Inflammatory pouch disease: The spectrum of pouchitis

Restorative proctocolectomy with ileal-pouch anal anastomosis(IPAA) is the operation of choice for medically refractory ulcerative colitis(UC), for UC with dysplasia, and for familial adenomatous polyposis(FAP). IPAA can be a treatment option for selected patients with Crohn's colitis without perianal and/or small bowel disease. The term "pouchitis" refers to nonspecific inflammation of the pouch and is a common complication in patients with IPAA; it occurs more often in UC patients than in FAP patients. This suggests that the pathogenetic background of UC may contribute significantly to the development of pouchitis. The symptoms of pouchitis are many, and can include increased bowel frequency, urgency, tenesmus, incontinence, nocturnal seepage, rectal bleeding, abdominal cramps, and pelvic discomfort. The diagnosis of pouchitis is based on the presence of symptoms together with endoscopic and histological evidence of inflammation of the pouch. However, "pouchitis" is a general term representing a wide spectrum of diseases and conditions, which can emerge in the pouch. Based on the etiology we can sub-divide pouchitis into 2 groups: idiopathic and secondary. In idiopathic pouchitis the etiology and pathogenesis are still unclear, while in secondary pouchitis there is an association with a specific causative or pathogenetic factor. Secondary pouchitis can occur in up to 30% of cases and can be classified as infectious, ischemic, non-steroidal antiinflammatory drugs-induced, collagenous, autoimmuneassociated, or Crohn's disease. Sometimes, cuffitis or irritable pouch syndrome can be misdiagnosed as pouchitis. Furthermore, idiopathic pouchitis itself can be sub-classified into types based on the clinical pattern, presentation, and responsiveness to antibiotic treatment. Treatment differs among the various forms of pouchitis. Therefore, it is important to establish the correct diagnosis in order to select the appropriatetreatment and further management. In this editorial, we present the spectrum of pouchitis and the specific features related to the diagnosis and treatment of the various forms.     

Probiotic therapy for pouchitis and its endoscopic findings

Restorative proctocolectomy with ileal pouch anal anastomosis has become the most frequently performed operation for ulcerative colitis. Patients having this operation, however, experience more short‐ and long‐term complications than those with a permanent ileostomy. Pouchitis, acute non‐specific inflammation within an ileal pouch, is one of the most common long‐term complications after this procedure, and is specific to it. Although most pouchitis is amenable to simple antibiotic therapy including metronidazole and ciprofloxacin, 5–15% of patients suffer from refractory pouchitis, in which the acute inflammation either relapses frequently after the cessation of the antibiotics or does not respond to them at all. Probiotic therapy is intended to re‐establish natural bacterial conditions with live organisms belonging to natural bacterial flora. Recently, there have been an increasing number of reports that probiotic therapy is effective for inflammatory bowel disease including pouchitis, and might be the best approach to treat them. In this paper, the rationale and evidence for benefit of probiotic therapy in treating pouchitis have been reviewed, and representative endoscopic pictures of pouchitis have been included.     

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

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 antibiotic‐refractory 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.     

Successful treatment of severe pouchitis with rebamipide refractory to antibiotics and corticosteroids： A case report

The antibiotics,metronidazole and ciprofloxacin,arethe first-line treatment for pouchitis.Patients who donot respond to antibiotics or conventional medicationsrepresent a major challenge to therapy.In this report,we have described a successful treatment of severerefractory pouchitis with a novel agent,rebamipide,known to promote epithelial cell regeneration andangiogenesis.A 27-year-old male with ileo-anal pouchsurgery presented with worsening anal pain,diarrhea,and abdominal pain.The patient was diagnosed tohave pouchitis and was given metronidazole togetherwith betamethasone enema(3.95 mg/dose).However,despite this intensive therapy,the patient did notimprove.On endoscopy,ulceration and inflammationwere seen in the ileal pouch together with contactbleeding and mucous discharge.The patient was treatedwith rebamipide enema(150 mg/dose)twice a day for 8 wkwithout additional drug therapy.Two weeks after therebamipide therapy,stool frequency started to decreaseand fecal hemoglobin became negative at the 4~(th) wk.Atthe end of the therapy,endoscopy revealed that ulcers inthe ileal pouch had healed with no obvious inflammation.The effect of rebamipide enema was dramatic and wasmaintained throughout the 11-mo follow-up.The patientcontinued to be in remission.No adverse effects wereobserved during the treatment or the follow-up period.The sustained response seen in this case with severeand refractory pouchitis indicates that agents,whichpromote epithelial cell growth,angiogenesis and mucosaltissue regeneration,are potential therapeutic agents forthe treatment of refractory colorectal lesions.     

Pouchitis atlas for objective endoscopic diagnosis

“Pouchitis” is a term for nonspecific mucosal inflammation of the pouch after total proctocolectomy and ileal pouch–anal anastomosis for ulcerative colitis. Pouchitis is the most frequent complication of the pelvic pouch at the late stage. To improve the accuracy of the pouchitis diagnosis, sets of clinical symptoms and endoscopic findings (with or without histology of biopsy samples) have previously been evaluated. Endoscopic findings are central to the diagnosis, and a universal consensus of various endoscopic findings must be the initial step toward an objective diagnosis of pouchitis. Since a proper signpost for the endoscopic evaluation of pouchitis has been absent, we developed this pouchitis atlas to minimize the diagnostic variation inherent among individual endoscopists. We also propose new criteria for the diagnosis of pouchitis: the Japanese criteria for diagnosis of pouchitis. These criteria are based on clinical symptoms and endoscopic findings that are clearly categorized in the atlas, and exclude infectious enteritis, anastomotic insufficiency, pelvic infection, anal dysfunction, and Crohn's disease. Advantages of the new criteria include ease of bedside diagnosis, without the calculation of points required by the other criteria for pouchitis. This pouchitis atlas, together with our new criteria, should contribute to the establishment of a clear-cut diagnosis for pouchitis and promote better evaluation and treatment of this novel intestinal inflammation.     

Factors associated with disease activity of pouchitis after surgery for ulcerative colitis

Background: Pouchitis occurs in 20% to 59% of patients operated on for ulcerative colitis. Several risk factors have been identified for the development of pouchitis. This study was undertaken to assess the incidence of pouchitis at least 5 years after ileal pouch‐anal anastomosis for ulcerative colitis, and to evaluate possible predictive factors for inflammation activity. Methods: A total of 107 subjects were enrolled (54 M, 53 F, mean age 45 years, range 23–69) with a J‐pouch created between 1985 and 1994. Preoperative medical history was determined, an endoscopy performed, and biopsies taken from the pouch and neoterminal ileum above the pouch. Sera from all patients were tested for perinuclear antineutrophil cytoplasmic antibodies (pANCAs). Results: After a mean 7.5‐years' follow‐up time, the cumulative incidence of pouchitis was 58%. Risk for development of active inflammation (PDAI?≥?7) was significantly higher in patients with preoperative extraintestinal manifestations (OR 2.7, 95% CI 1.1–6.4, P?=?0.03). Patients who had had ankylosing spondylitis (AS) (OR 11.7, P?=?0.006) or iritis (OR 9.8, P?=?0.013) were especially at risk. Positive titres of pANCAs were associated with inflammation in the neoterminal ileum; 80% of patients with high pANCA levels (>100) had pouchitis. Current smokers tended to have a more benign disease course. Conclusions: A correlation existed between the prevalence and titre of pANCAs and extent and disease activity of pouchitis. Chronic pouchitis may continuously stimulate the immunological process, keeping pANCAs at detectable levels. A strong correlation between AS, iritis and pouchitis suggests a common link in their pathogenesis.     

Leukocytapheresis for the treatment of active pouchitis: a pilot study

BACKGROUND: Pouchitis is a major long-term complication of ileal pouch-anal anastomosis for ulcerative colitis. The aim of this study is to investigate the efficacy of leukocytapheresis for the treatment of active pouchitis. METHODS: Eight patients with active pouchitis received leukocytapheresis weekly for 5 weeks in an open-label treatment protocol together with baseline therapy. RESULTS: Patients showed significant improvement in their pouchitis disease activity index scores, from 9.5 (range, 8-10) to 4.0 (range, 2-8) (P < 0.05). Six (75%) of the 8 treated patients achieved remission. No adverse events were observed. CONCLUSIONS: Leukocytapheresis therapy could be a new therapeutic strategy for patients with pouchitis after ileal pouch-anal anastomosis for ulcerative colitis. These encouraging results lead us to propose a randomized controlled trial.     

Secondary pouchitis in a post-operative patient with ulcerative colitis, successfully treated by salvage surgery

We report a case of secondary pouchitis, defined as a mucosal inflammatory lesion in the ileal reservoir provoked by pouch-related complication following total colectomy and pouch anal anastomosis, which was successfully treated by salvage surgery- A 20-year-old woman with ulcerative colitis developed acute severe bloody diarrhea following proctocolectomy, ileal pouch-anal anastomosis and diverting ileostomy. She was diagnosed as having a secondary pouchitis mainly caused by a peripouch abscess and partly concerned with the abnormal pouch formation. The remnant rectum and ileal pouch were excised and ileal pouch-anal anastomosis and diverting ileostomy were constructed. The postoperative course was uneventful with no sign of pouchitis. Salvage surgery may be indicated to treat secondary pouchitis when caused by surgery-related complications.     

Perinuclear anti-neutrophil cytoplasmic antibody and refractory pouchitis

Refractory pouchitis (RP) is a debilitating complication of ileal pouch reservoirs that affects hypothesized that it reflects underlying Crohn's disease. Since perinuclear anti-neutrophil cytoplasmic antibody (pANCA) is found in approximately 70% of ulcerative colitis patients but only rarely in Crohn's disease patients, it may help distinguish Crohn's disease from ulcerative colitis. Therefore, to test whether RP reflects missed Crohn's disease, we determined the ANCA status of 26 patients with RP. The pANCA was positive in 42% of cases [50% of Kock pouch cases and 33% of ileoanal pull-through (IAPT) cases] and 57% of matched control subjects without pouchitis (N=42,P=NS). Moreover, 3/6 (50%) of IAPT RP subjects whose signs and symptoms most suggested Crohn's disease tested positive for pANCA. When compared to controls, IAPT cases exhibited significantly more preoperative extraintestinal manifestations (EIMs) of inflammatory bowel disease (P<0.05). The presence of preoperative EIMs was 100% predictive of postoperative EIMs (P<0.05). Review of pouch biopsies from cases of RP revealed no pathognomonic histologic features of Crohn's disease. These data confirm our previous suggestion that RP does not reflect underlying Crohn's disease but may be associated with the EIMs of inflammatory bowel disease.     

Acute and chronic pouchitis--pathogenesis, diagnosis and treatment

Restorative proctocolectomy with ileal pouch-anal anastomosis has become the procedure of choice for the majority of patients with ulcerative colitis who require surgical treatment. Pouchitis, the most common long-term complication of the procedure, involves a spectrum of disease processes with heterogeneous risk factors, clinical features, disease courses and prognoses. In addition, clinical symptoms of pouchitis are not specific and often overlap with those of other inflammatory and functional pouch disorders, such as Crohn's disease of the pouch and irritable pouch syndrome. Pouchoscopy and biopsy, along with laboratory and radiographic evaluations, are often required for accurate diagnosis in patients with symptoms indicative of pouchitis. Dysbiosis has been implicated as a triggering factor for pouchitis, and concurrent infection with pathogens, such as Clostridium difficile, might contribute to disease relapse and exacerbation. Antibiotic therapy is the main treatment modality. However, the management of antibiotic-dependent and antibiotic-refractory pouchitis remains challenging. Secondary causes of pouchitis, such as ischaemia, NSAID use, the presence of concurrent primary sclerosing cholangitis and other systemic immune-mediated disorders, should be evaluated and properly managed.     

Reduction in bone resorption by exogenous glucagon-like peptide-2 administration requires an intact gastrointestinal tract

Objective. According to epidemiological studies, smoking habit is strongly associated with inflammatory bowel disease. Non-smokers, and especially recent ex-smokers, have an increased risk of ulcerative colitis (UC). Conversely, concerning Crohn's disease, the risk is increased among smokers. Pouchitis is the major long-term complication of restorative proctocolectomy for UC, and seems to be pathogenetically related to this condition. The aims of this study were to test the hypothesis that smoking reduces the risk of pouchitis, and to investigate whether cessation of smoking precedes the onset of the inflammation. Material and methods. All living patients operated on for UC with proctocolectomy and ileal pouch anal anastomosis (IPAA) between November 1982 and November 1996 at Sahlgren's University Hospital were included in the study (n=410). Data concerning smoking habits and pouchitis were obtained from questionnaires and from medical records. The correlation between smoking habits and incidence of pouchitis was statistically evaluated by means of a survival test and a multivariate analysis, i.e. a Poisson model. Results. In all, 327 patients (80%) completed the questionnaires. Ninety-six (29%) of these patients had had at least one episode of pouchitis. Smoking habits during follow-up did not significantly influence the risk of pouchitis (p=0.29). Nor did smoking habits before and at the time of IPAA correlate with the incidence of pouchitis. Women had a decreased risk of pouchitis, compared to men (p=0.014). There was a non-significant tendency for smoking to increase the risk, which was more pronounced in women. Conclusions. Smoking does not decrease the risk of pouchitis following IPAA for UC, and in this respect the pathogenetic model of pouchitis, suggested to be a manifestation of UC, is not supported.     

Long term outcomes of initial infliximab therapy for inflammatory pouch pathology: a multi-Centre retrospective study

Background: Restorative proctocolectomy with ileal pouch-anal anastomosis is considered the procedure of choice in patients with ulcerative colitis refractory to medical therapy. Subsequent inflammation of the pouch is a common complication and in some cases, pouchitis fails to respond to antibiotics, the mainstay of treatment. In such cases, corticosteroids, immunomodulatory or biologic treatments are options. However, our understanding of the efficacy of anti-tumour necrosis factor medications in both chronic pouchitis and Crohn’s-like inflammation is based on studies that include relatively small numbers of patients.

Methods: This was an observational, retrospective, multi-centre study to assess the long-term effectiveness and safety of infliximab (IFX) for inflammatory disorders related to the ileoanal pouch. The primary outcome was the development of IFX failure defined by early failure to IFX or secondary loss of response to IFX.

Results: Thirty-four patients met the inclusion criteria; 18/34 (53%) who were initiated on IFX for inflammatory disorders of the pouch had IFX failure, 3/34 (8%) had early failure and 15/34 (44%) had secondary loss of response with a median follow-up of 280 days (range 3–47 months). In total, 24/34 (71%) avoided an ileostomy by switching to other medical therapies at a median follow-up of 366 days (1–130 months).

Conclusions: Initial IFX therapy for pouch inflammatory conditions is associated with IFX failure in just over half of all patients. Despite a high failure rate, an ileostomy can be avoided in almost three-quarters of patients at four years by using other medical therapies.     

Diagnosis and Management of Pouchitis and Ileoanal Pouch Dysfunction

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) has become the surgical treatment of choice for patients with medically refractory ulcerative colitis (UC) or UC with dysplasia and for the majority of patients with familial adenomatous polyposis. However, UC patients with IPAA are susceptible to inflammatory and noninflammatory sequelae, such as pouchitis, Crohn’s disease of the pouch, cuffitis, and irritable pouch syndrome, in addition to common surgery-associated complications, which adversely affect the surgical outcome and compromise health-related quality of life. Pouchitis is the most frequent long-term complication of IPAA in patients with UC, with a cumulative prevalence of up to 50%. Pouchitis may be classified based on the etiology into idiopathic and secondary types, and the management is often different. Pouchoscopy is the most important tool for the diagnosis and differential diagnosis in patients with pouch dysfunction. Antibiotic therapy is the mainstay of treatment for active pouchitis. Some patients may develop dependency on antibiotics, requiring long-term maintenance therapy. Although management of antibiotic-dependent or antibiotic-refractory pouchitis has been challenging, secondary etiology for pouchitis should be evaluated and modified, if possible.     

Fecal lactoferrin for diagnosis of symptomatic patients with ileal pouch-anal anastomosis

BACKGROUND & AIMS: Increased stool frequency, urgency, and abdominal pain in patients with ileal pouch-anal anastomosis (IPAA) may be due to inflammatory conditions, including pouchitis, cuffitis, or Crohn's disease or noninflammatory conditions such as irritable pouch syndrome. Distinction among these entities requires pouch endoscopy and biopsy. Noninvasive means of diagnosis are preferable. METHODS: Sixty consecutive subjects with IPAA for inflammatory bowel disease had measurements of fecal lactoferrin and alpha1-antitrypsin and underwent pouch endoscopy with biopsy, with calculation of the pouchitis disease activity index in a prospective cross-sectional study. RESULTS: Symptomatic patients with an inflammatory condition had significantly higher fecal lactoferrin concentrations (median, 176.0 microg/mL, interquartile range [IQR] 79.0-450.8) compared with those with a noninflammatory condition (median, 4.8 microg/mL; IQR, 1.2-11.0) or those who were asymptomatic (median, 7.8 microg/mL; IQR, 1.4-12.9), P < 0.001. At a cutoff level of 7 microg/mL, fecal lactoferrin could distinguish patients with irritable pouch syndrome from those with pouchitis, cuffitis, or Crohn's disease with a sensitivity of 100% and specificity of 85%. Fecal alpha1-antitrypsin was not able to distinguish symptomatic patients with and without an inflammatory condition. CONCLUSIONS: Fecal lactoferrin can serve as a sensitive and noninvasive initial screening test in an algorithm for evaluation of symptomatic patients with IPAA. If fecal lactoferrin levels are low (<7 microg/mL), IPS can be diagnosed. If fecal lactoferrin levels are high, pouch endoscopy with biopsy is warranted to distinguish among different causes of inflammation. Longitudinal studies are needed to define better the role of this test in the management of patients with IPAA.     

Patients with extraintestinal manifestations have a higher risk of developing pouchitis in ulcerative colitis: multivariate analysis

Background: Restorative proctocolectomy and ileal pouch‐anal anastomosis (IPAA) have been the surgical treatments of choice for ulcerative colitis (UC). However, the IPAA is sometimes complicated with pouchitis. Furthermore, the cumulative risk and risk factors for developing pouchitis in patients with UC undergoing IPAA have not been reported in any Asian population. The aim of our study is to clarify the cumulative risk and risk factors for developing pouchitis in Japanese patients with UC undergoing IPAA. Methods: Fifty‐eight patients with UC undergoing IPAA were retrospectively evaluated for the presence of pouchitis, gender, age of onset, history of smoking, presence of extraintestinal manifestations (EIMs) and type of operation. The diagnosis of pouchitis was based on the pouchitis disease activity index. The cumulative risk and risk factors for developing pouchitis were assessed. Results: The cumulative risks for developing pouchitis at 1 and 5 years were 9.0% and 14.4%, respectively. The estimated risks of pouchitis at 5 years was 48.1% in patients with EIMs and 4.6% in those without. Both univariate and multivariate analyses revealed that the presence of EIMs is a significant risk factor (hazard ratio 16.85, 95% confidence interval 3.12–91.00; P?=?0.001). Conclusions: The presence of EIMs is a significant risk factor for the development of pouchitis in Japanese patients with UC undergoing IPAA.     

Effect of probiotics (Lactobacillus plantarum 299 plus Bifidobacterium Cure21) in patients with poor ileal pouch function: a randomised controlled trial

Objective: Poor pouch function after restorative proctocolectomy for ulcerative colitis is a considerable problem. Pouchitis and functional disorders are the most common reasons. Probiotics seem to have a beneficial effect in pouchitis but have not been assessed in functional pouch disorders. The aim was to analyse the effects of probiotics in patients with poor pouch function.

Methods: Thirty-three patients were randomized to probiotics (Lactobacillus plantarum 299 and Bifidobacterium infantis Cure 21) or placebo in a double blinded, 1:1 fashion. The treatment effect was assessed by the pouch functional score (PFS; 0–15, 15 worst), pouchitis disease activity index (PDAI; 0–18, 18 worst), and levels of four faecal biomarkers of inflammation (calprotectin, lactoferrin, myeloperoxidase [MPO] and eosinophilic cationic protein [ECP]).

Results: Thirty-two patients were included (probiotics?=?17, placebo?=?16). There was no difference in change in the PFS from before to after treatment between the groups (median difference: ?1.00, 95% C.I. ?3.00 to 0.00, p?=?0.119). Furthermore, probiotics had no effect on PDAI (median difference: 0.00, 95% C.I. 0.00–1.00, p?=?0.786), or on faecal biomarkers. Significant correlations were observed between PDAI and each of the faecal biomarkers at study start. There were no correlations between PFS or PDAI symptom subscore and the biomarkers. PDAI endoscopic and histologic subscores correlated significantly to each of the biomarkers.

Conclusion: The hypothesis that probiotics improves pouch-related dysfunction was not confirmed. Faecal biomarkers could play a future role in the management of pouch patients.     

Permanently increased mucosal permeability in patients with backwash ileitis after ileoanal pouch for ulcerative colitis

Objective. Backwash ileitis (BI) has not been identified as a risk factor for pouchitis. The aim of this study was to investigate the barrier function of the ileoanal pouch depending on the presence of BI. The incidence of pouchitis in a population of ulcerative colitis patients with BI is also reported. Material and methods. Biopsies were taken from 80 patients with ulcerative colitis: a) terminal ileum prior to pouch creation (pre-IAP); b) 16 months after ileostomy closure (intact pouch); and c) during pouchitis. Patients were stratified into the BI group and the non-BI (ØBI) group. Barrier function was determined in Ussing-chambers as epithelial resistance by impedance analysis and as mannitol permeability from ³H-mannitol fluxes. Na⁺-glucose co-transport was measured as a change in short-circuit current (I_SC) after addition of glucose. Relative risk of developing pouchitis was calculated by corrected χ² test. Results. In 13/21 (BI/ØBI) pre-IAP patients, 23/37 (BI/ØBI) with an intact pouch, and 35/7 (BI/ØBI) with pouchitis, epithelial resistance in BI/ØBI was 13.5±1.6/14.3±0.9 Ω·cm² for pre-IAP, 12.7±1.3/16.8±1.2 Ω·cm² (p<0.05 BI versus ØBI) for the intact pouch, and 10.1±1.1/9.9±1.8 Ω·cm² for pouchitis (p<0.05 BI versus ØBI with an intact pouch). No differences were found for electrogenic chloride secretion and active Na⁺-glucose co-transport between BI/ØBI in the three groups. In patients with BI, pouchitis was more common (35 versus 7 patients, odds ratio 33.0 (95% CI 8.3–143.9; p<0.0001)). Conclusions. Ulcerative colitis patients with BI show impaired barrier function in the further course of the ileoanal pouch. Thus, BI has a long-term impact on epithelial barrier function.     

Diversion colitis and pouchitis: A mini-review

Diversion colitis is characterized by inflammation of the mucosa in the defunctioned segment of the colon after colostomy or ileostomy. Similar to diversion colitis, diversion pouchitis is an inflammatory disorder occurring in the ileal pouch, resulting from the exclusion of the fecal stream and a subsequent lack of nutrients from luminal bacteria. Although the vast majority of patients with surgically-diverted gastrointestinal tracts remain asymptomatic, it has been reported that diversion colitis and pouchitis might occur in almost all patients with diversion. Surgical closure of the stoma, with reestablishment of gut continuity, is the only curative intervention available for patients with diversion disease. Pharmacologic treatments using short-chain fatty acids, mesalamine, or corticosteroids are reportedly effective for those who are not candidates for surgical reestablishment; however, there are no established assessment criteria for determining the severity of diversion colitis, and no management strategies to date. Therefore, in this mini-review, we summarize and review various recently-reported treatments for diversion disease. We are hopeful that the information summarized here will assist physicians who treat patients with diversion colitis and pouchitis, leading to better case management.     

Misdiagnosis of specific cytomegalovirus infection of the ileoanal pouch as refractory idiopathic chronic pouchitis

PURPOSE: Chronic nonspecific reservoir ileitis (pouchitis) occurs in 5 to 10 percent of patients who undergo ileal pouch-anal anastomosis for ulcerative colitis. Specific infection of the ileal pouch-anal anastomosis with cytomegalovirus has not been reported. AIM: We report two patients with specific cytomegalovirus infection of the ileal pouchanal anastomosis, initially misdiagnosed as idiopathic chronic pouchitis. CASE SERIES: Patient 1 had ileal pouchanal anastomosis for ulcerative colitis. Three years later she had diarrhea, fever, pelvic pain, and pouch inflammation at endoscopy consistent with pouchitis. She had no response to medical therapy. Repeat endoscopy showed persistent inflammation and biopsies showed cytomegalovirus. She had symptomatic improvement after treatment with intravenous ganciclovir, 10 mg/kg/day for ten days (stopped for rash). Repeat pouch biopsies were negative for cytomegalovirus. Patient 2 had ileal pouch-anal anastomosis for ulcerative colitis. Nine years later she had resection of obstructing stricture at previous loop ileostomy site. She underwent reoperation with ileostomy and pouch defunctionalization for peritonitis. Four weeks later she had fever and bloody discharge from the diverted pouch. Pouch endoscopy with biopsy showed inflammation consistent with pouchitis. She had no response to medical therapy. Re-examination of pouch biopsies with a specific monoclonal immunofluorescent stain showed cytomegalovirus. She had symptomatic improvement after treatment with intravenous ganciclovir, 10 mg/kg/day for 21 days. Repeat pouch biopsies were negative for cytomegalovirus. CONCLUSIONS: Specific cytomegalovirus infection of the ileal pouch-anal anastomosis may be misdiagnosed as idiopathic refractory chronic pouchitis. Cytomegalovirus must be excluded before immune modifier therapy or pouch excision in these patients.     

Pouchitis: A spectrum of diseases

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical treatment of choice for ulcerative colitis and familial adenomatous polyposis patients who require surgery. Pouchitis is the most common longterm complication after IPAA. Patients with pouchitis represent a heterogeneous group in terms of pathogenesis, clinical presentation, disease course, and prognosis, suggesting a wide range of disease mechanisms. Before the diagnosis of pouchitis is made, other inflammatory and non-inflammatory disease conditions, such as Crohn’s disease, cuffitis, and irritable pouch syndrome, should be ruled out. Pouch endoscopy is the most important tool for diagnosis and differential diagnosis. Accurate diagnosis and classification are essential for appropriate management. Although the majority of patients with pouchitis respond to antibiotic therapy, a subset of these patients cannot achieve remission by means of antibiotics and thus require anti-inflammatory or immunosuppressive treatment.