Pouchitis after ileal pouch‐anal anastomosis in ulcerative colitis: Diagnosis, management, risk factors, and incidence

Abstract

Restorative proctocolectomy with ileal pouch-anal anastomosis has been the surgical treatment of choice for patients with ulcerative colitis who require surgery. Quality of life after this procedure is satisfactory in most cases; however, pouchitis is a troublesome condition involving inflammation of the ileal pouch. When a patient presents with symptoms of pouchitis, such as increased bowel movements, mucous and/or bloody exudates, abdominal cramps, and fever, endoscopy is essential for a precise diagnosis. The proximal ileum and rectal cuff, as well as the ileal pouch, should be endoscopically observed. The reported incidence of pouchitis ranges from 14% to 59%, and antibiotic therapy is the primary treatment for acute pouchitis. Chronic pouchitis includes antibiotic-dependent and refractory pouchitis. Intensive therapy including antitumor necrosis factor antibodies and steroids may be necessary for antibioticrefractory pouchitis, and pouch failure may occur despite such intensive treatment. Reported risk factors for the development of pouchitis include presence of extraintestinal manifestations, primary sclerosing cholangitis, non-smoking, and postoperative non-steroidal anti-inflammatory drug usage. In the present review, we focus on the diagnosis, endoscopic features, management, incidence, and risk factors of pouchitis in patients with ulcerative colitis who underwent ileal pouch-anal anastomosis.

Meta‐analysis of the association of extraintestinal manifestations with the development of pouchitis in patients with ulcerative colitis

“…It should be stressed that diagnostic criteria for pouchitis are essential for the precise elucidation of the risk of pouchitis, because symptoms did not necessarily correlate with endoscopic and histological findings in the pouch. Symptoms of pouchitis may occur in patients with irritable pouch syndromes, Crohn's disease of the pouch, or cuffitis. Therefore, pouchoscopy is unavoidable to make a definite diagnosis of pouchitis.…”

“…Symptoms of pouchitis may occur in patients with irritable pouch syndromes, Crohn's disease of the pouch, or cuffitis. Therefore, pouchoscopy is unavoidable to make a definite diagnosis of pouchitis.…”

“…Pouchitis is an idiopathic inflammation of the ileal pouch. First‐line treatment for pouchitis is antibiotics such as metronidazole and ciprofloxacin. One‐third to one‐half of patients with pouchitis, however, experience chronic pouchitis.…”

The relationship between preoperative T helper cytokines in the ileal mucosa and the pathogenesis of pouchitis

“…On the other hands, CARP may be a result of abnormal host immune response. Thus, a subgroup of patients with CARP does not respond to standard antibiotic therapy 4,[33][34][35] . The treatment of choice is immunosuppressive therapy with a good response in the treatment of CARP and Crohn's pouchitis [36][37][38] .…”

“…The incidence of pouchitis is 40-70% in UC patients who receive IPAA [1][2][3] . Although the immunopathogenesis of pouchitis is unclear, there are two major mechanisms associated with pouchitis: microbial dysbiosis and abnormal immune responses 4 . Whether in ammation of the pouch mucosa represents a recurrence of immune mechanisms in UC or a new form of in ammatory bowel disease (IBD) remains a topic of discussion.…”