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Pouchitis

Discuss pouchitis?

Pouchitis is the inflammation of the ileal pouch reservoir. It is the most common long-term complication in patients with IPAA which significantly affects patients’ quality of life. It is estimated that approximately 50% of patients who have undergone IPAA surgery for UC will develop at least one episode of pouchitis.

Discuss the pathogenesis?

Pouchitis almost exclusively occurs in patients with underlying UC and is rarely seen in patients with FAP. Although the etiology and pathogenesis of pouchitis are not entirely clear, bulk of evidence points towards an abnormal mucosal immune response (innate and adaptive) to altered microflora in the pouch leading to acute and/or chronic inflammation.

Discuss the diagnosis of pouchitis?

  • Clinical features- increased stool frequency, urgency, tenesmus, abdominal pain, hematochezia, fever, and extraintestinal manifestations of inflammatory bowel disease.
  • Endoscopy- erythematous, friable mucosa, and haemorrhages, erosions and/or ulcerations.
  • Histology- Both acute and chronic inflammatory changes are seen
  • The diagnosis is based on the combination of clinical, endoscopic and histologic features.
  • Natural history- 50% of the affected patients will have recurrent episodes of pouchitis requiring repeated treatment.

Discuss the treatment for pouchitis?

  • Acute episodes of pouchitis respond well to a single course of antibiotics. The first-line therapy includes a 7 day course of oral metronidazole (1-2 gm per day) or ciprofloxacin (1gm/d).
  • Some develops chronic, relapsing symptoms, which may require long-term or continuous therapy. Low dose ciprofloxacin may be used. The probiotic VSL#3 (3 to 6 g/day) may also be an acceptable alternative.
  • A Cochrane review concluded that oral probiotic therapy with VSL-3 over a 36 week period appears to be an effective therapy for reducing the risk of disease recurrence among patients with non-active pouchitis.
  • Antibiotic-refractory pouchitis which is often difficult to treat is a common cause of pouch failure.

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