Pouch Disorders Research Articles

Types, behaviour and therapeutic requirements of inflammatory pouch disorders: Results from the RESERVO study of GETECCU

Background and AimsInflammatory pouch disorders exhibit a heterogeneous clinical spectrum and therapeutic requirements have not been properly studied. MethodsThis retrospective, multicentre study included ulcerative colitis patients with ileal pouch construction and were later diagnosed with an inflammatory pouch disorder between 1995 and 2020. Classifications, behaviour and therapies applied were recorded and compared in the long-term. ResultsOverall, 338 patients were recruited. The most common disorders were pouchitis (n = 258, 76%), Crohn's disease of the pouch (n = 55, 16%) and cuffitis (n = 25, 7%). Pouchitis presented mainly as chronic (65.2%) and recurrent (87%) forms. Crohn's disease manifested as stricturing/penetrating in 53% of cases and perianal disease in 42%. Patients received multiple therapies: 86% antibiotics, 42% steroids, 27% immunosuppressants, 43% biologics and 27% surgery. Compared with pouchitis, Crohn's disease of the pouch was characterised by a later diagnosis (99 vs. 55 months, p < 0.001) and greater needs for immunosuppressants (OR 3.53, 1.79–6.94, p < 0.0001), biologics (OR 5.45, 2.78–10.6, p < 0.0001) and surgeries (OR 2.65, 1.43–4.89, p < 0.001). ConclusionsChronic pouchitis is the most common pouch disorder presentation. These entities have diverse therapeutics requirements, particularly for Crohn's disease of the pouch.

Are Small Molecules Effective in Treating Inflammatory Pouch Disorders Following Ileal Pouch-Anal Anastomosis for Ulcerative Colitis? Here Is Where We Stand.

Ulcerative colitis (UC) management encompasses conventional and advanced treatments, including biological therapy and small molecules. Surgery, particularly in the form of ileal pouch-anal anastomosis (IPAA), is indicated in cases of refractory/severe disease. IPAA can lead to acute complications (e.g., acute pouchitis) as well as late complications, including chronic inflammatory disorders of the pouch. Chronic pouchitis, including the antibiotic-dependent (CADP) and antibiotic-refractory (CARP) forms, represents a significant and current therapeutic challenge due to the substantial need for evidence regarding viable treatment options. Biological therapies have shown promising results, with infliximab, adalimumab, ustekinumab, and vedolizumab demonstrating some efficacy in chronic pouchitis; however, robust randomized clinical trials are only available for vedolizumab. This narrative review focuses on the evidence concerning small molecules in chronic pouchitis, specifically Janus kinase (JAK) inhibitors and sphingosine-1-phosphate receptor (S1P-R) modulators. According to the preliminary studies and reports, Tofacitinib shows a potential effectiveness in CARP. Upadacitinib presents variable outcomes from the case series, necessitating further evaluation. Filgotinib and ozanimod demonstrate anecdotal efficacy. This review underscores the need for high-quality studies and real-world registries to develop robust guidelines for advanced therapies in post-IPAA inflammatory disorders, supported by vigilant clinical monitoring and ongoing education from international IBD specialist societies.

Endoscopic Evaluation of the Ileal Pouch.

Structural and inflammatory adverse sequelae are common after restorative proctocolectomy and IPAA. On rare occasions, neoplasia can occur in patients with ileal pouches. Pouchoscopy plays a key role in the diagnosis, differential diagnosis, disease monitoring, assessment of treatment response, surveillance, and delivery of therapy. A systematic review of the literature was performed, and principles and techniques of pouchoscopy were described. PubMed, Google Scholar, and Cochrane databases. Relevant articles on endoscopy in ileal pouches published between January 2000 and May 2023 were included based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Diagnostic, surveillance, and therapeutic endoscopy in ileal pouch disorders were included. Accurate characterization of the ileal pouch in healthy or diseased states. The main anatomic structures of a J- or S-pouch are the stoma closure site, prepouch ileum, inlet, tip of the "J," pouch body, anastomosis, cuff, and anal transition zone. Each anatomic location can be prone to the development of structural, inflammatory, or neoplastic disorders. For example, ulcers and strictures are common at the stoma closure site, inlet, and anastomosis. Leaks are commonly detected at the tip of the "J" and anastomosis. Characterization of the anastomotic distribution of inflammation is critical for the differential diagnosis of subtypes of pouchitis and other inflammatory disorders of the pouch. Neoplastic lesions, albeit rare, mainly occur at the cuff, anal transition zone, or anastomosis. This is a qualitative, not quantitative, review of mainly case series. Most structural, inflammatory, and neoplastic disorders can be reliably diagnosed with a careful pouchoscopy. The endoscopist and other clinicians taking care of pouch patients should be familiar with the anatomy of the ileal pouch and be able to recognize common abnormalities. See video from symposium.

Effectiveness and safety of azathioprine for inflammatory pouch disorders: results from the RESERVO study of GETECCU.

The usefulness of thiopurines has been poorly explored in pouchitis and other pouch disorders. To evaluate the effectiveness and safety of azathioprine as maintenance therapy in inflammatory pouch disorders. This was a retrospective and multicentre study. We included patients diagnosed with inflammatory pouch disorders treated with azathioprine in monotherapy. Effectiveness was evaluated at 1 year and in the long term based on normalization of stool frequency, absence of pain, faecal urgency or fistula discharge (clinical remission), or any improvement in these symptoms (clinical response). Endoscopic response was evaluated using the Pouchitis Disease Activity Index (PDAI). In all, 63 patients were included [54% males; median age, 49 (28-77) years]. The therapy was used to treat pouchitis (n = 37) or Crohn's disease of the pouch (n = 26). The rate of clinical response, remission and non-response at 12 months were 52%, 30% and 18%, respectively. After a median follow-up of 23 months (interquartile range 11-55), 19 patients (30%) were in clinical remission, and 45 (66%) stopped therapy. Endoscopic changes were evaluated in 19 cases. PDAI score decreased from 3 (range 2-4) to 1 (range 0-3). In all, 21 patients (33%) presented adverse events and 16 (25%) needed to stop therapy. Azathioprine may be effective in the long term for the treatment of inflammatory pouch disorders and could be included as a therapeutic option.

Solitary pouch ulcer syndrome-a newly recognized phenotype of the ileal pouch disorders.

Solitary pouch ulcer syndrome-a newly recognized phenotype of the ileal pouch disorders.

Accuracy of Gastrointestinal Ultrasound and Calprotectin in the Assessment of Inflammation and its Location in Patients with an Ileoanal Pouch.

In symptomatic patients with ileoanal pouches, pouchoscopy is needed for accurate diagnosis but is invasive. We aimed to assess the utility of non-invasive gastrointestinal ultrasound and faecal calprotectin in ileoanal pouch patients. Patients with an ileoanal pouch were consecutively enrolled in this cross-sectional study from clinics in Victoria, Australia. The pouchitis disease activity index was used as a reference standard. Video-recorded pouchoscopies were reviewed by three gastroenterologists. Pouch, pre-pouch, and cuff biopsies were reviewed by a single pathologist. Ultrasound was performed by a single gastroenterologist transabdominally and transperineally. Faecal calprotectin was measured from morning stool samples. All examiners were blinded to patients' clinical history. A total of 44 participants had a pouchoscopy, of whom 43 had a faecal calprotectin test and 42 had an ultrasound; 17 had pouchitis, 15 had pre-pouch ileitis, and 16 had cuffitis. Pouch wall thickness of <3 mm was 88% sensitive in excluding pouchitis, and pouch wall thickness of ≥4 mm was 87% specific in diagnosing pouchitis. Transabdominal ultrasound had good utility [area under the curve: 0.78] in diagnosing moderate-severe pre-pouch ileitis. Transperineal ultrasound had good utility for the diagnosis of pouchitis [area under the curve: 0.79]. Faecal calprotectin differentiated inflammatory from non-inflammatory pouch disorders, such as irritable pouch syndrome, with an area under the curve of 0.90. Faecal calprotectin <100 µg/g ruled out inflammatory pouch disorders with a sensitivity of 94%. Faecal calprotectin and ultrasound are accurate and complementary tests to diagnose and localise inflammation of the ileoanal pouch. Prospective studies are needed to validate proposed sonographic indices and calprotectin levels.

Outcomes of Standard and Intensified Dosing of Ustekinumab for Chronic Pouch Disorders.

Up to 10% of patients with ulcerative colitis (UC) require total proctocolectomy (TPC) within 10 years after diagnosis.1 Ileal pouch-anal anastomosis (IPAA) is the preferred operation in this population. However, chronic pouch disorders (CPDs), including chronic antibiotic-refractory pouchitis (CARP) and Crohn’s disease of the pouch (CDoP), may occur in up to 30% and 10% of patients after IPAA, respectively.2 Patients with refractory CPDs often require biologic therapy or pouch excision.3 Ustekinumab (UST) is an anti-interleukin therapy approved for UC and CD. Limited data from small cohorts suggest that every 8 week (q8w) dosing of UST effectively treats CPDs.4,5 However, patients with CPDs may lose response to q8w dosing. Dose intensification to every 4 weeks (q4w) or every 6 weeks (q6w) appears to be effective among CD patients who lose response to UST, however similar data does not exist for CPDs.6 We therefore sought...

P104 Inflammatory complications of the pouch, and therapetic requirements after colectomy in patients with ulcerative colitis. Results from the RESERVO Study of GETECCU

Abstract Background Pouchitis and other inflammatory pouch diseases (IPD) are frequent in pouch-carrying patients operated for a previous diagnosis of ulcerative colitis. We evaluated characteristics and differences in therapeutic requirements between pouchitis, Crohn′s-like disease of the pouch (CDP) and cuffitis. Methods This is a retrospective and multicentric Spanish cohort of GETECCU (RESERVO Study), including pouch-carrying patients (operated 1995 to 2016) with previous ulcerative colitis, ileostomy closure and subsequent diagnosis of IPD (pouchitis, CDP or cuffitis), following ECCO diagnostic criteria1. Follow up extended to June 2020. Pouchitis was categorized attending current classifications. Use of medical and surgical therapies was collected and differences between pouchitis and CDP were analyzed using descriptive and comparative statistics. Results A total of 338 patients were included. Demographic and clinical characteristics are presented in Table 1. The most frequent IPD was pouchitis (n=258, 76%), followed by CDP (n=55, 16%) and cuffitis (n=25, 7.4%). Pouchitis was diagnosed at a median time of 27 (range 1–342) months. Prevalence according to pouchitis classification is presented in Figure 1. CDP was diagnosed at a median time of 77 (range 5–324) months, around 75% with a previous pouchitis diagnosis. Location of CDP (not mutually excludent) was pouch CDP (91%), 87% pre-pouch ileitis, and 41% perianal disease. Regarding behavior: 26 (47%) were inflammatory, 12 (22%) stricturing and 17 (31%) penetrating (8 rectovaginal fistulas). Cuffitis was diagnosed at a median time of 18 (range 1–219) months. Medical and surgical therapies used are shown in Figure 2. Immunosuppressants (58.2 vs 22.4%, p 0.001), biologics (74.5 vs 34.8%, p 0.0001), and surgery (41.8 vs 21.3%, p 0.003) were more used in CDP than in pouchitis. Conclusion Pouchitis and CDP are heterogeneous inflammatory pouch complications with a wide and high therapeutic requirement. CDP presents a later diagnosis and has higher therapeutic needs than pouchitis. 1. Fernando Magro, Paolo Gionchetti, Rami Eliakim et al, for the European Crohn’s and Colitis Organisation [ECCO], Third European Evidence-based Consensus on Diagnosis and Management of Ulcerative Colitis. Part 1: Definitions, Diagnosis, Extra-intestinal Manifestations, Pregnancy, Cancer Surveillance, Surgery, and Ileo-anal Pouch Disorders, J Crohns Colitis 2017; 11(6): 649–670.

P372 Effectiveness and safety of immunosuppressants for pouch disorders: results from the RESERVO Study of GETECCU

Abstract Background Pouchitis and other inflammatory disorders of the pouch (IDP), such as Crohn′s-like disease of the pouch (CDP), are frequent in patients operated for a previous diagnosis of ulcerative colitis. Many different therapies have been used, but the effectiveness of immunosupresants (IMM) has been poorly explored in this setting. Our aim was to evaluate the use, efficacy and safety of IMM in patients with pouchitis or another IDP. Methods Retrospective and multicentric study of a Spanish cohort of pouch-carrying patients with previous diagnosis of ulcerative colitis, and subsequent diagnosis of IDP, following ECCO diagnostic criteria. Patients who used IMM to treat these conditions were selected. Clinical effectiveness was evaluated at long-term. We defined clinical remission as returning to the previous stool frequency, no pain or defecatory urgency, clinical response as the improvement in these parameters without the achievement of remission, and non-response as no improvement or worsening symptoms. Endoscopic response was evaluated when possible using modified pouchitis disease activity index (PDAI) endoscopic subscore. Adverse events were collected. We used descriptive statistics. Results In the overall cohort of 338 patients with IDP, 93 (27%) were treated with IMM. Of those, 57% males, median age 40 (20-71) ys, and 72% non-smokers. Colectomy was performed at a median age of 31 (18-63) ys and IPD was diagnosed 25 (1-235) months after ileostomy closure. IMM used were thiopurines (n=86), methotrexate (n=4), cyclosporine (n=2) and tacrolimus (n=1). IMM were used as monotherapy in 66 (71%) cases and were indicated as treatment of pouchitis (n=60, 65%), CDP (n=32, 34.4%) and cuffitis (n=1, 1%). Effectiveness was evaluated only for thiopurine monotherapy (n=62). After a median follow-up of 23 (1-234) months, clinical remission was achieved in 31%, clinical response in 31% and non-response in 38% (Figure 1). There were no differences in effectiveness between pouchitis and CDP (63.9% vs 57.7%, p= 0.62). Endoscopic response was evaluated in 19 (30.6%) cases. After a median of 9 months of follow-up median PDAI endoscopic subscore dropped from 3 (range 2-4) to 1 (range 0-3), (Figure 2). Adverse events related with treatment appeared in 28 patients (45%). Thiopurines were discontinued in 39 cases (63%) due to failure (17), toxicity (16) and long remission (6 cases). Conclusion In our cohort, thiopurines were used in 27% of patients with IDP, with long-term benefit (remission or response) in around two-thirds of them. This therapy could be one more option to manage these disorders.

The Effectiveness and Safety of Hyperbaric Oxygen Therapy in Various Phenotypes of Inflammatory Bowel Disease: Systematic Review With Meta-analysis.

Accumulating evidence suggests that hyperbaric oxygen therapy (HBOT) may be effective for inflammatory bowel disease (IBD). Our systematic review aimed to quantify the effectiveness and safety of HBOT in various IBD phenotypes. We performed a proportional meta-analysis. Multiple databases were systematically searched from inception through November 2020 without language restriction. We included studies that reported effectiveness and/or safety of HBOT in IBD. Weighted summary estimates with 95% confidence intervals (Cis) were calculated for clinical outcomes for each IBD phenotype using random-effects models. Study quality was assessed using the Cochrane evaluation handbook and National Institute of Health criteria. Nineteen studies with 809 patients total were eligible: 3 randomized controlled trials and 16 case series. Rates of clinical remission included 87% (95% CI, 10-100) for ulcerative colitis (n = 42), 88% (95% CI, 46-98) for luminal Crohn's disease (CD, n = 8), 60% (95% CI, 40-76) for perianal CD (n = 102), 31% (95% CI, 16-50) for pouch disorders (n = 60), 92% (95% CI, 38-100) for pyoderma gangrenosum (n = 5), and 65% (95% CI, 10-97) for perianal sinus/metastatic CD (n = 7). Of the 12 studies that reported on safety, 15% of patients (n = 30) had minor adverse events. Study quality was low in the majority of studies due to an absence of comparator arms, inadequate description of concomitant interventions, and/or lack of objective outcomes. Limited high-quality evidence suggests that HBOT is safe and associated with substantial rates of clinical remission for multiple IBD phenotypes. Well-designed randomized controlled trials are warranted to confirm the benefit of HBOT in IBD.

A158 THE EFFECTIVENESS AND SAFETY OF HYPERBARIC OXYGEN THERAPY IN INFLAMMATORY BOWEL DISEASE AND ITS ASSOCIATED CONDITIONS: A SYSTEMATIC REVIEW AND META-ANALYSIS

Abstract Background Hyperbaric oxygen therapy (HBOT) corrects tissue hypoxia, mobilizes stem cells and has immunomodulatory effects, all of which are key mechanisms for healing wounds. A number of studies have suggested that HBOT may be effective for healing inflammatory bowel disease (IBD). Aims Our systematic review aimed to quantify the effectiveness and safety of HBOT in IBD and its associated conditions. Methods We performed a proportional meta-analysis. MEDLINE, EMBASE, Web of Knowledge and The Cochrane Central Register of Controlled Trials were systematically searched from inception through November 2020 with no language restriction. We included randomized controlled studies, cohort studies and case series that contained a minimum of three patients and reported effectiveness and/or safety outcomes for HBOT in patients with IBD. Studies were stratified by IBD phenotype and weighted summary estimates with 95% confidence intervals (CI) were calculated for clinical response and remission using random-effects models. Study quality was assessed using the Cochrane risk-of-bias tool for randomized trials and a modified version of the National Institutes of Health (NIH) checklist for observational studies. Results Nineteen studies met our study criteria: 3 randomized controlled trials and 16 case series. The studies reported outcomes for luminal ulcerative colitis (UC) (n=373), luminal Crohn’s disease (CD) (n=250), enterocutaneous fistulae (ECF) (n=21), perianal CD (n=115), pouch disorders (n=60), pyoderma gangrenosum (PG) (n=5) and perianal sinus/metastatic CD (n=7). Rates of clinical response were 86% (95% CI, 66–95%) for luminal UC, 86% (95% CI, 81–90%) for luminal CD, 85% (95% CI, 61–95%) for ECF, 80% (95% CI, 70–87%) for perianal CD, 65% (95% CI, 52–76%) for pouch disorders, 92% (95% CI, 38–99%) for PG and 79% (95% CI, 36–96%) for perianal sinus/metastatic CD. Rates of clinical remission were 87% (95% CI, 10–100%) for luminal UC, 88% for luminal CD (95% CI, 46–98%), 50% for ECF (95% CI, 12–88%), 64% (95% CI, 52–75%) for perianal CD, 31% (95% CI, 16–50%) for pouch disorders, 92% (95% CI, 38–100%) for PG and 65% (95% CI, 10–97%) for perianal sinus/metastatic CD. Of the ten studies that reported on safety of HBOT, 19 patients (10.5%) had minor adverse events and no major event was reported. Study quality was low in the majority of studies due to an absence of comparator arms, inadequate description of interventions, and poorly defined outcomes. Conclusions Limited high-quality evidence suggest that HBOT is safe and associated with high rates of clinical response and remission for luminal IBD, perianal CD and pouch disorders. A well-designed large multicenter randomized controlled trial is warranted to confirm the benefit of HBOT in IBD. doi:10.17605/osf.io/gpz6d Funding Agencies None

How Do I Diagnose and Manage Ileal Pouch Disorders?

How Do I Diagnose and Manage Ileal Pouch Disorders?

P028 Outcomes of Standard and Intensified Dosing of Ustekinumab for Chronic Pouch Disorders

BACKGROUND: Patients with chronic antibiotic-refractory pouchitis and Crohn's disease (CD) of the pouch are often treated with biologic agents. Data regarding the efficacy of ustekinumab therapy dosed every 8 weeks (q8w) and intensified dosing to q6w or q4w for these conditions is limited. We sought to assess outcomes of standard and intensified ustekinumab dosing and identify factors associated with clinical response among patients with chronic pouch disorders. METHODS: This retrospective cohort study included adults initiated on ustekinumab for chronic pouch disorders between January 1, 2016 and March 1, 2020. Electronic health records were reviewed to obtain demographic and clinical data. The primary outcome was physician-reported clinical response 2-4 months after ustekinumab initiation (q8w) or dose intensification (q6w or q4w). The secondary outcome was time to dose intensification. Additional outcomes included pouch excision with permanent ileostomy, improvement in the 6-point clinical subscore of the pouchitis disease activity index (PDAI), IBD-related hospitalization, improvement in severity/extent of inflammation on pouchoscopy, and discontinuation of chronic antibiotics. Univariable logistic and cox regression were used to identify characteristics associated with primary and secondary outcomes, respectively. RESULTS: 46 patients were initiated on ustekinumab for pouchitis (n = 6), cuffitis (n = 4), or CD of the pouch (n = 36). Outcomes after initiation were as follows (denominators vary due to missing data or insufficient follow-up time): 80.4% (37/46) of patients had a physician-reported clinical response at 2-4 months, 50.0% (23/46) underwent dose intensification after a median of 223 days, 8.7% (4/46) had a permanent ileostomy after a median of 571.5 days, 59.1% (26/44) had an improvement in PDAI clinical subscore at 2-4 months, 16.2% (6/37) were hospitalized within 12 months, 53.6% (15/28) of those who underwent pouchoscopy after initiation had improvement in pouch inflammation, and 30.8% (4/13) of patients on chronic antibiotics discontinued antibiotics within 12 months. Logistic regression demonstrated that female sex (OR 10.5; 95% CI 1.2-92.7; P = 0.03) and pouch fistula (OR could not be calculated; 37.8% clinical response vs. 0.0% no clinical response; P = 0.04 by Fisher's exact test) were positively associated with clinical response after initiation and cannabis use (OR 0.15; 95% CI 0.03-0.75; P = 0.02) was inversely associated with clinical response. Cox regression demonstrated that younger age at IBD diagnosis (HR 0.94; 95% CI 0.90-0.99; P = 0.01) and younger age at initiation (HR 0.96; 95% CI 0.92-0.99; P = 0.04) were associated with shorter time to dose intensification. After dose intensification to q4w or q6w, there were similar rates of clinical response at 2-4 months (61.9% q4w, 66.7% q6w), improvement in pouchoscopy (70.0% q4w, 75.0% q6w), and improvement in PDAI clinical subscore (47.6% q4w, 46.7% q6w) at 2-4 months. One patient experienced an adverse event (acneiform reaction), leading to ustekinumab discontinuation 807 days after dose intensification. On logistic regression analysis, no baseline characteristics were significantly associated with clinical response after dose intensification. CONCLUSION: While ustekinumab was effective for the majority of patients in our cohort, nearly 50% ultimately required dose intensification, which was effective in recapturing response for most patients. Larger, prospective studies are needed to determine the optimal subpopulations in which to employ various dosing strategies of ustekinumab for chronic pouch disorders.

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

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

Lower peripouch fat area is related with increased frequency of pouch prolapse and floppy pouch complex in inflammatory bowel disease patients.

Pouch prolapse is a rare pouch complication which often leads to pouch failure in inflammatory bowel disease (IBD) patients. Its exact cause remains unknown. Floppy pouch complex (FPC) was defined as the presence of any one of the following pouch disorders: pouch prolapse, afferent limb syndrome (ALS), redundant loop, and pouch folding. We aimed to explore the role of peripouch fat area in the occurrence of pouch prolapse and FPC. Pouch patients with available pouchoscopy and abdominal CT scans who were followed up between 2011 and 2017 in Cleveland Clinic were reviewed. Peripouch fat was measured on CT images. Of the 93 included patients, 31 were females; 87 had J pouches and 6 had S pouches. The median duration of pouch was 8.0 (interquartile range [IQR] 5.0-16.5) years. A total of 18 cases (19.4%, 18/93) were identified as FPC, including 12 pouch prolapse, 5 ALS, 1 redundant loop, and 3 pouch folding. Patients with pouch prolapse had lower peripouch fat area (13.6 (9.3-18.5) vs. 27.6 (11.0-46.2)cm2, P = 0.022) than those without. Patients with FPC had lower peripouch fat area (15.4 (11.4-20.6) vs. 27.6 (11.0-46.9)cm2, P = 0.040) than those without. Univariate and multivariate analyses demonstrated that lower peripouch fat area, lower weight, and family history of IBD were independent predictors of pouch prolapse and FPC. A lower peripouch fat area was observed in inflammatory bowel disease patients with pouch prolapse and FPC. Longitudinal studies are needed to further elucidate the role of peripouch fat in the pathogenesis of pouch prolapse and FPC.

A Personalized Approach to Managing Patients With an Ileal Pouch-Anal Anastomosis.

Quality of life after ileal pouch-anal anastomosis (IPAA) surgery is generally good. However, patients can be troubled by pouch-related symptoms and pouch disorders that can be inflammatory, mechanical/surgical, and functional. Management of patients with IPAA begins with measures to maintain a healthy pouch such as optimizing pouch function, providing tailored advice on a healthy diet and lifestyle, screening for and addressing metabolic complications of IPAA, pouch surveillance, and risk stratification for risk of pouchitis and pouch failure. Pouchitis is the most common inflammatory disorder. Primary pouchitis is a spectrum currently classified into three progressive phases—an antibiotic-responsive, an antibiotic-dependent, and an antibiotic-refractory phase. It is predominately microbially mediated in acute antibiotic-responsive pouchitis and predominately immune mediated in chronic antibiotic-refractory pouchitis (CARP). Secondary prophylaxis is recommended for recurrent antibiotic-responsive and for antibiotic-dependent pouchitis. Secondary causes of antibiotic-refractory pouchitis should be ruled out before a diagnosis of CARP is made. CARP is best classified as primary sclerosing cholangitis associated, immunoglobulin G4-associated, and autoimmune. Primary sclerosing cholangitis-associated CARP can be treated with budesonide or oral vancomycin. Early recognition of immunoglobulin G4-associated pouchitis minimizes ineffective antibiotic use. Autoimmune CARP can be managed in a manner similar to UC. The current place of immunosuppressives in the treatment algorithm depends on availability and early access to biological agents. Vedolizumab and ustekinumab are the preferred first- and second-line biologics for autoimmune CARP owing to their efficacy, better side effect profile, and low immunogenicity and need for concomitant immunomodulatory therapy. Antitumor necrosis factor should be reserved for autoimmune CARP failing the above and for CD of the pouch. There are no guidelines for the surveillance of pouches for dysplasia. Incidence varies based on a patient's risk. Since incidence is low, a risk-stratified approach is recommended.

Mo1852 – Investigation of Correlation Between Pouch Wall Thickness and Mucosal Inflammation on Endoscopy in Inflammatory Pouch Disorders

Mo1852 – Investigation of Correlation Between Pouch Wall Thickness and Mucosal Inflammation on Endoscopy in Inflammatory Pouch Disorders

Loss of tolerance to glycoprotein 2 isoforms 1 and 4 is associated with Crohn's disease of the pouch.

Zymogen granule glycoprotein 2 (GP2) is a major autoantigen of Crohn's disease-specific pancreatic autoantibodies. To test a link between loss of tolerance to isoforms of GP2 and pouch disorders in a cross-sectional study in ulcerative colitis patients with ileal pouch-anal anastomosis (IPAA). Serum samples of 117 consecutive ulcerative colitis patients after IPAA were tested for presence of Anti-GP2 isoforms 1 (GP21 ) & 4 (GP24 ) IgG and IgA as well as anti-Saccaromyces cervisiae (ASCA) IgG and IgA antibodies in a blinded fashion via enzyme-linked immunosorbent assay. Pouch disorders were diagnosed based on clinical, endoscopic, histological and radiographic criteria. Crohn's disease of the pouch was defined as involvement of the small bowel mucosa proximal to the ileal pouch with Crohn's disease, development of perianal complications or pouch fistula more than 3months after ileostomy closure. Positivity and level of Anti-GP21 IgG (AUC 0.77; P<0.001 & P=0.02, respectively), Anti-GP24 IgG (AUC 0.74; P<0.001 & P=0.025, respectively) and Anti-GP24 IgA (AUC 0.77; P<0.001 to P=0.018, respectively) were specifically associated with Crohn's disease of the pouch. Anti-GP2 was not associated with endoscopic or histological pouch disease activity index. Neither positivity nor levels of ASCA IgG (AUC 0.63; P=0.12 & P=0.35, respectively) or ASCA IgA (AUC 0.67; P=0.38 & P=0.53) were associated with pouch phenotypes. The novel anti-GP21 and GP24 antibodies are associated with Crohn's disease of the pouch in ulcerative colitis patients after IPAA. Serological anti-GP2 antibodies could aid in diagnosis of Crohn's disease of the pouch.

A Comprehensive Approach to Pouch Disorders.

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical procedure of choice for patients with medically refractory ulcerative colitis (UC) or indeterminate colitis, UC with colonic dysplasia or neoplasia, and familial adenomatous polyposis. In general, patients experience good function outcomes and quality of life with an IPAA. Although pouchitis is the most well-recognized and frequent complication after IPAA, a number of additional inflammatory, postsurgical, structural, neoplastic, and functional complications may occur, resulting in pouch dysfunction. We herein provide a comprehensive review of pouch function and an approach to diagnosis and management of pouch complications.

Diagnosis and management of floppy pouch complex.

Restorative proctocolectomy with ileal pouch–anal anastomosis has become the surgical treatment of choice for patients with refractory ulcerative colitis, colitis-associated dysplasia or familial adenomatous polyposis. There are various pouch disorders and associated complications. Floppy pouch complex is defined as the presence of pouch prolapse, afferent limb syndrome, enterocele, redundant loop and folding pouch on pouchoscopy, gastrografin pouchogram or defecography. Common clinical presentation includes dyschezia, bloating, abdominal pain, straining or the sense of incomplete evacuation. Each disorder has its own unique endoscopic, radiographic and manometry findings. A range of therapeutic options are available for the management of the various causes of a pouch.