Pouchitis: A Comprehensive Guide

Pouchitis: What is it?

Following a total proctocolectomy (surgical removal of the colon and rectum), a procedure known as ileal pouch-anal anastomosis (IPAA) is performed. In this operation, the ileum (the lowest part of the small intestine) is connected to the anus to create a pouch for storing and eliminating waste. A J-pouch is typically constructed, resembling the letter J, but other pouch shapes like S and K can also be made. This pouch enhances the patient's quality of life by preserving the natural route of defecation and reducing the risk of growths that could develop into cancer. However, some patients may develop pouchitis after this surgery.

Pouchitis is an inflammation of the pouch that occurs when it becomes irritated. The inflammation can lead to increased bowel movements, abdominal cramping or bloating, lower abdominal discomfort, or blood in the stool. It is essential for this condition to be assessed and managed by an experienced gastroenterologist.

Pouchitis Prevalence

Approximately half of patients who undergo IPAA surgery for ulcerative colitis will experience pouchitis at least once in their lives. Up to 40 percent of patients with IPAA develop pouchitis annually.

Symptoms and Causes

Pouchitis Causes

The exact cause of pouchitis remains unknown, but it almost always occurs in patients with ulcerative colitis or another form of colitis, and sometimes in those with familial adenomatous polyposis (FAP), a genetic condition characterized by the formation of numerous polyps in the colon.

The bowel pattern changes that occur during IPAA surgery may contribute to pouchitis. The ileum's primary function is to absorb nutrients, but after IPAA surgery, it is artificially converted into a waste storage space. The ileum's mucous membrane, or inner lining, triggers an immune response to the different bacteria it encounters, leading to inflammation.

Several factors are associated with the development of pouchitis, including:

  • Genetic predispositions
  • Extensive ulcerative colitis
  • Backwash ileitis (inflammation of the ileum caused by widespread ulcerative colitis)
  • Increased platelet count after a proctocolectomy
  • Primary sclerosing cholangitis (inflamed and hardened bile ducts in the liver)
  • Smoking
  • Presence of certain antibodies in the blood
  • Long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs)
  • Other conditions, such as diabetes or heart disease

Additionally, reduced blood flow to the pouch can cause ischemic pouchitis.

Pouchitis Symptoms

Symptoms of pouchitis may include:

  • Increased urgency to pass stools
  • Tenesmus (painful spasms and straining of the anal sphincter with little or no waste matter passing)
  • Straining during defecation
  • Blood in the stool
  • Incontinence (loss of control of bodily functions)
  • Waste matter leakage while asleep
  • More frequent nighttime bowel movements
  • Abdominal cramps
  • Pelvic area or lower abdominal discomfort
  • Tail bone pain

In severe cases, symptoms may also include:

  • Fever
  • Dehydration (extreme thirst, dry skin, dry lips, confusion in severe cases) caused by loss of electrolytes and water
  • Malnutrition requiring emergency room or hospital visits
  • Iron-deficiency anemia and/or low vitamin D levels
  • Severe joint pain
  • Fatigue

Diagnosis and Tests

Pouchitis Diagnosis

To diagnose pouchitis, a doctor will consider the patient's symptoms and the results of an endoscopy (examination of the pouch's interior with an endoscope). A pouchoscopy (endoscopy of the pouch) can reveal the extent of the inflammation, irritation of the ileum, or the presence of Crohn's disease or Crohn's-like disease of the pouch.

Endoscopy can also determine if the patient has cuffitis (inflammation at the anal transition zone or cuff) or other abnormalities like narrowed passages or cavities or openings. Patients with cuffitis often have mild to moderate bright red blood in their stool or upon wiping.

During the endoscopy, the doctor may take a biopsy (tissue sample) to check for other unusual findings, such as polyps, infections, inflamed granulated (grainy) tissue, or restricted blood supply.

Imaging studies like contrast pouchography, CT (computed tomography), gastrografin enema, barium defecography, and/or MRI (magnetic resonance imaging) of the pelvis or abdomen may also aid in diagnosis. Anorectal manometry testing can help determine if the pelvic floor is not functioning correctly, especially in patients who strain during defecation.

Management and Treatment

Pouchitis Treatment

Pouchitis is typically treated with a 14-day course of antibiotics. The doctor may also recommend probiotics, such as Lactobacillus, Bifidobacterium, and Thermophilus, which are "good" bacteria that normally live in the digestive tract.

Some patients may develop chronic pouchitis, for which a low-carbohydrate, low-fiber, and high-protein diet may help alleviate symptoms. In some cases, therapy with anti-inflammatory agents or even biological agents may be necessary. Antidiarrheal agents may be used to treat frequent or loose bowel movements.

Post-treatment Expectations for Pouchitis

Patients experiencing their first pouchitis episode are almost always treated successfully with antibiotics. However, the disease often relapses at a later time.

Outlook / Prognosis

Pouchitis Prognosis

The prognosis for pouchitis patients depends on each individual's condition:

  • Patients requiring antibiotics may need long-term therapy with either antibiotics or probiotics.
  • Antibiotic-resistant pouchitis can be challenging to treat and is a common reason for pouch failure. In such cases, pouch removal or permanent diversion may be necessary. Some patients may also experience pouchitis after the diversion, requiring further evaluation and treatment.
  • When antibiotics are ineffective, it is crucial to investigate other causes of pouchitis, such as NSAID use, infections, autoimmune diseases, reduced blood flow to the pouch, or inflammatory polyps.
  • For patients without an obvious cause of pouchitis, treatment options include antibiotics combined with corticosteroids, immunosuppressants, or biological therapy.

One potential issue with long-term antibiotic use is that bacteria may adapt and become resistant to the antibiotics.

Additional Information

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