Pouchitis and pre-pouch ileitis developed after restorative proctocolectomy for ulcerative colitis： A case report

We report a case of pouchitis and pre-pouch ileitis, and inflammation in the neo-terminal ileum proximal to the pouch, developed after restorative proctocolectomy for ulcerative colitis. A 35-year old female presented with fever and abdominal pain five weeks after ileostomy closure following proctocolectomy. ComputEd tomography showed collection of feces in the pouch and proximal ileum. A drainage tube was placed in the pouch perianally, and purulent feces were discharged. With antibiotic treatment, her symptoms disappeared, but two weeks later, she repeatedly developed fever and abdominal pain along with anal bleeding. Pouchscopy showed mucosal inflammation in both the pouch and the pre-pouch ileum. The mucosal cytokine production was elevated in the pouch and pre-pouch ileum. With antibiotic and corticosteroid therapy, her symptoms were improved along with improvement of endoscopic inflammation and decrease of mucosal cytokine production. The fecal stasis with bacterial overgrowth is the major pathogenesis of pouchitis and pre-pouch ileitis in our case.     

Ten years experience of one-stage restorative proctocolectomy for ulcerative colitis

Background Ileal-pouch anal anastomosis has an established role in the treatment of ulcerative colitis. Controversy exists regarding the routine use of a diverting ileostomy. The aim of this study was to review the clinical and functional outcome of patients undergoing restorative proctocolectomy in the absence of a diverting ileostomy (one-stage). Materials and methods Between 1990 and 1999, 87 patients with ulcerative colitis underwent a one-stage restorative proctocolectomy. The median age at the time of operation was 34 years (range 12–64 years) and median follow-up was 36 months (range 24–144 months). The clinical notes were reviewed retrospectively. Results The median in-patient stay was 15 days (range 9–36). There were no post-operative deaths. The complication rate within 30 days of surgery approximated to 40%. The median daytime pouch evacuation rate was 5. Only 13% of patients had to empty their pouch at night on a regular basis. Pelvic sepsis secondary to anastomotic leakage was the most commonly encountered problem, occurring in 15 patients. Small bowel obstruction was encountered in ten patients. One pouch required excision for a recurrent pouch-vaginal fistula. Conclusion Despite refinements in the surgical technique, restorative proctocolectomy is associated with significant morbidity. For a selected group of patients undergoing an ileo-anal anastomosis, a defunctioning ileostomy may be avoided.     

Matrix metalloproteinases in the restorative proctocolectomy pouch of pediatric ulcerative colitis

AIM: To investigate matrix metalloproteinases (MMPs) and their tissue inhibitors (TIMPs) in pouch mucosa of pediatric onset ulcerative colitis (UC).METHODS: In this cross-sectional study, 28 patients with pediatric onset UC underwent ileal pouch biopsy 13 years (median) after proctocolectomy. Expression of MMPs-3, -7, -8, -9, -12 and -26 and TIMPs-1, -2 and -3 in samples was examined using immunohistochemichal methods, and another biopsy was used to evaluate the grade of histological inflammation. Two investigators independently graded the immunohistochemical specimens in a semiquantitative fashion, using a scale marking staining intensity as follows: 0 = less than 20 positive cells; 1 = 20-50 positive cells; 2 = 50-200 positive cells; 3 = over 20 positive cells. Fecal calprotectin and blood inflammatory markers [serum C-reactive protein (CRP) and erythrocyte sedimentation rate] were determined during a follow-up visit to examine correlations between these markers and the expression of MMPs and TIMPs.RESULTS: Of the 28 patients with pediatric onset UC, nine had not experienced pouchitis, whereas thirteen reported a single episode, and six had recurrent pouchitis (≥ 4 episodes). At the time of the study, six patients required metronidazole. In all of the others, the most recent episode of pouchitis had occurred over one month earlier, and none were on antibiotics. Only four samples depicted no sign of inflammation, and these were all from patients who had not had pouchitis. Two samples were too small to determine the grade of inflammation, but both had suffered pouchitis, the other recurrent. No sample depicted signs of colonic metaplasia. Most pouch samples showed expression of epithelial (e) and stromal (s) MMP-3 (e, n = 22; s, n = 20), MMP-7 (e, n = 28; s, n = 27), MMP-12 (e, n = 20; s, n =24), TIMP-2 (e, n = 23; s, n = 23) and MMP-3 (e, n = 23; s, n = 28) but MMP-8 (e, n = 0; s, n = 1), MMP-9 (e, n = 0; s, n = 9) and MMP-26 (e, n = 0; s, n = 3) and TIMP-1 (n = 0, both) were lacking. In samples with low grade of inflammatory activity, the epithelial MMP-3 and MMP-7 expression was increased (r = -0.614 and r = -0.472, respectively, P < 0.05 in both). MMPs and TIMPs did not correlate with the markers of inflammation, fecal calprotectin, erythrocyte sedimentation rate, or CRP, with the exception of patients with low fecal calprotectin (< 100 μg/g) in whom a higher expression of epithelial MMP-7 was found no differences in MMP- or TIMP-profiles were seen in patients with a history of pouchitis compared to ones with no such episodes. Anastomosis with either straight ileoanal anastomosis or ileoanal anastomosis with J-pouch did depict differences in MMP- or TIMP-expression.CONCLUSION: The expression of MMPs pediatric UC pouch in the long-term shares characteristics with inflammatory bowel disease, but inflammation cannot be classified as a reactivation of the disease.     

Use of cyclosporin retention enemas in a patient with intractable pouchitis after proctocolectomy for ulcerative colitis: a case report

We report the case of a 46-year-old male with a 24-year history of ulcerative colitis who underwent proctocolectomy and ileal S-pouch-anal anastomosis. Six months after surgery the patient complained of increased daytime bowel frequency; pouchoscopy revealed severe pouchitis. Because of the failure of conventional treatments, the patient underwent a cycle of cyclosporin A (CsA) enemas. The therapy consisted of one enema each day for 5 weeks (35 administrations). The patient was submitted to a total of five pouchoscopies, the first before the beginning of the enemas cycle and the last one 2 months after the end of the treatment, Endoscopy showed a remarkable improvement at day 10, but these findings were not confirmed later. Biopsies showed a marked improvement at 10 days, but at later stages a reappearance of crypt abscesses with an increasing number of inflammatory infiltrates. In spite of the grim picture at endoscopy and histology, the patient felt better and noted a progressive reduction of the bowel movements and cessation of mucous and bloody discharge. At present, he reports six bowel movements per day and no bleeding. Received: 2 October 1996 / Accepted in revised form: 6 January 1999     

Clinical results after restorative proctocolectomy without diverting ileostomy for ulcerative colitis

Background and aims This study evaluated the postoperative complications and clinical results of restorative proctocolectomy without diverting ileostomy for ulcerative colitis.Patients and methods One hundred selected patients had a hand-sewn ileal J-pouch anal anastomosis with mucosectomy using an ultrasonically activated scalpel.Results Three patients with pouch-related complications who needed diverting ileostomy. Five patients showed intestinal obstruction; two of the five needed relaparotomy and division of adhesions. The median number of bowel movements per 24 h was 6.5 (2–13) at 3 months and 5 (3–10) at 12 months. The corresponding nightly frequencies were 0 (0–5) at 3 months and 0 (0–3) at 12 months. After 3 months 82% of patients had no soiling during the daytime, and 45% were fully continent day and night. After 3 months 89% had recovered the ability to distinguish flatus from feces.Conclusion Ileal pouch anal anastomosis can be performed safely without diverting ileostomy using an ultrasonically activated scalpel. The postoperative functional result was stabilized 3 months after the operation.     

Functional outcome after restorative proctocolectomy

Incontinence and pouchitis are complications that affect most patients who have undergone restorative proctocolectomy. Incontinence, with particular regard to night leakage, is related to the combination of poorly functioning ileal reservoir and poor anal sphincter function. Pouchitis, the major late complication of restorative proctocolectomy, is quite similar to the previous inflammatory bowel disease. Pouchitis has an important impact on functional results after restorative proctocolectomy, causing a significant increase in defecation frequency, pain on evacuation, urgency, watery bowel movements, bloody diarrhea, anal irritation and stool leakage. In particular, chronic pouchitis can cause distress, anxiety and disappointment for patients needing continuous treatment. The influence of anal sphincter and ileal pouch function on clinical outcome after ileal pouch-anal anastomosis (IPAA) is reviewed, together with the correlation between ileal pouch function and pouchitis. The possible correlation between pouchitis and long-term functional outcome after restorative proctocolectomy is examined. Received: 28 May 1998 / Accepted in revised form: 22 September 1999     

Small-bowel obstruction after restorative proctocolectomy in patients with ulcerative colitis

Backgroud and aims The reported risk of small-bowel obstruction (SBO) after major abdominal surgery varies. The aim of this study was to study frequency and risk factors of SBO after ileal pouch-anal anastomosis for ulcerative colitis. Methods Review of the medical records of 188 patients operated with restorative proctocolectomy between 1985 and 1997. All admissions to the hospital were registered and symptoms and X-ray findings consistent with ileus were analysed in relation to preoperative and operative data. Results SBO was the dominating cause of hospitalization. Forty-eight patients (25.5%) had developed SBO after a median of 76 (range 6–196) months of follow-up, of whom 26 were operated on. The cause of obstruction was adhesion in all but one patient. Early obstruction events were common and accounted for 27% of all operations. Twenty-five of 26 patients who were operated on had a diverting loop-ileostomy compared to 111/162 in the not-operated-on group (p < 0.01). In total, 696 days were spent at the hospital because of SBO. Conclusion SBO is common following pouch surgery and is the dominating cause of hospitalization postoperatively. About 25% of patients developed SBO and half of them needed surgery. The use of a diverting loop-ileostomy was related to an increased risk of surgery for SBO.     

Anatomic extent of colitis and disease severity are not predictors of pouchitis after restorative proctocolectomy for mucosal ulcerative colitis

Background Pouchitis is a common complication following restorative proctocolectomy with ileal pouch anal anastomosis (RPC–IPAA) for mucosal ulcerative colitis (MUC). The aim of this study was to determine if perioperative anatomic extent and severity of disease are predictors of pouchitis. Methods All consecutive patients who underwent RPC–IPAA for MUC between 1988 and 2002 were retrospectively studied. Pouchitis was classified as acute, recurrent or refractory. Colectomy specimen slides were histopathologically evaluated by a single blinded pathologist (MB), who assessed extent and severity of disease. Results Of 112 patients assessed, 70 (62.5%) had some form of pouchitis at a median follow–up of 38 months (range, 1–204 months). No association was found between the extent or severity of disease and subsequent development of acute or chronic pouchitis. A positive correlation was found between the histopathologic score and the occurrence of clinical pouchitis (p=0.014). The presence of colonic metaplasia in the pouch biopsy was significantly correlated with a histopathologic diagnosis of pouchitis (p<0.0001, r=–0.449). Conclusions Following RPC for MUC, the extent and severity of disease do not predict the subsequent development of pouchitis.     

Relationship between pouch microbiota and pouchitis following restorative proctocolectomy for ulcerative colitis

Restorative proctocolectomy with ileal pouch-anal anastomosis(IPAA)has become the surgical treatment of choice for many patients with medically refractory ulcerative colitis(UC)and familial adenomatous polyposis(FAP).UC patients with IPAA(UC-IPAA)are,nevertheless,susceptible to inflammatory and noninflammatory sequelae such as pouchitis,which is only rarely noted in FAP patients with IPAA.Pouchitis is the most frequent long-term complication of UC-IPAA patients,with a cumulative prevalence of up to 50%.Although the aetiology of pouchitis remains unclear,accumulating evidence suggests that a dysbiosis of the pouch microbiota and an abnormal mucosal immune response are implicated in its pathogenesis.Studies using culture and molecular techniques have detected a dysbiosis of the pouch microbiota in patients with pouchitis.Risk factors,genetic associations,and serological markers suggest that interactions between the host immune response and the pouch microbiota underlie the aetiology of this idiopathic inflammatory condition.This systematic review focuses on the dysbiosis of the microbiota that inhabit the pouch in UC and FAP patients and its interaction with the mucosal immune system.A metaanalysis was not attempted due to the highly heterogeneous microbiota composition and the different detection methods used by the various studies.Although no specific bacterial species,genus,or family has as yet been identified as pathogenic,there is evidence that a dysbiosis characterized by decreased gut microbiota diversity in UC-IPAA patients may,in genetically predisposed subjects,lead to aberrant mucosal immune regulation triggering an inflammatory process.     

The role of scintigraphic defecography in the assessment of bowel function after restorative proctocolectomy for ulcerative colitis

Background The aim of the study was to evaluate the efficiency of defecation in patients with ileal pouch for ulcerative colitis by using the mean of scintigraphic defecography.Methods Sixteen patients were classified into two groups according to the presence of good (group A) or poor (group B) pouch function. Emptying efficiency was calculated by scintigraphic defecography and measured as percentage of evacuation. This involves the use of up to 200 ml of an artificial stool made up of methyl cellulose paste labeled with 180 MBq of technetium-99 m (Tc-99 m) methylene diphosphonate. Potential causes of increased frequency in the absence of additional associated symptoms of dysfunction were excluded in all patients. Maximum tolerated volume (MTV) and balloon expulsion tests were also performed on all patients.Results No patient in both groups showed evidence of organic pouch dysfunction. Percentage of emptying was higher in patients of group A (n=6) than in group B (n=10) (81±9 vs 71±9%, respectively, P<0.05; correlation, −0.51, P<0.04). Mean MTV was similar in the two groups (group A: 361±118 ml and group B: 338±77 ml, P=0.7). Results of the balloon expulsion test were normal in all patients except for one individual in group B.Conclusion In patients with ileal pouch for ulcerative colitis, increased frequency of defecation without any evidence of pouch dysfunction may be correlated with an alteration of emptying efficiency. Scintigraphic defecography is appropriate to use for investigation of this condition with no disadvantages for the patients.This work was presented in part at the 4th Scientific and Annual Meeting of the European Association of Coloproctology, Sitges, Barcelona, Spain, 18–20 September 2003.     

Diffuse gastroduodenitis and pouchitis associated with ulcerative colitis

INTRODUCTIONPouchitis after total colectomy with ileal pouch anal anastomosis can sometimes occur in patients with ulcerative colitis (UC). Despite intensive studies the cause of pouchitis remains unknown, but many contributing factors, such as faecal sta…     

Mucosal changes in ileal pouches after restorative proctocolectomy for ulcerative and crohn's colitis

PURPOSE: Inflammation and dysplasia may affect the ileal pouch after restorative proctocolectomy and ileal pouchanal anastomosis. The aim of this prospective study was to evaluate the morphologic changes and the risk of dysplasia within the pouch after ileal pouch-anal anastomosis. METHODS: Thirty-seven patients with ileal pouch-anal anastomosis underwent endoscopies and biopsies of the pouch: 21 patients were affected by ulcerative colitis and 16 by Crohn's colitis. The mucosal biopsy specimens were studied to investigate the degree of acute and chronic inflammation and the occurrence of dysplasia. A score system was calculated for each patient and correlated with the histologic diagnosis of ulcerative colitis or Crohn's colitis. RESULTS: After a median follow-up of 85 (range, 7–198) months, the inflammation histologic score evaluated was 3.8 (95 percent confidence interval, 2.4–5.1) and 3.5 (95 percent confidence interval, 2.6–4.3), respectively, in patients with Crohn's colitis and ulcerative colitis (mean and 95 percent confidence interval;P=0.74, not significant), and no patient developed mucosal dysplasia. Fifteen patients (40.5 percent) developed clinical pouchitis that occurred in Crohn's colitis (9/16 patients or 56 percent) and in ulcerative colitis (6/21 patients or 28 percent;P not significant). The score was 4.1 (95 percent confidence interval, 3.2–5) in patients with pouchitis and 3.2 (95 percent confidence interval, 2.1–4.3) in patients without clinical pouchitis (P=0.012) and was 4.1 (95 percent confidence interval, 2.6–5.5) and 4 (95 percent confidence interval, 2.9–5.3), respectively, in pouchitis patients with Crohn's colitis and ulcerative colitis. CONCLUSION: No difference in the inflammation histologic score was observed in ileal pouches after restorative proctocolectomy for ulcerative and Crohn's colitis. In our series, which includes those patients with longer follow-up (>5 years) or with chronic unremitting pouchitis, no case of dysplasia was found. The occurrence of pouchitis was higher in the case of ileal pouch-anal anastomosis for Crohn's disease than for ulcerative colitis, but no difference in the severity of the histologic score was noted.Presented at the XVIIth Biennial Congress of the International Society of University Colon and Rectal Surgeons, Malmö, Sweden, June 7 to 11, 1998.     

CD40/CD40L在毛细支气管炎发病机制中的作用

CD40/CD40L是T、B细胞表达的重要膜表面蛋白质分子,它们之间的相互作用对T、B细胞具有重要的影响,在炎症反应、免疫紊乱等方面具有重要的作用.它们之间的交联反应促进气道炎症反应和气道高反应性.目前认为CD40/CD40L在毛细支气管炎发病的多个环节中发挥作用,本文就其与毛细支气管炎的关系进行综述.     

Incidence of and risk factors for dysplasia in mucosectomy area in ulcerative colitis patients undergoing restorative proctocolectomy

Background and aims We evaluated the incidence of dysplasia in the mucosectomy area using resected specimens to determine preoperative risk factors for the occurrence of dysplasia in this area. Patients and methods We prospectively studied a consecutive series of 137 patients, each of whom underwent a restorative proctocolectomy with a mucosectomy and hand-sewn ileal J-pouch anal anastomosis between January 2003 and December 2004. Sections from the anal transitional zone mucosa were taken from the dentate line to 2.5 cm above the resected line and stained with hematoxylin and eosin then characterized as indefinite for dysplasia, low-grade dysplasia, and high-grade dysplasia based on the criteria of an international working group for rectal mucosal atypia. Results Dysplasia of the mucosectomy area was present in six (4.4%) of the patients, including one with low-grade and five with high-grade dysplasia. A multivariate analysis showed relations between age at time of surgery (≥40 years) and duration of disease (≥10 years) with a risk for development of mucosectomy area dysplasia. Conclusion The incidence of dysplasia of the mucosectomy area was 4.4%, and preoperative risk factors were shown to be duration of disease and age at time of surgery.     

CD40-CD40L及基质蛋白酶在大鼠动脉粥样硬化中的表达

目的：为探讨粘附分子CD40、CD40配体（CD40 Ligand，CD40L）及基质蛋白酶在动脉粥样硬化中的表达；方法：利用高脂饮食制作大鼠动脉粥样硬化模型（AS组，n=6），与正常饮食大鼠模型（N组，n=6）作对照，流式细胞技术法检测外周血中CD40及CD40L，Zymography法检测外周血中基质蛋白酶-2（MMP-2）及基质蛋白酶-9（MMP-9）的表达情况，免疫组织化学法观察CD40、CD40L及MMP-2、MMP-9在主动脉弓表达情况；并对CD40、CD40L与MMP-2、MMP-9做相关性分析；结果：动脉粥样硬化模型大鼠外周血CD40、CD40L、MMP-2、MMP-9表达均高于正常饮食组大鼠，免疫组织化学法显示CD40、CD40L在主动脉弓内膜上表达，MMP-2、MMP-9在主动脉弓内皮细胞及内皮细胞间质中表达，而且AS组表达强于N组；CD40、CD40L与MMP-2、MMP-9有相关性；结论：提示动脉粥样硬化的形成可能与CD40、CD40L及基质蛋白酶的异常表达有关。     

Defensin expression in chronic pouchitis in patients with ulcerative colitis or familial adenomatous polyposis coli

AIM:Pouchitis develops in ileoanal pouches in up to50% of patients with ulcerative colitis during the first 10years after pouch surgery while being rare in patientsafter proctocolectomy for familial adenomatous polyposiscoil(FAP)syndrome.Defensins are major components ofthe innate immune system and play a significant role ingastrointestinal microbial homeostasis.Pouch defensinand cytokine expression were correlated with states ofpouch inflammation to study their role in pouchitis.METHODS:Patients with ulcerative colitis and FAPsyndrome were stratified into groups with pouches aftersurgery,pouches without or with pouchitis.Biopsies fromterminal ileum from a healthy intestine or from normalterminal ileum of patients with ulcerative colitis served ascontrols,mRNA from pouches and controls was analysedfor defensin and cytokine expression.RESULTS:Expression of defensins was increased in allpouches immediately after surgery,compared to ileumof controls.Initially,pouches in ulcerative colitis revealedhigher defensin expression than FAP pouches.Defensinexpression declined in both patient groups and increasedagain slightly in pouchitis in patients with ulcerativecolitis.FAP pouches without pouchitis had strongexpression of β-defensin hBD-1,while all other defensinsremained at low levels.Cytokine expression in ulcerativecolitis pouches was high,while FAP pouches showedmoderately elevated cytokines only after surgery.CONCLUSION:Development of pouchitis correlates with decreased defensin expression in ulcerative colitisin addition to high expression of cytokines.The lowincidence of pouchitis in FAP pouches correlates withincreased expression of hBD-1 β-defensin in associationwith low cytokine levels.     

One-stage restorative proctocolectomy without temporary ileostomy for ulcerative colitis

PURPOSE: This study was designed to determine the safety of omitting a temporary defunctioning ileostomy in restorative proctocolectomy for ulcerative colitis. METHOD: One hundred consecutive patients with ulcerative colitis were treated electively by restorative proctocolectomy and pouch-anal anastomosis, without mucosal stripping; 50 had a defunctioning ileostomy added, and 50 underwent a one-stage procedure without ileostomy. RESULTS: There was no operative mortality. The incidence of postoperative complications was similar in the two groups of patients. Lifethreatening complications, however, were more common among patients who did not have a defunctioning ileostomy, of whom 11 developed pelvic sepsis and 7 required reoperation. Among patients with an ileostomy, seven developed pelvic sepsis but none required reoperation (P <0.02). Emergency reoperations were required in 11 patients without an ileostomy but in only 1 patient with an ileostomy (P <0.01). CONCLUSION: One-stage restorative proctocolectomy without a defunctioning ileostomy is associated with increased risk to life. Its routine use cannot be recommended.Read at the meeting of The American Society of Colon and Rectal Surgeons, Orlando, Florida, May 8 to 13, 1994.