Crohn's disease of the pouch: diagnosis and management

Risks Factors Associated with the Development of Crohn's Disease After Ileal Pouch-Anal Anastomosis for Ulcerative Colitis: A Systematic Review and Meta-Analysis

BACKGROUND

Following ileal pouch-anal anastomosis [IPAA] for ulcerative colitis [UC], up to 16% of patients develop Crohn's disease of the pouch [CDP], which is a major cause of pouch failure. This systematic review and meta-analysis aimed to identify preoperative characteristics and risk factors for CDP development following IPAA.

METHODS

A literature search of the MEDLINE, EMBASE, EMCare and CINAHL databases was performed for studies that reported data on predictive characteristics and outcomes of CDP development in patients who underwent IPAA for UC between January 1990 and August 2022. Meta-analysis was performed using random-effect models and between-study heterogeneity was assessed.

RESULTS

Seven studies with 1274 patients were included: 767 patients with a normal pouch and 507 patients with CDP. Age at UC diagnosis (weighted mean difference [WMD] -2.85; 95% confidence interval [CI] -4.39 to -1.31; p = 0.0003; I2 54%) and age at pouch surgery [WMD -3.17; 95% CI -5.27 to -1.07; p = 0.003; I2 20%) were significantly lower in patients who developed CDP compared to a normal pouch. Family history of IBD was significantly associated with CDP (odds ratio [OR] 2.43; 95% CI 1.41-4.19; p = 0.001; I2 31%], along with a history of smoking [OR 1.80; 95% CI 1.35-2.39; p < 0.0001; I2 0%]. Other factors such as sex and primary sclerosing cholangitis were found not to increase the risk of CDP.

CONCLUSIONS

Age at UC diagnosis and pouch surgery, family history of IBD and previous smoking have been identified as potential risk factors for CDP post-IPAA. This has important implications towards preoperative counselling, planning surgical management and evaluating prognosis.

Diagnosis and Classification of Inflammatory Bowel Disease Strictures

Intestinal strictures are a common complication in inflammatory bowel disease (IBD). Symptoms due to intestinal strictures range from mild bloating and/or abdominal discomfort to complete bowel obstruction. Careful selection of available medical, endoscopic, or surgical therapies is critical for optimizing patient outcomes and is dependent on the effective characterization of the stricture. This article will focus on the diagnosis and classification of IBD strictures.

Therapeutic Endoscopy in Postoperative Pouch Complications

Ileal pouch-anal anastomosis (IPAA) or "J"-pouch as it is commonly referred to, is the treatment of choice in patients with medically refractory ulcerative colitis. IPAA can have infectious, inflammatory, and mechanical complications. Currently, there are no Food and Drug Administration-approved medical therapies for these complications. Surgery that may be eventually required can have significant morbidities due to the complexity of IPAA. Endoscopy is fast emerging as a leading modality of treatment for some of these pouch complications. Endoscopy in adjunct with medical treatment can help manage the majority of pouch-related disorders and improve the outcome.

#MondayNightIBD: Management of Chronic #Pouchitis

We present a #MondayNightIBD case of chronic pouchitis and discuss key diagnostic and therapeutic challenges commonly encountered in clinical practice. We make reference not only to the limited published literature but also to the informed opinions of the #MondayNightIBD discussion participants, identifying gaps where management guidelines and research are needed. A #MondayNightIBD Algorithm for Pouchitis Management is proposed.

Hemorrhoidectomy and Excision of Skin Tags in IBD: Harbinger of Doom or Simply a Disease Running Its Course?

BACKGROUND

Controversy in performing hemorrhoidectomy and anal skin tag excision in patients with IBD stems from dated reports of nonhealing wounds resulting in proctectomy.

OBJECTIVE

This study aimed to determine the safety of interventional management of hemorrhoids or anal skin tags in patients with Crohn's disease or ulcerative colitis.

DESIGN

This study is a retrospective review of patient records from 2000 to 2017.

SETTING

The patient records were retrieved from a multistate health system.

PATIENTS

Adult patients with IBD undergoing interventional management of hemorrhoids or skin tags were included.

MAIN OUTCOME MEASURE

The primary outcome measured was the long-term requirement of proctectomy.

RESULTS

Ninety-seven patients (n = 49 Crohn's disease, 48 ulcerative colitis) underwent interventional management of hemorrhoids or anal skin tags (n =35 rubber band ligation, 27 anal skin tag excision, 21 hemorrhoidectomy, 14 excision/incision of thrombosed hemorrhoid). Thirty-day complications were observed in 5 patients (n = 4 urinary retention, 1 perianal abscess). Five patients with Crohn's disease eventually required proctectomy at a median of 7 years after skin tag excision (range, 6 months to 10 years), but none were secondary to impaired wound healing. Two patients with ulcerative colitis who had previously undergone IPAA were subsequently diagnosed with Crohn's disease of the pouch after skin tag excision. No other long-term complications were seen in patients with ulcerative colitis.

LIMITATIONS

The study's retrospective design does not allow identification of patients with IBD who underwent only medical management of their hemorrhoids. There is also selection bias in which patients were selected for interventional management of their disease.

CONCLUSIONS

The requirement for proctectomy after hemorrhoidectomy/skin tag excision appears to be secondary to the natural disease course of perianal Crohn's disease rather than perianal intervention. Selective hemorrhoidectomy and skin tag excision in patients with well-controlled luminal disease should be considered. See Video Abstract at http://links.lww.com/DCR/B55. HEMORROIDECTOMÍA ASOCIADA A LA EXCISIÓN DE PLICOMAS EN CASOS DE ENFERMEDAD INFLAMATORIA INTESTINAL: ¿ANUNCIO DE FATALIDAD O SIMPLEMENTE EVOLUCIÓN NATURAL DE LA ENFERMEDAD?: Está controvertida la realización de una hemorroidectomía asociada a la excisión de plicomas ano-cutáneos en pacientes con enfermedad inflamatoria intestinal, así lo han demostrado informes detallados sobre la no cicatrisación de las heridas conllevando a una proctectomía.Determinar los margenes de seguridad en casos de tratamiento instrumental de hemorroides asociadas a la excisión de plicomas ano-cutáneos en pacientes portadores de colitis ulcerosa o enfermedad de Crohn.Revisión retrospectiva de historias clinicas de pacientes entre 2000 y 2017.Servicio Multiestatal de Salud.Adultos con enfermedad inflamatoria intestinal sometidos a tratamiento instrumental de hemorroides asociado a la excisión de plicomas ano-cutáneos.Requisitos a largo plazo para una proctectomía.Noventa y siete pacientes (49 con enfermedad de Crohn, 48 con colitis ulcerosa) se sometieron a un tratamiento instrumental de hemorroides asociada a la excisión de plicomas ano-cutáneos (35 ligadura con bandas elásticas, 27 excisión de plicomas ano-cutáneos, 21 hemorroidectomías, 14 excisiones / incisiones de hemorroides trombosadas) Se observaron complicaciones a los 30 días en cinco pacientes (4 con retención urinaria, 1 absceso perianal). Cinco pacientes con enfermedad de Crohn requirieron proctectomía en una media de 7 años después de la excisión de los plicomas ano-cutáneos (rango, 6 meses a 10 años), pero ninguno fue secundario a la mala cicatrización de la herida. Dos pacientes con colitis ulcerosa que previamente se habían sometido a una anastomosis colo-anal protegia por ilestomía fueron diagnosticados posteriormente con enfermedad de Crohn localizada en la ostomía después de la excisión de plicomas ano-cutáneos. No se observaron complicaciones a largo plazo en pacientes con colitis ulcerosa.El diseño retrospectivo del estudio no permite la identificación de pacientes con enfermedad inflamatoria intestinal que se sometieron únicamente al tratamiento médico de las hemorroides. También existe un sesgo de selección de pacientes escogidos para tratamiento instrumental de la enfermedad hemorroidaria.El requisito de proctectomía después de la hemorroidectomía / excisión de plicomas anocutáneos parece ser secundario al curso de la enfermedad natural de la enfermedad de Crohn perianal en el sitio de la intervención perianal. Se debe considerar la hemorroidectomía selectiva y la excisión de plicomas ano-cutáneos solo en pacientes con enfermedad endoluminal controlada. Vea el video del resumen en http://links.lww.com/DCR/B55.

Long term outcomes of initial infliximab therapy for inflammatory pouch pathology: a multi-Centre retrospective study

BACKGROUND

Restorative proctocolectomy with ileal pouch-anal anastomosis is considered the procedure of choice in patients with ulcerative colitis refractory to medical therapy. Subsequent inflammation of the pouch is a common complication and in some cases, pouchitis fails to respond to antibiotics, the mainstay of treatment. In such cases, corticosteroids, immunomodulatory or biologic treatments are options. However, our understanding of the efficacy of anti-tumour necrosis factor medications in both chronic pouchitis and Crohn's-like inflammation is based on studies that include relatively small numbers of patients.

METHODS

This was an observational, retrospective, multi-centre study to assess the long-term effectiveness and safety of infliximab (IFX) for inflammatory disorders related to the ileoanal pouch. The primary outcome was the development of IFX failure defined by early failure to IFX or secondary loss of response to IFX.

RESULTS

Thirty-four patients met the inclusion criteria; 18/34 (53%) who were initiated on IFX for inflammatory disorders of the pouch had IFX failure, 3/34 (8%) had early failure and 15/34 (44%) had secondary loss of response with a median follow-up of 280 days (range 3-47 months). In total, 24/34 (71%) avoided an ileostomy by switching to other medical therapies at a median follow-up of 366 days (1-130 months).

CONCLUSIONS

Initial IFX therapy for pouch inflammatory conditions is associated with IFX failure in just over half of all patients. Despite a high failure rate, an ileostomy can be avoided in almost three-quarters of patients at four years by using other medical therapies.

Vedolizumab in the treatment of Crohn's disease of the pouch

Background

Our recent study showed the efficacy and safety of vedolizumab in the treatment of chronic antibiotic-refractory pouchitis. However, there are no published studies on its efficacy and safety in Crohn’s disease (CD) of the pouch. The aim of this study was to assess the efficacy and safety of vedolizumab in those patients.

Methods

This case series included all eligible patients with CD of the pouch from our prospectively maintained, IRB-approved Pouchitis Registry from 2015 to 2017. Disease activity in pouch patients can be monitored using the modified Pouchitis Disease Activity Index (mPDAI). mPDAI is the 18-point pouchitis disease activity index consisting of three principal component scores: symptom (range, 0–6 points), endoscopy, (range 0–6 points), and histology (range, 2–6 points). Pre- and post- treatment (minimum 6 months) pouchoscopy and clinical visits were used to calculate mPDAI.

Results

A total of 12 patients were included in this study, who had restorative proctocolectomy with ileal pouch anal anastomosis for medically refractory ulcerative colitis (UC). The mean age at the time of pre-colectomy diagnosis of UC was 25.0 ± 11.5 years. The mean current age was 41.0 ± 12.1 years, nine (75.0%) were female, three (25.0%) had smoked and eight (66.7%) had used anti-tumor necrosis factor agents prior to vedolizumab use. The mean duration of vedolizumab use was 1.0 ± 6.4 years. There was a significant reduction in mPDAI symptom subscores after vedolizumab therapy (3.50 ± 1.93 vs 5.08 ± 0.79, P = 0.015). The pre- and post-treatment mean endoscopy subscores were 1.25 ± 1.36 and 0.91 ± 1.50 in the afferent limb (P = 0.583); 2.58 ± 1.68 and 2.27 ± 2.05 (P = 0.701) in the pouch body; and 2.67 ± 1.93 and 2.09 ± 2.12 (P = 0.511) in the cuff, respectively. None of the patients experienced side effects throughout the vedolizumab therapy.

Conclusion

The findings of our study suggests that vedolizumab appears to be effective and safe in reducing the symptoms in patients with CD of the pouch.

Neoterminal Ileal Polyposis and Ulceration after Restorative Proctocolectomy with a Current Review of the Literature

After ileal pouch anal anastomosis, one of the frequently encountered complications is polyposis of the pouch. We describe a case of proximal neoterminal ileal polyposis associated with deep ulceration suggestive of Crohn's disease and review the available literature. A 36-year-old male presented with resistant pouchitis 11 years after surgery for ulcerative colitis. With all-negative initial workup, pouchoscopy showed multiple deep ulcers in the proximal ileum with some polyps. Biopsy of polyps showed inflammatory polyps with negative immunohistological staining for IgG pouchitis. With no treatable etiology for pouchitis and the presence of inflammatory polyps, there are no guidelines for surveillance of this condition. Definitive diagnosis is challenging and there is no consensus or recommended guidelines on the management.

Management of Pouchitis and Other Common Complications of the Pouch

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) has become the preferred surgical treatment for refractory or complicated ulcerative colitis (UC) and familial adenomatous polyposis (FAP). Pouchitis is the most common complication of this procedure and can occur in about 50% of patients. Treatment of pouchitis depends on the phenotype of disease. Pouchitis can be classified as acute, chronic/refractory, or secondary pouchitis, which includes pouchitis occurring due to Crohn's disease (CD). CD of the pouch is becoming an increasingly recognized problem, and management is challenging. This article reviews the literature and offers treatment recommendations regarding management of pouchitis and CD of the pouch.

A Systematic Review: The Management and Outcomes of Ileal Pouch Strictures

BACKGROUND

Restorative proctocolectomy with ileal pouch-anal anastomosis removes the diseased tissue in ulcerative colitis but also allows gastrointestinal continuity and stoma-free living. Pouch strictures are a complication with a reported incidence of 5-38%. The three areas where pouch strictures occur are in the pouch inlet, mid-pouch and pouch-anal anastomosis.

AIM

To undertake a systematic review of the literature and to identify management strategies available for pouch-anal, mid-pouch and pre-pouch ileal strictures and their outcomes.

METHODS

A computer-assisted search of the online bibliographic databases MEDLINE and EMBASE limited to 1966 to February 2016 was performed. Randomized controlled trials, cohort studies, observational studies and case reports were considered. Those where data could not be extracted were excluded.

RESULTS

Twenty-two articles were considered eligible. Pouch-anal strictures have been initially managed using predominately dilators which include bougie and Hegar dilators with various surgical procedures advocated when initial dilatation fails. Mid-pouch strictures are relatively unstudied with both medical, endoscopic and surgical management reported as successful. Pouch inlet strictures can be safely managed using a combined medical and endoscopic approach.

CONCLUSION

The limited evidence available suggests that pouch-anal strictures are best treated in a stepwise fashion with initial treatment to include digital or instrumental dilatation followed by surgical revision or resection. Management of mid-pouch strictures requires a combination of medical, endoscopic and surgical management. Pouch inlet strictures are best managed using a combined medical and endoscopic approach. Future studies should compare different treatment modalities on separate stricture locations to enable an evidenced-based treatment algorithm.

Patchy colitis, and young age at diagnosis and at the time of surgery predict subsequent development of Crohn's disease after ileal pouch-anal anastomosis surgery for ulcerative colitis

BACKGROUND AND AIM

A proportion of patients having total proctocolectomy and ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) are later diagnosed with Crohn's disease (CD). The aim of this study was to identify preoperative and perioperative predictors for the subsequent development of CD in patients who had IPAA for presumed UC.

METHODS

A retrospective case-control study of patients undergoing IPAA surgery for presumed UC was undertaken. Cases were patients who had a revised diagnosis of CD after surgery. Preoperative and perioperative variables were examined and analyzed.

RESULTS

Fifteen cases were compared with 39 controls. Patients aged ≤25 years at initial UC diagnosis were more likely to develop CD compared to those aged >25 years (odds ratio, OR [95% confidence interval, CI]: 7.1 [1.6-31.3]; P = 0.01). Patients aged ≤30 years at the time of colectomy had an increased risk of subsequent development of CD compared to those aged >30 years (OR [95% CI]: 4.5 [1.3-16.0]; P = 0.02). Cases were more likely to have patchy colitis on their colectomy specimen (OR [95% CI]: 6.7 [1.1-41.8]; P = 0.04). There was no significant difference between groups regarding transmural inflammation, ileitis, or fissuring ulcers on colectomy specimens, or preoperative C-reactive protein (CRP), albumin, family history, and smoking status.

CONCLUSION

Predictors of the development of CD in the pouch include young age at diagnosis and at the time of surgery, and patchy colitis in the resected colon.

Pouchitis Associated With Pelvic Radiation for Prostate Cancer

Radiation therapy is a viable option in managing potentially life-threatening malignancies including prostate cancer. It is known that pelvic radiation can result in injury of the distal large bowel with the development of radiation proctitis. Despite reports from retrospective studies, there is a lack of direct endoscopic and histologic evidence of external pelvic radiation injury to the ileal pouch-anal anastomosis. We present a case of a 68-year-old male with pouchitis resulting from pelvic radiation for prostate cancer.

Risk factors for Crohn’s disease of the neo-small intestine in ulcerative colitis patients with total proctocolectomy and primary or secondary ileostomies

BACKGROUND

De novo Crohn’s disease (CD) of the neo-small intestine in ulcerative colitis (UC) patients after total proctocolectomy (TPC) is a new disease entity, which may persist even after a secondary diverting permanent ileostomy for pouch failure. We sought to compare outcomes of primary ileostomy (PI, i.e., stoma created after colectomy without trying of ileal pouch) and secondary ileostomy (SI, i.e., stoma created after pouch failure) and to evaluate factors associated with the development of CD of the neo-small intestine proximal to ileostomy.

METHODS

A total of 123 eligible patients were identified from our Pouch Center Registry (PI group, n = 57 and SI group, n = 66). Demographics, clinical features and outcomes (CD of theneo-small intestine, non-CD related strictures, requirement of CD-related medications use, ileostomy-associated hospitalization, ileostomy failure with stoma revision/relocation, and shortgut syndrome) were compared. Step-wise logistic regression models were performed.

RESULTS

The median follow-up for the whole cohort was 5.0 (2.0–12.0) years. Younger age at diagnosis and surgery, family history of IBD, toxic megacolon/fulminant colitis, pre-diversion severe diarrhea, prediversion anti-TNF biological therapy, arthralgia/arthropathy and staged surgery were more common in the SI group (p < 0.05). In multivariate analysis, the presence of SI [odds ratio (OR), 8.23; 95% confidence interval (CI), 2.43–27.85], family history of IBD (OR, 9.14; 95% CI, 3.13–26.69), and pre-diversion of weight loss (OR, 3.72; 95% CI, 1.23–11.21) were contributing factors for developing CD of the neo-small intestine.

CONCLUSIONS

CD of the neo-small intestine in stoma patients was associated with the presence of SI, family history of IBD, and pre-diversion poor nutrition status. Patients with secondary ileostomy due to pouch failure should be carefully monitored. Aggressive medical, endoscopic or surgical therapy may be needed in patients at risk, before permanent diversion.

Is pyloric gland metaplasia in ileal pouch biopsies a marker for Crohn's disease?

BACKGROUND

Approximately 5-10 % of ulcerative colitis (UC) patients who undergo ileal pouch-anal anastomosis (IPAA) will develop postoperative complications such as refractory pouchitis or a change in diagnosis to Crohn's disease (CD). Serological markers and histologic aspects of the pouch such as pyloric gland metaplasia (PGM) have been associated with a risk for these complications.

METHODS

Twenty-eight IPAA patients with either CD of the pouch or chronic pouchitis (cases) and 36 IPAA controls who experienced a normal postoperative course were originally consented. Of these 64 subjects, 22 cases and 17 controls had histopathologic and serologic data available and were subsequently enrolled. Demographic and clinical data were entered into a database, blood analyzed for serological markers (Prometheus Labs, San Diego, CA) and biopsies of the pouch and the afferent limb reviewed by two GI pathologists.

RESULTS

Of the cases, 55 % (12/22) had evidence of PGM in their pouch and/or small bowel biopsies, as compared to 12 % (2/17) of the controls (p = 0.006). Of 13 subjects with CD, 77 % (10/13) were found to have PGM versus subjects with chronic pouchitis in which 22 % (2/9) were found to have PGM (p = 0.03). There was a trend of ASCA positivity (both IgG and IgA, p = 0.20) and of higher ASCA titer levels (p = 0.07) with postoperative complications.

CONCLUSION

This study suggests that the presence of ileal pouch PGM is associated with postoperative complications and favors a diagnosis of CD over UC with chronic pouchitis.

Evaluation of upper and lower gastrointestinal histology in patients with ileal pouches

BACKGROUND

Inflammatory complications of ileal pouch-anal anastomosis (IPAA), including pouchitis and Crohn's disease (CD) of the pouch, are common in patients with restorative proctocolectomy for ulcerative colitis. It is not clear whether these inflammatory conditions can affect upper GI tract. The aim of the study was to evaluate correlation between duodenal and pouch histology in patients with healthy and diseased pouches.

METHODS

All IPAA patients who had esophagogastroduodenoscopy with biopsy after colectomy (N = 96) were included. H&E slides of gastric, duodenal, neo-terminal ileum, and pouch body biopsies were blindly re-reviewed by an expert GI pathologist for acute and chronic inflammation. Demographic and clinical variables and pouch outcome were analyzed.

RESULTS

There was a significant correlation between acute inflammation in the duodenum as measured by neutrophil infiltration score and the presence of chronic pouchitis (kappa coefficient = 0.21, P < 0.05). Intraepithelial lymphocytosis of the duodenum, though uncommon, only occurred in patients with irritable pouch syndrome, chronic pouchitis, or CD of the pouch. Crypt distortion of duodenal epithelium was only seen in patients with inflammatory or structural diseases of the pouch, including acute (18.2%) and chronic (5%) pouchitis, CD of the pouch (14.3%), and surgical complications of the pouch (14.4%).

CONCLUSION

Histologic evaluation of duodenal biopsy may provide additional information in patients with ileal pouches, as patients with normal histology of the pouch may have an abnormal duodenal histology.