Infliximab in refractory pouchitis complicated by fistulae following ileo‐anal pouch for ulcerative colitis

Abstract

SUMMARYAim: To determine the efficacy of infliximab in the treatment of chronic refractory pouchitis complicated by fistulae following ileal pouch-anal anastomosis for ulcerative colitis.Methods: This open study included seven patients (four females, three males) with chronic refractory pouchitis complicated by fistulae. Pouchitis was diagnosed by clinical, endoscopic and histological criteria. The sites of the fistulae were as follows: pouch-bladder in one, vaginal in three, perianal in two, and both vaginal and perianal in one. Extra-intestinal manifestations (erythema nodosum, arthralgia) were present in four patients. Crohn's disease was carefully excluded in all patients after re-evaluation of the history, re-examination of the original proctocolectomy specimen and examination of the proximal small bowel. All patients had been treated with antibiotics and three with steroids. Patients received infliximab, 5 mg/kg, at 0, 2 and 6 weeks. Azathioprine (2.5 mg/kg) was also started for all patients as bridge therapy. Clinical response was classified as complete, partial or no response. Fistulae closure was classified as complete (cessation of fistulae drainage and total closure of all fistulae), partial (a reduction in the number, size, drainage or discomfort associated with fistulae) or no closure. The pouchitis disease activity index and quality of life were also used as outcome measures. Results: Clinically, all patients improved. At the 10-week follow-up, six of the seven patients had a complete clinical response, and five had complete fistulae closure. At the 10-week follow-up, the median pouchitis disease activity index decreased from 12 (baseline) (range, 10-15) to 5 (range, 3-8); the median quality of life decreased from 37 points (range, 33-40) to 14 (range, 9-18). Erythema nodosum and arthralgia showed complete remission soon after the first infusion of infliximab. Conclusions: These preliminary results indicate that infliximab may be recommended for the treatment of refractory pouchitis complicated by fistulae following ileal pouch-anal anastomosis for ulcerative colitis.

Enterocutaneous Fistulas: A Look at Causes and Management

“…There has been interest in the use of Infliximab in patients with ECF due to reported success with treatment of perianal fistulas in patients with IBD [49,50]. The role remains to be defined as these studies were small and nonrandomized.…”

Leukocytapheresis for the treatment of active pouchitis: a pilot study

“…The medical therapies of pouchitis include antibiotics, 7 probiotics, 8 antiinfl ammatory agents, 9,10 immunomodulators, 11 and biological therapy. 12 However, resistance to medical therapy is reported in 5%-20% of cases. 13 Therefore, more effective treatments for pouchitis are needed.…”

Combined Ciprofloxacin and Tinidazole Therapy in the Treatment of Chronic Refractory Pouchitis

“…While the majority of patients with pouchitis (i.e., antibiotic-responsive pouchitis) respond to a two-week treatment course with a single antibiotic, some may have refractory disease, requiring combination antibiotic therapy, 9 anti-inflammatory agents, 10,11 immunomodulators, 8 or even biologic therapy. 12 Management of chronic antibiotic-refractory pouchitis is often challenging. In fact, this type of pouchitis is a common cause for pouch failure resulting in pouch resection.…”