Acute Pouchitis Research Articles

Vedolizumab in the treatment of chronic, antibiotic-dependent or refractory pouchitis.

The most common complication after ileal pouch anal anastomosis in up to 50% of patients is an acute pouchitis. The majority of patients respond to antibiotic treatment. However, 10%-15% develops chronic antibiotic-dependent or refractory pouchitis which is usually hard to treat. To evaluate the effectiveness of vedolizumab in patients with chronic pouchitis. Patients with chronic antibiotic-dependent or refractory pouchitis were treated with vedolizumab (300mg at week 0, 2, 6 and 10) in 10 IBD centres and retrospectively registered. Data were recorded until week 14 of vedolizumab treatment. In total 20 patients (12 male, median age 43years) were included for analysis. The effectiveness was measured using the Oresland Score (OS) at week 2, 6, 10 and 14 and the pouch disease activity index (PDAI) at week 0 and 14. The mean OS declined from 6.8 (range 2-12) to 3.4 (range 0-11). Concordantly, the mean PDAI after 14weeks of treatment dropped from 10 (range 5-18) to 3 (range 0-10). Only three patients reported moderate side effects. No serious side effects were recorded. In addition, symptomatic co-medication such as loperamide and tincture of opium could be terminated in 8 out of 12 patients as well as antibiotic treatment could be stopped in 17 out of 19 patients. Our data indicate that vedolizumab could be an option in the treatment of patients with chronic, antibiotic-dependent or refractory pouchitis.

Systematic review: ileoanal pouch microbiota in health and disease.

The resident gut microbiota is essential for physiological processes; the disturbance of its balance is linked to intestinal inflammation. The ileoanal pouch is a model for the study of intestinal inflammation, as inflammation of the pouch is common and mostly develops within 12months following ileostomy closure. This allows the longitudinal study of the microbiota, giving insight into the microbiota changes during transition from a normal to an inflamed pouch. To explore the literature on the microbiota of the ileoanal pouch in health and disease. A systematic computer search of the on-line bibliographic databases MEDLINE and EMBASE was performed between 1966 and February 2017. Randomised controlled trials, cohort studies and observational studies were included. Studies were included if they reported microbiota analysis on faecal samples or tissue from the ileoanal pouch. Twenty-six papers were eligible. Following ileostomy closure, anaerobic bacteria are the abundant species in the ileoanal pouch with presence of a diverse microbiota key to maintaining a healthy ileoanal pouch. Acute pouchitis is associated with an increase in Clostridia species, while chronic pouchitis is associated with an increase in Staphylococcus aureus. In the treatment of pouchitis, a decrease in Clostridia species appears to be associated with treatment response. The microbiota plays an important role in both the inflamed and the healthy ileoanal pouch. A direct causal relationship between individual microbiota changes and inflammation has not yet been established, but manipulation of the ileoanal pouch microbiota may be a novel therapeutic avenue to explore.

The outcome of ulcerative colitis patients undergoing pouch surgery is determined by pre-surgical factors.

Pouch surgery, a common intervention for ulcerative colitis (UC) complications, is often associated with the development of pouchitis. To identify predictors of pouch outcome in a cohort of patients with UC. We conducted a retrospective unmatched case-cohort study in a tertiary IBD referral centre. Adult patients with UC were classified into the worst phenotype throughout follow-up: normal pouch, a form of chronic pouchitis (either chronic pouchitis or Crohn's like disease of pouch [CLDP]), or episodic recurrent acute pouchitis (RAP). Risk factors for pouchitis (chronic forms) were detected using statistical models. Two hundred and fifty-three pouch patients were followed up for 13.1±7.3 years. Only 71 patients (28.1%) maintained a favourable outcome of a sustained normal pouch. These patients were older at UC diagnosis (27.8±12.5 vs 23.0±11.4 years), had longer UC duration until surgery (13.4±9.5 vs 8.2±7.9 years), and had higher rates of referral to surgery due to nonrefractory (dysplasia/neoplasia) complications (42.3% vs 16.2%) compared with pouchitis patients. Median survival for sustained normal pouch was 10.8 years (95% CI 8.9-12.7 years), and it was longer in the nonrefractory group (20.3 vs 9.4 years for the refractory group, HR=2.37, 95% CI 1.25-3.52, P=.004). Most patients with UC undergoing pouch surgery will develop pouchitis. Patients operated for nonrefractory indications have a more favourable outcome. These results may contribute to pre- and post-surgical decision-making. The findings imply that the processes determining UC severity may be similar to that causing pouchitis.

Treatment of acute pouchitis

Acute pouchitis is a common disease that affects many patients with an ileal pouch-anal anastomosis. The management of acute pouchitis remains largely empiric with the mainstay of therapy being the antibiotics ciprofloxacin and metronidazole. Probiotics may have a role in the primary and secondary prophylaxis of acute pouchitis. In addition, there are modest data that probiotics are effective in the treatment of mild acute pouchitis. There are limited data for other treatments of acute pouchitis including oral and rectal budesonide and glutamine suppositories. Diet plays a largely undefined role in the development and management of acute pouchitis, and, although many have been studied, no specific diet can currently be recommended. Larger well-designed clinical trials are necessary to confirm the efficacy of current treatments and to investigate new treatments for the management of acute pouchitis.

P478 The current place of probiotics in treatment of pouchitis: systematic review

Abstract Background: Pouchitis is a common complication in patients undergoing restorative proctocolectomy for ulcerative colitis. Therapeutic attempts include manipulations of pouch flora composition. In this systematic review, we aimed to score the evidence supporting the use of probiotics and prebiotics in pouchitis patients, to clarify the place of these treatments in current therapeutic regimens. Methods: We conducted extensive electronic searches of the PubMed and SCOPUS databases, from their earliest records through Nov 2016, for MESH terms “probiotics” and “pouchitis”. Results: The electronic search retrieved 20 citations [1–20]. Six published RCTs [2,3,9,10,13,14] and a RCT presented as an abstract [12] evaluated clinical, endoscopic end/or histological effect of probiotics as a primary outcome; other reports ranged in level of evidence between meta-analyses [16–19] (4), open-labeled trials [1,4–8,11,15] (8) and letters [20] (1). Conclusions: Prevention of onset of pouchitis/Primary prevention. Three studies examined the ability of various probiotic regimens to prevent the onset of pouchitis after the restorative proctocolectomy [1–3]. Primary preventive effect of VSL#3 was indicated by a single RCT, with calculated effect ratio of 1.50 [1.02, 2.21] [16]. Table 1. Use of probiotics for prevention of onset of pouchitis Study No. of patients Duration (months) probiotic strain Strain Control Pouchitis-free survival Gosselink (2004) 117 36 LGG No treatment (historical control) 93% vs. 71% (p=0.011) Gionchetti (2003) [2] 40 12 VSL#3 Placebo 90% vs. 60% (p<0.05) Yasueda (2015) [3] 17 24 Clostridium butyricum Placebo 89% vs. 50% (NS) Treatment of acute episode. Seven – mostly open-labeled and uncontrolled – trials examined the use of probiotics for treatment of acute pouchitis episode [4–10]. Efficacy of probiotics in acute episodes of pouchitis needs to be proved in randomized controlled trials. Table 2. Use of probiotics for treatment of active pouchitis Study No. of patients Duration (months) Strain Control Outcome Gionchetti et al. (2007) [4] 23 1 VSL#3 Open-labeled; uncontrolled 69% remission rate Laake et al. (2005) [5] 51 (10 with active disease) 1 Cultura® fermented milk product Open-labeled; uncontrolled Symptomatic and endoscopic improvement in patients with active disease Laake et al. (1999) [21] Cultura® fermented milk product Open-labeled; uncontrolled Symptomatic improvement Laake et al. (2003) [7] 10 ½ month Cultura® fermented milk product Open-labeled; uncontrolled Endoscopic improvement Laake et al. (2004) [8] 41 UC + 10 FAP 1 Cultura® fermented milk product Open-labeled; uncontrolled Symptomatic remission and endoscopic improvement Tomasz et al. (2014) [9] 43 (14 with active disease) 9 Lactobacillus acidophilus, Lactobacillus delbrueckii subsp. Bulgaricus, Bifidobacterium bifidus Placebo 43% remission rate vs 0% on placebo Kuisma (2003) [10] 20 3 LGG Placebo No benefit Seven studies aimed to determine the efficacy of probiotic strains in preventing recurrences in patients with previous episode/s of pouchitis [4,9,11–15]. Probiotic mixture VSL#3 effectively prevents relapses after successful antibiotic treatment of active inflammation, with calculated effect ratio of 20.24 [4.28, 95.81] [16]. Side effects may affect the adherence of the patients with the long-term treatment [15,16]. Table 3. Use of probiotics for prevention of recurrences of pouchitis Study No. of patients Duration (months) Probiotic strain Control Outcome Pronio (2008) [11] 31 12 VSL#3 No treatment Small reduction of PDAI scores Brown (2004) [12] (abstract) 17 6 Bifidobacterium longum BB-536 Placebo Pouchitis-free survival 86% vs. 60% on placebo (NS); small reduction of PDAI scores Tomasz et al. (2014) [9] 43 9 Lactobacillus acidophilus, Lactobacillus delbrueckii subsp. Bulgaricus, Bifidobacterium bifidus Placebo 43% in remission vs 0% on placebo Gionchetti et al. (2007) [4] 16 6 VSL#3 Open-labeled; uncontrolled 69% remission rate Gionchetti (2000) [13] 40 9 VSL#3 Placebo Pouchitis-free survival 85% vs. 0% on placebo (P<0.001) Mimura (2004) [14] 36 12 VSL#3 Placebo Pouchitis-free survival 85% vs. 6% on placebo (P<0.0001) Shen (2005) [15] 31 8 VLS#3 (self administration) Open-labeled compliance trial 80% non-adherence; 74% self-reported recurrence of symptoms

Sulfasalazine in Prevention of Pouchitis After Proctocolectomy with Ileal Pouch–Anal Anastomosis for Ulcerative Colitis

Pouchitis is the most frequent complication after ileal pouch-anal anastomosis for refractory ulcerative colitis. A non-standardized preventative treatment exists. Sulfasalazine has proved effective in acute pouchitis therapy. The aim of this study was to retrospectively evaluate the effect of sulfasalazine in primary prophylaxis of pouchitis after proctocolectomy with ileal pouch-anal anastomosis. Data files of patients who underwent total proctocolectomy with ileal pouch-anal anastomosis for refractory ulcerative colitis and/or dysplasia from January 2007 to December 2014, with a follow-up until August 2015, were analyzed. After closure of loop ileostomy, on a voluntary basis, patients received a primary prophylaxis of pouchitis with sulfasalazine (2000mg per day) continually until acute pouchitis flare and/or drop out due to side effects. Follow-up data were available for 51 of the 55 surgical patients. Median follow-up time was 68months (range 10-104). Thirty postoperative complications occurred in 25 patients. 45% of patients developed pouchitis. Sulfasalazine prophylaxis was administered in 39.2% of patients; 15% of the these developed pouchitis versus 64.5% (20/31) of the non-sulfasalazine patients (p<0.001). Pouchitis-free survival curves were 90.55months in sulfasalazine patients and 44.46 in non-sulfasalazine patients (log-rank test p=0.001, Breslow p=0.001). Sulfasalazine may be potentially administered in pouchitis prophylaxis after proctocolectomy with ileal pouch-anal anastomosis, but large prospectively controlled trials are needed.

Pouchitis after ileal pouch-anal anastomosis in ulcerative colitis: Diagnosis, management, risk factors, and incidence.

Restorative proctocolectomy with ileal pouch-anal anastomosis has been the surgical treatment of choice for patients with ulcerative colitis who require surgery. Quality of life after this procedure is satisfactory in most cases; however, pouchitis is a troublesome condition involving inflammation of the ileal pouch. When a patient presents with symptoms of pouchitis, such as increased bowel movements, mucous and/or bloody exudates, abdominal cramps, and fever, endoscopy is essential for a precise diagnosis. The proximal ileum and rectal cuff, as well as the ileal pouch, should be endoscopically observed. The reported incidence of pouchitis ranges from 14% to 59%, and antibiotic therapy is the primary treatment for acute pouchitis. Chronic pouchitis includes antibiotic-dependent and refractory pouchitis. Intensive therapy including antitumor necrosis factor antibodies and steroids may be necessary for antibiotic-refractory pouchitis, and pouch failure may occur despite such intensive treatment. Reported risk factors for the development of pouchitis include presence of extraintestinal manifestations, primary sclerosing cholangitis, non-smoking, and postoperative non-steroidal anti-inflammatory drug usage. In the present review, we focus on the diagnosis, endoscopic features, management, incidence, and risk factors of pouchitis in patients with ulcerative colitis who underwent ileal pouch-anal anastomosis.

East Meets West: The Increasing Incidence of Inflammatory Bowel Disease in Asia as a Paradigm for Environmental Effects on the Pathogenesis of Immune-Mediated Disease

East Meets West: The Increasing Incidence of Inflammatory Bowel Disease in Asia as a Paradigm for Environmental Effects on the Pathogenesis of Immune-Mediated Disease

Alterations of Enteric Microbiota in Patients with a Normal Ileal Pouch Are Predictive of Pouchitis.

To examine whether patients with a mature normal pouch [> 1 year post ileostomy closure] have microbial stool characteristics that can predict pouch inflammation. Patients undergoing pouch surgery were recruited prospectively. Microbiota analysis of faecal samples was by 16S rRNA gene pyrosequencing. All patients had a normal pouch at baseline [T1]. Those without pouchitis during the first year of follow-up [T2] comprised the 'Normal Pouch-sustained' group and those who had experienced an episode of pouchitis comprised the 'Pre-Pouchitis' group. Twenty patients were recruited (age 53.6±13.1 years, pouch age [time from ileostomy closure] 8.1±5.1 years). Seven patients developed pouchitis during follow-up [within 265±93.6 days] and they were assigned to the Pre-Pouchitis group at T1: they had a decreased microbial diversity at T1 compared with the Normal Pouch-sustained patients [n = 13]. The Shannon diversity index for the Pre-Pouchitis patients was 3.4 vs 4.23 for the Normal Pouch-sustained patients [p = 0.011]. There were no substantial group differences in high taxonomic levels [order or above]. The genus Ruminococcus was significantly decreased in the Pre-Pouchitis patients' samples compared with those of the Normal Pouch-sustained patients (0.19% vs 0.78%, respectively, false discovery rate [FDR] = 0.05). The linear discriminant analysis with effect size estimation algorithm revealed that Lachnospira and Coprococcus genera were also decreased among Pre-Pouchitis patients compared with Normal Pouch-sustained patients [0.6% vs 1.95% and 2.1% vs 4%, respectively]. Patients with a normal mature pouch may be predisposed to acute pouchitis when faecal microbial diversity and certain microbial groups are decreased. These findings may aid in risk stratification of those patients.

Nonbloody Diarrhea but Not Significant Weight Loss at Diagnosis Is Associated with the Development of Denovo Crohn's Disease After Ileal Pouch-anal Anastomosis for Ulcerative Colitis.

Denovo Crohn's disease (CD) develops in 5% to 10% of patients after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) leading to increased morbidity and rates of pouch failure. Initial nonbloody diarrhea and weight loss at diagnosis are independent risk factors for a change in diagnosis from UC to CD in nonsurgical patients. We investigated whether these features were risk factors for denovo CD in a longitudinal cohort of patients with UC undergoing IPAA. Prospective profiles of patients with UC undergoing IPAA followed over a 22-year period by 1 surgeon were analyzed. Denovo CD was diagnosed when mucosal inflammation (5 or more ulcers) involved the small bowel mucosa proximal to the ileal pouch any time after surgery and/or when a pouch fistula or other perianal complication developed more than 3 months after ileostomy closure. Patients with inflammatory bowel disease unclassified, acute pouchitis, chronic pouchitis, and those lost to follow-up were excluded from analysis. Cox regression analysis was performed for statistical significance. Of the 199 study patients included in the analysis, denovo CD developed in 42 patients (21%). Patients who developed denovo CD had an increased incidence of nonbloody diarrhea (n = 12; 29%) compared with patients who had no evidence of pouch inflammation (n = 25; 16%) (P = 0.03). In contrast, the incidence of weight loss was not significantly increased in patients with denovo CD (n = 7; 17%) compared with patients who never had pouch inflammation (n = 16; 10%) (P = 0.12). Initial nonbloody diarrhea is associated with denovo CD after IPAA. This association warrants close consideration before surgery.

Clinical Uses of Probiotics.

Probiotics are live nonpathogenic microorganisms. Many of these microorganisms are part of the normal human gut flora, where they live in a symbiotic relationship. Probiotics have been used to treat gastrointestinal (GI) and non-GI medical conditions. However, the data supporting their use are often conflicting, especially for non-GI-associated illnesses. The strongest evidence supporting the use of probiotics is related to the treatment of acute diarrhea and pouchitis. Atopic eczema in children and genitourinary infections are the only non-GI-related medical conditions where probiotics may have some beneficial effects. Product selection and dosing are not the same in all conditions, and the beneficial effects of each probiotic strain cannot be generalized.The purpose of this article is to provide most recent information about probiotics and its uses. In contrast with previously published reviews on probiotics, we also discuss the composition of various products (Table 1), indications for their use (Table 2), product selection, and dosing of probiotics.Probiotics are safe and appear to exert some beneficial effects in GI-related illnesses. The use of probiotics in non-GI illnesses is not sufficiently supported by current data.

Frequency, Clinical Features and Factors Associated with Pouchitis after Proctocolectomy with Ileo-Pouch-Anal Anastomosis in Patients with Ulcerative Colitis: A Latin-American Country Retrospective-Cohort Study

Background: Pouchitis is the most common complication of proctocolectomy with ileo-pouch-anal anastomosis (IPAA) for ulcerative colitis (UC). No previous study in Mexico has evaluated this issue; our aim was to evaluate its frequency, clinical characteristics and factors associated with its presence in Mexican patients with UC and IPAA. Methods: Retrospective-cohort study including 70 patients with histopathological diagnosis of UC and IPAA between 1983 and 2014 from inflammatory bowel disease clinic of a tertiary care center. The statistical analysis used descriptive statistics, chi-square and Fisher's exact test for categorical variables and Student's t test for numeric variables. Univariate analysis was performed to identify the factors associated. Results: Patients presenting with pouchitis accounted for 48.6%. From the 34 cases, 12 (35.3%) had inactive pouchitis; 7 (20.6%) active acute pouchitis; 15 (44.1%) chronic active pouchitis. On average, pouchitis occurred 5.37 years after IPPA. Factors probably associated with its occurrence were the presence of autoimmune concomitant diseases (ACDs; p = 0.06, OR 4.40, 95% CI 0.84-22.9) and extra-intestinal manifestations (EIMs; p = 0.05, OR 2.53, 95% CI 0.96-6.64), which was also probably associated with chronic active pouchitis (p = 0.06, OR 0.31, 95% CI 0.07-1.31). Conclusions: The frequency of pouchitis is high in Mexican UC patients after IPAA. ACDs and EIMs were probably associated with its development.

Treatment and prevention of pouchitis after ileal pouch-anal anastomosis for chronic ulcerative colitis.

Treatment and prevention of pouchitis after ileal pouch-anal anastomosis for chronic ulcerative colitis.

Serum Anti-GP2 Antibody Isoforms 1 and 4 Are associated With Crohnʼs Disease of the Pouch in Patients With Ileal-Pouch Anal Anastomosis (IPAA)

Introduction: IPAA is the standard therapy for ulcerative colitis (UC) patients requiring colectomy. Inflammatory and non-inflammatory complications of the ileal pouch are common. Serologic antimicrobial antibodies, such as pANCA, cBir1 or anti-glycan antibodies have been linked to pouchitis in IPAA subjects, but limited accuracy restricts their clinical use. Zymogen granule glycoprotein 2 (GP2) is the major autoantigen of CD-specific pancreatic autoantibodies. We tested two novel serologic anti-GP2 isoforms for association with pouch disorders in a cross-sectional analysis in IPAA patients. Methods: 157 serum samples of 143 consecutive and eligible pouch patients (mean age 43.6 +/- 13.4 years, 45.5% female) were obtained from the pouch clinic of a tertiary academic center. Serial samples were available for 13 subjects. Pouch disorders were diagnosed based on clinical, endoscopic, histologic and radiographic criteria. Presence of Anti-GP2 IgG and IgA Isoforms 1 & 4 was tested in serum samples using enzyme-linked immunosorbent assay (ELISA). Clinical data was recorded prospectively (pre-operative diagnosis, indication for colectomy, pouch type, pouch complications). Analysis was performed using Kruskal-Wallis, Pearson's chi square, Wilcoxon signed rank or Fisher's exact tests. Results: Median interval from construction of IPAA to sample procurement was 7.1 years (25th percentile 2.1; 75th percentile 13.2). 89.5% of participants had a J-pouch. Upon sample procurement, patient phenotypes included: normal pouch n=66, irritable pouch syndrome n=5, acute pouchitis n=17, refractory pouchitis n=24, CD of the pouch n=16, cuffitis n=30, other n=22. Presence of Anti-GP2 IgG Isoform 1 (p < 0.001) & 4 (p < 0.001) and Anti-GP2 IgA Isoform 1 (p=0.022) & 4 (p < 0.001) was associated with CD of the pouch. Presence of Anti-GP2 IgG Isoform 4 was linked to cuffitis (p=0.006). No marker was associated with pre-operative CD. Median interval time between serum procurement in IPAA subjects with serial samples was 3 months. There was no significant change in serum levels of Anti-GP2 antibodies over time. Conclusion: This study demonstrates a link between the two isoforms of Anti-GP2 antibodies with CD of the pouch in IPAA patients. Anti-GP2 was not associated with a pre-operative diagnosis of CD and anti-GP2 levels were stable over time. Serologic anti-GP2 antibodies could aid in diagnosis of CD of the pouch after IPAA.

Serology of Patients with Ulcerative Colitis After Pouch Surgery Is More Comparable with that of Patients with Crohn's Disease.

The serologic status of patients with ulcerative colitis (UC) who develop postoperative pouchitis was compared with that of patients with Crohn's disease (CD) and unoperated patients with UC. Pouch patients were stratified into normal pouch, acute/recurrent acute pouchitis, and chronic pouchitis/Crohn's-like disease of the pouch groups. Antibodies against glycans associated with CD (anti-Saccharomyces cerevisiae, anti-laminaribioside, anti-chitobioside, and anti-mannobioside carbohydrate antibodies [ASCA, ALCA, ACCA, and AMCA, respectively]) were detected and correlated with type of inflammatory bowel disease and pouch behavior. A total of 501 patients with inflammatory bowel diseases were recruited: 250 (50%) CD, 124 (24.7%) unoperated UC, and 127 (25.3%) UC-pouch. At least 1 positive antibody was detected in 77.6% CD, 52.0% UC-pouch and 33.1% unoperated UC (P < 0.0001 for all). ACCA and AMCA prevalence in CD, UC-pouch and unoperated patients with UC were 33.2%, 24.4%, and 16.9% (P = 0.003 for all) and 35.2%, 26.8%, and 7.3%, respectively (P < 0.0001 for all). ALCA and ASCA were more prevalent in patients with CD than unoperated UC and UC-pouch patients. A longer interval since pouch surgery was associated with inflammatory pouch behavior: 12.45, 11.39, and 8.5 years for acute/recurrent acute pouchitis, chronic pouchitis/Crohn's-like disease of the pouch, and normal pouch, respectively, P = 0.01 for all. The prevalence of the CD-associated anti-glycan antibodies ACCA and AMCA is significantly increased in UC-pouch patients, suggesting that pouch surgery may trigger differential immune responses to glycans. The finding that the serology of UC-pouch patients shares similarities with that of patients with CD supports the notion that those 2 inflammatory bowel diseases share a common pathogenic pathway.

Update on the pathogenesis and management of pouchitis.

Pouchitis is an inflammatory complication after restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA). IPAA is the surgical treatment of choice in patients with ulcerative colitis (UC) who require colectomy. Initial episodes of acute pouchitis generally respond to antibiotics but significant numbers of cases eventually become dependent on or refractory to antibiotics. Management of chronic antibiotic refractory pouchitis is challenging and can ultimately lead to pouch failure. The etiopathogenesis is unknown though recent studies have implicated bacterial dysbiosis of the pouch microbiota, NOD2 polymorphism, and Clostridium difficile infection in the development of severe pouchitis. Early identification of risk factors can help in tailoring therapy and reducing cases of chronic pouchitis.

Outcomes after ileal pouch anal anastomosis in patients with primary sclerosing cholangitis

Background and aimsOutcomes after ileal pouch anal anastomosis (IPAA) are not well established in patients with primary sclerosing cholangitis (PSC). We conducted a comprehensive outcomes assessment in these patients. MethodsA retrospective case note review of complications in all PSC-IPAA (n=21) and matched ulcerative colitis patients with IPAA (UC-IPAA; n=79) after surgery in Oxford (1983–2012) was conducted, and functional outcomes (Öresland score) were evaluated (2012). Quality of life [Cleveland Global Quality of Life Questionnaire, Short Form-36 (SF-36)], and sexual function were also assessed (2012) including patients with PSC-associated UC without IPAA (PSC-UC; n=19). Sub-group analysis of patients with large duct (ld) PSC-IPAA (n=17) was also performed. ResultsThe 1-, 5-, 10- and 20-year risk of acute pouchitis for PSC-IPAA was 10%, 19%, 31% and 65% respectively, compared to 3%, 10%, 14% and 28% in UC-IPAA (p=0.03). More PSC-IPAA (36%) had poor nocturnal pouch function (vs 2% in UC-IPAA; p=0.0016). There were no differences in surgical complications, quality of life or sexual function between the 3 main groups. LdPSC-IPAA had poorer pouch function (Öresland score: 7.7 vs 5.4 in UC-IPAA; p=0.02), and worse quality of life [SF-36 Physical: 42 vs 50.5 in UC-IPAA; 47.7 in PSC-UC; p=0.03 and Mental Health summary scores: 41.6 vs 51.2 in UC-IPAA; 42.3 in PSC-UC; p=0.04]. ConclusionsPSC-IPAA suffer more acute pouchitis and have worse functional outcomes than UC-IPAA. LdPSC-IPAA also have poorer quality of life.

P-161 Cost-Effectiveness of Colectomy with IPAA versus Colectomy with Permanent End-Ileostomy for Crohnʼs Colitis

The economic burden of Crohn’s disease (CD) in the US exceeds 15 billion dollars annually with a significant portion of these costs related to surgery. Twenty percent of patients with CD have disease isolated to the colon. Traditionally, in medically refractory cases these patients undergo total colectomy with end-ileostomy (EI) or subtotal colectomy with ileorectal anastomosis. Recently, ileal pouch-anal anastomosis (IPAA) has been found to be an effective option for this population. We determined the cost effectiveness of different surgical strategies in the management of medically refractory Crohn’s colitis. We used a lifetime Markov model with 1 year cycles to simulate quality adjusted life years (QALYs) and cost comparing 2 different surgical strategies: total colectomy with permanent EI versus colectomy with IPAA. After undergoing EI, patients could move between the following health states: permanent EI without treatment, permanent EI on infliximab, and additional surgery (Fig. 1). In the IPAA strategy, patients could move between remission without treatment, remission on infliximab, acute pouchitis, and pouch resection with EI at which point they would move between the health states in EI (Fig. 1). One-way sensitivity analysis and tornado analysis were performed. We used the third-party payer perspective for the analysis. The EI surgical strategy was more cost effective than IPAA, with an incremental cost effectiveness ratio (ICER) of $13,080 per QALY gained. We identified the following variables of importance in our model: 1) the cost of the EI surgery, 2) the cost of ostomy care, and 3) the cost of infliximab. One-way sensitivity analysis showed that if the costs associated with EI surgery were greater than $67,000 (base case: $53,600), then IPAA became cost-effective with an ICER of $9,029 per QALY gained. All other variations of the model maintained EI as the more cost effective strategy. In patients with medically refractory CD isolated to the colon, colectomy with permanent EI is more cost-effective than IPAA unless the costs associated with the EI surgery exceed $67,000.

Fecal transplantation therapy for Clostridium difficile-associated pouchitis

Dear Editor: Pouchitis is the most common long-term complication in patients who undergo total proctocolectomy with ileal pouch-anal anastomosis (IPAA) for refractory ulcerative colitis (UC) or colitis-associated neoplasia. Acute or chronic pouchitis can result from Clostridium difficile infection (CDI). Treatment for C . difficile -associated pouchitis can be challenging. We report the first reported case in which the patient with chronic antibiotic-refractory pouchitis associated with CDI, which was successfully treated by fecal microbiota transplantation (FMT).

Predictive Factors for Development of Chronic Pouchitis after Ileal Pouch-Anal Anastomosis in Ulcerative Colitis

Background: No previous studies have examined predictive factors for chronic pouchitis after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) with consideration of changes in pouchitis subtypes during follow-up. This study evaluated the independent predictive factors for chronic pouchitis. Methods: A total of 244 consecutive patients who underwent IPAA were enrolled. We assessed the possible associations between pouchitis and clinical factors using Cox proportional hazard regression. Results: 231 patients met the inclusion criteria. 66 (28.5%) patients developed pouchitis. In 9 of 44 (20.4%) patients, antibiotic-responsive pouchitis at the first episode changed into chronic pouchitis after the occurrence of a subsequent episode. The median duration from occurrence of antibiotic-responsive pouchitis to alteration into chronic pouchitis was 502 (range 147-1,697) days. Overall pouchitis was finally classified into 35 acute pouchitis and 31 chronic pouchitis cases. Multivariate analysis revealed that a ≥7.5-g cumulative steroid dose before colectomy and a ≥500-mg monthly steroid dose just before colectomy were significant predictive factors for chronic pouchitis (p = 0.0001 and 0.0095, respectively). Conclusion: Patients with UC and a higher cumulative steroid dose before colectomy or higher monthly steroid dose just before colectomy may have a predictive factor for developing chronic pouchitis.