Risk of dysplasia in long-term ileal pouches and pouches with chronic pouchitis

Thompson‐Fawcett, Mark; Cohen, Zane; McLeod, Robin S.; Marcus, Victoria; Redston, Mark

doi:10.1053/gast.2001.26442

Cited by 104 publications

(78 citation statements)

References 37 publications

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“…Th e development of dysplasia or adenocarcinoma in pouches is very infrequent ( 356,357 ). Risk factors for dysplasia include long duration of UC before proctocolectomy, chronic pouchitis, PSC, and dysplasia or adenocarcinoma in the colectomy specimen ( 356,358,359 ).…”

Section: Recommendations For the Management Of Pouchitismentioning

confidence: 99%

“…Th ese methods aim to increase the recognition of nearly fl at, or minimally raised lesions and their associated mucosal pit patterns using mucosal dye spraying with either carmine indigo or methylene blue ( 397 ). Some series have used additional imaging technologies not widely available, including confocal laser microscopy ( 398 ) and magnifi cation colonoscopy In a surveillance program of 106 high-risk patients, only 1 patient had multifocal LGD, and no adenocarcinoma was found ( 356 ). Nonetheless, adenocarcinoma remains a risk aft er IPAA as the duration of follow-up increases.…”

Section: Recommendations For the Management Of Pouchitismentioning

confidence: 99%

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Ulcerative Colitis Practice Guidelines in Adults: American College of Gastroenterology, Practice Parameters Committee

Kornbluth

Sachar

2010

American Journal of Gastroenterology

1,154

977

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Guidelines for clinical practice are aimed to indicate preferred approaches to medical problems as established by scientifi cally valid research. Double-blind placebo controlled studies are preferable, but compassionate-use reports and expert review articles are used in a thorough review of the literature conducted through Medline with the National Library of Medicine. When only data that will not withstand objective scrutiny are available, a recommendation is identifi ed as a consensus of experts. Guidelines are applicable to all physicians who address the subject regardless of specialty training or interests and are aimed to indicate the preferable but not necessarily the only acceptable approach to a specifi c problem. Guidelines are intended to be fl exible and must be distinguished from standards of care, which are infl exible and rarely violated. Given the wide range of specifi cs in any healthcare problem, the physician must always choose the course best suited to the individual patient and the variables in existence at the moment of decision. Guidelines are developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee and approved by the board of trustees. Each has been intensely reviewed and revised by the Committee, other experts in the fi eld, physicians who will use them, and specialists in the science of decision analysis. The recommendations of each guideline are therefore considered valid at the time of composition based on the data available. New developments in medical research and practice pertinent to each guideline will be reviewed at a time established and indicated at publication to assure continued validity. The recommendations made are based on the level of evidence found. Grade A recommendations imply that there is consistent level 1 evidence (randomized controlled trials), grade B indicates that the evidence would be level 2 or 3, which are cohort studies or case -control studies. Grade C recommendations are based on level 4 studies, meaning case series or poor-quality cohort studies, and grade D recommendations are based on level 5 evidence, meaning expert opinion.

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Section: Recommendations For the Management Of Pouchitismentioning

confidence: 99%

Section: Recommendations For the Management Of Pouchitismentioning

confidence: 99%

Ulcerative Colitis Practice Guidelines in Adults: American College of Gastroenterology, Practice Parameters Committee

Kornbluth

Sachar

2010

American Journal of Gastroenterology

1,154

977

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“…Although PSC is a risk factor for pouchitis [3,44,45] , liver transplantation with post-transplant use of immunosuppressive agents does not appear to have adverse effects on the course of pouchitis [81,82] . In addition, chronic inflammation of the pouch and cuff may pose an increased risk of developing dysplasia or cancer [83,84] . In summary, pouchitis is the most common long-term adverse sequela of IPAA after restorative proctocolectomy.…”

Section: Natural History and Prognosismentioning

confidence: 99%

Pouchitis

Yu¹,

Shao²,

Shen³

2007

WJG

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While restorative proctocolectomy with ileal pouch-anal anastomosis has significantly improved the quality of life in patients with underlying ulcerative colitis who require surgery, complications can occur. Pouchitis as the most common long-term complication represents a spectrum of disease processes ranging from acute, antibioticresponsive type to chronic antibiotic-refractory entity. Accurate diagnosis using a combined assessment of symptoms, endoscopy and histology and the stratification of clinical phenotypes is important for treatment and prognosis the disease. The majority of patients respond favorably to antibiotic therapy. However, management of chronic antibiotic-refractory pouchitis remains a challenge.

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“…However, the absolute number of cases of pouch dysplasia is small [128], with the incidence of pouch cancer even lower. In 2011, only 50 cases of pouch cancer had been reported in the literature, with mucosectomy at the time of initial surgery not reducing the incidence [129].…”

Section: The Problematic Pouchmentioning

confidence: 99%

Managing Intractable Proctitis and the Problematic Pouch

Kent

Keshav²

2014

Dig Dis

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Proctitis accounts for a significant proportion of cases of ulcerative colitis (UC), and some patients subsequently develop more extensive disease. However, most patients continue to have limited inflammation, although the changes in the distal colon and rectum can occasionally be severe, and symptoms of increased frequency, rectal bleeding and urgency can be as disabling as they are for patients with more extensive colitis. Furthermore, although symptoms are typically well controlled with standard medications, medically refractory proctitis poses particular problems. Patients generally are not systemically unwell, and there is no added fear of cancer. Therefore, the prospect of colectomy for such limited disease is resisted by patients, physicians and surgeons alike. Unusual therapies, often delivered locally by enema or suppository, have been tested in small case series without definitive outcomes. The pathogenesis of such limited, yet intractable inflammation remains unclear, and the differential diagnosis should be carefully reviewed to ensure that local disease, whether it is infectious, vascular, or a result of injury or degeneration, is not overlooked. Ileo-anal pouch formation is the surgery of choice for about 20% of patients with UC who undergo colectomy. In the majority of cases, this surgery results in an acceptable quality of life and freedom from a stoma. However, in a sizeable minority of cases, pouch dysfunction can cause intractable problems. The causes of pouch dysfunction are varied and must all be considered carefully, particularly in refractory cases. Pouchitis is a common issue and is usually transient and easily treated. However, refractory and chronic pouchitis can be challenging. Ischaemia, injury, infection and Crohn's disease can all cause refractory pouch dysfunction. In a minority of cases, there appears to be no apparent organic pathology, and the presumptive diagnosis is that of a functional pouch disorder. Although it is much rarer, neoplastic changes in the pouch must also be considered, and the risk managed appropriately. The management of both intractable proctitis and the problematic pouch is made more challenging by the wide differential diagnosis that must be considered and by the paucity of high-quality clinical trials to support any one therapy. Key strategies to overcoming these limitations include methodical and systematic investigation and review, and a willingness to tailor therapy to the individual patient. Clinical trials of new treatments should be supported, and data from the experience with small cohorts of patients should be meticulously collected, critically analysed and widely disseminated.

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Risk of dysplasia in long-term ileal pouches and pouches with chronic pouchitis

Cited by 104 publications

References 37 publications

Ulcerative Colitis Practice Guidelines in Adults: American College of Gastroenterology, Practice Parameters Committee

Ulcerative Colitis Practice Guidelines in Adults: American College of Gastroenterology, Practice Parameters Committee

Pouchitis

Managing Intractable Proctitis and the Problematic Pouch

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