Chronic Antibiotic-Refractory Pouchitis: Management Challenges

Abstract

Background Pouchitis is the most common long-term complication in patients with ulcerative colitis who underwent restorative proctocolectomy with ileal pouch-anal anastomosis. The incidence of acute pouchitis is 20% after 1 year and up to 40% after 5 years. Chronic antibiotic-refractory pouchitis develops in approximately 10% of patients. Aim To present a narrative review of published literature regarding the management of chronic antibiotic-refractory pouchitis. Methods Current relevant literature was summarized and critically evaluated. Results Clear definitions should be used to classify pouchitis into acute versus chronic, and responsive versus dependent versus refractory to antibiotics. Before treatment is started for chronic antibiotic-refractory pouchitis, secondary causes should be ruled out. There is a need for validated scoring systems to measure the severity of the disease. Because chronic antibiotic-refractory pouchitis is a rare condition, only small studies with often a poor study design have been performed. Treatments with antibiotics, aminosalicylates, steroids, immunomodulators and biologics have shown to be effective and safe for chronic antibiotic-refractory pouchitis. Also, treatments with AST-120, hyperbaric oxygen therapy, tacrolimus enemas, and granulocyte and monocyte apheresis suggested some efficacy. Conclusion The available data are weak but suggest that therapeutic options for chronic antibiotic-refractory pouchitis are similar to the treatment strategies for inflammatory bowel diseases. However, randomized controlled trials are warranted to further identify the best treatment options in this patient population.

Personalized Approach to Chronic Antibiotic-Refractory Pouchitis: A Case Report and Review of the Literature

“…Some of the main treatment options include antibiotics, immunomodulators, anti-tumor necrosis factor (anti-TNF), and even probiotics. Although requiring prolonged use of antibiotics, CARP has shown to be responsive in some studies to ciprofloxacin in combination with metronidazole [1,14]. In addition to antibiotics, an immunosuppressive approach has also proven successful in treating the inflammation associated with CARP.…”

“…The ileal pouch is a surgically implanted artificial pouch that functions to replace the colon. The pouch can be inflamed leading to CARP [1]. Patients with CARP frequently experience symptoms like diarrhea, rectal bleeding, abdominal pain, and a lower quality of life.…”

Insights into the role of gastrointestinal ultrasound in ulcerative colitis

“…Diagnosing and managing pouchitis and identifying surgical failures are challenging tasks for physicians who care for these patients. 43 …”

Refractory Pouchitis: Antibiotic-Resistant Chronic Refractory Pouchitis

“…Bismuth, bismuth carbomer, and alicaforsen enema in CARP treatment have reported conflicting results. 18,24 On the contrary, it was observed that topical tacrolimus and cyclosporine exhibited efficacy in cases of CARP. 20,25-27 • Biological agents are utilized as rescue therapy in CARP treatment for patients who do not respond to budesonide.…”

“…Insufficient data exists to provide a definitive assessment of the efficacy of immunomodulators as an induction therapy for CARP, whether utilized independently or in conjunction with biologic agents. 6,20,24 However, they can be used as an option for remission maintenance. 20…”