Management of Pouchitis: Clinical Pearls for the Gastroenterologist

Authors

  • Neeraj Narula, MD, MPH, FRCPC Division of Gastroenterology, McMaster University

DOI:

https://doi.org/10.58931/cibdt.2023.116

Keywords:

pouchitis, inflammatory bowel disease

Abstract

Ileal pouch anal anastomosis (IPAA) is a surgical procedure conducted in patients with ulcerative colitis (UC) with medically refractory disease; in patients with the autosomal dominant inherited disease familial adenomatous polyposis (FAP); or in patients who have experienced dysplasia/colon cancer. The procedure aids in the management of these diseases, improves patients’ quality of life, prevents the need for a permanent stoma, and reduces the risk of colorectal cancer. A common complication from IPAA is pouchitis, which is characterized as an idiopathic non-specific inflammation within the created pouch resulting in symptoms including increased frequency of bowel movements and abdominal pain. Pouchitis is much more common in patients treated for UC (up to 60%) than in those receiving treatment for other indications (0-10%). This might be due to immune activation or dysbiosis in these patients.

Author Biography

Neeraj Narula, MD, MPH, FRCPC, Division of Gastroenterology, McMaster University

Neeraj Narula is currently an Associate Professor of Medicine at McMaster University and Staff Gastroenterologist at Hamilton Health Sciences, with a clinical and research focus in Inflammatory Bowel Diseases (IBD). He also serves as Director of the IBD clinic at Hamilton Health Sciences and Director of the IBD fellowship for McMaster University. During the course of his career, he has published over 120 peer-reviewed articles and 4 book chapters and he has received over $3 million in research funding and grants. His advanced training includes Present-Levison Advanced Inflammatory Bowel Diseases Fellowship at Mount Sinai Hospital (New York, NY) and Masters of Public Health at Harvard TH Chan School of Public Health (Boston, MA). He has been an invited speaker at several international congresses including Digestive Diseases Week (American Gastroenterology Association), European Crohn’s and Colitis Organization Conference, United European Gastroenterology Week, and Ontario Association of Gastroenterology Annual Meetings.

References

Ng KS, Gonsalves SJ, Sagar PM. Ileal-anal pouches: A review of its history, indications, and complications. World J Gastroenterol. Aug 21 2019;25(31):4320- 4342. doi:10.3748/wjg.v25.i31.4320 DOI: https://doi.org/10.3748/wjg.v25.i31.4320

de Negreiros LMV, Pascoal LB, Genaro LM, et al. Pouchitis: insight into the pathogenesis and clinical aspects. Am J Transl Res. 2022;14(7):4406-4425.

Sandborn WJ, Tremaine WJ, Batts KP, Pemberton JH, Phillips SF. Pouchitis after ileal pouch-anal anastomosis: a Pouchitis Disease Activity Index. Mayo Clin Proc. May 1994;69(5):409-15. doi:10.1016/s0025-6196(12)61634-6 DOI: https://doi.org/10.1016/S0025-6196(12)61634-6

Sedano R, Ma C, Hogan M, et al. P268 Development and validation of a novel composite index for the assessment of endoscopic and histologic disease activity in pouchitis: The Atlantic pouchitis index. Poster presented at: ECCO 2023. Clinical: Diagnosis and Outcome 2023. European Crohn’s and Colitis Organization. 2023 Mar 1–4; Copenhagen, Denmark. DOI: https://doi.org/10.1093/ecco-jcc/jjac190.0398

Dalal RL, Shen B, Schwartz DA. Management of Pouchitis and Other Common Complications of the Pouch. Inflamm Bowel Dis. Apr 23 2018;24(5):989-996. doi:10.1093/ibd/izy020 DOI: https://doi.org/10.1093/ibd/izy020

Pardi DS, Sandborn WJ. Systematic review: the management of pouchitis. Aliment Pharmacol Ther. Apr 15 2006;23(8):1087-96. doi:10.1111/j.1365-2036.2006.02884.x DOI: https://doi.org/10.1111/j.1365-2036.2006.02884.x

Mimura T, Rizzello F, Helwig U, et al. Once daily high dose probiotic therapy (VSL#3) for maintaining remission in recurrent or refractory pouchitis. Gut. Jan 2004;53(1):108-14. doi:10.1136/gut.53.1.108 DOI: https://doi.org/10.1136/gut.53.1.108

Miglioli M, Barbara L, Di Febo G, et al. Topical administration of 5-aminosalicylic acid: a therapeutic proposal for the treatment of pouchitis. N Engl J Med. Jan 26 1989;320(4):257. doi:10.1056/NEJM198901263200423 DOI: https://doi.org/10.1056/NEJM198901263200422

Shen B, Lashner BA, Bennett AE, et al. Treatment of rectal cuff inflammation (cuffitis) in patients with ulcerative colitis following restorative proctocolectomy and ileal pouch-anal anastomosis. Am J Gastroenterol. Aug 2004;99(8):1527-31. doi:10.1111/j.1572-0241.2004.30518.x DOI: https://doi.org/10.1111/j.1572-0241.2004.30518.x

Navaneethan U, Venkatesh PG, Bennett AE, et al. Impact of budesonide on liver function tests and gut inflammation in patients with primary sclerosing cholangitis and ileal pouch anal anastomosis. J Crohns Colitis. Jun 2012;6(5):536-42. doi:10.1016/j.crohns.2011.10.011 DOI: https://doi.org/10.1016/j.crohns.2011.10.011

Sambuelli A, Boerr L, Negreira S, et al. Budesonide enema in pouchitis--a double-blind, double-dummy, controlled trial. Aliment Pharmacol Ther. Jan 2002;16(1):27-34. doi:10.1046/j.1365-2036.2002.01139.x DOI: https://doi.org/10.1046/j.1365-2036.2002.01139.x

Shen B, Kochhar GS, Rubin DT, et al. Treatment of pouchitis, Crohn’s disease, cuffitis, and other inflammatory disorders of the pouch: consensus guidelines from the International Ileal Pouch Consortium. Lancet Gastroenterol Hepatol. Jan 2022;7(1):69-95. doi:10.1016/S2468-1253(21)00214-4 DOI: https://doi.org/10.1016/S2468-1253(21)00214-4

Gionchetti P, Rizzello F, Poggioli G, et al. Oral budesonide in the treatment of chronic refractory pouchitis. Aliment Pharmacol Ther. May 15 2007;25(10):1231-6. doi:10.1111/j.1365-2036.2007.03306.x DOI: https://doi.org/10.1111/j.1365-2036.2007.03306.x

Gionchetti P, Calabrese C, Calafiore A, et al. Oral beclomethasone dipropionate in chronic refractory pouchitis. J Crohns Colitis. Jul 2014;8(7):649-53. doi:10.1016/j.crohns.2013.12.001 DOI: https://doi.org/10.1016/j.crohns.2013.12.001

Chandan S, Mohan BP, Kumar A, et al. Safety and Efficacy of Biological Therapy in Chronic Antibiotic Refractory Pouchitis: A Systematic Review With Meta-analysis. J Clin Gastroenterol. Jul 1 2021;55(6):481-91. doi:10.1097/MCG.0000000000001550 DOI: https://doi.org/10.1097/MCG.0000000000001550

Travis S, Silverberg MS, Danese S, et al. OP04 Vedolizumab intravenous is effective across multiple treatment targets in chronic pouchitis: Results of the randomised, double-blind, placebo-controlled EARNEST trial. Journal of Crohn’s and Colitis. 2022;16(Supplement_1):i004-i005. doi:10.1093/ecco-jcc/jjab232.003 DOI: https://doi.org/10.1093/ecco-jcc/jjab232.003

Kjaer MD, Qvist N, Nordgaard-Lassen I, Christensen LA, Kjeldsen J. Adalimumab in the treatment of chronic pouchitis. A randomized double-blind, placebo- controlled trial. Scand J Gastroenterol. Feb 2019;54(2):188-193. doi:10.1080/00365521.2019.1569718 DOI: https://doi.org/10.1080/00365521.2019.1569718

Ollech JE, Rubin DT, Glick L, et al. Ustekinumab Is Effective for the Treatment of Chronic Antibiotic-Refractory Pouchitis. Dig Dis Sci. Dec 2019;64(12):3596-3601. doi:10.1007/s10620-019-05697-1 DOI: https://doi.org/10.1007/s10620-019-05697-1

Kayal M, Lambin T, Pinotti R, Dubinsky MC, Grinspan A. A Systematic Review of Fecal Microbiota Transplant for the Management of Pouchitis. Crohns Colitis 360. Apr 2020;2(2):otaa034. doi:10.1093/crocol/otaa034 DOI: https://doi.org/10.1093/crocol/otaa034

Godny L, Maharshak N, Reshef L, et al. Fruit Consumption is Associated with Alterations in Microbial Composition and Lower Rates of Pouchitis. J Crohns Colitis. Sep 27 2019;13(10):1265-1272. doi:10.1093/ecco-jcc/jjz053 DOI: https://doi.org/10.1093/ecco-jcc/jjz053

McLaughlin SD, Culkin A, Cole J, et al. Exclusive elemental diet impacts on the gastrointestinal microbiota and improves symptoms in patients with chronic pouchitis. J Crohns Colitis. Jul 2013;7(6):460-6. doi:10.1016/j.crohns.2012.07.009 DOI: https://doi.org/10.1016/j.crohns.2012.07.009

Published

2023-04-11

How to Cite

1.
Narula N. Management of Pouchitis: Clinical Pearls for the Gastroenterologist. Can IBD Today [Internet]. 2023 Apr. 11 [cited 2024 Dec. 22];1(1):12–17. Available from: https://canadianibdtoday.com/article/view/1-1-2-narula

Issue

Section

Articles