S0695 Appropriateness of Medical and Surgical Treatments in Patients With Chronic Inflammation of the Ileal Pouch: A RAND Panel Approach

Abstract

INTRODUCTION: The optimal treatment of chronic inflammatory pouch disorders remains a challenge due to the paucity of high-quality studies. We aimed to provide guidance for clinicians on the appropriateness of medical and surgical treatments in patients with these disorders. METHODS: The appropriateness of medical and surgical treatments in patients with pouchitis was considered in 16 clinical scenarios incorporating pouchitis symptoms, antibiotic response, prepouch ileitis (PI) (extending >10 cm proximal to pouch inlet) and Crohn's disease (CD)-like complications. Appropriateness of permanent ileostomy was considered in 8 additional scenarios. Using the RAND/UCLA modified Delphi method, 13 international inflammatory bowel diseases experts rated appropriateness of treatments on a 1–9 scale (1–3 inappropriate, 4–6 uncertain, 7–9 appropriate) via a web-based survey, then met to discuss and re-rate scenarios. Disagreement was assessed using a validated index; scenarios with disagreement were rated as uncertain. RESULTS: Chronic antibiotic therapy was rated appropriate only in asymptomatic antibiotic-dependent patients with no CD-like complications and was otherwise inappropriate (Table 1). Ileal-release budesonide was rated appropriate in 6/16 (38%) scenarios including patients with extensive PI but no CD-like complications. Its use was considered inappropriate (5/8) or uncertain (3/8) in the presence of CD-like complications. Probiotics were considered inappropriate in 14/16 (88%) and uncertain in 2/16 (12%) scenarios. Biologic therapy was considered appropriate in 14/16 (88%) scenarios and uncertain in the absence of extensive PI or CD-like complications (12%). Permanent ileostomy was considered appropriate in 3/16 (19%) scenarios including symptomatic patients with extensive PPI and CD-like complications (Table 2). In patients refractory to all medical treatments, permanent ileostomy was considered appropriate in all scenarios except in asymptomatic patients with no CD-like complications. CONCLUSION: In the presence of extensive PI or CD-like complications, chronic antibiotics and probiotics are inappropriate. Ileal-release budesonide is appropriate in patients who have chronic pouchitis with extensive PI but no CD-like complications. Biologic use is appropriate in patients with chronic pouchitis except in asymptomatic patients with no evidence of complications. Permanent ileostomy is appropriate in most patients who have failed all medical treatments.Table 1.: Appropriateness of medical and surgical treatments in patients with chronic pouch inflammationTable 2.: Appropriateness of a permanent ileostomy in patients with chronic pouch inflammation who have failed antibiotics, ileal release budesonide, probiotics and biologics