Diagnostic Value of EGD in Patients with Ileal Pouch-Anal Anastomosis

Abstract

Purpose: BACKGROUND: Inflammatory and non-inflammatory complications of ileal pouch-anal anastomosis (IPAA) are common after restorative proctocolectomy of ulcerative colitis. Some of the patients can have upper gastrointestinal pathology. The diagnostic role of EGD in these patients has not been evaluated. The aims of the study were to estimate the prevalence of upper GI diseases detected by EGD either as a conclusive diagnosis or an incidental finding and to assess factors associated with EGD findings. Methods: IPAA patients with underlying inflammatory bowel disease undergoing diagnostic EGD were recruited from subspecialty Pouchitis Clinic. Diagnostic yield and incidental findings of EGD were evaluated. 23 variables were evaluated including age, gender, UC duration, IPAA duration, Pouchitis Disease Activity Index scores, pouch type, pre-IPAA diagnosis, and disease category of the pouch. Univariable and multivariable analyses were performed. Stepwise selection with 0.35 and 0.10 as entry and exit criteria. Results: 66 patients undergoing EGD were enrolled in the study, of whom 64 (97%) patients had a concomitant pouch endoscopy. Indications for EGD include anemia, upper abdominal pain, weight loss, nausea and vomiting, and persistent diarrhea refractory to antibiotic therapy. A total of 17 subjects (25.8%) had a conclusive diagnosis and 14 (21.2%) had an incidental finding. Overall, 44% of subjects had upper GI disease detected by the EGD (conclusive diagnosis and/or incidental finding). The most common abnormal findings on EGD were Crohn's disease (N = 8; 12%), peptic ulcer disease (N = 2; 3%), gastritis/duodenitis (N = 7; 11%), Candida esophagitis (N = 2; 3%), and arteriovenous malformations (N = 2; 3%). Other findings included gastric outlet obstruction from malignancy, celiac disease, gastric fundic gland polyps, duodenal polyps, and hiatal hernia. In multivariable analysis, factors associated with conclusive EGD diagnosis were the Pouchitis Disease Activity Index endoscopy score (odds ratio = 1.8; 95% CI: 1.09, 2.9; P= 0.02) and pouch types other than original J pouch, i.e. S, Kock, or redo J pouches (odds ratio = 5.9; 95% CI: 1.08, 32.2; P= 0.041). Conclusion: EGD evaluation can yield valuable diagnostic information in selected symptomatic patients with IPAA. Inflammation of the afferent limb and a non-J pouch IPAA condition appeared to be associated with a high risk for concurrent upper GI disease.