De novo Crohn's Disease after Ileal Pouch-Anal Anastomosis for Ulcerative Colitis and Inflammatory Bowel Disease Unclassified: Long-Term Follow-Up of a Prospective Inflammatory Bowel Disease Registry

Abstract

The risk of de novo Crohn's disease (CD) after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) versus inflammatory bowel disease unclassified (IBDU) or indeterminate colitis (IC) remains debatable. Here, we present updated results after long-term follow-up of a previously studied cohort of 334 patients with UC, IBDU, or IC who underwent IPAA during a 10-year period ending 2007. Of 334 study patients, 56 per cent were male and median age was 38 years (range: 8–81). Patients were classified as UC (n = 237) or IBDU (n = 97) preoperatively and UC (n = 236) or IC (n = 98) postoperatively. After a median follow-up of 76 months (range: 3–236), 63 patients (19%) developed CD within a median of 22 months (range: 1–213) from ileostomy closure compared with the previously published 40 patients (12%) with 26-month follow-up ( P = 0.01). The development of de novo CD was similar for patients undergoing IPAA for UC (n = 40; 17%), IBDU (n = 21; 22%) or those classified as having UC (n = 42; 18%) or IC (n = 19; 19%) postoperatively; P > 0.05. Thus, patients with IBDU and IC can expect equivalent long-term outcome to patients with UC after IPAA. Pouch failure occurred in 13 (4%) study patients and was equal among all four groups.

Human alpha defensin 5 is a candidate biomarker to delineate inflammatory bowel disease

“…To date, there is no diagnostic gold standard tool for IBD. Differentiating UC and CC among patients with IC has remained painstaking and is a major challenge in endoscopic medicine and colorectal surgery [ 1 , 12 , 28 , 29 ]. Clinicians use an inexact classification system of clinical, endoscopy, radiologic, and histopathology findings in order to diagnose CC and UC [ 21 , 30 , 31 ].…”

“…Even with a combination of these diagnostic modalities, up to 15% of IBD patients are labeled as IC when no definitive evaluations can be made [ 13 , 30 , 32 ]. In addition, CC is mistakenly diagnosed and RPC and IPAA-operated as definitive UC in another 15% of IBD patients because of overlap in the clinical, endoscopic, radiological and histologic findings [ 12 , 33 – 36 ]. Further, most IC patients who undergo RPC and IPAA surgery for presumed UC are subsequently found to develop a recurrent de novo Crohn’s disease in the ileal pouch [ 1 , 12 , 33 ].…”

“…In addition, in predominantly colonic IBD, the distinction between UC and CC is of utmost importance when determining a patient’s candidacy for restorative proctocolectomy [ 9 – 11 ]. Approximately 15% of patients whose IC is surgically treated with IPAA resolve with an ultimate diagnosis of de novo Crohn’s, for which surgery may have been contraindicated [ 1 , 12 ]. Construction of an ileoanal pouch in these patients indicate that positive outcomes require painstaking clinical evaluations to identify those with Crohn’s or IC that turns to de novo Crohn’ s , which may result in pouch failure and significant morbidity in the interim [ 10 , 13 ].…”

“…Construction of an ileoanal pouch in these patients indicate that positive outcomes require painstaking clinical evaluations to identify those with Crohn’s or IC that turns to de novo Crohn’ s , which may result in pouch failure and significant morbidity in the interim [ 10 , 13 ]. Change of diagnosis of IC to UC or CC is sometimes observed in patients with IBD before colectomy, as is the development of de novo Crohn’s disease after surgery, restorative proctocolectomy (RPC) and ileal pouch-anal anastomosis (IPAA) [ 1 , 10 , 12 , 13 , 14 ]. Incorrect diagnosis and treatment carries potential morbidity from inappropriate and unnecessary surgeries and underscores the necessity of research efforts aimed at a more accurate diagnosis of the colitides [ 6 , 7 , 10 , 11 ].…”

Is There a Role for Ileal Pouch Anal Anastomosis in Crohn's Disease?

“…27,[34][35][36] Whether preoperative diagnosis of IC is associated with increased risk of de novo Crohn's is yet to be determined, as some studies have suggested a clear association between preoperative diagnoses of IC and the development of pouch CD, while others have shown none. 23,24,[26][27][28][37][38][39][40] CD of the pouch can affect the afferent limb, the pouch, or the anal transition zone and patients present with a variety of symptoms. They may experience abdominal pain, diarrhea, increased frequency of stool, urgency, and incontinence, making it difficult to distinguish from more common causes of these symptoms such as surgical complications, cuffitis, or pouchitis.…”