Diagnosis and Management of Pouchitis and Ileoanal Pouch Dysfunction

Abstract

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) has become the surgical treatment of choice for patients with medically refractory ulcerative colitis (UC) or UC with dysplasia and for the majority of patients with familial adenomatous polyposis. However, UC patients with IPAA are susceptible to inflammatory and noninflammatory sequelae, such as pouchitis, Crohn's disease of the pouch, cuffitis, and irritable pouch syndrome, in addition to common surgery-associated complications, which adversely affect the surgical outcome and compromise health-related quality of life. Pouchitis is the most frequent long-term complication of IPAA in patients with UC, with a cumulative prevalence of up to 50%. Pouchitis may be classified based on the etiology into idiopathic and secondary types, and the management is often different. Pouchoscopy is the most important tool for the diagnosis and differential diagnosis in patients with pouch dysfunction. Antibiotic therapy is the mainstay of treatment for active pouchitis. Some patients may develop dependency on antibiotics, requiring long-term maintenance therapy. Although management of antibiotic-dependent or antibiotic-refractory pouchitis has been challenging, secondary etiology for pouchitis should be evaluated and modified, if possible.

Elevated Serum IgG4 is Associated with Chronic Antibiotic-Refractory Pouchitis

“…Alterations in T-cell immunity with imbalance between proinflammatory and immunoregulatory cytokines have been described in pouchitis patients. 13 The findings of this study suggest a role of alterations in B cell immunity in the pathogenesis of pouchitis in some patients, as further evidenced by their role in IgG4 sclerosing disease. 18 The lymphoplasmacytic infiltrates seen in these patients include polyclonal B cells, plasma cells, and T cells.…”

“…12 The diagnosis of CD of the pouch was defined by ulcerated lesions of the small bowel or afferent limb without diffuse pouchitis (excluding backwash pouchitis) that persisted after ≥4 weeks of antibiotic therapy or by ulcerated strictures in the distal small bowel or pouch inlet with concurrent ulcers or inflammation of the afferent limb. 13 Those criteria were applied after the exclusion of non-steroidal anti-inflammatory drug (NSAID) use at the time of diagnosis. Irritable pouch syndrome (IPS) was defined as the presence of abdominal pain, pelvic discomfort, and diarrhea with no inflammation of the afferent limb, pouch, or cuff on endoscopy.…”

Use of Probiotics in Abdominal Surgery

“…The predominant finding that emerges from careful review of the current literature is, however, that the majority of these trials have only been able to find positive effects when applying a per protocol analysis. On the other hand, other studies have failed to demonstrate significant effects on abdominal infection rates by synbiotic and probiotic therapies [1,13,14]. Altogether, it can be concluded that the use of potentially clinically relevant surrogate markers has consistently demonstrated positive effects.…”

Colonic Histological Criteria Predict Development of Pouchitis after Ileal Pouch: Anal Anastomosis for Patients with Ulcerative Colitis

“…Pouchitis was defined as a modified Pouchitis Disease Activity Index score of ≥5 points [12] within 3 years after restoration of gastrointestinal continuity. Chronic pouchitis was defined as symptoms lasting ≥4 weeks that failed to respond to a 4-week course of single antibiotic therapy (ciprofloxacin or metronidazole) [13] during the same period.…”