Bacteria have been implicated in the development of pouchitis after ileal pouch anal anastomosis. The change in gastric pH with the use of proton pump inhibitors and H2 antagonists may lead to alteration of enteric bacteria. We hypothesized that chronic use of these medications would decrease the incidence of pouchitis.
Patients who had undergone ileal pouch anal anastomosis for ulcerative colitis were classified by history of pouchitis. Patients were further classified by their use of proton pump inhibitors, H2 blockers, antacids, and other known risk factors for pouchitis.
Eighty-five patients were identified. There was a statistically significant increase in the use of daily acid suppression in patients without pouchitis. There was also a statistically significant increase in the use of antacids in patients without pouchitis. Occasional use of acid suppression did not alter the rate of pouchitis.
Our data suggest that the daily use of proton pump inhibitors, H2 antagonists, or antacids is associated with a decreased risk of pouchitis in ulcerative colitis. Occasional use of these agents did not seem to afford the same protection. These data suggest that altering the pH of the gastrointestinal tract may influence the development of pouchitis.
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Dr. Scott D. Goldstein (Philadelphia, PA): This paper is a small retrospective, but intriguing study. If the study’s findings are found to be accurate after future randomized controlled trials, it could lead to a significant new approach to the management and prevention of pouchitis in ulcerative colitis patients.
The frequency of pouchitis is seen in approximately 23–40 % of patients undergoing J-pouch reconstruction by 10 years, with 70 % experiencing their first attack within 1 year. The mechanism of pouchitis is thought to be the result of a dysbiosis in the pouch lumen. Viable sulfate-reducing bacteria are seen in the pouches of ulcerative colitis patients, but not in FAP patients. Normal pouches harbor large numbers of anaerobes. During pouchitis episodes, a reduction in anaerobes and an increased number of aerobic bacteria and Clostridium perfringens are seen.
The natural history of pouchitis appears to be an acute process of bacterial origin, which may develop into a chronic disease of persistent inflammation. Antibiotics have a beneficial effect by altering the bacterial flora of the pouch to a more normal state and are usually effective in the management of pouchitis. Other approaches, such as probiotics, may also be beneficial.
This paper proposes that a change in the gastric pH may lead to a beneficial alteration in enteric bacteria, resulting in a decrease in the incidence of pouchitis.
I have three questions for the authors:
(a) What sparked your interest in this study? Was there a simple clinical observation, or was it based upon theoretical grounds?
(b) Were any qualitative or quantitative bacteriologic studies performed on the pouchitis and normal pouch patients?
(c) If pH-altering therapy proves to be effective, which groups of patients would you suggest using this form of therapy for, i.e.,
(1) Antibiotic responsive
(2) Antibiotic dependent
(3) Antibiotic refractory
(4) All ulcerative colitis patients
Dr. Lisa S. Poritz: Dr. Goldstein, thank you very much for your comments.
1. I got the idea for the study while listening to a grand rounds lecture on the consequences of chronic acid reduction on the stomach. The speaker discussed the effects of chronic acid suppression on bacterial overgrowth in the upper gastrointestinal tract and I became curious about the potential effects on the bacterial flora in an ileal pouch.
2. At the time that we presented this study we had not as of yet done any qualitative on quantitative studies of the bacterial flora. These studies are now currently ongoing.
3. We would anticipate that altering the pH would be most beneficial in patients with antibiotic dependent pouchitis. This group of patients essentially requires chronic antibiotic therapy. If acid suppression could reduce the need for long term antibiotics in this group that would be a benefit to the patient. Those patients with antibiotic responsive pouchitis have relatively infrequent episodes and respond well to a course of antibiotics. There is probably not enough benefit to those patients to warrant chronic acid suppression. On the other hand, patients with antibiotic refractory pouchitis probably have disease that is too severe to be significantly improved with acid suppression. As far as the use in all ulcerative colitis pouch patients, there might be potential in starting post-operative patients on acid suppression in an attempt to prevent pouchitis in the first place.
This was a plenary podium presentation at the SSAT Annual Meeting in San Diego, CA, May 2012.
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Poritz, L.S., Sehgal, R., Berg, A.S. et al. Chronic Use of PPI and H2 Antagonists Decreases the Risk of Pouchitis After IPAA for Ulcerative Colitis. J Gastrointest Surg 17, 1027–1031 (2013). https://doi.org/10.1007/s11605-013-2172-y
- Proton pump inhibitors
- H2 blockers
- Ileal pouch anal anastomosis
- Ulcerative colitis