Inflammatory Bowel Disease
The Clinical Syndrome of Pouchitis—Evaluation, Etiology, and Management Kathryn E Coan, MD,1
Jacques P Heppell, MD2 and Jonathan A Leighton, MD3
1. Second-year Surgical Resident; 2. Professor of Surgery; 3. Professor of Medicine, and Chair, Division of Gastroenterology, Divisions of Colon and Rectal Surgery and Gastroenterology, Mayo Clinic Arizona
Abstract
Proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical treatment of choice for patients with ulcerative colitis who have failed medical therapy. Pouchitis is a non-specific inflammation of the mucosa of the ileal pouch, and is the most frequent long-term post-operative complication after IPAA. Symptoms are variable between patients and the initial differential diagnosis of pouch dysfunction remains broad. Therefore, appropriate evaluation is necessary for proper diagnosis of pouchitis and subsequent treatment. Fortunately, the majority of patients respond well to antibiotics but up to 15% will develop chronic refractory symptoms, greatly impacting their quality of life. This article will deal with the current understanding of this enigmatic and frustrating clinical syndrome, including evaluation, etiology, and treatment.
Keywords Pouchitis, ulcerative colitis, ileal pouch-anal anastomosis, management
Disclosure: The authors have no conflicts of interest to declare. Received: March 18, 2011 Accepted: May 20, 2011 Citation: US Gastroenterology & Hepatology Review, 2011;7(1):23–6 Correspondence: Jacques P Heppell, MD, Division of Colon and Rectal Surgery, Mayo Clinic Arizona, 5777 East Mayo Blvd, Phoenix, AZ, 85054. E:
heppell.jacques@mayo.edu
Ileal pouch-anal anastomosis (IPAA) has been used as an alternative to conventional ileostomy for more than 30 years for patients with ulcerative colitis requiring proctocolectomy.1
and function of the terminal ileum to provide ‘reservoir continence’.2
Surgeons have modified the anatomy The
ileal pouch mucosa is then exposed to stagnant enteric content, leading to colonic metaplasia associated with inflammation.3–6
is defined as a non-specific, idiopathic inflammation of the ileal mucosa superimposed on adaptive morphologic changes. It has become the most common long-term post-operative complication8 subjecting patients to an enigmatic,9
perhaps iatrogenic, disease10 that
may overshadow the benefits of the operation. This article will deal with recent advances in the understanding, treatment, and consequences of pouchitis.
Signs and Symptoms
Pouchitis presents with a wide range of symptoms similar to those of ulcerative colitis including foul-smelling watery diarrhea sometimes containing blood, abdominal cramping and pelvic pain, urgency, tenesmus, nocturnal leakage, and fecal incontinence. The onset of diarrhea is often rapid and delays in treatment may lead to more severe manifestations with fever, dehydration, and weight loss. In patients chronically affected, a systemic syndrome that includes fever, general malaise, arthralgia,11,12 such as uveitis,13 has been observed.
and other extraintestinal manifestations of colitis erythema nodosum, and pyoderma gangrenosum14
© TOUCH BRIEFINGS 2011
Pouchitis, a clinical syndrome first described with the continent ileostomy by Kock et al.,7
Laboratory Tests
Iron deficiency anemia may be the presenting symptom.15 lactoferrin,17
and pyruvate kinase (M2-PK)18 Calprotectin,16 are non-invasive fecal
markers of mucosal pouch inflammation that may be elevated but are non-specific.
Endoscopy
Concerning pouch endoscopy, the mucosa typically has a hallmark appearance similar to that of acute mucosal colitis, consisting of mucosal edema, erythema, increased friability and granularity, and the presence of punctate ulcers. These changes may be focal or diffuse in nature. Changes similar to pseudomembranous enteritis may also be observed. A sample of pouch content can be taken for cultures to include Clostridium difficile, fecal pathogens, ova and parasites, and Candida. Biopsies should be obtained even with normal-appearing mucosa to assess for microscopic evidence of inflammation.19
Recently, wireless
capsule endoscopy has been used to evaluate the small intestine in chronic refractory pouchitis. Interestingly, diffuse lesions from the duodenum to the ileum were observed.20
is not clear at this time. Histology
The mucus changes from the small bowel-type sialomucin to a sulfated sialomucin more typical of the colon.22
Ileal pouch mucosa adapts toward a colonic type in reaction to the new luminal environment, acquiring glandular morphology of the large bowel. The villi atrophy, the crypts elongate, and the goblet cells become larger.21
In addition, chronic 23 The significance of these lesions
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