4. Pouchitis

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The patient is able to state the definition of pouchitis, signs and symptoms of pouchitis, diagnosis, occurrence, causes, treatment and prevention for pouchitis.


Pouchitis is an inflammation of the mucosa, or lining of the pouch.

Symptoms

The main symptom for most patients is an abnormally large number of stools: an increase from 4 to 6 (on average), or more. Patients may also experience rectal bleeding, abdominal cramping, a sense of "urgency" before having a bowel movement, and fever.

Diagnosis

Patients who have any of the symptoms listed above could have pouchitis. However, several other conditions also could cause similar symptoms. These include irritable bowel syndrome, small bowel obstruction from scar tissue, narrowing of the join (anastomosis) between the anus and the pouch, an intestinal infection with bacteria or parasites, and Crohn’s disease. For this reason, patients whose symptoms suggest pouchitis should be seen by either their colorectal surgeon or gastroenterologist or have a flexible sigmoidoscopy (examination of the pouch with a flexible lighted instrument). At this time, biopsies (tissue samples) of the pouch should also be obtained. In patients with pouchitis, flexible sigmoidoscopy will reveal inflammation, similar to that found in ulcerative colitis, in the mucosa of the pouch. When examined under the microscope, the biopsies will also show inflammation. If inflammation is not present, then other causes for the symptoms should be considered.

Occurrence

The cause of pouchitis is not known. Researchers have suggested several theories; an excess of bacteria in the pouch related to stool stasis; a recurrence of inflammatory bowel disease in the pouch and misdiagnosis of ulcerative colitis. In a minority of patients, it may be difficult to differentiate between Crohn’s disease and colitis. Problems that may occur postoperatively could be related to the fact that the patient has Crohn’s disease.

People who suffer from pouchitis often improve with antibiotics, which suggest that bacteria are an important factor in the development of this condition. Pouchitis occurs more commonly in people with extraintestinal problems associated with ulcerative colitis (e.g., arthritis or abnormalities of the liver, skin, or eyes). These findings suggest that pouchitis may be a new type of IBD, which recurs in the pouch. Most patients with pouchitis do not have Crohn’s disease.

Research is being done to identify the cause of pouchitis. Some investigators are looking for “triggering” bacteria or disease markers, such as antibodies. One early finding is that pouchitis is more common in ulcerative colitis patients who have antineutrophil cytoplasmic antibodies (ANCA) in their blood. Not everyone who has ANCA will get pouchitis. The most likely cause is two fold: a genetic susceptibility to both ulcerative colitis and pouchitis, combined with a “trigger,” such as bacteria, within the stool in the pouch.

Treatment

Antibiotics are the most common treatment for pouchitis. The most commonly used antibiotic is metronidazole (Flagyl). Most, if not all, patients initially improve after taking metronidazole, usually within one or two days. The length of treatment is usually one-two weeks. A small minority of patients may require continual treatment for chronic pouchitis.

Italian researchers are reporting that high doses of probiotics appear to be an effective therapy for maintaining remission in patients with chronic pouchitis who are in remission. Other studies have shown that 5-aminosalicylates, steroids, immunomodulators, anti-TNF-alpha therapies, may also be effective in treating recurrent or chronic pouchitis.

Prevention

Helpful suggestions include a liberal intake of fluids to keep the system flushed, and yogurt that includes the healthy bacteria acidophilus (yogurts that contain the living strains of L. bulgaricus and S. thermophilus are more appropriate). Another suggestion is not to allow stool to stay inside the pouch for long periods of time. Going to the bathroom prior to sleep is recommended.

Pouchitis does not affect everyone with the pelvic pouch. Even people who do develop pouchitis report that their quality of life is better than when they had ulcerative colitis. In almost all cases, having an ileostomy can eliminate the problem of chronic pouchitis.

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