Pouchitis

Pouchitis

ECCO statement 10A (UC 2017)

The diagnosis of pouchitis requires the presence of symptoms, together with characteristic endoscopic and histological abnormalities [EL3]. Extensive ulcerative colitis, primary sclerosing cholangitis, being a non-smoker, pANCA-positive serology, and non-steroidal anti-inflammatory drug use are possible risk factors for pouchitis [EL3]

Further information

  • Suspicious symptoms are increased stool frequency and consistency, cramping, tenesmus, incontinence and urgency
  • Bleeding, fever, and EIM are rarer presenting symptoms
  • Pouchitis more likely with:
    • Extensive UC
    • EIM especially PSC
    • Non-smokers (smoking increases risk of Crohn’s disease of the pouch)
    • P-ANCA positivity
    • NSAIDs
    • Backwash ileitis
    • Previous colonic dysplasia
Symptoms of pouchitis

ECCO statement 9E (UC 2017)

Early pouchoscopy is recommended in symptomatic patients with pouch dysfunction, in order to distinguish between pouchitis and other conditions [EL 4]

Further information

  • Request stool culture and exclude C. difficile

  • Patchy erythema suggests pouchitis, confirmed by biopsy

Investigations

Treat symptoms

  • Up to 50% of patients develop acute pouchitis during the initial 10 years following IPAA

  • Recurrent in majority (infrequent < annually or relapsing with 1-3 episodes / yr)

Acute pouchitis

  • Complications include abscesses, fistulae, anastomotic stenosis

  • Adenocarcinoma of the pouch exceedingly rare. Regular (e.g. annual) surveillance required if history of colo-rectal neoplasia.

Suspected pouchitis complication

Pelvic MR +/or pouchogram

ECCO statement 10B (UC 2017)

The majority of patients respond to metronidazole or ciprofloxacin, although the optimum modality of treatment is not clearly defined [EL2]. Side effects are less frequent using ciprofloxacin [EL2]. Antidiarrhoeal drugs may reduce the number of daily liquid stools, independently of pouchitis [EL5]

Further information

  • Ciprofloxacin 1 g/d for 2 weeks

  • Metronidazole 20 mg/kg/d for 2 weeks 2nd line therapy

  • Budesonide enemas (2 mg/100 mL) at bedtime as effective as metronidazole

  • VSL#3 (6g/d) effective in mildly active pouchitis

Treatment

ECCO statement 9J (UC 2017)

Non-inflammatory causes of pouch dysfunction include pouch-anal stricture, pouch fistula, problems with pouch capacity, efferent limb dysfunction [S-pouch], retained rectal stump, and chronic pre-sacral sepsis. Deciding on appropriate management requires discussion in a multidisciplinary team setting [EL5]

ECCO Statement 8E (UC 2012)

Probiotic therapy with VSL#3 (18 × 1011 of 8 bacterial strains for 9 or 12 months) has shown efficacy for maintaining antibiotic-induced remission [EL1b, RG B]. VSL#3 (9 × 1011 bacteria) has also shown efficacy for preventing pouchitis [EL2b, RG C]

Prophylaxis

  • Defined by symptoms > 4 weeks

  • Chronic pouchitis develops in ≈ 10% patients overall

Chronic pouchitis

ECCO Statement 8F (UC 2012)

Rectal cuff inflammation (cuffitis) may induce symptoms similar to pouchitis or irritable pouch syndrome, although bleeding is more frequent [EL2a, RG B]. Topical 5-ASA has shown efficacy [EL4, RGD]

Further information

  • Crohn’s disease of the pouch

  • Cuffitis

  • Ischaemia

  • Infection e.g. C. difficile or CMV

  • Small pouch volume

  • Incomplete pouch evacuation

  • Pouch volvulus

  • Focal pouchitis, secondary to localised pelvic sepsis

  • Irritable pouch (more common in those previously treated with anti-depressants or anxiolytics)

Exclude complications

ECCO statement 10C (UC 2017)

In chronic pouchitis a combination of two antibiotics is effective [EL3]. Oral budesonide, oral beclomethasone dipropionate [EL3], and topical tacrolimus [EL3] are alternatives. Infliximab is effective for the treatment of chronic refractory pouchitis [EL4]. Adalimumab may represent an alternative treatment in patients refractory to infliximab [EL4]

Further information

  • Preferably combination antibiotic therapy, e.g. ciprofloxacin 1g & tinidazole 1g daily for 4 weeks. Remission in > 80%

  • Alternative treatment includes rifaximin 2g daily or metronidazole 1g daily for 4 weeks. Remission in > 80%

  • Budesonide 9mg daily for 8 weeks an alternative therapy

Combination antibiotics or budesonide

  • More than 80% respond to infliximab , with just over 50% those treated still responding at 20 months

  • Treatment duration tailored to individual patient

  • Adalimumab also benefits patients with chronic pouchitis

Anti-TNF

  • Ciclosporin enema

  • Azathioprine in those dependent on budesonide

  • Alicaforsen (anti-sense to ICAM-1) enema

  • Surgery would require pouch excision

Alternative agents or surgery

Terms and conditions

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