Frequency Of Pouchitis Research Articles

S946 Relationship Between Timing of IPAA Stages and Frequency of Pouchitis Within 2 Years of IPAA for UC

S946 Relationship Between Timing of IPAA Stages and Frequency of Pouchitis Within 2 Years of IPAA for UC

24 ENDOSCOPIC AND CLINICAL CHARACTERISTICS OF POUCHITIS INVOLVING THE RECTAL CUFF IN PATIENTS WITH INFLAMMATORY BOWEL DISEASE TREATED BY PROCTOCOLECTOMY WITH ILEAL POUCH-ANAL ANASTOMOSIS

Abstract Background For patients with inflammatory bowel disease (IBD), surgical intervention is sometimes required due to medically refractory colitis or development of neoplasia. Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the most common procedure for patients with colitis. However, pouchitis can develop in up to 80% of patients after the surgery and significantly impairs quality of life. Despite the high prevalence of pouchitis, endoscopic phenotypes have not been clarified. This study assessed the frequency and characteristics of inflammation involving the rectal cuff. Methods This is a retrospective study from a tertiary IBD center of IBD patients treated by total proctocolectomy with IPAA and subsequently underwent pouchoscopies at the University of Chicago between January 2007 and September 2019. We reviewed the endoscopic findings in different areas of the pouch: the pre-pouch ileum, inlet, “tip of the J”, proximal and distal pouch, anastomosis, rectal cuff, anal canal, and perianal area. This analysis evaluated all available pouchoscopies per patient and included patients with normal cuff and those with cuffitis noted in every pouchoscopy. Demographic and endoscopic data were assessed to compare patients with normal cuff and those with cuffitis. Fisher’s test was used for a univariate analysis to assess factors contributing to cuffitis. Logistic regression analysis was performed as a multivariate analysis including univariate variables with a P-value < 0.15. Results We reviewed 1,081 pouchoscopies from 426 IBD patients who underwent proctocolectomy with IPAA and identified 184 patients (43%) with normal cuff and 107 (25%) with cuffitis. Of these 291 patients, 57% were men, 92% were Caucasian, the mean age at the diagnosis (SD) was 26 ± 12 years, and mean BMI 26 ± 5 kg/m2. The diagnosis before surgery for these patients were for ulcerative colitis (91%), indeterminate colitis (5.8%), and Crohn’s disease (1.7%). A significant difference (P = 0.003) was found in the frequency of pouchitis between patients with normal cuff (126/184, 69%) and those with cuffitis (90/107, 84%) (Table 1). Although not statistically significant, the frequency of pouch failure in patients with cuffitis (13/107, 12%) was higher than those with normal cuff (12/184, 6.5%). Multivariate analysis showed pouchitis was significantly associated with cuffitis (OR = 2.2; 95% CI = 1.2–4.2; P = 0.01) (Table 2). Endoscopic data showed that the pre-pouch ileum was significantly (P = 0.001) involved in patients with cuffitis (45/90, 50%) compared with those with normal cuff (36/126, 29%). Conclusion Our analysis of 291 patients suggested that cuff inflammation can be a significant risk factor of pouchitis and is significantly associated with the development of inflammation in the pre-pouch ileum. Cuffitis can be a therapeutic target to improve J pouch outcomes.

Difference in the frequency of pouchitis between ulcerative colitis and familial adenomatous polyposis: is the explanation in peripouch fat?

Patients with ulcerative colitis (UC) have an unexplained higher incidence of pouchitis and a greater amount of peripouch fat compared with patients with familial adenomatous polyposis (FAP). The aims of this study were to compare the peripouch fat areas between patients with UC and patients with FAP, and to explore relationship between peripouch fat and pouchitis or chronic antibiotic-refractory pouchitis (CARP). Patients with an abdominal CT image from our prospectively maintained Pouch Database were included. Abdominal fat and peripouch fat were measured on CT images at different levels or planes. Comparisons of peripouch fat and CARP were performed before and after propensity score matching. A total of 277 patients with UC and 40 patients with FAP were included. Compared with patients with FAP, patients with UC were found to have a higher incidence of pouchitis (58.5% vs 15.0%, P<0.001) and CARP (24.5% vs 2.5%, P=0.002) and a higher total peripouch fat area (P=0.030) and mesenteric peripouch fat area (P=0.022) at Level-3. Univariate and multivariate analyses showed that diagnosis (UC vs FAP) and peripouch fat areas at Level-3 and Level-5 were independent risk factors for CARP. With propensity score matching, 38 pairs of patients with UC and FAP were matched successfully. After matching, patients with UC were found to have higher total peripouch fat area and higher mesenteric peripouch fat area at Level-3, and a higher incidence of pouchitis (57.9% vs 13.2%, P<0.001) and CARP (23.7% vs 2.6%, P=0.007). Our study demonstrates that patients with UC have more peripouch fat than those with FAP, which may explain the difference in the frequency of pouchitis and CARP between these groups of patients.

Preoperative Clostridium difficile Infection Does Not Affect Pouch Outcomes in Patients with Ulcerative Colitis Who Undergo Ileal Pouch-anal Anastomosis.

The operation of choice for patients with chronic ulcerative colitis (CUC) is restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). Pouchitis is the most common complication after IPAA. The incidence of Clostridium difficile infection (CDI) is higher in CUC patients than the general population and can lead to significant disease flares and higher rates of colectomy. We sought to determine the risk of pouchitis in patients with precolectomy CDI and 90-day postoperative IPAA complications. A retrospective case-control study was conducted on patients with CUC who underwent an IPAA between January 1, 2000 and January 10, 2015. The study cohort was comprised of patients diagnosed with CDI within 90 days before colectomy; patients with CUC without CDI comprised the control cohort. The primary outcome measure was the frequency of pouchitis after IPAA. Secondary outcomes included time to pouchitis, 90-day postoperative pouch morbidity: surgical site infection, hemorrhage, anastomotic leak, fistula formation, pouchitis treatment and response, and pouch failure requiring end-ileostomy or fecal diversion. Univariate and multivariable analysis was used to determine differences between CDI and non-CDI groups. Forty-eight case patients and 154 control patients were included. Patients with preoperative CDI were younger (P = 0.010), had higher rates of medically refractory disease (P = 0.002), and had greater use of biologic therapy (P = 0.046). The rate of pouchitis was 50.0% (n = 24) and 46.8% (n = 72) (P = 0.694) among patients with and without preoperative CDI, respectively. Patients with preoperative CDI who developed pouchitis post-IPAA were more likely to require medical management with an anti-TNFα (P = 0.042) and surgical management with end/diverting ileostomy (P = 0.042). Preoperative CDI was associated with higher rates of postoperative IPAA anastamotic or pouch strictures (P = 0.018). Multivariable analysis revealed primary sclerosing cholangitis (PSC) as the only variable associated with increased risk for pouchitis (OR 10.59; 95% CI, 3.07-51.08; P < 0.001). Preoperative CDI does not seem to be associated with an increased risk of pouchitis in patients with CUC.

Surgical outcomes, bowel habits and quality of life in young patients after ileoanal anastomosis for ulcerative colitis

PurposeWe aim to investigate the postoperative outcomes, bowel habits and quality of life (QoL) of younger pediatric ulcerative colitis (UC) patients following surgical intervention compared to an older pediatric population. MethodsMedical records of UC patients after colectomy with ileoanal reconstruction (2002–2013) at our institution were reviewed. Patients/parents completed a QoL, bowel habits and disease course questionnaire. Surgical outcomes, bowel habits and QoL were reported comparing the younger (≤11years old, n=26) to older (>11years old, n=38) cohorts. ResultsThe mean age at colectomy was 7.04±0.63years vs 14.71±0.32years in the two groups. Patients had a significant (P<0.001) reduction in stooling frequency after surgery in both age groups and had favorable rates of fecal continence. The frequency of pouchitis and postoperative small bowel obstruction was similar in both cohorts. Dehydration was slightly increased in the younger population but not significant. Anastomotic leak and stricture rates were slightly reduced in younger patients. Postoperative QoL was favorable and similar regardless of age at surgery. ConclusionsColectomy with ileoanal anastomosis for young children (≤11years old) with UC is without increased complications relative to older patients and maintains a postoperative QoL and stool patterns.

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.

Quality of life, continence and frequency of pouchitis following laparoscopic versus open colectomy and ileal pouch-anal anastomosis: an Irish perspective.

This study aims to assess quality of life outcomes, continence, rates of pouchitis and predictors of pouchitis for patients undergoing laparoscopic versus open three-stage ileal pouch-anal anastomosis (IPAA) surgery in our institution. Forty-two patients having had three-stage (IPAA) surgery were identified. One was excluded as they had undergone pouchectomy. A postal questionnaire followed by telephone contact was undertaken. The questionnaire was based on The Gastrointestinal Quality of Life Index (GIQLI) and Wexner/Cleveland Clinic Faecal Incontinence Symptom Severity Scoring Systems. Our aim was to assess morbidity, quality of life, incidence of pouchitis and continence following restorative panproctocolectomy and IPAA. Thirty-five patients completed the response. The median age at colectomy of our patient population was 32 years. 57 % were male and 43 % were female. 54.3 % of cases were carried out laparoscopically. 8/19 patients who had laparoscopic surgery had pouchitis (42.1 %) versus 9/16 patients who had open surgery (56.3 %). The median Wexner score was 0. Nine patients (25.7 %) had a GIQLI score that was within or above the range reported for healthy controls. The rate of complications was 31.7 % for emergency cases and 25.7 % for elective cases. The rate of pouchitis in this group was 48.5 %. Overall pelvic sepsis rate was 12.8 %. Ileal pouch-anal anastomosis is a successful and well-tolerated procedure with 94 % of patients opting to have the surgery again. Preliminary results do not show any significant difference in the incidence of pouchitis following laparoscopic surgery.

Stricture of ileo-anal J pouch anastomosis increased the intensity of pouchitis in an experimental rat model

SummaryBackgroundPouchitis appears to be the most common complication after restorative proctocolectomy.Material/MethodsIn experimental models we investigated the correlation between the width of anastomosis and the frequency of pouchitis. Twenty-three Wistar rats underwent restorative proctocolectomy under pentobarbital anesthesia. Normal width anastomosis was performed in 11 animals (Group I). In the remaining 12 animals (Group II) the diameter of anastomosis was reduced by 50%. All animals were sacrificed and the pouch mucosa was histologically (Moskowitz score) and immunohistochemically (IL-1, IL-6, IL-10, IL-12 expression) examined.ResultsMorphological assessment of pouchitis symptoms based on Moskowitz scale revealed considerably more severe inflammation (p=0.0079) in the animals from Group II than in the rats from Group I. The expressions of investigated cytokines, assessed qualitatively in histopathological examination, were higher in rats with narrow anastomosis in comparison with animals with normal anastomosis.ConclusionsThe stricture of anastomosis increases the intensity of pouchitis and stimulates the production of interleukins. It seems that anastomotic stricture plays an important role in the development of pouchitis.

Management of Patients with Ulcerative Colitis after Proctocolectomy:Pouchitis is a Real Danger

Pouchitis develops in about 50% of the patients with ulcerative colitis (UC) undergoing colectomy. Aim: The aim of this study was to evaluate the frequency of pouchitis, to determine risk factors and to assess the efficacy of infliximab in refractory pouchitis. Patients and Methods: 76% of the 46 UC patients requiring colectomy underwent ileal pouch-anal anastomosis (IPAA) procedure. Demographic, clinical and therapeutic parameters were compared between patients who did and did not develop pouchitis and between those with pouchitis responding or being refractory to the conservative therapy. Results: 40% of the patients developed pouchitis. Six patients received infliximab therapy. Extraintestinal manifestation and non smoking was characteristic for refractory pouchitis. Discussion: Pouchitis developed in 40% of our patients undergoing IPAA. The development of pouchitis seems to be predisposed by frequent preoperative hospitalization. The earlier onset of pouchitis seems to be a prognostic factor for the unsuccessful conservative treatment and the need for biological therapy.

Fecal calprotectin mirrors inflammation of the distal ileum and bowel function after restorative proctocolectomy for pediatric-onset ulcerative colitis†

The goal was to cross-sectionally assess fecal calprotectin after restorative proctocolectomy for pediatric-onset ulcerative colitis (UC). Fecal calprotectin, histology of the distal ileum, inflammation biochemistry, episodes of pouchitis, and bowel function were cross-sectionally determined at early adulthood in 32 patients who had undergone proctocolectomy with ileoanal anastomosis for UC at a mean (SD) age of 12.0 +/- 4.1 years. A total of 15 (47%) patients showed increased (>100 microg/g) fecal calprotectin (669 +/- 866 microg/g), although their serum C-reactive protein (5.2 +/- 3.8 mg/L), erythrocyte sedimentation rate (13 +/- 13 mm/h), and white blood cell count (6.7 +/- 1.7 E9/L) were normal or slightly elevated. Calprotectin correlated positively with the histological neutrophil count of the distal ileum (r = 0.715; P < 0.001), the frequency of pouchitis (r = 0.468; P < 0.01), and with the maximum daily frequency of bowel actions (r = 0.610; P < 0.001). Mean fecal calprotectin was 71 +/- 50 microg/g among patients with no history of pouchitis (n = 10), 290 +/- 131 microg/g among patients with a single episode of pouchitis (n = 15), and 832 +/- 422 microg/g among those with recurrent pouchitis (P = 0.019 between recurrent pouchitis and no pouchitis). Sensitivity, specificity, positive predictive value, and negative predictive value for fecal calprotectin concentration over 300 microg/g to detect recurrent pouchitis were 57%, 92%, 67%, and 89%, respectively. Neutrophilic inflammation of the distal ileum, as reflected by fecal calprotectin, is common after restorative proctocolectomy for pediatric-onset UC.

A cost-effectiveness analysis of diagnostic strategies for symptomatic patients with ileal pouch–anal anastomosis

Objective Pouchitis is often diagnosed based on symptoms and empirically treated with antibiotics ( treat-first strategy). However, symptom assessment alone is not reliable for diagnosis, and an initial evaluation with pouch endoscopy ( test-first strategy) has been shown to be more accurate. Cost-effectiveness of these strategies has not been compared. The aim of this study was to compare cost-effectiveness of different clinical approaches for patients with symptoms suggestive of pouchitis. Methods Pouchitis was defined as pouchitis disease activity index scores ≥ 7. The frequency of pouchitis in symptomatic patients with ileal pouch was estimated to be 51%; the efficacy for initial therapy with metronidazole (MTZ) and ciprofloxacin (CIP) was 75% and 85%, respectively. Cost estimates were obtained from Medicare reimbursement data. Results Six competing strategies (MTZ trial, CIP trial, MTZ-then-CIP trial, CIP-then-MTZ trial, pouch endoscopy with biopsy, and pouch endoscopy without biopsy) were modeled in a decision tree. Costs per correct diagnosis with appropriate treatment were $194 for MTZ trial, $279 for CIP trial, $208 for MTZ-then-CIP trial, $261 for CIP-then-MTZ trial, $352 for pouch endoscopy with biopsy, and $243 for pouch endoscopy without biopsy. Of the two strategies with the lowest cost, the pouch endoscopy without biopsy strategy costs $50 more per patient than the MTZ trial strategy but results in an additional 15 days for early diagnosis and thus initiation of appropriate treatment (incremental cost-effectiveness ratio $3 per additional day gained). The results of base-case analysis were robust in sensitivity analyses. Conclusions Although the MTZ-trial strategy had the lowest cost, the pouch endoscopy without biopsy strategy was most cost-effective. Therefore, based on its relatively low cost and the avoidance of both diagnostic delay and adverse effects associated with unnecessary antibiotics, pouch endoscopy without biopsy is the recommended strategy among those tested for the diagnosis of pouchitis.

Restorative proctocolectomy with ileo-anal reservoir, a histopathological, histochemical, and electron microscopic study

This study was conducted to investigate the nature of colonic metaplasia in ileo-anal pouches and incidence / frequency of pouchitis in the same. Biopsy specimens from 8 patients with functioning ileal pouches were studied using routine histology, mucin histochemistry and electron microscopy, over a 2 - year period. All 8 patients had villous abnormalities in the form of blunting of villi and sub total or partial villous atrophy. 6 patients had an increase in the goblet cell population and Paneth cell hyperplasia. These changes were supported by electron microscopic findings of a decrease in number and flattening of ileal type microvilli and their transformed morphologic resemblance to colonic type microvilli. All the ileal pouches also had acquired colorectal type sulphomucin, when sections stained with Alcian-blue and High Iron Diamine - Alcian blue, were studied. However, no case of pouchitis as defined in literature, was found in this study.

Ileal pouch–anal anastomosis in children with ulcerative colitis

: This study is a retrospective review of all pediatric patients with ulcerative colitis who underwent colectomy and ileal pouch-anal anastomosis (IPAA) between 1982 and 1992 at the Cleveland Clinic Foundation. The purpose of the review was to determine the effectiveness of IPAA in treating children with ulcerative colitis. Demographic, preoperative, and surgical data were abstracted from archival research of medical records. Quality-of-life information was obtained from patient or parent interviews. Ninety-one children were identified during the study period with a median age of 14.2 years. The principal indication for colectomy was intractable symptoms despite vigorous medical therapy. J-pouches (n = 51) and S-pouches (n = 38) were most commonly constructed. Median follow-up was 1.9 years after ileostomy closure. Thirty early complications (occurring within 30 days of pouch construction) were documented in 21 patients, and 57 late complications (occurring after 30 days) were documented in 34 patients. Small bowel obstruction was the most common early postoperative complication and accounted for 13 of 30 early complications; reoperation was required in four of nine patients. Pouchitis was the most frequent late complication (15 episodes in 12 patients), followed by perineal infection (14 episodes in eight patients), and anastomotic stricture (10 episodes in nine patients). Pouch type, age at colectomy, and disease interval from colectomy to pouch construction were analyzed with relation to the frequency of pouchitis, anastomotic stricture, sepsis, and incontinence. An S-pouch had been used in eight of nine patients with an anastomotic stricture (p = 0.004). The disease interval and age at initial surgery had no bearing on the presence of late complications. The pouches of four female patients were excised as a result of pelvic infection and were subsequently converted to continent ileostomies. Quality-of-life information was obtained for 78 patients. Daytime continence was complete in 67 (86%) children and nocturnal continence was complete in 56 (72%) patients. Seventy-three (94%) patients were very satisfied with their quality of life after IPAA. We conclude that IPAA is an effective surgical procedure for children with ulcerative colitis and results in a relatively normal pattern of defecation with a good long-term functional outcome. Early postoperative complications are common, but only a few patients require further hospitalization or surgery. The most common late complication is pouchitis, which responds to medical treatment. Continence is preserved in the majority of the children, and overall satisfaction with the operation is high.