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Pouchitis After Ileal Pouch-Anal Anastomosis

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Pediatric Inflammatory Bowel Disease

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Abstract

Pouchitis is defined as idiopathic inflammation of the ileal reservoir in patients who are status-post proctocolectomy with an Ileal Pouch-Anal Anastomosis (IPAA). IPAA is the preferred surgical treatment for patients diagnosed with familial adenomatous polyposis syndrome (FAP) and ulcerative colitis (UC). There are various types of pouch reservoirs that have been fashioned some of which include the J-type, W-type, and S-type pouch reservoirs. The J-type is however the most common type of pouch used. Long-term results with IPAA are excellent with minimal mortality related to the procedure. Majority of patients are satisfied with the IPAA procedure primarily due to the ability to maintain bowel continence. Despite the low mortality associated with IPAA, there are significant complications that can occur over time such as stricture, infection, pouch dysfunction, dysplasia, and pouchitis.

Certain risk factors have been associated with the development of pouchitis such as immune dysregulatory states as seen with some carriers of IL-1RN*2 and the presence of certain genetic polymorphisms or mutations like NOD2/CARD 15 mutations. Other risk factors include fecal stasis, bacterial overgrowth, mucosal ischemia, and the presence of extraintestinal manifestations. The diagnosis of pouchitis is based on a combination of clinical symptoms, endoscopic features, and histological findings. It is however common in clinical practice to make a presumptive diagnosis of pouchitis based on clinical symptoms and patients response to antibiotics. Most patients with pouchitis respond to antibiotic treatment with medications such as ciprofloxacin or metronidazole. Combinations of probiotics, antibiotics, anti-inflammatory agents, and/or immunosuppressive medications have also been used in the treatment of some patients with more severe pouchitis. Surgical intervention is needed if medical management of chronic, severe pouchitis is ineffective. This is a rare occurrence and requires takedown of the pouch and creation of an ileostomy or reconstruction of the pouch. The most concerning complication of chronic inflammation of the surgically created pouch is development of dysplasia and progression to malignancy. The overall incidence of dysplasia in the pouch is more common in patients with FAP compared to those that have UC. Dysplasia of the pouch is, however, a very rare occurrence in pediatric patients.

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Authors and Affiliations

  1. Cleveland clinic, 9500 Euclid Ave, Cleveland, OH, 44195-0001, USA

    Victor Uko MD & Robert Wyllie MD

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  1. Victor Uko MD
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  2. Robert Wyllie MD
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Correspondence to Robert Wyllie MD .

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Editors and Affiliations

  1. Perelman School of Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, 34th St. & Civic Ctr. Blvd., Philadelphia, 19104, Pennsylvania, USA

    Petar Mamula

  2. School of Medicine--Greenville, Pediatric Gastroenterology & Nutrition, University of South Carolina, 200 Patewood Drive, Suite A-140, Greenville, 29615, South Carolina, USA

    Jonathan E. Markowitz

  3. Perelman School of Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th St. & Civic Ctr. Blvd., Philadelphia, 19104, Pennsylvania, USA

    Robert N. Baldassano

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Uko, V., Wyllie, R. (2013). Pouchitis After Ileal Pouch-Anal Anastomosis. In: Mamula, P., Markowitz, J., Baldassano, R. (eds) Pediatric Inflammatory Bowel Disease. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-5061-0_39

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  • DOI: https://doi.org/10.1007/978-1-4614-5061-0_39

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