Relationship between pouch microbiota and pouchitis following restorative proctocolectomy for ulcerative colitis

Abstract

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) has become the surgical treatment of choice for many patients with medically refractory ulcerative colitis (UC) and familial adenomatous polyposis (FAP). UC patients with IPAA (UC-IPAA) are, nevertheless, susceptible to inflammatory and noninflammatory sequelae such as pouchitis, which is only rarely noted in FAP patients with IPAA. Pouchitis is the most frequent long-term complication of UC-IPAA patients, with a cumulative prevalence of up to 50%. Although the aetiology of pouchitis remains unclear, accumulating evidence suggests that a dysbiosis of the pouch microbiota and an abnormal mucosal immune response are implicated in its pathogenesis. Studies using culture and molecular techniques have detected a dysbiosis of the pouch microbiota in patients with pouchitis. Risk factors, genetic associations, and serological markers suggest that interactions between the host immune response and the pouch microbiota underlie the aetiology of this idiopathic inflammatory condition. This systematic review focuses on the dysbiosis of the microbiota that inhabit the pouch in UC and FAP patients and its interaction with the mucosal immune system. A meta-analysis was not attempted due to the highly heterogeneous microbiota composition and the different detection methods used by the various studies. Although no specific bacterial species, genus, or family has as yet been identified as pathogenic, there is evidence that a dysbiosis characterized by decreased gut microbiota diversity in UC-IPAA patients may, in genetically predisposed subjects, lead to aberrant mucosal immune regulation triggering an inflammatory process.

Keywords: Pouchitis; Inflammation of the ileal pouch; Microbiota; Bacteria; Microbiome; Ileal-pouch-anal anastomosis; Ulcerative colitis; Crohn’s disease; Inflammatory bowel disease

Core tip: This is a systemic review assessing the relationship between the microbiota that inhabit the ileal-anal pouch following restorative proctocolectomy in ulcerative colitis and familial adenomatous polyposis patients and the inflammatory response that can occur. A meta-analysis was not attempted in view of the highly heterogeneous microbiota composition and the different detection methods utilized. Although no specific bacterial species, genus, or family has as yet been identified as pathogenic, there is evidence that dysbiosis and reduced bacterial diversity of the microbiota found in ulcerative colitis patients who have undergone restorative proctocolectomy may, in genetically predisposed subjects, lead to aberrant mucosal immune regulation triggering an inflammatory process.