Management of de Novo Crohn’s Disease after Reconstructive Surgery with Continent Ileostomy in Ulcerative Colitis

Abstract

Pouchitis, i.e. de novo inflammation of the ileal pouch, is a common complication in patients with ileal pouch anal anastomosis (IPAA) or continent ileostomy (Kock pouch) following colectomy for Ulcerative Colitis. It has an endoscopic appearance resembling the colorectal inflammation of Ulcerative Colitis, and causes symptoms with increased stool frequency, urgency, abdominal cramps, mucous and/or bloody exudates, and fever. The cumulative incidence is increasing with time from ileostomy takedown and is reported to affect more than 50% of patients within 10 years. About 10% develop chronic antibiotic refractory pouchitis. Some patients with pouchitis develop an inflammation with a phenotype resembling Crohn’s disease, although they preoperatively had a clinical presentation, endoscopic features and histopathology data indicating they had Ulcerative Colitis, including reexamination of the pathology specimens. There is no agreed definition of de novo Crohn’s disease of the pouch, but it often includes a Crohn-like ulcerative inflammation, involvement of the pre-pouch afferent limb, and non-anastomotic complications with strictures or fistulas unrelated to surgery. Making a firm diagnosis of de novo Crohn’s disease of the pouch can be challenging since the distinction of de novo Crohn’s disease from chronic antibiotic resistant pouchitis or technical complications related to surgery is often difficult. Making an accurate diagnosis of Crohn of the pouch versus a postoperative complication is important for both decisions regarding medical management, and pouch excision versus reconstruction. Most patients diagnosed with Crohn’s disease will no longer be considered for pouch reconstructive surgery. There is very limited data on the medical management of de novo Crohn of pouches and the study quality is often poor. The management of de novo Crohn of the continent ileostomy is therefore mainly taken from management of IBD in general and Crohn’s disease in particular. A successful management is facilitated by cooperation in a multidisciplinary team with gastroenterologists and colorectal surgeons, closely involving the patient in therapeutic decisions with a person centered approach.