Predictors of Pouchitis Following Ileal Pouch Anal Anastamosis

Abstract

Purpose: Primary endpoint is to determine risk factors that predict chronic pouchitis in those patients having ileal pouch anal anastamosis (IPAA.) Methods: 237 patients with ulcerative colitis (UC) and undergoing IPAA by one surgeon at Oregon Health & Science University from 1993–2003 were evaluated. Data were gathered via retrospective chart reviews and by a questionnaire administered by telephone in 2004. Patients were excluded if there was less than one year follow-up documented in the chart or they could not be contacted by telephone (n = 63), post-operative diagnosis of Crohn's disease (n = 3), failed ileoanal procedure (n = 1), and 1-stage IPAA (n = 3.) Patients were defined as having chronic pouchitis (CP = >3 episodes of pouchitis) or having no pouchitis (≤3 episodes of pouchitis.) Potential risk factors included number of operations used to perform IPAA, fulminant UC with 2-stage operation, duration of diverting ileostomy following pouch formation, primary sclerosing cholangitis (PSC), other extra-intestinal manifestations (EIMs) of UC, pre-operative liver function tests, duration of UC, and the occurrence of post-operative complications. Initial univariate analysis was performed on all risk factors. Multivariate analysis was performed on all univariate risk factors with p values < 0.2. Results: The prevalence of CP in our population was 46%. The following variables were identified during univariate analysis and entered into a multivariate model: pre-operative serum albumin (p = .07), PSC (p = 0.126), duration of diverting ileostomy (p = 0.111), fulminant UC with 2-stage operation, (p = .051), and occurrence of post-operative complications (p = .007). Patients who did not undergo diverting ileostomy at the time of their IPAA trended towards a lower likelihood of developing CP (p = 0.06.) Multivariate analysis showed that patients with post-operative complications (53%) were more likely to develop CP (p = .009.) 8% of patients had PSC and 11% of patients had at least one EIM of UC. Patients with PSC and EIMs were not more likely to develop CP (p = 0.273, p = 0.126.) Conclusions: Chronic pouchitis (CP) is a frequent complication following IPAA. In this study patients with PSC or other EIMs of UC were not more likely to develop CP. Patients with post-operative complications following IPAA were more likely to develop CP and may benefit from early strategies to prevent pouchitis.