Abstract
Quality of life after ileal pouch-anal anastomosis (IPAA) surgery is generally good. However, patients can be troubled by pouch-related symptoms and pouch disorders that can be inflammatory, mechanical/surgical, and functional. Management of patients with IPAA begins with measures to maintain a healthy pouch such as optimizing pouch function, providing tailored advice on a healthy diet and lifestyle, screening for and addressing metabolic complications of IPAA, pouch surveillance, and risk stratification for risk of pouchitis and pouch failure. Pouchitis is the most common inflammatory disorder. Primary pouchitis is a spectrum currently classified into three progressive phases—an antibiotic-responsive, an antibiotic-dependent, and an antibiotic-refractory phase. It is predominately microbially mediated in acute antibiotic-responsive pouchitis and predominately immune mediated in chronic antibiotic-refractory pouchitis (CARP). Secondary prophylaxis is recommended for recurrent antibiotic-responsive and for antibiotic-dependent pouchitis. Secondary causes of antibiotic-refractory pouchitis should be ruled out before a diagnosis of CARP is made. CARP is best classified as primary sclerosing cholangitis associated, immunoglobulin G4-associated, and autoimmune. Primary sclerosing cholangitis-associated CARP can be treated with budesonide or oral vancomycin. Early recognition of immunoglobulin G4-associated pouchitis minimizes ineffective antibiotic use. Autoimmune CARP can be managed in a manner similar to UC. The current place of immunosuppressives in the treatment algorithm depends on availability and early access to biological agents. Vedolizumab and ustekinumab are the preferred first- and second-line biologics for autoimmune CARP owing to their efficacy, better side effect profile, and low immunogenicity and need for concomitant immunomodulatory therapy. Antitumor necrosis factor should be reserved for autoimmune CARP failing the above and for CD of the pouch. There are no guidelines for the surveillance of pouches for dysplasia. Incidence varies based on a patient's risk. Since incidence is low, a risk-stratified approach is recommended.
Highlights
Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the preferred surgical treatment for most patients with ulcerative colitis (UC) and familial adenomatous polyposis (FAP)
Secondary prophylaxis is recommended for recurrent antibiotic-responsive and for antibiotic-dependent pouchitis
Autoimmune chronic antibiotic-refractory pouchitis (CARP) can be managed in a manner similar to UC
Summary
Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the preferred surgical treatment for most patients with ulcerative colitis (UC) and familial adenomatous polyposis (FAP). Patients with IPAA are at risk of pouch-related symptoms of increased frequency, dietary intolerances, Personalised Management of Ileoanal Pouches urgency, and incontinence [1]. Patients should be educated about dietary and pharmacological measures that can help improve pouch frequency and consistency. We recommend a trial of water-soluble minimally fermentable supplemental fibers such as psyllium husk in symptomatic patients who have an adequate intake of dietary fibers, starting at the smallest dose, increasing it in those who show partial response, and stopping in those who develop paradoxical worsening of symptoms or diarrhea. Readily fermentable fibers as fructooligosaccharides, inulin, and soluble non-starch polysaccharides, found in vegetables and fruits, induce an increase in pouch microbial mass and gas production, both of these factors contributing to increased stool bulk, reduced consistency, and increased frequency.
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