Pouchitis

This term covers a spectrum of symptomatic inflammatory conditions of the ileal pouch mucosa. We understand this to be a syndrome combining histopathologic evidence of ileal pouch mucosal inflammation with clinical features characterized by one or more of the following:

1. Significant increase in stool frequency above the patient's usual base level

2. Low grade fever and malaise

3. Bleeding

4. Dull pelvic pressure/pain

Most cases respond to metronidazole with or without ciprofloxacin given over a 5 to 10 day period. A chronic variety of pouchitis is much less common. We usually will treat such patients with initial long term (6 months plus) antibiotic therapy. Probiotics have been used to replace long term antibiotics in some patients. If there is little or no response, we will use, 5-ASA orally and/or by enema. The next chapter (Chapter 80,"Crohn's Colitis") details treatment of pouchitis, including a discussion of CD in IPAA. Occasionally ileostomy with pouch excision is necessary.

Irritable Pouch Syndrome

Diarrhea, abdominal pain, urgency, and pelvic discomfort are common after surgery. Pouchitis with those symptoms is the most common long term complication. However, these most frequently reported symptoms in patients with IPAA are not specific for pouchitis. Shen and colleagues (2001) showed that symptom assessment alone is not sufficient for the diagnosis of pouchitis, and that pouch endoscopy and biopsy may be required for diagnosis. Based on symptom, endoscopy and histology assessment using the Pouchitis Disease Activity Index criteria (the most commonly used and validated diagnostic instrument for pou-chitis), we examined 61 consecutive symptomatic patients with UC and IPAA, and found that 43% of patients with symptoms suggestive of pouchitis had no endoscopic or histologic evidence of pouchitis or cuffitis. These patients have a condition resembling irritable bowel syndrome (IBS), which we termed it irritable pouch syndrome (IPS) (Shen et al, 2002).

IPS is common in patients with IPAA, and this new disease category has become increasingly recognized. Patients with IPS comprise a substantial portion of outpatient clinic visits in tertiary care centers. Clinical features of pouchitis, cuffitis, and IPS overlap, with the most common symptoms being increased stool frequency, abdominal cramps, and pelvic discomfort. The only way to differentiate the three disease entities is by pouch endoscopy. Patients with IPS also share clinical features of IBS, such as abdominal pain, bloating, urgency, and pelvic discomfort, which are largely relived with defecation. Similar to IBS, weight loss, bloody bowel movement, and fever are not features of IPS.

In a recent study, we found patients with IPS, similar to those with pouchitis or cuffitis, had significantly poorer quality of life scores than patients with normal pouches. Appropriate diagnosis and treatment are important for improving a patient's quality of life. Currently, the diagnosis of IPS is based on the exclusion of structural and inflammatory conditions (such as pouchitis, cuffitis, anastomotic stricture or CD) using pouch endoscopy. We prefer the test-first strategy with diagnostic pouchoscopy rather than the treat first strategy (empiric antibiotics for 5 to 7 days) in the management of patients who present pouchitis-like symptoms. We have recently shown that testfirst strategy with pouch endoscopy without biopsy is cost effective and it avoids both diagnostic delay and adverse effects associated with unnecessary antibiotics (Shen et al, 2003). If a patient has symptoms of abdominal or perianal pain, diarrhea, or pelvic discomfort while having a normal pouch endoscopy, he or she is diagnosed as having IPS.

There are no published controlled drug trials for the treatment of patients with IPS. In our institution, we have adopted some safe and effective drug regimens in patients with IBS to treat patients with IPS. The first line therapy includes low dose antidepressants and antispasmodic agents. We believe that safer and more effective agents will become available once we learn more about the cause and mechanism of this new disease.*

^Editor's Note: Sometimes a "predict-first" strategy is helpful because some of the IBS patients give a very clear history of irritable bowel type symptoms for many years before they developed recognized UC. Because the small bowel is also "irritable", an IPAA may not be the best option for such patients (Bayless), one can expect more than 10 evacuations per day in some because the irritable or "spastic" pouch can only hold 90 to 100 cc in contrast to the "normal" pouch capacity of 300 to 400 cc. In addition, the patient with irritable pouch can only expel half of the diminished pouch contents, thus this patient may have more than 10 movements per day (Schmidt et al, 1996). The next chapter (Chapter 80, "Crohn's Colitis") has more details in high output IPAAs.

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