S752 Early Pouchitis Is Associated With an Increased Likelihood of Chronic Antibiotic Dependent Pouchits and Crohn’s-Like Disease of the Pouch

Abstract

Introduction: Approximately 80% of patients will develop pouchitis at some point after an IPAA for ulcerative colitis (UC), with 17% of patients developing chronic antibiotic dependent pouchitis (CADP) and and 10% developing Crohn’s-like disease of the pouch. Few reliable risk factors for these chronic inflammatory conditions of the pouch have been identified. We aimed to investigate the relationship between early pouchitis, defined as acute pouchitis within the first 180 days of the final stage of IPAA surgery, and the future development of CADP and Crohn’s-like disease of the pouch. Methods: We performed a retrospective cohort study, evaluating patients who underwent proctocolectomy with IPAA at our center between January 1, 2004 and December 31, 2016. Multivariable logistic regression was used to evaluate the relationship between early pouchitis and the development of CADP and Crohn’s-like disease of the pouch, adjusting for other relevant clinical and demographic factors. Results: Among 626 patients undergoing IPAA for UC, 137 (22%) developed early pouchitis, 75 (12%) developed CADP, and 59 (9%) developed Crohn’s-like disease of the pouch. Patients developing early pouchitis were significantly more likely to be of Hispanic ethnicity compared to patients who did not develop early pouchitis (5.6% vs. 1.4%, p=0.006, Table). Early pouchitis was associated with a significant increase in the odds of developing CADP (adjusted odds ratio [aOR] 3.65, 95% CI 2.19-6.10). A preoperative diagnosis of PSC was also associated with an increase in the odds of developing CADP (aOR 3.97, 95% CI 1.44-11.0). Early pouchitis was also associated with an increased likelihood of developing Crohn’s-like disease of the pouch (aOR 2.68, 95% CI 1.50-4.80) as was a family history of inflammatory bowel disease (aOR 2.10, 95% CI 1.11-3.96). The median duration of follow up for all patients in the study was 5.18 years (interquartile range 0.94 – 10.8 years). Conclusion: In a cohort of patients with UC who underwent IPAA, the development of pouchitis within the first 180 days of surgery was associated with an increased risk of developing CADP and Crohn’s-like disease of the pouch. These findings highlight early pouchitis as a unique risk factor for chronic pouch-related disorders and the need for future studies evaluating potential interventions including secondary prophylaxis strategies in this population. Table 1. - Univariate comparison of demographic and clinical characteristics of patients with and without pouchitis in the two years following an ileal pouch-anal anastomosis Patients without early pouchitis (n=489) Patients with early pouchitis (n=137) p-value Median IQR Median IQR Age at surgery, in years 40.3 28.8-52.4 43.1 33.7-54.5 0.094 Disease duration prior to surgery 5.9 2.2-14.2 6.3 2.0-13.6 0.854 n % n % Race 0.923 White 424 89.3 121 89.0 Non-White 51 10.7 15 11.0 Hispanic 6 1.4 7 5.6 0.006 Family history of Crohn's disease or ulcerative colitis 83 16.2 14 20.0 0.421 Indication for surgery 0.059 Medically-refractory colitis 376 76.9 118 86.1 Dysplasia or cancer 72 14.7 11 8.0 Other indications/multiple indications 41 8.4 8 5.8 Disease extent prior to surgery 0.405 Proctitis 23 5.0 3 2.3 Left-sided colitis 133 29.1 40 30.8 Extensive colitis 301 65.9 87 66.9 Stages involved in IPAA surgery 0.977 1 92 18.9 24 17.5 2 173 35.5 51 37.2 Modified 2 183 37.5 11 37.2 3 40 8.2 51 8.0 Abscess or pelvic sepsis after IPAA surgery 94 19.2 23 16.8 0.518 Evidence of an IPAA leak immediately after IPAA surgery 38 7.8 8 5.8 0.444 Primary Sclerosing Cholangitis 13 2.7 6 4.4 0.299 Medications used prior to colectomy Systemic aminosalicylate 380 77.7 115 83.9 0.113 Topical aminosalicylate 230 47.0 72 52.6 0.253 Thiopurine 299 61.2 91 66.4 0.256 Methotrexate 58 11.9 9 6.6 0.077 Anti-TNF 252 51.5 69 50.4 0.809 Vedolizumab 11 2.3 6 4.4 0.175 Cyclosporine 13 2.7 13 9.5 < 0.001 Prednisone use at the time of last stage of surgery 192 39.3 58 42.7 0.487