disease Centre & Department of Surgery; Yokkaichi Social Insurance Hospital; 10-8 Hazuyamacho; Yokkaichi; Mie; 510-0016; Japan
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Singh S, Sharma PK, Loftus EV, Pardi DS. Meta-analysis: serological markers and the risk of acute and chronic pouchitis. Aliment Pharmacol Ther 2013; 37:867-75. [PMID: 23480145 DOI: 10.1111/apt.12274] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 02/09/2013] [Accepted: 02/16/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Serological markers such as anti-neutrophil cytoplasmic antibody (ANCA) and anti-Saccharomyces cerevisiae antibody (ASCA) may be associated with pouchitis after ileal pouch-anal anastomosis (IPAA). AIM To perform a systematic review with meta-analysis of studies evaluating the association of ANCA and ASCA status with risk of acute and chronic pouchitis after IPAA. METHODS We searched multiple databases (upto September 2012) for studies reporting ANCA and/or ASCA status along with risk of acute or chronic pouchitis after IPAA in adults with ulcerative colitis (UC). We abstracted odds ratio (OR) or raw data from the individual studies to calculate summary OR estimates with 95% CIs using random-effects model. RESULTS Eight studies reporting 184 cases of acute pouchitis and six studies reporting 151 cases of chronic pouchitis were included. The odds of chronic pouchitis were 76% higher in ANCA-positive patients than ANCA-negative (six studies; OR: 1.76; 95% CI: 1.19-2.61; P < 0.01). ASCA-positivity was not associated with the risk of chronic pouchitis (three studies; OR: 0.89; 95% CI: 0.49-1.59; P = 0.68). Neither ANCA (eight studies; OR: 1.54; 95% CI: 0.79-3.02; P = 0.21) nor ASCA-positivity (two studies; OR: 1.28; 95% CI: 0.25-6.54; P = 0.77) were associated with the risk of acute pouchitis. CONCLUSIONS The risk of chronic pouchitis after IPAA is higher in ANCA-positive patients, but the risk of acute pouchitis is unaffected by ANCA status. ASCA status was not associated with the risk of acute or chronic pouchitis. This information may be used to counsel UC patients regarding their risk of pouchitis after IPAA.
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Affiliation(s)
- S Singh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
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