Long‐term efficacy of bismuth carbomer enemas in patients with treatment‐resistant chronic pouchitis

Abstract

Background: Mucosal inflammation of the ileal pouch (pouchitis) is the major long‐term complication after ileal pouch‐anal anastomosis for ulcerative colitis. Broad‐spectrum antibiotics are the mainstay of treatment, however, 15% of patients with pouchitis have a chronic, treatment‐resistant disease. Aim: To determine the safety and efficacy of bismuth carbomer enemas in achieving and maintaining remission in treatment‐resistant chronic pouchitis. Methods: Twelve patients with treatment‐resistant chronic pouchitis were treated nightly for 45 days with enemas containing elemental bismuth complexed with carbomer. Diagnosis of pouchitis and response to treatment were evaluated with the Pouchitis Disease Activity Index (PDAI), which includes clinical, sigmoidoscopic and histological criteria. Serum bismuth concentrations were determined by atomic absorption. Results: Ten of 12 patients (83%) went into remission, with a significant decrease of mean total PDAI score from 12 (range 9–15) to 6 (4–15) (P < 0.002), and were continued on bismuth carbomer enemas administered every third night for 12 months. Patients were monitored clinically, sigmoidoscopically and histologically every 2 months for evidence of recurrence (increase ≥ 2 in the clinical symptom portion of the PDAI). Six of 10 patients (60%) were able to maintain remission throughout the 12‐month trial; 4/10 had an exacerbation, two of which occurred soon after discontinuing daily treatment. Serum bismuth levels were negligible in all patients and no side‐effects were registered. Conclusions: Our findings suggest that bismuth carbomer enemas are safe and effective in achieving and maintaining remission in patients with treatment‐resistant chronic pouchitis.

Intriguing Gastrointestinal Properties of Bismuth: A Folk Remedy Brought into the Realm of Clinical and Investigative Medicine

“…In a study of colitis in the rat, this group also showed that both BSS and CBS had efficacy in healing colitis (10). This result concurs with results from several recent clinical reports demonstrating efficacy of oral BSS in microscopic colitis (11) and bismuth carbomer enemas in treatment-resistant chronic pouchitis (12).…”

Bismuth carbomer foam enemas for active chronic pouchitis: a randomized, double‐blind, placebo‐controlled trial

“…In an open label trial lasting 45 days, bismuth carbomer enemas appeared effective for chronic treatment-resistant pouchitis. 12 Perhaps a longer treatment period in this current study would have shown a therapeutic bene®t. 12 (8±17) 9 (2±16)à 11 (7±16) 9 (2±16)à * Two subjects missing data at completion in bismuth group.…”

“…9±11 More recently, bismuth complexed with carbomer (an acrylic acid polymer) and administered as a liquid enema was reported to result in clinical improvement in 10 of 12 patients in an open trial. 12 The rationale for the use of bismuth and bismuth carbomer in ulcerative colitis and pouchitis includes both non-speci®c anti-diarrhoeal effects and anti-bacterial effects. Some preparations of bismuth no longer in use caused neurotoxicity when taken in high doses, such as bismuth subnitrate in France and bismuth subgallate in Australia.…”

Benefit of antibiotic therapy on pouchitis after ileal pouch anal anastomosis: A systematic review and meta-analysis of clinical trials

“…These modalities include budesonide [36], bismuth carbomer enema [37], glutamine and butyrate suppository compounds [38], and allopurinol [39]. None of these therapies have shown significant beneficial effect in comparison to placebo [17].…”