Pouchitis

Pouchitis is inflammation of the ileal pouch (an artificial rectum surgically created out of ileal gut tissue in patients who have undergone a colectomy), which is created in the management of patients with ulcerative colitis, indeterminate colitis, FAP, or, rarely, other colitides.[1][2]

Pouchitis
Specialty	General surgery

A variety of pathophysiological mechanisms have been proposed for pouchitis, but the precise pathogenesis (biological cause) remains unknown. A pilot study on the effect of reducing dietary FODMAP intake on bowel function in patients without a colon ran by Croagh C, Shepherd SJ, Berryman M, Muir JG, Gibson PR indicates there might be a relation between Pouchitis and FODMAP content of diets.[3]

The incidence of a first episode of pouchitis at 1, 5 and 10 years post-operatively is 15%, 33% and 45% respectively.[2][4]

Patients with pouchitis typically present with bloody diarrhea, urgency in passing stools, or discomfort while passing stools. The loss of blood and/or dehydration resulting from the frequent stools will frequently result in nausea. Extreme cramping and pain can occur with pouchitis.

Endoscopy in patients with pouchitis usually reveals erythematous pouch mucosa, loss of pseudocolonic vasculature or other architecture, and friability of the mucosa. Biopsies show evidence of inflammatory cells or red blood cells in the lamina propria.

Classification

Once a diagnosis of pouchitis is made, the condition is further classified. The activity of pouchitis is stratified as:

• remission (no active pouchitis).
• mild to moderately active (increased stool frequency, urgency, infrequent incontinence).
• severely active (hospitalised for dehydration, frequent incontinence).

The duration of pouchitis is defined as acute (less than or equal to four weeks) or chronic (four weeks or more) and the pattern classified as infrequent (1-2 acute episodes), relapsing (three or fewer episodes) or continuous. Finally, the response to medical treatment as labelled as treatment responsive or treatment refractory, with the medication for either case being specified.

Signs and symptoms

Symptoms of pouchitis include Increased stool frequency, urgency, incontinence, nocturnal seepage, abdominal cramping, pelvic discomfort, and arthralgia.[5]

Symptom severity does not always correlate with severity of endoscopically- or histologically-evaluated pouch inflammation.[5] Additionally, these symptoms are not necessarily specific for pouchitis, as they may arise from other inflammatory or functional pouch disorders such as Crohn's disease of the pouch, cuffitis, pouch sinus, or irritable pouch syndrome.[5] The most reliable tool for diagnosis is endoscopy combined with histologic features (derived from tissue biopsies obtained during endoscopy).[5]

Diagnosis

Treatment

There is no clinically approved treatment for pouchitis.[6] First line treatment is usually with antibiotics, specifically with ciprofloxacin and metronidazole.[7] Ampicillin or piperacillin can also be considered as alternatives to empiric ciprofloxacin and metronidazole. Administration of metronidazole at a high daily dose of 20 mg/kg can cause symptomatic peripheral neuropathology in up to 85% of patients. This can be a limiting factor in the use of maintenance metronidazole to suppress chronic pouchitis.[8][9]

Other therapies which have been shown to be effective in randomised clinical trials include probiotic therapy, the application of which usually begins as soon as any antibiotic course is completed so as to re-populate the pouch with beneficial bacteria. Biologics, such as anti-TNF antibodies, may also be useful but the evidence for their use is largely anecdotal. In addition, discussion by patients using related internet forums appears to give evidence of benefits (again, after cessation of antibiotics) from certain diets, such as the Specific Carbohydrate Diet, Paleolithic Diet, and low-FODMAP diet . In particular, attention has been drawn to the exclusion of complex carbohydrates, as well as other foods with high starch content (such as grains, rice, and potatoes) and certain dairy products including milk and soft cheese.[10][11]

Research

Alicaforsen (an antisense inhibitor which targets the messenger RNA for the production of human ICAM-1 protein) was evaluated in a Phase 3 clinical trial, which did not meet the co-primary endpoints in the primary analysis (an adaptation of the Mayo Score of improvement in endoscopic remission and bowel frequency)[12].

References

1. "Pouchitis". Mayo Clinic.
2. Mahadevan, Uma; Sandborn, William J. (2003). "Diagnosis and management of pouchitis". Gastroenterology. 124 (6): 1636–50. doi:10.1016/S0016-5085(03)00325-1. PMID 12761722.
3. Croagh, Catherine; Shepherd, Susan J.; Berryman, Melissa; Muir, Jane G.; Gibson, Peter R. (2007). "Pilot study on the effect of reducing dietary FODMAP intake on bowel function in patients without a colon". Inflammatory Bowel Diseases. 13 (12): 1522–8. doi:10.1002/ibd.20249. PMID 17828776.
4. Penna, C; Dozois, R; Tremaine, W; Sandborn, W; Larusso, N; Schleck, C; Ilstrup, D (1996). "Pouchitis after ileal pouch-anal anastomosis for ulcerative colitis occurs with increased frequency in patients with associated primary sclerosing cholangitis". Gut. 38 (2): 234–9. doi:10.1136/gut.38.2.234. PMC 1383029. PMID 8801203.
5. Shen, Bo (2010-12-01). "Diagnosis and management of postoperative ileal pouch disorders". Clinics in Colon and Rectal Surgery. 23 (4): 259–268. doi:10.1055/s-0030-1268252. ISSN 1530-9681. PMC 3134805. PMID 22131896.
6. The FSE Group
7. Gosselink MP, Schouten WR, van Lieshout LM, Hop WC, Laman JD, Ruseler-van Embden JG (September 2004). "Eradication of pathogenic bacteria and restoration of normal pouch flora: comparison of metronidazole and ciprofloxacin in the treatment of pouchitis". Diseases of the Colon and Rectum. 47 (9): 1519–25. doi:10.1007/s10350-004-0623-y. PMID 15486751.
8. Tremaine, W. J.; Sandborn, W. J.; Wolff, B. G.; Carpenter, H. A.; Zinsmeister, A. R.; Metzger, P. P. (1997). "Bismuth carbomer foam enemas for active chronic pouchitis: A randomized, double-blind, placebo-controlled trial". Alimentary Pharmacology and Therapeutics. 11 (6): 1041–6. doi:10.1046/j.1365-2036.1997.00253.x. PMID 9663827.
9. "Pouchitis Treatment". Mayo Clinic.
10. http://j-pouch.org/eve/forums/a/tpc/f/3251071921/m/8147045836
11. http://j-pouch.org/eve/forums/a/tpc/f/3251071921/m/4977059936
12. "Atlantic Healthcare Announces Results from Phase 3 Trial of Alicaforsen Enema for Orphan-Designated Pouchitis". Biospace. 31 July 2019. Retrieved 17 January 2020.

External links

Classification	D ICD-10-CM: K91.850 MeSH: D019449
External resources	Orphanet: 217067

Classification	D ICD-10: K91.8 MeSH: D019449