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Pouchitis: What do we really know?

Pouchitis: What do we really know?. Non specific inflammation of the pouch Usually acute episodes but may be chronic. Pelvic Pouch. Background. PELVIC POUCH.

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Pouchitis: What do we really know?

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  1. Pouchitis:What do we really know? • Non specific inflammation of the pouch • Usually acute episodes but may be chronic

  2. Pelvic Pouch

  3. Background PELVIC POUCH • Ileal pouch-anal anastomosis is the gold standard for the treatment of refractory Ulcerative Colitis (UC) and Familial Adenomatous Polyposis (FAP). • Quality of life is improved. • Most frequent complication is inflammation of the ileal pouch. • Cumulative risk of pouchitis Year 1: 15% , Year 5: 36%, Year 10: 46%

  4. Clinical Manifestations • Increased stool frequency, liquid stool, blood, abdominal pain, cramps, malaise, low grade fever • 2/3 have one to few mild episodes, remainder have repeated episodes or continuous activity

  5. Pelvic Pouch ADAPTIVE CHANGES Normal Ileum Normal Colon Normal Pelvic Pouch

  6. Goldberg Luukonen Salemans Mayo Clinic U of Toronto % affected patients 33 - 47 20 40 37 8 Frequency of Pouchitis

  7. Risk of Pouchitis 100 80 60 Risk of Pouchitis 40 20

  8. Pattern of Pouchitis Luukonen 36% 38% 26% Mayo 39% 46% 15% 1 episode 2 + episodes chronic

  9. Pouch Disease Activity Index • Clinical Criteria • Stool frequency • Rectal bleeding • Urgency • Fever • Endoscopic Criteria • Histologic Criteria

  10. Pouchitis : Pathogenesis

  11. Possible Etiological Agents 1. Bacterial 2. Decreased SCFA levels 3. Glutamine deficiency 4. Ischemia (oxygen free radicals) 5. Genetic/Immune mechanism

  12. Pouchitis : IL - 1 RA Gene Allele 2 GENETIC SUSCEPTIBILITY * Acute UC No Pouchitis Refractory UC • Pouchitis 45% vs 72% Carter Gastro 2001;121:805

  13. Treatment of Pouchitis • Broad spectrum antibiotics • metronidazole • 5 ASA/steroids • Immunosuppressive meds • Imuran, methotrexate • Cyclosporin enemas • Probiotics

  14. IBD: Probiotics MICROBIAL INTERFERENCE TREATMENT FRIEND FOE Lactobacilli Bifidobacterium Yeast Bacteroides Clostridium E.Coli Bengmark Gut 1998; 42: 2

  15. Probiotics in PouchitisGionchetti et al, 1998 • VSL-3 • 4 strains of lactobacilli • 3 strains of bifidobacteria • 1 strain of streptococcus

  16. Pouchitis: Probiotics POUCHITIS : EFFECT OF VSL - 3 Chronic Pouchitis Prophylaxis P < 0.001 100% 40% * * 15% 10% Each Group n = 20 Relapse 1 Year Relapse 9 Months Gastro 2000;119:305 Gastro 2003;124:1535

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