Inflammatory Bowel Disease Figure 1: Treatment Algorithm for Pouchitis Diagnosis of pouchitis


Infrequent relapse


Remission


Frequently/prompt recurrence


Ciprofloxacin 500mg BID or flagyl 250mg TID x 14 days


No response or rapid relapse


Ciprofloxacin 500mg BID or flagyl 250mg TID x 28 days


No response Remission


Low-dose antibiotic consider VSL#3


Maintenance therapy Remission No response Oral budesonide


Anti-inflammatory agents Immunomodulators


Alternative antibiotic combination


Diagnosis


Although pouchitis is the most common cause of pouch dysfunction, it is essential to be aware of, and rule out, other conditions that present with similar symptoms. Indeed, pouchitis has been referred as a “wastebasket diagnosis”30


and a “spectrum of diseases”31 including inflammatory and


non-inflammatory conditions. Cuffitis represents recurrent/residual ulcerative colitis of the mucosal remnant in patients with a stapled ileal pouch distal rectal anastomosis.32


Crohn’s disease should be considered


if pre-pouch ileitis/ulcers, nonanastomotic stricturing, and pouch fistulas are present. Also, the presence of rake-type ulcers should raise suspicion for Crohn’s disease, as these may be seen in severe pouchitis.19


Irritable


pouch syndrome presents with symptoms similar to pouchitis, with negative findings on endoscopy and biopsy33


differentiated from pouchitis by quantification of mucosal levels of proinflammatory gene transcript.34


warranted for specific infections including C. difficile,35,36 (CMV),37


Candida, and Campylobacter.38


should also be considered including pouch ischemia,39 pouch strictures, or pelvic floor dysfunction.19


and may also be


An investigation may also be cytomegalovirus


Specific problems with the pouch pouch emptying,


Early post-operative pouchitis is suggestive of inadequate perfusion of the mucosa.40 Surgery BID = two times a day; TID = three times a day.


Ideally, the diagnosis of pouchitis should be made by a combined evaluation of symptoms, endoscopy, and histology. There may also be benefit in using the Pouch Disease Activity Index, although it is not routinely used in practice.41,42


inflammation has been described and the grade of mononuclear, plasma cells, and eosinophilic infiltration increases.4


pouchitis appear, the histology shows acute mucosal inflammation with predominance of neutrophils, ulcerations, crypt abscesses, and goblet cell depletion. Crypt cells4


and immature plasma cells23 or histologic diagnosis has been a source of debate.43 When symptoms of display increased


proliferation. The histologic changes, like the endoscopic changes, can be patchy. A diagnostic histologic score has been established, taking into consideration acute polymorph infiltration and ulcerations as stigmata of acute pouchitis, and chronic inflammatory cells and villous atrophy as a sign of chronicity.21


The degree of inflammation can be


mild, moderate, or severe. Based on the severity and fluctuation of the inflammation, patients have been divided into three groups: chronic changes are minor and acute inflammation is never observed; chronic changes are more severe and there are transient episodes of acute inflammation; and severe chronic and severe acute inflammation are constantly present. Differentiation of the three groups is usually well-established within six months after restoration of the fecal stream.24 Pyloric gland metaplasia is associated with chronic antibiotic refractory pouchitis or Crohn’s disease.25


Radiology


There are no specific findings for pouchitis identified on pouchography, CT scan, or MRI. However, pouchograms may reveal non-specific findings such as spicules, thickened folds, and pouch spasm. CT scan may show a thickened pouch wall with stranding in the peripouch fat.26


Mucosal


disease may manifest on MRI as pouch mural thickening (2mm or greater thickness of pouch wall) and abnormal enhancement.27


of imaging is to detect peripouch inflammatory complications such as abscess, sinus, fistula formation, or phlegmon that can lead to a diagnosis of secondary pouchitis from treatable surgical complication or Crohn’s disease.28,29


24 Another benefit


Whether pouchitis is a clinical, endoscopic, Some advocate


Most patients are instructed to start antibiotics within two days of symptoms to minimize delay in treatment that may lead to a more severe form of pouchitis. A good response to metronidazole or ciprofloxacin is supportive of the diagnosis.


the treatment of symptoms empirically with antibiotics first and proceed with endoscopy, biopsy, and bacteriology in patients who are not responding or have recurrent symptoms. However, in one study, 49% of symptomatic patients did not have pouchitis, and therefore, pouch endoscopy was found to be the most cost-effective means of diagnosis.44


Incidence


The true incidence of pouchitis varies with the duration of follow-up and thoroughness of evaluation. The first episode usually occurs in the first year in the majority of patients.45


Up to 50% of patients will develop


symptomatic inflammation of the mucosa of the pouch as the cumulative risk for developing pouchitis increases with time.46


In one retrospective


study with a mean follow-up of to three years, the incidence was 59%, varying with the duration of follow-up: 25% after six months; 37% after 12 months; and 50% at three years.47


Patients with pouchitis can be


divided according to the frequency and severity of symptoms: Group 1 (76%)—single or few mild episodes responding promptly to antibiotics with relatively long periods between attacks; Group 2 (18%)—frequent relapses, mostly mild, short-lasting symptoms; and Group 3 (6%)—chronic, troublesome symptoms.48


There appears to be a clear difference between


those patients with occasional episodes who respond well to treatment and the smaller group who are refractory.


Pathogenesis


The pathogenesis of pouchitis remains elusive. The clinical observation that pouchitis can be treated with antibiotics suggests a role for microflora


US GASTROENTEROLOGY & HEPATOLOGY REVIEW


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