Histopathology of Pouch and Para-Pouch Inflammatory and Neoplastic Disorders

BACKGROUND: Chronic antibiotic refractory pouchitis after restorative proctocolectomy with ileal pouch-anal anastomosis, characterized by at least 4 weeks of pouchitis symptoms that have not responded to standard antibiotic therapy, presents a therapeutic challenge for patients and healthcare providers. OBJECTIVE: The aim of this narrative review was to summarize the current evidence regarding management of chronic antibiotic refractory pouchitis. DATA SOURCES: Studies were identified through search of PubMed database from the National Library of Medicine. STUDY SELECTION: We included case series, cohort studies, randomized-controlled trials, and systematic reviews with meta-analyses that addressed chronic antibiotic refractory pouchitis management, with prioritization of data published within the last 3-5 years. INTERVENTION: Studies examining pharmacologic and select non-pharmacologic interventions were included. MAIN OUTCOME MEASURE: Outcomes measures included clinical, endoscopic, and histologic endpoints. RESULTS: Mesalamine has demonstrated efficacy in symptom improvement but no improvement in quality of life. Budesonide has demonstrated high rates of clinical remission that have mostly been sustained in a small number of patients. Anti-tumor necrosis factor alpha therapies have demonstrated efficacy in reaching clinical and even endoscopic endpoints, although rates of treatment discontinuation were not insignificant. Limited evidence is encouraging for use of ustekinumab in achieving clinical response. Data for vedolizumab are favorable across clinical, endoscopic, and histologic endpoints, including one of the only randomized, placebo-controlled trials. Non-medication therapies including hyperbaric oxygen therapy and fecal microbiota transplant have undergone limited evaluation and concerns about ultimate accessibility of these therapies remain. LIMITATIONS: Overall, studies assessing therapeutic options for chronic antibiotic refractory pouchitis are mostly limited to case series and retrospective studies with small sample sizes. CONCLUSIONS: Biologic therapies have demonstrated efficacy in the management of chronic antibiotic refractory pouchitis and offer a steroid-sparing option for refractory disease. Non-pharmacologic therapies, including hyperbaric oxygen and fecal microbiota transplant, require further exploration. See video.

Section: Diagnostic Evaluationmentioning

confidence: 99%

Evidence-Based Approach to Chronic Antibiotic Refractory Pouchitis: A Review

Weber,

Lichtenstein

2024

“…33,34 Routine surveillance pouchoscopy with segmental biopsy, particularly image-enhanced endoscopy, is recommended for these patients. [35][36][37][38] Oral Budesonide Oral budesonide with or without concurrent immunomodulators or ursodeoxycholic acid (UDCA) has been described to treat IgG4-associated sclerosing cholangitis 39 or PSC 40 with minimum or no efficacy. In contrast, a double-blinded, double-dummy, controlled trial of budesonide enema and oral metronidazole in 26 patients with pouchitis showed comparative efficacy as measured by the Pouchitis Disease Activity Index.…”

Section: S109mentioning

confidence: 99%

“…33,34 Routine surveillance pouchoscopy with segmental biopsy, particularly image-enhanced endoscopy, is recommended for these patients. 35–38…”

Section: Psc and The Pouchmentioning

confidence: 99%

Management of Primary Sclerosing Cholangitis and Extraintestinal Disorders in Patients with Ileal Pouches: A Systemic Review

Shen,

Yao,

Scherl

2024

BACKGROUND: Restorative proctocolectomy with ileal pouch-anal anastomosis improves the quality of life in patients with ulcerative colitis by the removal of diseased large bowel and preservation of the natural route of defecation. Although the surgery may improve preexisting extraintestinal manifestations in the joint, skin, and eyes, extraintestinal manifestations, particularly primary sclerosing cholangitis can persist after colectomy. OBJECTIVES: A systemic review of diagnosis and treatment of liver, joint, skin, and eye manifestations in patients with restorative proctocolectomy and ileal pouch-anal anastomosis for ulcerative colitis DATA SOURCES: PubMed, Google Scholar, and Cochrane database. STUDY SELECTION: Relevant articles on primary sclerosing cholangitis and extraintestinal manifestations in ileal pouches published between Jan 2001 and July 2023 in English were included based on Preferred Reporting Items For Systemic Review and Meta-Analysis guidelines. INTERVENTION: Diagnosis and treatment of primary sclerosing cholangitis and extraintestinal manifestations in patients with restorative proctocolectomy and ileal pouch-anal anastomosis were included. MAIN OUTCOME MEASURES: Association between primary sclerosing cholangitis, extraintestinal manifestations, and inflammatory disorders of the pouch and their management. RESULTS: The presence of primary sclerosing cholangitis and extraintestinal manifestations is associated with pouchitis, particularly chronic pouchitis. Primary sclerosing cholangitis is associated with both chronic pouchitis and enteritis, and possible pouch neoplasia. However, disease severity and disease course of primary sclerosing cholangitis and pouchitis do not appear to parallel. Despite that oral vancomycin or budesonide have been used to treat primary sclerosing cholangitis-associated pouchitis, their impact on the disease course of primary sclerosing cholangitis is not known. Biological therapy for chronic inflammatory disorders of the pouch may be also beneficial for the concurrent extraintestinal manifestations of the joints, skin, and eyes. However, studies on the correlation between the severity of inflammatory pouch disorders and the severity of joint, skin, and eye diseases are lacking. LIMITATIONS: This is a qualitative, not quantitative review of case series and case reports. CONCLUSIONS: Primary sclerosing cholangitis and extraintestinal manifestations of the joints, skin, and eyes appear to be associated with inflammatory disorders of the ileal pouch. While the treatment of pouchitis does not seem to affect the disease course of primary sclerosing cholangitis, effective therapy of inflammatory pouch disorders, particularly with biologics, likely benefits concurrent disorders of the joints, skin, and eyes. See 20-minute symposium video.

“…A biopsy should be taken from the suture lines or staple lines because foreign body-associated granulomas may be mistaken for noncaseating granulomas. 58…”

Section: S60mentioning

confidence: 99%

“…Although pouchoscopy may be performed for the insertion of a decompression tube, most patients require surgical intervention. 58…”

Section: Pouch Bodymentioning

confidence: 99%

Endoscopic Evaluation of the Ileal Pouch

Shen

2024

BACKGROUND: Structural and inflammatory adverse sequelae are common after restorative proctocolectomy and ileal pouch-anal anastomosis. On rare occasions, neoplasia can occur in patients with ileal pouches. Pouchoscopy plays a key role in the diagnosis, differential diagnosis, disease monitoring, assessment of treatment response, surveillance, and delivery of therapy. OBJECTIVE: A systemic review of the literature was performed and principles and techniques of pouchoscopy were described. DATA SOURCES: PubMed, Google Scholar, and Cochrane database. STUDY SELECTION: Relevant articles on endoscopy in ileal pouches published between Jan 2000 and May 2023 were including based on PRISMA guidelines. INTERVENTION: Diagnostic, surveillance, and therapeutic endoscopy in ileal pouch disorders were included. MAIN OUTCOME MEASURES: Accurate characterization of the ileal pouch at the healthy or diseased states. RESULTS: The main anatomic structures of a J or S pouch are the stoma closure site, prepouch ileum, inlet, tip of the “J,” pouch body, anastomosis, cuff, and anal transition zone. Each anatomic location can be prone to the development of structural, inflammatory, or neoplastic disorders. For example, ulcers and strictures are common at the stoma closure site, inlet, and anastomosis. Leaks are commonly detected at the tip of the “J” and anastomosis. Characterization of the anastomotic distribution of inflammation is critical for the differential diagnosis of subtypes of pouchitis and other inflammatory disorders of the pouch. Neoplastic lesions, albeit rare, mainly occur at the cuff, anal transition zone, or anastomosis. LIMITATIONS: This is a qualitative, not quantitative review of mainly case series. CONCLUSIONS: Most structural, inflammatory, and neoplastic disorders can be reliably diagnosed with a careful pouchoscopy. The endoscopist and other clinicians taking care of pouch patients should be familiar with the anatomy of the ileal pouch, and recognize common abnormalities. See video from symposium. See Video.