Severe Pouchitis Research Articles

Ataxia and Slurred Speech Following Severe Pouchitis

A 74 year old woman with PSC and cirrhosis (Child class B) presented to the hospital with slurred speech, unsteady gait, and falls. She has a history of chronic ulcerative colitis for which she underwent ileal pouch-anal anastomosis in the 1980s. 2 weeks prior to presentation she was briefly hospitalized for worsening diarrhea with fecal incontinence despite chronic ciprofloxacin. She responded clinically to metronidazole and had been dismissed on oral metronidazole 500 mg t.i.d. for histologically confirmed pouchitis. This medication was discontinued on admission. On examination, she was alert and oriented but was severely dysarthric. Finger to nose was slow bilaterally and her gait was ataxic. Strength was preserved. There were no sensory deficits or asterixis. Ascitic fluid analysis showed no infection. Brain imaging was performed. MRI of the head without and with IV gadolinium demonstrated homogeneous abnormal increased T2 signal within the cerebellar dentate nuclei. (Figure 1) Within 24-hours of discontinuation of metronidazole, her neurologic deficits improved significantly. Physical and speech therapy were initiated. Her speech and gait improved dramatically and she he was dismissed to a subacute facility for further rehabilitation. In the setting recent metronidazole treatment for pouchitis, the patient's clinical presentation and MRI findings are consistent with metronidazole neurotoxicity. In this uncommon occurrence, brain MRI characteristically demonstrates increased signal intensity (T2) within the dentate nuclei. Clinical symptoms resolve after discontinuation of metronidazole; the MRI abnormalities also reverse within weeks of metronidazole withdrawal. Because metronidazole is extensively metabolized by the liver, patients with cirrhosis may be more susceptible to toxic effects of the drug. Neurotoxicity is an uncommon effect of metronidazole use that may be more likely to occur in patients with hepatic impairment. Recognition of the clinical presentation is essential as the neurologic symptoms are nearly always reversible with medication withdrawal. [figure 1]Figure

Successful treatment of severe pouchitis with rebamipide refractory to antibiotics and corticosteroids: A case report

The antibiotics, metronidazole and ciprofloxacin, are the first-line treatment for pouchitis. Patients who do not respond to antibiotics or conventional medications represent a major challenge to therapy. In this report, we have described a successful treatment of severe refractory pouchitis with a novel agent, rebamipide, known to promote epithelial cell regeneration and angiogenesis. A 27-year-old male with ileo-anal pouch surgery presented with worsening anal pain, diarrhea, and abdominal pain. The patient was diagnosed to have pouchitis and was given metronidazole together with betamethasone enema (3.95 mg/dose). However, despite this intensive therapy, the patient did not improve. On endoscopy, ulceration and inflammation were seen in the ileal pouch together with contact bleeding and mucous discharge. The patient was treated with rebamipide enema (150 mg/dose) twice a day for 8 wk without additional drug therapy. Two weeks after the rebamipide therapy, stool frequency started to decrease and fecal hemoglobin became negative at the 4th wk. At the end of the therapy, endoscopy revealed that ulcers in the ileal pouch had healed with no obvious inflammation. The effect of rebamipide enema was dramatic and was maintained throughout the 11-mo follow-up. The patient continued to be in remission. No adverse effects were observed during the treatment or the follow-up period. The sustained response seen in this case with severe and refractory pouchitis indicates that agents, which promote epithelial cell growth, angiogenesis and mucosal tissue regeneration, are potential therapeutic agents for the treatment of refractory colorectal lesions.

Adenocarcinoma of the ileoanal pouch for ulcerative colitis—a complication of severe chronic atrophic pouchitis?

The appearance of a carcinoma in the ileal pouch after restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative proctocolitis is rare. Most of these adenocarcinomas previously described in literature develop from residual viable rectal mucosa. We report a case of an adenocarcinoma arising in all probability from the ileal pouch after malignant transformation of the ileal pouch mucosa based on a chronic atrophic pouchitis. A 34-year-old man developed an adenocarcinoma after a double-stapled ileorectal J-pouch for ulcerative colitis (UC) proceeded from malignant ileal transformation. Before surgery, he had a 20-year history of UC refractory to medical therapy, but no occurrence of backwash ileitis, dysplasia or colitis-associated illness. He experienced severe pouchitis after IPAA since the ileostomy closure. Carcinoma was ensured by endoscopy, and the patient underwent an abdominoperineal pouch extirpation combined with excision of perirectal tissues and anal canal. Histology after surgery showed a pT4,pN2(4/16)pM0,G3 adenocarcinoma with global severe chronic atrophic pouchitis (CAP), villous atrophy and malignant ileal transformation. No metaplasia of the rectal mucosa was found, not even malignant epithelial transformation of the anal canal. This case suggests that a malignant transformation of the ileal pouch mucosa may occur as a pure complication of severe CAP, even in the absence of backwash ileitis or a previous history of cancer. The absence of metaplasia of the rectal mucosa revealed the passage from CAP to dysplastic epithelium and to cancer. A multifactorial development of carcinogenesis is supposed, but we emphasize the importance of severe CAP, and that careful surveillance is needed in patients after IPAA. We must submit that this is just a case report and cannot stand for general cancer development in ulcerative colitis, but it may point out the risk factor of chronic inflammation and leads the surgeon to skillful working when building the pouch.

Diagnosis and management of pouchitis

Diagnosis and management of pouchitis

Cancer risk assessment in long-standing pouchitis

In a small subgroup of patients with ulcerative colitis (UC) undergoing proctocolectomy and restorative ileal pouch-anal anastomosis (IPAA), a colonic-like pouch mucosa with severe and persistent villous atrophy (type C pattern) develops. Neoplastic transformation of the mucosa in the neorectum may occur in these patients. We hypothesized that genetic alterations associated with colorectal carcinoma (CRC) could be an early finding in this transformational process and thus potentially useful as clinical monitors in carcinoma risk assessment. In six patients with long-standing severe pouchitis and a type C-pattern mucosa, biopsies were obtained from five different locations of the pouches. DNA was PCR-amplified and analyzed by automated fragment analysis for loss of heterozygosity (LOH) at chromosome 5q14-22, 17p12-13, and 18q12-22. Point mutations of the K-ras and adenomatous polyposis coli (APC) genes were studied by sequencing. The patients had varying degrees of dysplasia and one displayed DNA aneuploidy. Loss of heterozygosity at 5q15-22 was detected in three of five biopsies in one patient. This particular patient had no signs of dysplasia or DNA aneuploidy and a normal exon 15 sequence of the APC gene. No alterations of either the K-ras or the APC genes or LOH of 5q, 17p, or 18q were seen in any of the other patients. Dysplasia, aneuploidy, and LOH in 5q may all reflect different parts of an atrophic mucosa-dysplasia-carcinoma sequence, in line with current concepts of carcinogenesis for CRC in long-standing pouchitis. Further studies of histological and molecular events in IPAA patients with severe atrophy are warranted.

SIMPLIFIED TECHNIQUE WITH SHORT AND LONG-TERM FOLLOWUP OF CONVERSION OF AN ILEAL CONDUIT TO AN INDIANA POUCH

We report a simplified technique for converting an existing conduit to an Indiana pouch as well as short and long-term results. From May 1988 to February 1998 we evaluated short and long-term outcome and complications in 23 patients 14 to 82 years old (average age 51.8) who underwent conversion of a conduit to an Indiana pouch. When no obstruction of the existing ureteroileal anastomoses was identified, the conduit was freed from the abdominal wall and surrounding bowel. The proximal conduit and ureteral anastomoses were not dissected. The conduit was opened along the antimesenteric wall proximal to the ureteral anastomoses and attached to 25 to 28 cm. of detubularized right colon as a refluxing Studer limb. The pouch was completed in the usual fashion and the stoma was matured at a virgin site. Surgical indications included stomal complications in 10 patients, an infected nonfunctioning kidney in 2 and patient preference in 11. There were no perioperative deaths although 3 patients died of cancer progression. Average operative time was 6.6 hours, estimated blood loss 518 cc and length of stay 7.8 days. Average followup after conversion was 4.7 years (range 0.2 to 11.0). Six late complications developed in 4 cases, including pyelonephritis in 2, severe pouchitis in 1, dehydration in 1 and stomal revision in 2. Renal function was well preserved with an average preoperative and postoperative creatinine of 0.91 and 1.14 mg./dl., respectively. This technique simplifies conversion and decreases bowel requirements. The low complication rate and stable serum creatinine support the finding that conversion of a conduit to an Indiana pouch is a safe, viable procedure.

Long-term Clinical Outcome and Anemia after Restorative Proctocolectomy for Ulcerative Colitis

Background: The purpose of this study was to evaluate long-term outcome and hematologic data after restorative proctocolectomy (RPC) and mucosectomy with hand-sewn J-pouch-anal anastomosis for ulcerative colitis (UC). Methods: Forty-eight (75%) out of 64 consecutive patients operated on during the period 1985-1990 participated in a long-term follow-up in 1998. Study visits involved an interview according to a 23-item functional questionnaire, pouch endoscopy and blood samples. Pre- and postoperative data on these patients were reviewed at our own database covering all operations performed for UC at our institute. Results: Functional disturbances were common and unchanged during long-term follow-up. Minor incontinence occurred in 37.5% and outlet difficulties in 10.5% of patients. Bowel obstruction occurred in 16.7% and usually needed operative treatment. Twenty-four (50.0%) patients had had at least one episode of pouchitis and chronic or severe pouchitis occurred in 18 (37.5%) cases. Males seem to have chronic pouchitis more often. Ten (20.8%) patients had anemia during follow-up. Recurrent bleeding from the pelvic pouch and chronic pouchitis exposed to the anemia. Conclusions: Minor morbidity is common after RPC. Pouchitis occurred in half of our patients during long-term follow-up. There may be a risk of anemia with chronic pouchitis and bleeding from the pelvic pouch mucosa.

Use of cyclosporin retention enemas in a patient with intractable pouchitis after proctocolectomy for ulcerative colitis: a case report

We report the case of a 46-year-old male with a 24-year history of ulcerative colitis who underwent proctocolectomy and ileal S-pouch-anal anastomosis. Six months after surgery the patient complained of increased daytime bowel frequency; pouchoscopy revealed severe pouchitis. Because of the failure of conventional treatments, the patient underwent a cycle of cyclosporin A (CsA) enemas. The therapy consisted of one enema each day for 5 weeks (35 administrations). The patient was submitted to a total of five pouchoscopies, the first before the beginning of the enemas cycle and the last one 2 months after the end of the treatment, Endoscopy showed a remarkable improvement at day 10, but these findings were not confirmed later. Biopsies showed a marked improvement at 10 days, but at later stages a reappearance of crypt abscesses with an increasing number of inflammatory infiltrates. In spite of the grim picture at endoscopy and histology, the patient felt better and noted a progressive reduction of the bowel movements and cessation of mucous and bloody discharge. At present, he reports six bowel movements per day and no bleeding.

Pouchitis following pelvic pouch operation for ulcerative colitis. Incidence, cumulative risk, and risk factors.

This study was undertaken to assess the risk for pouchitis in patients with ulcerative colitis who underwent surgery with colectomy, restorative pelvic pouch, and ileoanal anastomosis and to evaluate possible factors predictive for pouchitis development. All patients receiving a pelvic pouch because of ulcerative colitis at Huddinge University Hospital between 1980 and 1993 (n = 149; 89 men) were prospectively evaluated for symptoms suggestive of pouchitis. Diagnosis of pouchitis was based on occurrence of certain symptoms in combination with endoscopic findings. Pouchitis was divided into mild and severe, and the time span until the first attack of mild or severe pouchitis was calculated for each patient. Median follow-up time was 54 (5-152) months. The absolute cumulative risk of developing mild pouchitis was 21, 26, and 39 percent at 6, 12, and 48 months, respectively. The corresponding cumulative risk of developing severe pouchitis was 9, 11, and 14 percent, respectively. Risk for both groups together was 51 percent at 48 months. The occurrence of pouchitis, calculated at six-month intervals after closure of the loop ileostomy, was highest (23.1 percent) during the first six months. Incidence during the next six-month period was 11.4 percent and then only 3.1 percent thereafter. Thirty-two patients (21.5 percent) had chronic continuous symptoms requiring long-term metronidazole treatment, and 14 (9.4 percent) of those had chronic severe pouchitis. In two patients, removal of the pouch and permanent ileostomy became necessary. Extracolonic manifestations and early onset of ulcerative colitis were predictive factors for developing pouchitis. Former smoking seemed to be a protective factor. The risk for pouchitis was highest during the initial six-month period. Cumulative risk leveled off after two years but was substantial (51 percent) at four years. Less than 10 percent of patients had severe, chronic pouchitis, and only two patients (1.3 percent) had their pouches removed.

Long-term histomorphological surveillance of the pelvic ileal pouch: Dysplasia develops in a subgroup of patients

Background & Aims : Little is known about the longterm morphology of the pelvic ileal pouch after restorative proctocolectomy in patients with ulcerative colitis. This study analyzed the mucosal adaptation in the pouch during a long-term follow-up. Methods : Mucosal biopsy specimens were obtained from 87 patients during a follow-up of 6.3 years (SD, 2.7; range, 3–14 years). The villous surface density, degree of inflammation, and type of mucin were determined from glycolmethacrylate-embedded sections. Results : Three basic patterns of mucosal adaptation were observed: regular response with normal mucosa or mild villous atrophy and no or mild inflammation (type A, 51%), transient atrophy response with temporary moderate or severe villous atrophy followed by normalization of architecture (type B, 40%), and constant atrophy response with permanent subtotal or total villous atrophy developing from the early functioning period accompanied by severe pouchitis (type C, 9%). Low-grade dysplasia occurred in 3 patients with type C response. Conclusions : In a small group of patients with ulcerative colitis, the mucosa of the pelvic pouch adapts with constant severe villous atrophy accompanied by long-standing pouchitis. This group of patients should be identified and undergo regular endoscopic and histomorphological surveillance because of risk of developing neoplasia in the pouch mucosa.