Pouchitis — what’s new in etiology and management?

  • R. J. Nicholls


Pouchitis is a clinical condition associated with inflammation of the ileal reservoir. It was recognized first in continent ileostomies by Kock et al.1 and subsequently in ileoanal ileal reservoirs by Handelsman et al.2 . Histological changes in ileal reservoirs of a chronic inflammatory or atrophic type had been reported in both types of reconstruction by Philipson et a1.3 and Nicholls et a1 4 . Subsequently it was appreciated that pouchitis occurs predominantly in ulcerative colitis and only rarely (if at all) in familial adenomatous polyposis. Various possible causes, including stasis, bacterial flora and biochemical factors (for example short-chain fatty acids or bile salts) have been studied. Various treatments from antibiotics, bile salts, short-chain fatty acids, xanthene oxidase inhibitors and conventional antiinflammatory medication have been tried.


Inflammatory Bowel Disease Ulcerative Colitis Familial Adenomatous Polyposis Ileal Pouch Restorative Proctocolectomy 
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  1. 1.
    Kock NG, Dar le N, Hulton L, Kewenter J, Myrvold, Philipson B. Ileostomy. Curr Prob Surg. 1977; 14: 36–8.Google Scholar
  2. 2.
    Handelsman JC, Fishbein RH, Hoover HE, Smith GW, Haller JA. Endorectal pull-through operation in adults after colectomy and excision of rectal mucosa. Surgery. 1983; 93: 247–53.PubMedGoogle Scholar
  3. 3.
    Philipson B, Brandberg A, Jagenburg R, Kock NG, Lager I, Ahren C. Mucosal morphology, bacteriology and absorption in intra-abdominal ileostomy reservoir. Scand J Gastroenterol. 1975; 10: 145–53.PubMedGoogle Scholar
  4. 4.
    Nicholls RJ, Belleveau P, Neill M, Wilks M, Tabaqchali S. Restorative proctocolectomy with ileal reservoir: a patho-physiological assessment. Gut. 1981; 22: 462–8.PubMedCrossRefGoogle Scholar
  5. 5.
    Moskowitz RL, Shepherd NA, Nicholls RJ. An assessment of inflammation in the reservoir after restorative proctocolectomy with ileo-anal ileal reservoir. Int J Colorectal Dis. 1986; 1: 167–74.PubMedCrossRefGoogle Scholar
  6. 6.
    Shepherd NA, Healey CJ, Warren BF, Richman PI, Thomson WHF, Wilkinson SP. Distribution of mucosal pathology and an assessment of colonic phenotypic change in the pelvic ileal reservoir. Gut. 1993; 34: 101–5.PubMedCrossRefGoogle Scholar
  7. 7.
    De Silva HJ, Millard PR, Prince C, Kettlewell M, Mortensen NJMcC, Jewell DP. Serial observations of the mucosal changes in ileoanal pouches. Gut. 1990; 31: A1168–9.CrossRefGoogle Scholar
  8. 8.
    Setti-Carraro P, Talbot IC, Nicholls RJ. The longitudinal distribution of endoscopic and histological changes in the ileal reservoir after restorative proctocolectomy. 1994 ( Unpublished observations).Google Scholar
  9. 9.
    Setti-Carraro P, Talbot IC, Nicholls RJ. A long term appraisal of the histological appearances of the ileal reservoir mucosa after restorative proctocolectomy for ulcerative colitis. Gut. 1994 (In press).Google Scholar
  10. 10.
    Nasmyth DG, Godwin PGR, Dixon MF, Williams NS, Johnston D. Ileal ecology after pouch anal anastomosis or ileostomy. A study of mucosal morphology, fecal bacteriology, fecal volatile fatty acids and their interrelationship. Gastroenterology. 1989; 96: 817–24.PubMedGoogle Scholar
  11. 11.
    De Silva HJ, Gatter KC, Millard PR, Kettlewell M, Mortensen NJMcC, Jewell DB. Crypt cell proliferation and HLA-DR expression in pelvic ileal pouches. J Clin Pathol. 1990; 43: 824–49.PubMedCrossRefGoogle Scholar
  12. 12.
    Martelli B, Talbot IC, Nicholls RJ. Changes in mucosal morphology and crypt cell turnover with construction of an ileoanal reservoir. 1994 (In press).Google Scholar
  13. 13.
    Shepherd NA, Jass JR, Duval I, Moskowitz RL, Nicholls RJ, Morson BC. Restorative proctocolectomy with ileal reservoir: pathological and histochemical study of mucosal biopsy specimens. J Clin Pathol. 1987; 40: 601–7.PubMedCrossRefGoogle Scholar
  14. 14.
    De Silva HJ, Millard PR, Kettlewell M, Mortensen NJMcC, Jewell DP. Mucosal characteristics of pelvic ileal pouches. Gut. 1991; 32: 61–5.PubMedCrossRefGoogle Scholar
  15. 15.
    Corfield AP, Warren BF, Bartolo DCC. Colonic metaplasia following restorative proctocolectomy monitored using a new metabolic labelling technique for mucin. J Pathol. 1990; 160: 170A.Google Scholar
  16. 16.
    Warren BF, Bartolo DCC, Collins CMP. Preclosure pouchitis - a new entity. J Pathol. 1990; 160: 170A.Google Scholar
  17. 17.
    Honig JM, Soergel KH, Komorowski RA, Wood CM. Treatment of diversion colitis with short chain fatty acid irrigation. N Engl J Med. 1989; 320: 23–38.CrossRefGoogle Scholar
  18. 18.
    Editorial, Diversion colitis. Lancet. 1989; 1: 764.Google Scholar
  19. 19.
    Jass JR, England, Miller K. Value of mucin histochemistry in follow up surveillance of patients with long-standing ulcerative colitis. J Clin Pathol. 1986; 39: 393–8.PubMedCrossRefGoogle Scholar
  20. 20.
    Shepherd NA. Pouchitis Workshop: The pathology of the ileal reservoir. Int J Colorectal Dis. 1989; 4: 206–8.Google Scholar
  21. 21.
    Madden MV, Neale KF, Nicholls RJ et al. Comparison of morbidity and function after colectomy with ileorectal anastomosis or restorative proctocolectomy for familial adenomatous polyposis. Br J Surg. 1991; 78: 789–92.PubMedCrossRefGoogle Scholar
  22. 22.
    Veress B, Reinholt FP, Lindquist K, Liljeqvist L. Mucosal adaptation in the ileal reservoir after restorative proctocolectomy. A long term follow up study. Ann Chir. 1992; 46: 10–18.Google Scholar
  23. 23.
    Nasmyth DG, Williams NS. Pouch ecology. In: Nicholls RJ, Bartolo DCC, Mortensen NJMcC, editors. Restorative proctocolectomy. Oxford: Blackwell Scientific Publications; 1993: 132–46.Google Scholar
  24. 24.
    Brandberg A, Kock NG, Philipson D. Bacterial flora in intraabdominal ileostomy reservoir. A study of 23 patients provided with `continent ileostomy’. Gastroenterology. 1972; 63: 413–16.PubMedGoogle Scholar
  25. 25.
    Luukkonen P, Vultonen V, Sivonen A, Sipponen P, Jarveinen H. Faecal bacteriology and reservoir ileitis in patients operated on for ulcerative colitis. Dis Colon Rectum. 1988; 31: 864–7.PubMedCrossRefGoogle Scholar
  26. 26.
    O’Connell PR, Rankin DR, Weiland LH, Kelly KA. Enteric bacteriology, absorption, morphology and emptying after ileal pouch-anal anastomosis. Br J Surg. 1986; 73: 909–14.PubMedCrossRefGoogle Scholar
  27. 27.
    Fleshman JW, Cohen Z, McLeod RS, Stern H, Blair J. The ileal reservoir and ileoanal anastomosis procedure. Factors affecting technical and functional outcome. Dis Colon Rectum. 1988; 31: 10–16.PubMedCrossRefGoogle Scholar
  28. 28.
    Hill MJ, Fernandez F. Pouch Workshop: Bacteriology I. Int J Colorectal Dis. 1989; 4: 217–19.Google Scholar
  29. 29.
    Onderdonk AB, Dvorak AM, Cisneos RL et al. Microbiologic assessment of tissue biopsy samples from ileal pouch patients. J Clin Microbiol. 1992; 30: 312–17.PubMedGoogle Scholar
  30. 30.
    Kmiot WA, Hesslewood SR, Smith N et al. Evaluation of the inflammatory infiltrate in pouchitis with IIIIn-labelled granulocytes. Gastroenterology. 1993; 104: 981–8.PubMedGoogle Scholar
  31. 31.
    Dube S, Heyen F. Pouchitis and gastric hyposecretion: cause or effect? Int J Colorectal Dis. 1990; 5: 142–3.PubMedCrossRefGoogle Scholar
  32. 32.
    Madden MV, McIntyre A, Nicholls RJ. Double blind cross over trial of Metronidazole in chronic unremitting pouchitis. Dig Dis Sci. 1994; 39: 1193–6.PubMedCrossRefGoogle Scholar
  33. 33.
    Clausen MR, Trede M, Mortensen PB. Short chain fatty acids in pouch contacts from patients with and without pouchitis after ileal pouch-anal anastomosis. Gastroenterology. 1992; 103: 1144–53.PubMedGoogle Scholar
  34. 34.
    Wischmeyer P, Tremaine WJ, Haddad AC, Ambroze WL, Pemberton JH, Phillips SF. Fecal short chain fatty acids in patients with pouchitis after ileal pouch anal anastomosis. Gastroenterology. 1991; 100: A848.Google Scholar
  35. 35.
    Ambroze WL, Pemberton JH, Phillips SF, Bell AM, Haddad AC. Fecal short chain fatty acid concentrations and effect on ileal pouch function. Dis Colon Rectum. 1993; 36: 235–9.PubMedCrossRefGoogle Scholar
  36. 36.
    De Silva HJ, Ireland A, Kettlewell M, Mortensen NJMcC, Jewell DP. Short chain fatty acid irrigation in severe pouchitis (letter). N Engl J Med. 1989; 321: 1416–17.PubMedGoogle Scholar
  37. 37.
    Wischmeyer P, Pemberton JH, Phillips SF. Chronic pouchitis after ileal pouch-anal anastomosis: responses to butyrate and glutamine suppositories in a pilot study. Mayo Clin Proc. 1993; 68: 978–81.PubMedGoogle Scholar
  38. 38.
    Hill MJ, Owen RW. Pouch Workshop: Faecal bile acids in pouch and pouchitis patients. Int J Colorectal Dis. 1989; 4: 221–2.Google Scholar
  39. 39.
    Breuer NF, Rampton DS, Tammar A, Murphy GM, Dowling RH. Effect of colonic perfusion with sulfated and non-sulfated bile acids on mucosal structure and function in the rat. Gastroenterology. 1983; 84: 969–77.PubMedGoogle Scholar
  40. 40.
    Hulten L. Pouch Workshop: Pouchitis–incidence and characteristics in the continent ileostomy. Int J Colorectal Dis. 1989; 4: 208–10.CrossRefGoogle Scholar
  41. 41.
    Lohmuller JL, Pemberton JH, Dozois RR, Ilstrup D, van Heerden J. Pouchitis and extraintestinal manifestations of inflammatory bowel disease after ileal pouch-anal anastomosis. Ann Surg. 1990; 211: 622–9.PubMedGoogle Scholar
  42. 42.
    Meuwissen SGM, Hoitsma H, Boot H, Seldenrijk CA. Pouchitis (pouch ileitis). Neth J Med. 1989; 35: 554–66.Google Scholar
  43. 43.
    Merrett MN, Gatter K, Heryet A, Jewell DP. Pattern of mucosal immunoglobulin (IG) producing cells is similar in ulcerative colitis and pouchitis. Gastroenterology. 1992; 100: A935.Google Scholar
  44. 44.
    Gionchetti P, Campieri A, Belluzzi A et al. Macrophage subpopulations in pouchitis (letter). Gut. 1992; 33: 1008.PubMedCrossRefGoogle Scholar
  45. 45.
    Lauritsen K, Larusen LS, Bukhave K, Rask-Madsen J. Inflammatory intermediaries in inflammatory bowel disease. Int J Colorectal Dis. 1989; 4: 75–90.PubMedCrossRefGoogle Scholar
  46. 46.
    Gertner DJ, Madden MV, De Nucci G et al. Increased leukotriene B4 release from ileal pouch mucosa in ulcerative colitis compared with familial adenomatous polyposis. Gut. 1989; 30: A1481.Google Scholar
  47. 47.
    Chaussade S, Denziot Y, Nicoli J et al. Presence of stool PAF-acetor in stool of patients with pouch ileoanal anastomosis and pouchitis. Gastroenterology. 1991; 100: 1509–14.PubMedGoogle Scholar
  48. 48.
    Murch SH, Braegger CP, Walker-Smith JA, MacDonald TT. Location of tumour necrosis factor a by immunohistochemistry in chronic inflammatory bowel disease. Gut. 1993; 34: 1705–9.PubMedCrossRefGoogle Scholar
  49. 49.
    Kontakou M, Goldberg PA, Przemioslo RT, Nicholls RJ, Ciclitira P.I. Expression of interferon-y, tumour necrosis factor a, and interleukins 6 and 2 in pouchitis. Gut. 1994; 35: S40.CrossRefGoogle Scholar
  50. 50.
    Sakaguchi M, Hosie K, Tudor R, Kmiot W, Keighley MRB. Mucosal blood flow following restorative proctocolectomy: pouchitis is associated with mucosal ischaemia. Br J Surg. 1989; 76: 1331 (abstract).Google Scholar
  51. 51.
    Warren BF, Shepherd NA. Pouch pathology. In: Nicholls RJ, Bartolo DCC, Mortensen NJMcC, editors. Restorative proctocolectomy. Oxford: Blackwell Scientific Publications; 1993: 147–62.Google Scholar
  52. 52.
    Levin KE, Pemberton JH, Phillips SF, Zinsmeister AR, Pezim ME. Role of oxygen free radicals in the aetiology of pouchitis. Dis Colon Rectum. 1992; 35: 452–6.PubMedCrossRefGoogle Scholar

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© Kluwer Academic Publishers and Axcan Pharma, Inc. 1994

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  • R. J. Nicholls

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