Issue 22

Clinical Question

How common is pouchitis, who is at highest risk and are biologics effective?

Editor’s Bottom Line

Both acute and chronic inflammatory ileal-anal pouch complications are common. Biologic therapy appears to be well tolerated, but controlled prospective assessments of efficacy and safety are needed.

Reference

Kayal M, Plietz M, Rizvi A, et al. Inflammatory Pouch Conditions Are Common After Ileal Pouch Anal Anastomosis in Ulcerative Colitis Patients. Inflamm Bowel Dis. Epub October 6, 2019; https://doi.org/10.1093/ibd/izz227.

Synopsis

Researchers at Icahn School of Medicine at Mount Sinai, New York, retrospectively reviewed medical record data from 386 patients with ulcerative colitis or inflammatory bowel disease-unspecified (IBD-U) who had undergone total proctocolectomy with ileal pouch anal anastomosis (IPAA) between 2008 and 2017 for refractory disease, dysplasia or both. Rates of inflammatory pouch conditions were documented and correlated with possible risk factors.

Over a median of four years of follow-up (Interquartile range: 2–6.4 years), 53% of patients experienced acute pouchitis, 30% developed cuffitis and 12% developed Crohn’s disease-like condition (CDLC) of the pouch. Thirty percent of patients went on to chronic pouchitis, defined as symptoms lasting longer than four weeks and requiring chronic antibiotics.

Multivariate analyses showed that women were 61% less likely to experience acute pouchitis (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.39–0.97), while corticosteroid use within three months prior to surgery was linked with a nearly two-fold increase in the risk of acute pouchitis (OR, 1.9; 95% CI, 1.1–3.4) and medically refractory disease was associated with a two-fold higher risk (OR, 2.1; 95% CI, 1.1–4.2). IBDU was associated with a ten-fold increase in the risk of chronic pouchitis (OR, 10; 95% CI, 3.9–25.9). Rectal cuff length ≥2 cm raised the risk of cuffitis by 40% (OR, 1.4; 95% CI, 1.1–1.8) and medically refractory disease was associated with a seven-fold increased risk of cuffitis (OR, 6.9; 95% CI, 2.1–23.2).

Roughly 40% of pouchitis patients who received biologics experienced endoscopic remission within 12 months, and treatment with biologics did not reduce the likelihood of pouch failure.

Details

Study Design: Retrospective chart review
Funding: Not reported
Allocation: Not applicable
Setting: Single tertiary care center
Level of Evidence: 2b (Oxford Levels of Evidence)

The summary and conclusion in this issue of E-mentoring in IBD pertains to the manuscript(s) being reviewed, and should be considered in the context of what is already known surrounding the topic and incorporated into practice as deemed appropriate by the individual learner.