Pouchitis Research Articles

Pyloric and foveolar type metaplasia are important diagnostic features in Crohn's disease that are frequently missed in routine pathology.

Pyloric type metaplasia (PYME) as evidence of chronic mucosal damage, is one of the main histopathological findings for diagnosing Crohn's Disease (CD) in terminal ileum biopsies, according to the latest guidelines but still frequently underdiagnosed in routine pathology. Foveolar metaplasia (FOME) changes in mucosa, another aspect of the chronic post -inflammatory Ulcer Associated Cell Lineage (UACL), have only been reported in a few cases. However, their clinical significance has not been investigated in depth except in pouchitis. The aim of this study was to investigate the importance of meticulous study of terminal ileum biopsies for the recognition of PYME/FOME as an adjunct finding helpful for the diagnosis of CD. In the present study, two experienced gastrointestinal pathologists, have reviewed 105 terminal ileum biopsies from 105 patients with CD, using a protocol of 15 sections on average per biopsy. In 21% (22/105) of cases PYME was recognized and in 4% (4/105) FOME was also present. PYME/FOME had not been detected in 83% of these cases in the original reports. FOME was also identified in terminal ileum biopsies, a feature not reported previously in CD. Conclusively, PYME/FOME can be easily missed in terminal ileum biopsies from patients with suspected or known CD unless a meticulous study of the histologic material is carried out combined with awareness of the pathologist about its importance.

Precolectomy Flora Predict Pouchitis

Pouchitis is the most frequently occurring complication of ileal pouch–anal anastomosis for ulcerative colitis and is commonly treated with antibiotics

Gut microbiota, probiotics and prebiotics in pediatrics

Intestinal microbiota plays an important role in gut metabolism, defense against environmental pathogens, motility and immune system regulation. Microbiota is gradually aquired from the environment during and after delivery, with several factors, such as feeding habits, disease and antibiotic treatment, importantly influencing its composition. Growing awareness about the importance of the intestinal microbiota for the host physiologic processes and health has led to development of different strategies how to influence its composition and function. Probiotics, specific live microorganisms which when ingested in sufficient amount can promote health benefit to the host, and prebiotics, nondigestible food ingredients that benefit the host by selectively stimulating the favorable growth and/or activity of a limited number of health-promoting bacteria, have been increasingly used in the last decades. They exert their beneficial effects through three main mechanisms: by changing gut ecology, affecting the intestinal mucosal barrier, and by modulating the immune response. The efficacy of pro- and prebiotics in clinical practice has been extensively studied. The results of clinical studies with the specific strain or strains in a defined dose and vehicle should not be extrapolated to the use of other products. There is strong scientific evidence for the use of specific probiotics in acute gastroenteritis, antibiotic-associated diarrhea, prevention and treatment of atopic dermatitis, prevention of relapses of ulcerative colitis and pouchitis, as well as enhancing immune response, and some evidence of efficacy in prevention of necrotizing enterocolitis, treatment of Clostridium difficile- associated diarrhea, active ulcerative colitis, and functional gastrointestinal disorders.

Probiotics and Pouchitis

Probiotics and Pouchitis

ANCA Is Associated with Chronic Pouchitis

Pouchitis is a common and well-known complication of total proctocolectomy and ileoanal pouch anastomosis (IPAA) for inflammatory bowel disease. In some but not all studies, positivity for antineutrophil cytoplasmic antibody (ANCA) has been associated with an increased risk for pouchitis. A link between the anti– Saccharomyces …

Randomized Controlled Trials in Pouchitis

Randomized Controlled Trials in Pouchitis

Diagnosis and treatment of pouchitis and pouch dysfunction

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) has become the surgical treatment of choice for patients with medically refractory ulcerative colitis (UC) or UC with dysplasia and for the majority of patients with familial adenomatous polyposis. However, UC patients with IPAA are susceptible to a number of inflammatory and non-inflammatory sequelae, such as pouchitis, Crohn disease(CD) of the pouch, cuffitis, and irritable pouch syndrome, in addition to common surgery-associated complications, which adversely affect the surgical outcome and compromise patient's health-related quality of life. Pouchitis is the most frequent long-term complication of IPAA in patients with UC, with a cumulative prevalence of up to 50%. Pouchitis may be classified based on the etiopathogenesis into "idiopathic" and "secondary" types and the management is often different. Pouchoscopy is the most important tool for the diagnosis and differential diagnosis in patients with pouch dysfunction. Antibiotic therapy is the main stay of treatment for active pouchitis. Some patients may develop dependency on antibiotics, requiring long-term maintenance therapy. While management of antibiotic-dependent or antibiotic-refractory pouchitis has been challenging, secondary etiology for pouchitis should be evaluated and modified, if possible.

Pouchitis after Restorative Proctocolectomy for Ulcerative Colitis

回腸嚢炎は潰瘍性大腸炎（UC）に対する大腸亜全摘・回腸嚢肛門（管）吻合術後に回腸嚢に起こる非特異性炎症である・外科治療成績の向上に伴いクローズアップされてきた病態で，病因は未だ不明であるが，UCの病態と関連があり，腸内細菌の関与が濃厚である．抗菌剤が有効で，多くは一過性であるが，一部に難治例があり，病因・病態の解明とより有効な治療の開発が待たれる．

IgG4-associated Pouchitis

IgG4-associated Pouchitis

Which therapies are advisable in pouchitis?

Which therapies are advisable in pouchitis?

Which therapies are advisable in pouchitis?

Which therapies are advisable in pouchitis?

Managing Pouchitis

Managing Pouchitis

Managing Pouchitis

Managing Pouchitis

Authors' reply: Dysbiosis and pouchitis (Br J Surg 2006; 93: 1325–1334)

Authors' reply: Dysbiosis and pouchitis (<i>Br J Surg</i> 2006; 93: 1325–1334)

Tacrolimus Is Safe and Effective in Patients with Severe Steroid-Refractory or Steroid-Dependent Inflammatory Bowel Disease-A Long-Term Follow-Up

We and others have reported the use of tacrolimus in refractory inflammatory bowel disease (IBD). Little is known about its long-term efficacy and safety. In this retrospective, observational single center study the charts of 53 adult patients with steroid-dependent (n = 18) or steroid-refractory (n = 35) IBD, Crohn's disease (CD) (n = 11), ulcerative colitis (UC) (n = 40), or pouchitis (PC) (n = 2) were reviewed. Tacrolimus (0.1 mg/kg body weight per day) was administered orally in all and initially intravenously in 2 patients (0.01 mg/kg body weight per day), aiming for serum trough levels of 4-8 ng/mL. Forty-one of 53 (77.1%) patients were receiving concomitant azathioprine. The mean treatment duration was 25.2 +/- 4.6 SD months (0.43-164 months). Patients were followed for a mean of 39 +/- 4.1 SD months (5-164 months). Response was evaluated using a modified clinical activity index (M-CAI). Thirty-one UC (78%), 10 CD (90.1%), and both PC (100%) patients experienced an immediate clinical response or went into remission at 30 days. A statistically significant drop on the M-CAI was documented for UC and CD patients. Nine UC patients (22.5%) underwent colectomy between 1.6 and 41.3 months following initiation. Mean colectomy-free survival was 104.8 +/- 15.5 (95% CI 74.4-135.2) months (limited to 164.4 months). Cumulative colectomy-free survival was estimated 56.5% at 43.8 months. Steroids were reduced or discontinued in 40 of 45 UC and CD patients (90%) taking steroids. Side effects included a temporary rise of creatinine (n = 4, 7.6%), tremor or paresthesias (n = 5, 9.4%), hyperkalemia (n = 1, 1.9%), hypertension (n = 1, 1.9%), and opportunistic infections (n = 2, 3.8%). Long-term tacrolimus therapy appears safe and effective in refractory IBD.

Single-Dose VSL#3 Maintains Remission in Pouchitis

Maintaining remission in patients with refractory or treatment-resistant pouchitis is problematic. In this partially manufacturer-supported study,

潰よう性大腸炎術後のＰｏｕｃｈｉｔｉｓの診断，治療の問題点

目的・方法:潰瘍性大腸炎術後のpouchitisについて,診断,治療上の問題点を検討した.Pouchitisの診断にはPouchitis Disease Activity Index (PDAI) scoreと厚生省診断基準案を併用した.厚生省診断基準案の内視鏡所見で中等度以上に該当した症例に対して抗生剤を投与し,前後の臨床症状,内視鏡所見について検討した.結果:PDAI scoreと厚生省診断基準案は同様の結果であり,組織所見なしでも診断,重症度判定は可能であった.Pouchitis症例では排便回数は内視鏡所見とよく相関し,治療後有意に減少した.

Endoscopy without biopsy cost effective for pouchitis diagnosis

Endoscopy without biopsy cost effective for pouchitis diagnosis

Prevention of Pouchitis with Probiotics

The probiotic preparation VSL#3 has been shown to maintain remission of pouchitis after ileoanal pull-through for inflammatory bowel disease (IBD). The

The Role of Gastrointestinal Bacterial Ecology in Inflammatory Bowel Disease (IBD)

The pathogenesis of inflammatory bowel disease (IBD) is not yet fully understood. A genetic predisposition, some environmental factors and microbial flora of the gut are the key factors. The presence of bacteria in the intestinal lumen is a prerequisite for the development of IBD. In animal models, mice incapable of expressing IL2 or IL10 invariably develop a colitis- or Crohn-like inflammation. No inflammation occurs if they grow up in a pathogen-free environment or if they are fed with Lactobacillus sp when exposed to environmental bacteria. Thus, the absence of luminal bacteria or a different make-up there of prevents the development of inflammatory bowel disease in this model. Patients with IBD have been found to have a decreased stool excretion of Lactobacillus and/or Bifidobacteria. Furthermore, an increased number of bacteria adherents to the mucosa and within the epithelium has been demonstrated in quantitative studies. It appears that these bacteria trigger a strong abnormal mucosal immunological response, leading to intestinal epithelial cell injury mediated by activated T-cells, mononuclear cells and macrophages. If this response can not be down regulated by regulatory T-cells, numerous inflammatory cytokines are activated by stimulation of the intracellular transcription factor NF-kB. Recently it was shown that bacterial lipopolysaccharides can activate NF-kB by binding to two specific receptors on the cell membrane (Toll-like receptors [TLR’s]) or intracellular receptors (NOD’s). New insights of the role of bacteria in IBD became available by identifying susceptibility genes for IBD. Several IBD susceptibility loci were recently identified. The IBD-1 locus on chromosome 16 shows positive evidence for linkage in Crohn’s disease and IBD-2 locus on chromosome 12 for ulcerative colitis. The evidence for an association with Crohn’s disease at the IBD-1 locus have been shown to be attributed to mutations in the CARD15/NOD2 gene. This gene is expressed in peripheral blood monocytes and in intestinal epithelial cells and serves as a key factor of innate mucosal response to luminal bacteria as an antibacterial factor. The intact intercellular NOD2 protein binds LPS and activates NF-kB. This activation of the NF-kB signalling pathway in response to bacterial components plays a protective role in the mucosal epithelial cells for the host against inviting pathogens and an increased apoptosis of infected cells. There is evidence, that the defective NOD2 protein variants increase the susceptibility to pathogen invasion and a decrease in cellular apoptosis. NF-kB plays a dual role in IBD. On the mucosal epithelial cells, bacterial components bind on NOD2 proteins and protect bacterial invasion. If this barrier mechanism is not intact, the bacterial invasion stimulates via TLR- and NOD2 receptors in immune-active cells (macrophages, T-cells and monocytes) NF-kB and triggers an aberrant inflammatory response leading to tissue damage. These new insights in the pathogenesis in IBD have led to new treatment possibilities including pre- and probiotics. These therapies are aimed at directly modulating the host immune system to suppress intestinal inflammation. This has prompted considerable interest in manipulating the enteric microenvironment as a novel therapeutic strategy. Several clinical studies showed promising results using pre- and probiotics in patients with ulcerative colitis, pouchitis and Crohn’s disease. The introduction of genetically engineered probiotic organism to produce and deliver anti- inflammatory cytokines or other biological relevant molecules to the mucosa offers further new potential for the treatment of IBD. Keywords : Inflammatory Bowel Disease, inflammatory cytokines