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Pandrangi V, Mandel D, Gellada N, Kallman C, Zaghiyan K, Fleshner P. Abdominal Visceral Fat Area and Chronic Pouchitis after Ileal Pouch-Anal Anastomosis. Am Surg 2017. [DOI: 10.1177/000313481708301003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Chronic pouchitis (CP) after ileal pouch-anal anastomosis is a significant clinical problem. Adipose tissues produce antiinflammatory cytokines and chemokines. We evaluated the association between abdominal visceral fat area (VFA) and CP. Patients with a preoperative CT evaluation were included. The diagnosis of CP was confirmed in all cases by endoscopy with afferent ileal limb intubation. Patients were allocated into groups of high VFA and low VFA. The study cohort of 52 patients had a median body mass index of 22 (range, 14–32). Indications for surgery were medically refractory disease in 46 (88%) patients and cancer/dysplasia in six (12%) patients. Median VFA was 27.1 (range, 1–144). Six (12%) patients developed CP. Low VFA patients were significantly younger (29 vs 45 years; P < 0.0001), had lower body mass index (20.4 vs 24.7; P < 0.0001), had surgery more commonly for medically refractory disease than for cancer or dysplasia (100 vs 77%; P = 0.02), and had a higher incidence of CP than high VFA patients (23 vs 0%; P = 0.02). Multiple linear regression analysis demonstrated that only low VFA was associated with CP (P = 0.009). An association is present between VFA and CP after ileal pouch-anal anastomosis, implicating adipocytes in the pathogenesis of inflammatory bowel disease.
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Affiliation(s)
- Vivek Pandrangi
- Divisions of Colon and Rectal Surgery and Diagnostic Radiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel Mandel
- Divisions of Colon and Rectal Surgery and Diagnostic Radiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Norman Gellada
- Divisions of Colon and Rectal Surgery and Diagnostic Radiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Cindy Kallman
- Divisions of Colon and Rectal Surgery and Diagnostic Radiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Karen Zaghiyan
- Divisions of Colon and Rectal Surgery and Diagnostic Radiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Phillip Fleshner
- Divisions of Colon and Rectal Surgery and Diagnostic Radiology, Cedars-Sinai Medical Center, Los Angeles, California
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Zaghiyan K, Kaminski JP, Barmparas G, Fleshner P. De novo Crohn's Disease after Ileal Pouch-Anal Anastomosis for Ulcerative Colitis and Inflammatory Bowel Disease Unclassified: Long-Term Follow-Up of a Prospective Inflammatory Bowel Disease Registry. Am Surg 2016. [DOI: 10.1177/000313481608201026] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The risk of de novo Crohn's disease (CD) after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) versus inflammatory bowel disease unclassified (IBDU) or indeterminate colitis (IC) remains debatable. Here, we present updated results after long-term follow-up of a previously studied cohort of 334 patients with UC, IBDU, or IC who underwent IPAA during a 10-year period ending 2007. Of 334 study patients, 56 per cent were male and median age was 38 years (range: 8–81). Patients were classified as UC (n = 237) or IBDU (n = 97) preoperatively and UC (n = 236) or IC (n = 98) postoperatively. After a median follow-up of 76 months (range: 3–236), 63 patients (19%) developed CD within a median of 22 months (range: 1–213) from ileostomy closure compared with the previously published 40 patients (12%) with 26-month follow-up ( P = 0.01). The development of de novo CD was similar for patients undergoing IPAA for UC (n = 40; 17%), IBDU (n = 21; 22%) or those classified as having UC (n = 42; 18%) or IC (n = 19; 19%) postoperatively; P > 0.05. Thus, patients with IBDU and IC can expect equivalent long-term outcome to patients with UC after IPAA. Pouch failure occurred in 13 (4%) study patients and was equal among all four groups.
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Affiliation(s)
- Karen Zaghiyan
- From the Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jan P. Kaminski
- From the Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Galinos Barmparas
- From the Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Phillip Fleshner
- From the Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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3
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Gonzalo DH, Collinsworth AL, Liu X. Common Inflammatory Disorders and Neoplasia of the Ileal Pouch: A Review of Histopathology. Gastroenterology Res 2016; 9:29-38. [PMID: 27785322 PMCID: PMC5040541 DOI: 10.14740/gr706e] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/07/2016] [Indexed: 12/24/2022] Open
Abstract
Ileal pouch-anal anastomosis (IPAA) is the standard restorative procedure after proctocolectomy in patients with ulcerative colitis (UC) who require colectomy. The ileal pouch is susceptible to a variety of insults including mechanical injury, ischemia, fecal stasis, and infectious agents. In addition, the development of recurrent and idiopathic inflammatory bowel disease and neoplasia may occur in the ileal pouch. Although clinical, endoscopic, and radiographic examination can diagnose many ileal pouch diseases, histologic examination plays an essential role in diagnosis and management, particularly in cases with antibiotic refractory chronic pouchitis and pouch neoplasia.
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Affiliation(s)
- David Hernandez Gonzalo
- Department of Pathology, Immunology and Laboratory Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Amy L. Collinsworth
- Department of Pathology, Immunology and Laboratory Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Xiuli Liu
- Department of Pathology, Immunology and Laboratory Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
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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. Inflamm Bowel Dis 2016; 22:654-61. [PMID: 26595552 DOI: 10.1097/mib.0000000000000630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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). CONCLUSIONS Initial nonbloody diarrhea is associated with denovo CD after IPAA. This association warrants close consideration before surgery.
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Mabvuure NT, Maclean L, Oien K, Gaya D. Cytomegalovirus pouchitis in a patient with Crohn's disease. BMJ Case Rep 2014; 2014:bcr-2014-205374. [PMID: 25035450 PMCID: PMC4112339 DOI: 10.1136/bcr-2014-205374] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Colectomy with ileoanal pouch formation is usually contraindicated in patients with Crohn's disease (CD) due to the risk of recurrent disease and pouch failure. We report the case of a patient, initially thought to have ulcerative colitis (UC), who underwent such surgery but subsequently developed perianal CD. She presented with diarrhoea and weight loss. Inflammatory markers were raised. Pouchoscopy revealed deep ulcers within the pouch. The main differential diagnoses were idiopathic pouchitis and recurrent CD. However, immunohistochemical staining demonstrated positivity for cytomegalovirus (CMV). Stool frequency, C reactive protein and albumin normalised within 48 h of starting oral valgancyclovir. At 15 weeks, pouch appearances were improved, no histological evidence of CMV was found and baseline pouch function had returned. This case highlights that CD can present many years after surgery for apparent UC. Also, CMV pouchitis should be considered as a differential cause of pouchitis especially as it is treatable with antiviral therapy.
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Affiliation(s)
| | | | - Karin Oien
- NHS Greater Glasgow and Clyde, Glasgow, UK
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Rupp C, Herpel E, Schnitzler P, Zawierucha A, Zwickel P, Klute L, Kadmon M, Stremmel W, Gauss A. Protracted primary cytomegalovirus infection presenting as ileoanal pouchitis in a non-immunosuppressed patient: a case report. J Med Case Rep 2014; 8:163. [PMID: 24885004 PMCID: PMC4061925 DOI: 10.1186/1752-1947-8-163] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Accepted: 01/27/2014] [Indexed: 12/02/2022] Open
Abstract
Introduction Pouchitis often occurs after proctocolectomy and ileal pouch-anal anastomosis for ulcerative colitis. It is usually deemed idiopathic and commonly responds to antibacterial therapy. To date, only a few cases of cytomegalovirus pouchitis have been documented, and only a single report describes pouchitis in a case of assumed primary cytomegalovirus infection. Case presentation A 26-year-old Caucasian woman underwent proctocolectomy and ileal pouch-anal anastomosis for refractory ulcerative colitis and adenocarcinoma. After 28 months she developed bloody diarrhoea, abdominal pain, fever, nausea and general malaise suggesting severe pouchitis. Antibiotic treatment reduced humoral inflammation, but failed to resolve her fever. A pouchoscopy revealed distinct pouchitis, and cytomegalovirus infection was diagnosed from pouch biopsies by polymerase chain reaction as well as conventional histology and immunohistochemistry. The infection was confirmed in her blood by polymerase chain reaction and pp65 antigen test, and was clearly defined as the ‘primary’ infection by serial serological tests. Intravenous treatment with ganciclovir (10mg/kg body weight/day) led to resolution of symptoms and negative cytomegalovirus deoxyribonucleic acid and pp65 within a few days. When symptoms and laboratory evidence of cytomegalovirus infection recurred a few days after completing 20 days of therapy with ganciclovir and valganciclovir, a second course of ganciclovir treatment was initiated. Conclusions Cytomegalovirus infection of the ileoanal pouch is an important differential diagnosis of pouchitis even in non-immunosuppressed patients and can be treated with ganciclovir.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Annika Gauss
- Department of Gastroenterology and Hepatology, University Hospital Heidelberg, INF 410, 69120 Heidelberg, Germany.
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Papaconstantinou I, Zampeli E, Dellaportas D, Giannopoulos C, Sotiropoulou M, Polymeneas G, Bamias G, Michopoulos S. Synchronous cytomegalovirus and Clostridium difficile infection of the pouch: a trigger for chronic pouchitis? Clin J Gastroenterol 2014; 7:132-5. [PMID: 26183628 DOI: 10.1007/s12328-014-0458-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 01/22/2014] [Indexed: 01/21/2023]
Abstract
Pouchitis occurs in up to one half of patients after restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). Cytomegalovirus (CMV) and Clostridium difficile are among the commonest secondary identifiable etiologies. A 17-year-old male with ulcerative colitis underwent IPAA due to refractory disease. Nine months later he experienced bloody diarrhea and fever. Laboratory testing and endoscopy confirmed pouch inflammation. Testing for C. difficile toxins A and B was positive. Histology revealed affluent inclusion bodies and immunohistochemistry detected reactivity against CMV protein. Treatment with metronidazole and vancomycin offered partial improvement, whereas the addition of gancyclovir led to a successful recovery. One month after completion of treatment symptoms recurred. Repeat testing precluded an identifiable infectious cause and the diagnosis of idiopathic chronic pouchitis was established. The patient is currently on maintenance treatment with the probiotic compound VSL#3.
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Affiliation(s)
- Ioannis Papaconstantinou
- 2nd Department of Surgery, Aretaieion Hospital, University of Athens, 76 Vas. Sofias Avenue, 115 28, Athens, Greece,
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8
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Pouchitis: what every gastroenterologist needs to know. Clin Gastroenterol Hepatol 2013; 11:1538-49. [PMID: 23602818 DOI: 10.1016/j.cgh.2013.03.033] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 03/12/2013] [Accepted: 03/28/2013] [Indexed: 02/07/2023]
Abstract
Pouchitis is the most common complication among patients with ulcerative colitis who have undergone restorative proctocolectomy with ileal pouch-anal anastomosis. Pouchitis is actually a spectrum of diseases that vary in etiology, pathogenesis, phenotype, and clinical course. Although initial acute episodes typically respond to antibiotic therapy, patients can become dependent on antibiotics or develop refractory disease. Many factors contribute to the course of refractory pouchitis, such as the use of nonsteroidal anti-inflammatory drugs, infection with Clostridium difficile, pouch ischemia, or concurrent immune-mediated disorders. Identification of these secondary factors can help direct therapy.
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Abstract
BACKGROUND Up to 30% of cases of pouchitis are felt to have a secondary cause. Cytomegalovirus (CMV) may represent a possible etiopathological agent. Here, we report our experience with CMV involvement of the pouch, including risk factors, clinical features, and pouch outcomes in patients with inflammatory bowel disease after proctocolectomy with ileal pouch-anal anastomosis. METHODS The pathology database at Mayo Clinic in Rochester was searched between January 1995 and October 2012 for patients with a tissue diagnosis of CMV of the pouch following ileal pouch-anal anastomosis. RESULTS Seven patients with CMV inclusions of the pouch were identified. The median age was 35 (range, 10-53) years, and the majority were female (71%). Five patients (71%) were on immunosuppressive medications including 4 who had undergone orthotopic liver transplantation for primary sclerosing cholangitis. The clinical presentation was similar among all patients: the majority had diarrhea (86%), fever (71%), and abdominal pain (57%). All had mucosal inflammation, with 71% having focal ulcerations in the pouch and 60% having inflammatory changes in the prepouch ileum. All patients improved with ganciclovir. None required pouch excision or had recurrent CMV infection. Three patients had recurrent nonspecific pouchitis. CONCLUSIONS A high index of suspicion is needed to diagnose CMV of the pouch. An increase in stool frequency and fever in patients on immune suppression or in those who have failed empiric antibiotics should prompt assessment for CMV infection. Antiviral therapy seems to be effective, and postinfection pouch outcomes seem favorable, particularly in those presenting with their first episode of pouchitis.
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Xue M, Chen SJ, Wang LJ, Du Y, Si JM. Cytomegalovirus: a probable cause of steroid-refractory ulcerative colitis. J Dig Dis 2013; 14:160-5. [PMID: 23324050 DOI: 10.1111/1751-2980.12037] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Cytomegalovirus, regarded as a trigger of several autoimmune diseases, is an opportunistic pathogen. Patients with ulcerative colitis (UC) undergoing steroid treatment are susceptible to this infection. In the presence of cytomegalovirus, inflammation becomes more complex. Patients with active UC who are infected with cytomegalovirus are usually non-responders to steroid, while antiviral drugs could induce remission. Cytomegalovirus should be suggested as a probable cause of steroid-refractory UC based on the clinical data in the literatures.
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Affiliation(s)
- Meng Xue
- Department of Gastroenterology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
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12
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Histoplasma capsulatum infection in refractory Crohn's disease of the pouch on anti-TNF biological therapy. Am J Gastroenterol 2013; 108:281-3. [PMID: 23381081 DOI: 10.1038/ajg.2012.396] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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13
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Garrido E, Carrera E, Manzano R, Lopez-Sanroman A. Clinical significance of cytomegalovirus infection in patients with inflammatory bowel disease. World J Gastroenterol 2013; 19:17-25. [PMID: 23326158 PMCID: PMC3545225 DOI: 10.3748/wjg.v19.i1.17] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Revised: 08/03/2012] [Accepted: 08/14/2012] [Indexed: 02/06/2023] Open
Abstract
Cytomegalovirus (CMV) infection is common in humans. The virus then enters a “latency phase” and can reactivate to different stimuli such as immunosuppression. The clinical significance of CMV infection in inflammatory bowel disease is different in Crohn’s disease (CD) and ulcerative colitis (UC). CMV does not interfere in the clinical course of CD. However, CMV reactivation is frequent in severe or steroid-resistant UC. It is not known whether the virus exacerbates the disease or simply appears as a bystander of a severe disease. Different methods are used to diagnose CMV colitis. Diagnosis is classically based on histopathological identification of viral-infected cells or CMV antigens in biopsied tissues using haematoxylin-eosin or immunohistochemistry, other tests on blood or tissue samples are currently being investigated. Polymerase chain reaction performed in colonic mucosa has a high sensitivity and a positive result could be associated with a worse prognosis disease; further studies are needed to determine the most appropriate strategy with positive CMV-DNA in colonic mucosa. Specific endoscopic features have not been described in active UC and CMV infection. CMV colitis is usually treated with ganciclovir for several weeks, there are different opinions about whether or not to stop immunosuppressive therapy. Other antiviral drugs may be used. Multicenter controlled studies would needed to determine which subgroup of UC patients would benefit from early antiviral treatment.
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Le Q, Melmed G, Dubinsky M, McGovern D, Vasiliauskas EA, Murrell Z, Ippoliti A, Shih D, Kaur M, Targan S, Fleshner P. Surgical outcome of ileal pouch-anal anastomosis when used intentionally for well-defined Crohn's disease. Inflamm Bowel Dis 2013; 19:30-6. [PMID: 22467562 PMCID: PMC4457327 DOI: 10.1002/ibd.22955] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Crohn's disease (CD) is considered a contraindication to ileal pouch--anal anastomosis (IPAA). In this study, we compare outcomes of CD and ulcerative colitis (UC) patients undergoing IPAA. METHODS Patients were considered to have CD before surgery based on a history of small bowel disease, perianal disease, noncrypt-associated granuloma, or pretreatment skip colonic lesions. Patients were prospectively assessed for pouchitis or CD. Postoperative CD (pouch inflammation into the afferent limb or pouch fistula) or pouch failure (need for permanent diversion) were assessed. Preoperative serum was assayed for IBD-associated antibodies using enzyme-linked immunosorbent assay (ELISA). RESULTS Seventeen patients with preoperative CD were identified. Seven (41%) patients developed postoperative recurrent CD in the afferent limb (n = 3) or pouch fistulizing disease (n = 4). One patient (6%) required pouch excision. The incidence of postoperative CD was higher (P = 0.002) in preoperative CD patients (41%) than UC patients (11%). There was no significant difference in pouchitis or pouch failure. There was also no significant difference in any preoperative clinical feature between patients with or without postoperative CD. Afferent limb inflammation developed in three (50%) of the six patients with pANCA+/OmpC- expression compared to none of the 11 patients without this serologic profile (P = 0.03). CONCLUSIONS Although the intentional use of IPAA in CD has a higher incidence of postoperative disease vs. UC patients, there was no significant difference in pouch failure. Demographics, clinical features, and serologic factors do not predict outcome of CD patients undergoing IPAA. IBD serology may identify the phenotype manifestation of postoperative recurrent CD.
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Affiliation(s)
- Quy Le
- Division of Colon and Rectal Surgery, Departments of Surgery, Pediatrics and Medicine, Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Gil Melmed
- Division of Gastroenterology, Departments of Surgery, Pediatrics and Medicine, Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Marla Dubinsky
- Division of Pediatric Gastroenterology, Departments of Surgery, Pediatrics and Medicine, Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Dermot McGovern
- Division of Medical Genetics, Departments of Surgery, Pediatrics and Medicine, Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric A. Vasiliauskas
- Division of Gastroenterology, Departments of Surgery, Pediatrics and Medicine, Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Zuri Murrell
- Division of Colon and Rectal Surgery, Departments of Surgery, Pediatrics and Medicine, Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Andrew Ippoliti
- Division of Gastroenterology, Departments of Surgery, Pediatrics and Medicine, Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - David Shih
- Division of Gastroenterology, Departments of Surgery, Pediatrics and Medicine, Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Manreet Kaur
- Division of Gastroenterology, Departments of Surgery, Pediatrics and Medicine, Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Stephan Targan
- Division of Gastroenterology, Departments of Surgery, Pediatrics and Medicine, Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Phillip Fleshner
- Division of Colon and Rectal Surgery, Departments of Surgery, Pediatrics and Medicine, Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, California
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Kaur M, Ippoliti AF. Ileal Pouch-Anal Anastomosis: A Gastroenterology Perspective. SEMINARS IN COLON AND RECTAL SURGERY 2012. [DOI: 10.1053/j.scrs.2012.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
BACKGROUND Pouchitis is the most common long-term complication in ulcerative colitis that follows restorative proctocolectomy. Clinical evidence suggests that dysbiosis plays a key role in its pathogenesis. METHODS Current literature on the topic was reviewed. A therapeutic approach was proposed based on the literature along with personal experience from the subspecialty Pouchitis Clinic. RESULTS Pouchitis represents a disease spectrum in the reservoir, with ranging etiopathogenesis, clinical phenotypes, disease courses and prognoses. Dysbiosis plays a critical role in disease initiation and progress, with antibiotic therapy as the mainstay for treatment. On the other hand, superimposed infection from pathogens contributes to flare-up of the disease. Pouchitis can progress into an 'IBD-like' condition, requiring anti-inflammatory, immunomodulator or even biological therapy. CONCLUSION Pouchitis represents a unique form of IBD. Investigation on the evolution from an antibiotic-responsive phenotype to chronic antibiotic-refractory pouchitis may shed some light on the pathogenesis and therapeutic targets of IBD.
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Affiliation(s)
- Bo Shen
- Digestive Disease Institute, the Cleveland Clinic Foundation, Cleveland, Ohio, USA.
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Tribonias G, Karmiris K, Giannikaki E, Konstantinidis K, Voudoukis E, Theodoropoulou A, Vardas E, Paspatis GA. Detection of CMV in pouch mucosa in a patient with acute pouchitis: the real enemy or an innocent bystander? J Crohns Colitis 2012; 6:728-9. [PMID: 22410348 DOI: 10.1016/j.crohns.2012.02.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2011] [Revised: 02/11/2012] [Accepted: 02/12/2012] [Indexed: 02/08/2023]
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Abstract
IPAA is a technically demanding procedure that requires appropriate skills and expertise. Adverse sequelae of IPAA are common. Accurate diagnosis and classification of pouch disorders and associated complications are important for proper management and prognosis. Based on presenting symptoms, appropriate and combined diagnostic modalities should apply. A multidisciplinary approach involving gastroenterologists, colorectal surgeons, gastrointestinal pathologists, and gastrointestinal radiologists is advocated for diagnosis and treatment of pouch disorders.
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Affiliation(s)
- Yue Li
- Department of Gastroenterology, Peking Union Medical College Hospital, Beijing, China
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Increased crypt apoptosis is a feature of autoimmune-associated chronic antibiotic refractory pouchitis. Dis Colon Rectum 2012; 55:549-57. [PMID: 22513433 DOI: 10.1097/dcr.0b013e31824ab7c6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Restorative proctocolectomy with IPAA is the surgical treatment of choice in patients with ulcerative colitis who require colectomy. Pouchitis is the most common long-term complication in patients with IPAA. While immune-mediated disorders frequently coexist with IBD, they appear to be associated with an increased risk for chronic antibiotic-refractory pouchitis. OBJECTIVE This study aimed to evaluate histologic features of autoimmune-associated chronic antibiotic-refractory pouchitis in comparison with controls and to assess their possible diagnostic utility. DESIGN Clinical definition for autoimmune-associated chronic pouchitis included 1) chronic antibiotic-refractory pouchitis with response only to corticosteroids, immunomodulators, or biologics; 2) positive serum autoantibodies, including antinuclear antibody, rheumatoid factor, and antimicrosomal antibody; and 3) concurrent immune-mediated disorders. Various histologic features of pouch biopsy specimens were evaluated. SETTING The investigation was conducted at a tertiary referral center. PATIENTS From our Pouchitis Registry, all eligible patients with autoimmune-associated pouchitis (n = 17) were included. The control groups included 16 patients with nonautoimmune-associated chronic antibiotic-refractory pouchitis, 39 with antibiotic-responsive pouchitis, and 19 patients with normal pouches. Various histologic features of pouch biopsy specimens were evaluated. RESULTS In comparison with the control groups, the autoimmune-associated pouchitis group showed a significant increase in deep crypt apoptosis (p < 0.001). It also showed more pyloric gland metaplasia in comparison with antibiotic-responsive pouchitis and normal pouches. With the use of apoptosis score which we developed as a diagnostic marker for autoimmune-associated chronic antibiotic-refractory pouchitis, we constructed a receiver operating curve and obtained an area-under-curve value of 0.89 (95% CI: 0.79, 0.99). CONCLUSION Increased deep crypt apoptosis is a distinctive histologic feature of autoimmune-associated chronic antibiotic-refractory pouchitis, and this feature may aid in the diagnosis and differential diagnosis in pouchitis.
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Abstract
Although restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) has become the surgical treatment of choice for patients with refractory ulcerative colitis (UC) or UC with dysplasia, surgical, inflammatory, and noninflammatory adverse sequelae are common. Pouchitis, representing a spectrum of disease phenotypes, is the most common long-term complication of IPAA. De novo Crohn disease (CD) of the pouch can occur in patients with a preoperative diagnosis of UC. Differential diagnosis between fibrostenotic or fistulizing CD and surgery-associated strictures, sinuses, and fistulas often requires a combined assessment of symptom, endoscopy, histology, radiography, and examination under anesthesia. There is a role for endoscopic therapy for stricturing complications of IPAA. Chronic antibiotic-refractory pouchitis, refractory cuffitis, as well as fibrostenotic or fistulizing CD of the pouch are the leading late-onset causes for pouch failure.
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Affiliation(s)
- Bo Shen
- Department of Gastroenterology/Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio. USA.
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Abstract
Restorative proctocolectomy with ileal pouch-anal anastomosis has become the procedure of choice for the majority of patients with ulcerative colitis who require surgical treatment. Pouchitis, the most common long-term complication of the procedure, involves a spectrum of disease processes with heterogeneous risk factors, clinical features, disease courses and prognoses. In addition, clinical symptoms of pouchitis are not specific and often overlap with those of other inflammatory and functional pouch disorders, such as Crohn's disease of the pouch and irritable pouch syndrome. Pouchoscopy and biopsy, along with laboratory and radiographic evaluations, are often required for accurate diagnosis in patients with symptoms indicative of pouchitis. Dysbiosis has been implicated as a triggering factor for pouchitis, and concurrent infection with pathogens, such as Clostridium difficile, might contribute to disease relapse and exacerbation. Antibiotic therapy is the main treatment modality. However, the management of antibiotic-dependent and antibiotic-refractory pouchitis remains challenging. Secondary causes of pouchitis, such as ischaemia, NSAID use, the presence of concurrent primary sclerosing cholangitis and other systemic immune-mediated disorders, should be evaluated and properly managed.
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Criscuoli V, Rizzuto MR, Montalbano L, Gallo E, Cottone M. Natural history of cytomegalovirus infection in a series of patients diagnosed with moderate-severe ulcerative colitis. World J Gastroenterol 2011; 17:633-8. [PMID: 21350712 PMCID: PMC3040335 DOI: 10.3748/wjg.v17.i5.633] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2010] [Revised: 10/26/2010] [Accepted: 11/02/2010] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the natural history of human cytomegalovirus (HCMV) infection in a series of 28 ulcerative colitis patients in whom the search for HCMV was positive.
METHODS: A series of 85 patients with moderate-severe ulcerative colitis flare-up were evaluated for a HCMV search by performing a haematoxylin and eosin stain, immunohistochemical assay and nested polymerase chain reaction on rectal biopsies. Among 85 screened patients (19 of whom were steroid resistant/dependant), 28 were positive for HCMV; after remission the patients were followed up clinically and histologically.
RESULTS: Among the 22 patients with complete follow-up, in 8 (36%) patients HCMV-DNA persisted in the intestinal specimens. Among the HCMV positive patients, 4 (50%) experienced at least one moderate-severe flare-up of colitis without evidence of peripheral HCMV. Among the 14 HCMV negative patients, 3 with pouches developed pouchitis and 5 out of 11 (45%) experienced a colitis flare-up.
CONCLUSION: Our preliminary results suggest that HCMV may remain in the colon after an acute colitis flare-up despite remission; it seems that the virus is not responsible for the disease relapse.
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White E, Melmed GY, Vasiliauskas EA, Dubinsky M, Berel D, Targan SR, Fleshner PR. A prospective analysis of clinical variables, serologic factors, and outcome of ileal pouch-anal anastomosis in patients with backwash ileitis. Dis Colon Rectum 2010; 53:987-94. [PMID: 20551749 PMCID: PMC5002988 DOI: 10.1007/dcr.0b013e3181dcb3f2] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE The outcome of ileal pouch-anal anastomosis in patients with backwash ileitis is controversial. We prospectively compared the outcomes of ileal pouch-anal anastomosis in colitis patients with backwash ileitis and colitis patients without backwash ileitis. METHODS Consecutive colitis patients undergoing ileal pouch-anal anastomosis were reviewed. All patients were classified after surgery as being either backwash ileitis-positive or backwash ileitis-negative. Serum drawn preoperatively was assayed, using enzyme-linked immunosorbent assay, for anti-Saccharomyces cerevisiae, anti-outer membrane of porin C, anti-CBir1, anti-I2, and perinuclear anti-neutrophil cytoplasmic antibody. Outcomes included acute pouchitis (antibiotic responsive), chronic pouchitis (antibiotic dependent or refractory), or de novo Crohn's disease (small inflammation above the pouch inlet or pouch fistula). RESULTS Out of 334 patients, 39 (12%) were backwash ileitis-positive. Compared with backwash ileitis-negative patients, backwash ileitis-positive patients had a higher incidence of pancolitis (100% vs 74%; P = .0001), primary sclerosing cholangitis (15% vs 2%; P = .001) and high-level (>100 enzyme-linked immunosorbent assay units/ml) perinuclear anti-neutrophil cytoplasmic antibody expression (29% vs 9%; P = .001). After a median follow-up of 26 months, 53 patients (16%) developed acute pouchitis, 37 (11%) developed chronic pouchitis, and 40 (12%) developed de novo Crohn's disease. There was no significant difference between the backwash ileitis-positive and backwash ileitis-negative patient groups in the incidence of acute pouchitis, chronic pouchitis, or de novo Crohn's disease. CONCLUSION There was a significantly higher incidence of pancolitis, primary sclerosing cholangitis, and high-level perinuclear anti-neutrophil cytoplasmic antibody expression in backwash ileitis-positive patients than in backwash ileitis-negative patients. The incidence of acute pouchitis, chronic pouchitis, and de novo Crohn's disease after ileal pouch-anal anastomosis does not differ significantly between backwash ileitis-positive and backwash ileitis-negative patients.
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Affiliation(s)
- Evan White
- Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
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He X, Bennett AE, Lian L, Shen B. Recurrent cytomegalovirus infection in ileal pouch-anal anastomosis for ulcerative colitis. Inflamm Bowel Dis 2010; 16:903-4. [PMID: 19821508 DOI: 10.1002/ibd.21121] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Shen B, Plesec TP, Remer E, Kiran P, Remzi FH, Lopez R, Fazio VW, Goldblum JR. Asymmetric endoscopic inflammation of the ileal pouch: a sign of ischemic pouchitis? Inflamm Bowel Dis 2010; 16:836-46. [PMID: 19998461 DOI: 10.1002/ibd.21129] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Pouchitis is associated with dysbiosis and dysregulated mucosal immunity, although secondary pouchitis with special etiologic factors, such as ischemia, can occur. The aim was to describe a disease phenotype of the ileal pouch with an endoscopic appearance suggestive of ischemia. METHODS We identified consecutive patients with endoscopic asymmetric inflammation of the pouch (inflammation of side of the pouch with a completely normal other limb of the pouch one limb and a sharp demarcation along the staple suture line). Patients with Crohn's disease (CD) of the pouch or antibiotic-responsive pouchitis, matched for duration of the pouch, served as controls. Histology slides of mucosal biopsies were re-reviewed independently by 2 blinded gastrointestinal pathologists. Demographic, clinical, endoscopic, histologic, and imaging characteristics were compared between the groups. RESULTS Ten patients with "ischemic" pouchitis, 15 with CD of the pouch, and 15 with antibiotic-responsive pouchitis were studied. Pyloric gland metaplasia was observed only in the groups with CD of the pouch (23.1%) or antibiotic-responsive pouchitis (13.3%). Of patients with "ischemic" pouchitis, 80% had extracellular hemosiderin or hematoidin deposits (versus 30.8% those with CD of the pouch and 13.3% of those with pouchitis, P = 0.003). The majority of patients (80%) with "ischemic" pouchitis did not respond to conventional antibiotic therapy. It appeared that subsequent abdominal surgeries after pouch construction and a history of postoperative portal vein thrombi were associated with "ischemic" pouchitis. CONCLUSIONS Endoscopic asymmetric inflammation of the pouch may represent an ischemia-associated pouchitis with characteristic clinical, radiographic, and histologic features. Its hemodynamic, cellular, and molecular basis of mechanism warrants further study.
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Affiliation(s)
- Bo Shen
- Pouchitis Clinic, Departmentsof Gastroenterology, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
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Abstract
PURPOSE The extent of preoperative small-bowel mucosal inflammation may be an important predictor of pouchitis after ileal pouch-anal anastomosis. This study examined the value of preoperative wireless capsule endoscopy in predicting outcome of ileal pouch-anal anastomosis in patients with ulcerative colitis or indeterminate colitis. METHODS Patients undergoing complete wireless capsule endoscopy before ileal pouch-anal anastomosis were identified. Findings on wireless capsule endoscopy were classified as positive (erosions, ulcers or erythema) or negative. Outcome was assessed prospectively and included no pouchitis, acute pouchitis, chronic pouchitis, or de novo Crohn disease. Patients with acute pouchitis, chronic pouchitis, or de novo Crohn disease were considered to have pouch inflammation. RESULTS The 68 study patients (48 ulcerative colitis; 20 indeterminate colitis) had a median age of 38 years and included 34 males. Median follow-up time after ileostomy closure was 12 months (range, 3-63 months). Wireless capsule endoscopy was positive in 15 patients (22%) and negative in 53 patients (78%). Pouch inflammation was observed in 23 patients (34%), and included 8 patients with acute pouchitis, 3 patients with chronic pouchitis, and 12 patients with de novo Crohn disease. The incidence of acute pouchitis, chronic pouchitis, de novo Crohn disease, and pouch inflammation in the wireless capsule endoscopy-positive patient group was 7%, 7%, 20%, and 33% compared with 13%, 4%, 17%, and 34% in the wireless capsule endoscopy-negative patient group (all P = NS). CONCLUSION There was no statistical association between the results of preoperative wireless capsule endoscopy and outcome after ileal pouch-anal anastomosis in patients with ulcerative colitis or indeterminate colitis. There seems to be little value of wireless capsule endoscopy in the preoperative evaluation of these patients.
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Abstract
Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical treatment of choice for most patients with ulcerative colitis who require surgery. Although the surgical procedure offers a cure in some patients, postoperative inflammatory and noninflammatory complications are common. Pouchitis is the most common long-term complication of the procedure. Pouchitis represents a spectrum of disease processes with heterogeneous risk factors, clinical phenotypes, natural history, and prognosis. Accurate diagnosis and classification are important for proper treatment and prognosis.
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Affiliation(s)
- Hao Wu
- Department of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai, China
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Navaneethan U, Shen B. Secondary pouchitis: those with identifiable etiopathogenetic or triggering factors. Am J Gastroenterol 2010; 105:51-64. [PMID: 19755972 DOI: 10.1038/ajg.2009.530] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical treatment of choice for the majority of patients with medically refractory ulcerative colitis (UC) or UC with dysplasia, or familial adenomatous polyposis. Various forms of pouchitis frequently occur after surgery. In fact, pouchitis is the most frequent long-term complication of IPAA in patients with UC, with a cumulative prevalence of up to 50%. The etiology and pathogenesis of pouchitis are not entirely clear. It is generally believed that the initiation and development of the disease process of pouchitis is associated with dysbiosis of pouch reservoir, as evidenced by a favorable response to antibiotic therapy. However, the majority of the patients do not show identifiable etiopathogenetic or triggering factors, therefore being labeled to have idiopathic pouchitis. In contrast, a subgroup of patients, particularly those with antibiotic-refractory pouchitis, may have obvious triggering factors for disease flare-up and progression and may be considered to have secondary pouchitis. Therefore, pouchitis can be classified on the basis of etiology into idiopathic and secondary causes. Approximately 20-30% of patients who present with chronic pouchitis have secondary identifiable and triggering factors, including cytomegalovirus or Clostridium difficile infection, ischemia, concurrent immune-mediated disorders, radiation, collagen deposition, and use of nonsteroidal anti-inflammatory drugs. Careful evaluation of these secondary causes of pouchitis that may contribute to resistance to antibiotics should be performed before the introduction of next-line medical therapy.
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Affiliation(s)
- Udayakumar Navaneethan
- The Pouchitis Clinic, Digestive Disease Institute, The Cleveland Clinic Foundation, Ohio 44195, USA
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29
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Abstract
Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical treatment of choice for most patients with ulcerative colitis who require surgery. Although the surgical procedure offers a cure in some patients, postoperative inflammatory and noninflammatory complications are common. Pouchitis is the most common long-term complication of the procedure. Pouchitis represents a spectrum of disease processes with heterogeneous risk factors, clinical phenotypes, natural history, and prognosis. Accurate diagnosis and classification are important for proper treatment and prognosis.
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Affiliation(s)
- Hao Wu
- Department of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai, China
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Ogasawara N, Sasaki M, Hijikata Y, Masui R, Tanida S, Kanematsu T, Kamiya T, Kataoka H, Joh T, Kasugai K. Successful treatment for pouchitis with rebamipide refractory to a combination of metronidazole (MNZ) and ciprofloxacin (CFX). Clin J Gastroenterol 2009; 2:404-407. [PMID: 26192795 DOI: 10.1007/s12328-009-0115-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2009] [Accepted: 09/11/2009] [Indexed: 11/29/2022]
Abstract
A 35-year-old male who had undergone proctocolectomy and ileo-anal pouch surgery (IPAA) because of ulcerative colitis presented with worsening diarrhea and hematochezia. Pouchitis was diagnosed, and he was prescribed with metronidazole (MNZ) and a betamethasone enema. However, his condition did not remarkably improve despite these strategies. Endoscopy revealed ulceration and inflammation in the ileal pouch together with contact bleeding and mucous discharge. He underwent granulocytapheresis (G-CAP) and was prescribed anal 5-aminosalicylic acid (5-ASA) and oral prednisolone. Oral azathioprine (AZA) and a combination of MNZ and ciprofloxacin (CFX) did not result in any improvement. He was then treated with rebamipide enemas twice daily for 8 weeks without additional drug therapy. Two weeks thereafter, stool frequency started to decrease, fecal hemoglobin became negative, and his symptoms gradually improved. Endoscopic findings after the rebamipide therapy showed that the ulcers in the ileal pouch had mostly healed without obvious inflammation and bleeding. Rebamipide was thus maintained throughout the therapeutic period and for 13 months of follow-up. Rebamipide effectively treated severe pouchitis that was refractory to intensive conventional medication including antibiotics and corticosteroids.
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Affiliation(s)
- Naotaka Ogasawara
- Department of Gastroenterology, Aichi Medical University School of Medicine, 21 Karimata, Yazako, Nagokute-cho, Aichi, 480-1195, Japan
| | - Makoto Sasaki
- Department of Gastroenterology, Aichi Medical University School of Medicine, 21 Karimata, Yazako, Nagokute-cho, Aichi, 480-1195, Japan.
| | - Yasutaka Hijikata
- Department of Gastroenterology, Aichi Medical University School of Medicine, 21 Karimata, Yazako, Nagokute-cho, Aichi, 480-1195, Japan
| | - Ryuta Masui
- Department of Gastroenterology, Aichi Medical University School of Medicine, 21 Karimata, Yazako, Nagokute-cho, Aichi, 480-1195, Japan
| | - Satoshi Tanida
- Departments of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Science, 1-Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Takayoshi Kanematsu
- Departments of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Science, 1-Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Takeshi Kamiya
- Departments of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Science, 1-Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Hiromi Kataoka
- Departments of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Science, 1-Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Takashi Joh
- Departments of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Science, 1-Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Kunio Kasugai
- Department of Gastroenterology, Aichi Medical University School of Medicine, 21 Karimata, Yazako, Nagokute-cho, Aichi, 480-1195, Japan
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Lian L, Fazio VW, Lavery IC, Hammel J, Remzi FH, Shen B. Evaluation of association between precolectomy thrombocytosis and the occurrence of inflammatory pouch disorders. Dis Colon Rectum 2009; 52:1912-8. [PMID: 19966641 DOI: 10.1007/dcr.0b013e3181b300f4] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND There are inconsistencies regarding the risk factors associated with pouchitis and Crohn's disease of the pouch after ileal pouch-anal anastomosis. The aim of this study was to evaluate the associations between precolectomy routine laboratory tests, including platelet counts, and occurrences of inflammatory pouch disorders. METHODS All eligible patients were included from The Pouchitis Clinic. All patients undergoing ileal pouch-anal anastomosis for ulcerative colitis were included if their preoperative laboratory tests were available. Demographic, clinical, endoscopic, and laboratory tests were evaluated with univariate and multivariate analyses. RESULTS A total of 251 patients were included. Fifty-five patients had acute pouchitis and 29 had chronic pouchitis. Forty-two patients were diagnosed with Crohn's disease of the pouch. In multivariate analysis, elevated platelet count was not associated with chronic pouchitis (odds ratio, 0.91; 95% confidence interval, 0.32-2.59; P = 0.86) or Crohn's disease of the pouch (odds ratio, 0.87; 95% confidence interval, 0.38-1.97, P = 0.73) after adjusting for gender, smoking, extraintestinal manifestations, and pouch duration. Active smoking was associated with Crohn's disease of the pouch (odds ratio, 5.64; 95% confidence interval, 1.98-16.1; P = 0.001). No other laboratory tests, including white blood cell counts, albumin levels, and hemoglobin levels, were associated with the pouch outcomes. The presence of extraintestinal manifestations was associated with acute pouchitis (odds ratio, 1.89; 95% confidence interval, 0.95-1.14; P = 0.05) and chronic pouchitis (odds ratio, 2.6; 95% confidence interval, 1.13-5.87; P = 0.03). CONCLUSION Precolectomy laboratory tests, including platelet counts, did not appear to impact the occurrence of inflammatory pouch disorders after ileal pouch-anal anastomosis.
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Affiliation(s)
- Lei Lian
- Pouchitis Clinic, Digestive Disease Institute, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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32
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Abstract
Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical treatment of choice for patients with medically refractory ulcerative colitis or ulcerative colitis with dysplasia and for the majority of patients with familial adenomatous polyposis. However, pouchitis and other pouch-associated complications frequently occur following surgery. Pouchitis is the most common long-term complication of ileal pouch-anal anastomosis in patients with ulcerative colitis, with a cumulative prevalence of up to 50%. The pathogenesis of pouchitis is probably associated with alterations in commensal bacterial flora, and most patients with pouchitis respond favorably to antibiotic therapy. Antibiotic therapy is the mainstay of treatment for active pouchitis, with ciprofloxacin or metronidazole traditionally being first-line agents. Some patients may develop dependency on antibiotics, thus requiring long-term maintenance therapy. In a subset of patients, the disease course may be refractory to antibiotic therapy, which is one of the common causes of pouch failure, requiring permanent ileostomy or pouch excision. On the other hand, long-term antibiotic use is expensive and can be associated with adverse effects and bacterial resistance. There may also be the risk of secondary infections, such as Clostridium difficile and fungal infections. The risks and benefits should be carefully balanced in patients who require long-term antibiotic therapy, and safe, efficacious, non-antibiotic-based agents are needed.
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Affiliation(s)
- Udayakumar Navaneethan
- The Pouchitis Clinic, Digestive Disease Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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Navaneethan U, Shen B. Laboratory tests for patients with ileal pouch-anal anastomosis: clinical utility in predicting, diagnosing, and monitoring pouch disorders. Am J Gastroenterol 2009; 104:2606-15. [PMID: 19603012 DOI: 10.1038/ajg.2009.392] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical treatment of choice for patients with medically refractory ulcerative colitis (UC) or UC-associated dysplasia, and for the majority of patients with familial adenomatous polyposis. Pouchitis and other complications of IPAA are common. There are scant data on laboratory markers for the evaluation and diagnosis of pouch disorders. The presence of immunogenotypic markers such as genetic polymorphisms of interleukin-1 (IL-1) receptor antagonist, NOD2/CARD15, Toll-like receptor, and tumor necrosis factor-alpha has been reported to be associated with pouchitis. Immunophenotypic/serologic markers such as perinuclear antineutrophil cytoplasmic antibody and anti-CBir1 have been investigated as possible markers for predicting and diagnosing pouchitis. Fecal markers including lactoferrin and calprotectin seem to be useful in distinguishing inflammatory from noninflammatory pouch disorders. In our practice, we have encountered a large number of pouch patients with Clostridium difficile infection. Laboratory evaluation provides information on the etiology and pathogenesis of pouchitis, and it also helps practicing clinicians with accurate diagnosis, differential diagnosis, disease stratification, and management of ileal pouch disorders.
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Affiliation(s)
- Udayakumar Navaneethan
- The Pouchitis Clinic, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Pardi DS, D'Haens G, Shen B, Campbell S, Gionchetti P. Clinical guidelines for the management of pouchitis. Inflamm Bowel Dis 2009; 15:1424-31. [PMID: 19685489 DOI: 10.1002/ibd.21039] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
When surgery is necessary in patients with ulcerative colitis, total proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the procedure of choice. Several inflammatory and noninflammatory complications can occur after IPAA. Pouchitis is the most common, occurring in approximately 50% of patients. Whereas "acute" pouchitis can be treated rapidly and successfully in the majority of patients, "refractory" and "chronic pouchitis" remain therapeutic challenges to patients and physicians. This article reviews the literature and offers consensus guidelines on issues related to the epidemiology, diagnosis, pathogenesis, risk factors, and treatment of pouchitis.
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Affiliation(s)
- Darrell S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA.
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Abstract
PURPOSE OF REVIEW One of the significant limitations to the investigation of inflammatory bowel disease (IBD) in humans is the impossibility of studying this condition from the beginning of the disease process to understand the individual contribution of the various microbiological and immunological components to its pathogenesis. Pouchitis can serve as a human model for IBD, as the time of the pouch creation is known, which allows to prospectively study the events that might eventually lead to the development of a form of intestinal inflammation (i.e., pouchitis) that mimics IBD. RECENT FINDINGS A considerable amount of progress has been made in the last few years on the mechanisms underlying the pathogenesis of pouchitis. Recent literature suggests that pouchitis may present a spectrum of disease processes, with a wide range of causes, risk factors, clinical phenotypes, disease courses, and prognoses. Genetic, microbiological, and immunological profiles in pouchitis were evaluated. SUMMARY Ileal pouch and pouchitis represent a valuable human model to study the evolution of bacterial communities and host-bacteria interactions in IBD by sequentially monitoring microbiological and immunological profile before, during, and after pouch construction and before and after development and treatment of pouchitis.
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Murrell ZA, Melmed GY, Ippoliti A, Vasiliauskas EA, Dubinsky M, Targan SR, Fleshner PR. A prospective evaluation of the long-term outcome of ileal pouch-anal anastomosis in patients with inflammatory bowel disease-unclassified and indeterminate colitis. Dis Colon Rectum 2009; 52:872-8. [PMID: 19502850 DOI: 10.1007/dcr.0b013e31819f5d4c] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE The long-term outcome of ileal pouch-anal anastomosis in patients with indeterminate colitis is controversial. The aim of this study was to prospectively evaluate the long-term outcome of ileal pouch-anal anastomosis in a closely monitored cohort of patients with ulcerative colitis or indeterminate colitis. METHODS Prospectively generated clinical profiles on consecutive patients with ulcerative colitis or indeterminate colitis undergoing ileal pouch-anal anastomosis with close postoperative follow-up by one surgeon were reviewed. All patients were classified before surgery as either ulcerative colitis or inflammatory bowel disease-unclassified, and after surgery as either ulcerative colitis or indeterminate colitis. Long-term outcomes included acute pouchitis (antibiotic responsive), chronic pouchitis (antibiotic dependent or refractory), or de novo Crohn's disease (small inflammation above the pouch inlet or pouch fistula). RESULTS The study cohort of 334 patients were classified before surgery as ulcerative colitis in 237 (71 percent) and inflammatory bowel disease-unclassified in 97 (29 percent). After surgery, patients were classified as ulcerative colitis in 236 (71 percent) and indeterminate colitis in 98 (29 percent). After a median follow-up after stoma closure of 26 months, 53 patients (16 percent) developed acute pouchitis, 37 patients (11 percent) developed chronic pouchitis, and 40 patients (12 percent) developed de novo Crohn's disease. There was no significant difference in the incidence of acute pouchitis, chronic pouchitis, or de novo Crohn's disease between the ulcerative colitis, inflammatory bowel disease-unclassified, and indeterminate colitis patient groups. CONCLUSION The incidence of acute pouchitis, chronic pouchitis, and de novo Crohn's disease after ileal pouch-anal anastomosis do not differ significantly between patients with ulcerative colitis, inflammatory bowel disease-unclassified, or indeterminate colitis. Patients with inflammatory bowel disease-unclassified and indeterminate colitis can undergo ileal pouch-anal anastomosis and expect a long-term outcome equivalent to patients with ulcerative colitis.
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Affiliation(s)
- Zuri A Murrell
- Department of Surgery, Division of Colon and Rectal Surgery, Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Abstract
Ileal pouch-anal anastomosis is the procedure of choice in the surgical management of refractory ulcerative colitis. Pouchitis affects up to 60% of patients following ileal pouch-anal anastomosis for ulcerative colitis. It overlaps significantly with ulcerative colitis such that improvements in our understanding of one will impact considerably on the other. The symptoms are distressing and impinge significantly on patients' quality of life. Despite 30 years of scientific and clinical investigation, the pathogenesis of pouchitis is unknown; however, recent advances in molecular and cell biology make a synergistic hypothesis possible. This hypothesis links interaction between epithelial metaplasia, changes in luminal bacteria (in particular sulfate-reducing bacteria), and altered mucosal immunity. Specifically, colonic metaplasia supports colonization by sulfate-reducing bacteria that produce hydrogen sulfide. This causes mucosal depletion and subsequent inflammation. Although in most cases antibiotics lead to bacterial clearance and symptom resolution, immunogenetic subpopulations can develop a chronic refractory variant of pouchitis. The aims of this paper are to discuss proposed pathogenic mechanisms and to describe a novel mechanism that combines many hypotheses and explains several aspects of pouchitis. The implications for the management of both pouchitis and ulcerative colitis are discussed.
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39
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Abstract
While the overall incidence of pouchitis is low, extensive research continues at clinical and experimental levels in attempts to unravel its etiology. The ileal pouch and pouchitis together represent a unique in vivo opportunity to study mucosal adaptation and inflammation in depth. In the recent past, molecular data relating to pouchitis has significantly expanded. These data provide invaluable insight into intracellular and extracellular events that underpin mucosal adaptation and inflammation. Advances in classification, risk factor evaluation, and prevention have meant that a review of this data, as well as its relationship to our current understanding of pouchitis, is both timely and warranted. Therefore, the aim of this review is to summarize recent data in the context of the established literature.
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Affiliation(s)
- John Calvin Coffey
- Department of Academic Surgery, Cork University Hospital, Cork, Ireland.
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40
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Fleshner P, Ippoliti A, Dubinsky M, Vasiliauskas E, Mei L, Papadakis KA, Rotter J, Landers C, Targan S. Both preoperative perinuclear antineutrophil cytoplasmic antibody and anti-CBir1 expression in ulcerative colitis patients influence pouchitis development after ileal pouch-anal anastomosis. Clin Gastroenterol Hepatol 2008; 6:561-8. [PMID: 18378498 PMCID: PMC2742560 DOI: 10.1016/j.cgh.2008.01.002] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Acute pouchitis (AP) and chronic pouchitis (CP) are common after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis. The aim of this study was to assess associations of preoperative perinuclear antineutrophil cytoplasmic antibody (pANCA) and anti-CBir1 flagellin on AP or CP development. METHODS Patients were assessed prospectively for clinically and endoscopically proven AP (antibiotic responsive) or CP (antibiotic-dependent or refractory to antibiotic therapy). Sera from 238 patients were analyzed for ANCA and anti-CBir1 using an enzyme-linked immunosorbent assay. pANCA(+) patients were substratified into high-level (>100 EU/mL) and low-level (<100 EU/mL) groups. RESULTS After a median follow-up period of 47 months, 72 patients (30%) developed pouchitis. Pouchitis developed in 36% of pANCA(+) patients versus 16% of pANCA(-) patients (P = .005), 46% of anti-CBir1(+) patients versus 26% of anti-CBir1(-) patients (P = .02), and 54% of 35 pANCA(+)/anti-CBir1(+) patients versus 31% of 136 pANCA(+)/anti-CBir1(-) patients (P = .02). AP developed in 37 pANCA(+) patients (22%) versus 6 pANCA(-) patients (9%) (P = .02), and 12 anti-CBir1(+) patients (26%) versus 31 anti-CBir1(-) patients (16%) (P = .1). Although AP was not influenced by pANCA level, AP was seen in 38% of low-level pANCA(+)/anti-CBir1(+) patients versus 18% low-level pANCA(+)/anti-CBir1(-) patients (P = .03). CP was seen in 29% of high-level pANCA(+) patients versus 11% of low-level pANCA(+) patients (P = .03). CONCLUSIONS Both pANCA and anti-CBir1 expression are associated with pouchitis after IPAA. Anti-CBir1 increases the incidence of AP only in patients who have low-level pANCA expression, and increases the incidence of CP only in patients who have high-level pANCA expression. Diverse patterns of reactivity to microbial antigens may manifest as different forms of pouchitis after IPAA.
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Affiliation(s)
- Phillip Fleshner
- Division of Colon and Rectal Surgery, Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, California, USA.
| | - Andrew Ippoliti
- Division of Gastroenterology, Departments of Surgery, Medicine and Pediatrics, Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048
| | - Marla Dubinsky
- Division of Pediatric Gastroenterology, Departments of Surgery, Medicine and Pediatrics, Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048
| | - Eric Vasiliauskas
- Division of Gastroenterology, Departments of Surgery, Medicine and Pediatrics, Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048
| | - Ling Mei
- Division of Medical Genetics, Departments of Surgery, Medicine and Pediatrics, Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048
| | - Konstantinos A. Papadakis
- Division of Gastroenterology, Departments of Surgery, Medicine and Pediatrics, Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048
| | - Jerome Rotter
- Division of Medical Genetics, Departments of Surgery, Medicine and Pediatrics, Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048
| | - Carol Landers
- Division of Gastroenterology, Departments of Surgery, Medicine and Pediatrics, Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048
| | - Stephan Targan
- Division of Gastroenterology, Departments of Surgery, Medicine and Pediatrics, Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048
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Shen B, Remzi FH, Lavery IC, Lashner BA, Fazio VW. A proposed classification of ileal pouch disorders and associated complications after restorative proctocolectomy. Clin Gastroenterol Hepatol 2008; 6:145-58; quiz 124. [PMID: 18237865 DOI: 10.1016/j.cgh.2007.11.006] [Citation(s) in RCA: 152] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Both medical and surgical therapies for ulcerative colitis have inherent advantages and disadvantages that must be balanced for patients with moderate to severe disease. Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical treatment of choice for the majority of patients with ulcerative colitis who require proctocolectomy. However, adverse sequelae of mechanical, inflammatory, functional, neoplastic, and metabolic conditions related to the pouch can occur postoperatively. Recognition and familiarization of the disease conditions related to the ileal pouch can be challenging for practicing gastroenterologists. Accurate diagnosis and classification of the disease conditions are imperative for proper management and prognosis.
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Affiliation(s)
- Bo Shen
- Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA.
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Abstract
While restorative proctocolectomy with ileal pouch-anal anastomosis has significantly improved the quality of life in patients with underlying ulcerative colitis who require surgery, complications can occur. Pouchitis as the most common long-term complication represents a spectrum of disease processes ranging from acute, antibiotic-responsive type to chronic antibiotic-refractory entity. Accurate diagnosis using a combined assessment of symptoms, endoscopy and histology and the stratification of clinical phenotypes is important for treatment and prognosis the disease. The majority of patients respond favorably to antibiotic therapy. However, management of chronic antibiotic-refractory pouchitis remains a challenge.
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Berton F, Gola G, Wilson SR. Sonography of benign conditions of the anal canal: an update. AJR Am J Roentgenol 2007; 189:765-73. [PMID: 17885043 DOI: 10.2214/ajr.07.2485] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The objective of this article is to describe our experience with sonography for the study of benign conditions of the anal canal and perianal soft tissues. CONCLUSION Assessment of the anal sphincters in patients with fecal incontinence and documentation of perianal inflammatory masses and tracts in those with perianal inflammatory disease are the major indications for imaging the anal canal. We augment traditional transanal sonography with transperineal scanning in both sexes and transvaginal scanning in women to better show the anal canal in its quiet state to allow an accurate assessment of the integrity of the anal sphincters and of evidence of acute or chronic inflammatory involvement.
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Affiliation(s)
- Francesca Berton
- Department of Medical Imaging, Section of Ultrasound, Toronto General Hospital, University of Toronto, Toronto, ON M5G 2N2, Canada
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Fleshner P, Ippoliti A, Dubinsky M, Ognibene S, Vasiliauskas E, Chelly M, Mei L, Papadakis KA, Landers C, Targan S. A prospective multivariate analysis of clinical factors associated with pouchitis after ileal pouch-anal anastomosis. Clin Gastroenterol Hepatol 2007; 5:952-8; quiz 887. [PMID: 17544871 DOI: 10.1016/j.cgh.2007.03.020] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Although acute pouchitis (AP) after ileal pouch-anal anastomosis (IPAA) for UC is common and easily treated, chronic pouchitis (CP) remains a difficult management issue. The aim of this study was to identify important clinical risk factors associated with AP or CP. METHODS AP and CP were prospectively assessed, and demographic, disease, and treatment characteristics were tabulated. Univariate and multivariate analyses were performed to evaluate associations between AP or CP and potential risk factors. RESULTS Two hundred IPAA patients were followed for a median of 24 months (range, 3-117 months). Thirty-six patients (18%) developed AP, and 23 patients (12%) developed CP. On univariate analysis, the use of steroids before colectomy and smoking were associated with the development of AP. CP was associated with male gender, smoking, length of follow-up, extraintestinal manifestations, backwash ileitis, and elevated (450x10(9)/L) platelet count. On multivariate analysis, the following risk factors were found to be independently associated with AP: use of steroids before colectomy (odds ratio [OR], 3.7; 95% confidence interval [CI], 1.5-8.9; P = .004) and smoking (OR, 2.3; 95% CI, 1.1-5.3; P = .04). CP was directly associated with extraintestinal manifestations (OR, 3.5; 95% CI, 1.1-11.1; P = .03), elevated platelet count (OR, 3.1; 95% CI, 1.1-8.9; P = .03), and increased length of follow-up (OR, 1.3; 95% CI, 1.1-1.6; P = .002). Smoking reduced the incidence of CP (OR, 0.2; 95% CI, 0.05-0.74; P = .04). CONCLUSIONS Clinical factors associated with AP included use of steroids before colectomy and smoking. Factors directly related to CP were extraintestinal manifestations, elevated platelet count, and length of follow-up after IPAA. Smoking appears to protect against the development of CP.
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Affiliation(s)
- Phillip Fleshner
- Division of Colon and Rectal Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA.
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Shen B, Fazio VW, Remzi FH, Bennett AE, Lopez R, Brzezinski A, Oikonomou I, Sherman KK, Lashner BA. Combined ciprofloxacin and tinidazole therapy in the treatment of chronic refractory pouchitis. Dis Colon Rectum 2007; 50:498-508. [PMID: 17279300 DOI: 10.1007/s10350-006-0828-3] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Management of chronic refractory pouchitis, a common cause for pouch failure with pouch resection or diversion, is often challenging. The aim of this study was to assess the efficacy and safety of a combination therapy of ciprofloxacin and tinidazole in patients with chronic refractory pouchitis compared with mesalamine therapy. METHODS Sixteen consecutive ulcerative colitis patients with chronic refractory pouchitis (disease>4 weeks and failure to respond to>4 weeks of single-antibiotic therapy) were treated with a four-week course of ciprofloxacin 1 g/day and tinidazole 15 mg/kg/day. A historic cohort of ten consecutive patients with chronic refractory pouchitis treated with oral (4 g/day), enema (8 g/day), or suppository (1 g/day) mesalamine served as controls. The Pouchitis Disease Activity Index, clinical remission, clinical response, the Cleveland Global Quality of Life, the Irritable Bowel Syndrome-Quality of Life, and the Short Inflammatory Bowel Disease Questionnaires scores were calculated before and after therapy and compared between the two treatment groups. RESULTS Patients taking ciprofloxacin and tinidazole had a significant reduction in the total Pouchitis Disease Activity Index scores and subscores and a significant improvement in quality-of-life scores (P < 0.002). For patients in the mesalamine group, there was a significant reduction in the total Pouchitis Disease Activity Index scores only. Patients in the antibiotic group had a greater reduction in the total Pouchitis Disease Activity Index scores and a greater improvement in the quality-of-life scores than those in the mesalamine group (P <or= 0.03). The rate of clinical remission and clinical response for the antibiotic group was 87.5 percent and 87.5 percent, respectively, and for the mesalamine group it was 50 percent and 50 percent, respectively (P = 0.069). Two patients in the antibiotic group (peripheral neuropathy and dysgeusia) developed adverse effects. CONCLUSIONS Combination therapy with ciprofloxacin and tinidazole was generally well tolerated and was effective in treating patients with chronic refractory pouchitis.
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Affiliation(s)
- Bo Shen
- Department of Gastroenterology/Hepatology, Center for Inflammatory Bowel Disease, Cleveland Clinic, Cleveland, Ohio 44195, USA.
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Casadesus D, Tani T, Wakai T, Maruyama S, Iiai T, Okamoto H, Hatakeyama K. Possible role of human cytomegalovirus in pouchitis after proctocolectomy with ileal pouch-anal anastomosis in patients with ulcerative colitis. World J Gastroenterol 2007; 13:1085-9. [PMID: 17373744 PMCID: PMC4146872 DOI: 10.3748/wjg.v13.i7.1085] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To detect the presence of human cytomegalovirus (HCMV) proteins and genes on the ileal pouch of patients with ulcerative colitis who have undergone proctocolectomy with ileal pouch-anal anastomosis (IPAA).
METHODS: Immunohistochemistry, polymerase chain reaction (PCR) and PCR sequencing methods were utilized to test the presence of HCMV in pouch specimens taken from 34 patients in 86 endoscopies.
RESULTS: HCMV genes and proteins were detected in samples from 12 (35.2%) patients. The rate of detection was significant in the endoscopies from patients diagnosed with pouchitis (5 of 12, 41.6%), according to the Japanese classification of pouchitis, in comparison to patients with normal pouch (7 of 62, 11.2%; P = 0.021). In all patients with pouchitis in which the HCMV was detected, it was the first episode of pouchitis. The virus was not detected in previous biopsies taken in normal endoscopies of these patients. During the follow-up, HCMV was detected in one patient with recurrent pouchitis and in 3 patients whose pouchitis episodes improved but whose positive endoscopic findings persisted.
CONCLUSION: HCMV can take part in the inflammatory process of the pouch in some patients with ulcerative colitis who have undergone proctocolectomy with IPAA.
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Affiliation(s)
- Damian Casadesus
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-dori, Niigata City 951-8510, Japan
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Jones OM, McCutcheon J, Herieka E, Fozard JB. High-grade lymphoma of the ileoanal pouch in an HIV-positive patient. Colorectal Dis 2007; 9:184-5. [PMID: 17223949 DOI: 10.1111/j.1463-1318.2006.00962.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Shen B, Goldblum JR, Hull TL, Remzi FH, Bennett AE, Fazio VW. Clostridium difficile-associated pouchitis. Dig Dis Sci 2006; 51:2361-4. [PMID: 17103037 DOI: 10.1007/s10620-006-9172-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2005] [Accepted: 11/27/2005] [Indexed: 12/13/2022]
Abstract
Pouchitis is the most common long-term sequela of ileal pouch-anal anastomosis (IPAA) following total proctocolectomy. No single pathogen is identified as being solely responsible for the pathogenesis of the disease. Here we describe a case of Clostridium difficile-associated pouchitis that was successfully treated with ciprofloxacin and tinidazole. Diagnosis and management of a patient with medically refractory pouchitis associated with Clostridium difficile infection is described. A 63-year-old male with underlying ulcerative colitis and IPAA presented with increased stool frequency and seepage for 2 months, which partially responded to oral metronidazole. While on the antibiotic therapy, pouch endoscopy was performed and showed severe pouchitis. Assays for Clostridium difficile toxins in stool specimens were positive. He was treated with a 4-week course of ciprofloxacin 500 mg BID and tinidazole 500 mg TID. His symptoms resolved within several days from the initiation of therapy. A repeat pouch endoscopy at week 5 showed a complete resolution of mucosal inflammation of the pouch, while tests for Clostridium difficile toxins became negative. Clostridium difficile-associated pouchitis is rare. However, Clostridium difficile infection should be excluded in patients with chronic refractory pouchitis.
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Affiliation(s)
- Bo Shen
- Center for Inflammatory Bowel Disease, Departments of Gastroenterology/Hepatology-Desk A30, The Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH 44195, USA.
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Abstract
Pouchitis is the most common complication following proctocolectomy and ileal pouch-anal anastomosis in patients with ulcerative colitis. We aim at discussing relevant information on epidemiology, clinical features, risk factors, diagnostic testing, differential diagnosis and treatment of this idiopathic inflammatory condition. A computerized search of PubMed was performed with the search term 'pouchitis', limited to English papers on humans. This strategy identified 514 references. Relevant articles were selected from this list. In addition, the reference list for each of the selected articles was reviewed to identify any additional references. Pouchitis occurs in up to 60% of patients after ileal pouch-anal anastomosis for ulcerative colitis, and has characteristic clinical, endoscopic and histological features. The most important test for diagnosis is pouch endoscopy with biopsy. Antibiotics remain the mainstay of treatment, and other options are discussed for those patients who are refractory to antibiotic therapy.
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Affiliation(s)
- D S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA.
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50
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Shen B, Lashner B. Diagnosis and treatment of ileal pouch diseases in patients with underlying ulcerative colitis. ACTA ACUST UNITED AC 2006; 9:3-12. [PMID: 16423309 DOI: 10.1007/s11938-006-0019-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Ileal pouch-anal anastomosis (IPAA) after total proctocolectomy is the surgical treatment of choice for ulcerative colitis (UC) patients with medically refractory disease or dysplasia. IPAA significantly improves quality of life in UC patients who require surgery. However, certain inflammatory and noninflammatory diseases can develop after the surgery, including pouchitis, Crohn's disease (CD) of the pouch, cuffitis, and irritable pouch syndrome. The cause and pathogenesis of these disease conditions of IPAA are largely unknown. Accurate diagnosis and classification are important for appropriate management.
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Affiliation(s)
- Bo Shen
- Department of Gastroenterology/Hepatology-Desk A30, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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