Ileal pouch-anal anastomosis and liver transplantation for ulcerative colitis complicated by primary sclerosing cholangitis

Risk factors associated with the development of chronic pouchitis following ileal-pouch anal anastomosis surgery for ulcerative colitis

BACKGROUND

Chronic pouchitis remains a significant and prevalent complication following ileal pouch-anal anastomosis in patients with ulcerative colitis.

AIM

To identify potential risk factors for the development of chronic pouchitis.

METHODS

Predictors of chronic pouchitis were investigated through a systematic review and meta-analysis. A comprehensive search of the Medline, EMBASE, and PubMed databases was undertaken to identify relevant studies published up to October 2023. Meta-analytic procedures employed random-effects models for the combination of estimates, with the I² statistic used to assess between-study heterogeneity.

RESULTS

Eleven studies with a total of 3722 patients, comprising 513 with chronic pouchitis and 3209 patients without, were included in the final analysis. Extraintestinal manifestation [odds ratio (OR) = 2.11, 95% confidence intervals (CI): 1.53-2.91, P < 0.001, I² = 0%], specifically primary sclerosing cholangitis (PSC) (OR = 3.69, 95%CI: 1.40-9.21, P = 0.01, I² = 48%), and extensive colitis (OR = 1.96, 95%CI: 1.23-3.11, P = 0.00, I² = 31%) were associated with an increased risk of chronic pouchitis. Other factors, including gender, smoking status, family history of inflammatory bowel disease and ileal pouch anal anastomosis surgical indication were not significantly associated with chronic pouchitis.

CONCLUSION

Extraintestinal manifestations, PSC and extensive colitis are associated with the development of chronic pouchitis. These findings underscore the importance of comprehensive pre-operative assessment and tailored post operative management strategies.

Ileal pouch-anal anastomosis and end ileostomy result in equivalent graft survival following liver transplantation for inflammatory bowel disease-primary sclerosing cholangitis

INTRODUCTION

Patients with inflammatory bowel disease and primary sclerosing cholangitis may require both liver transplantation and colectomy. There are concerns about increased rates of hepatic artery thrombosis, biliary strictures, and hepatic graft loss in patients with ileal pouch-anal anastomosis compared to those with end ileostomy. We hypothesized that graft survival was not negatively affected by ileal pouch-anal anastomosis compared to end ileostomy.

MATERIALS AND METHODS

A tertiary center's database was searched for patients meeting the criteria of liver transplantation because of primary sclerosing cholangitis and total proctocolectomy with ileal pouch-anal anastomosis or end ileostomy because of ulcerative colitis. Primary endpoints were hepatic graft survival and post-transplant complications.

RESULTS

Fifty-five patients met the inclusion criteria between January 1990 and December 2022. Of these, 46 (84%) underwent ileal pouch-anal anastomosis, and 9 (16%) underwent end ileostomy. The average age at total proctocolectomy (41.5 vs. 49.1 years; p = 0.12) and sex distribution (female: 26.1% vs. 22.2%; p = 0.99) were comparable. The rates of re-transplantation (21.7% vs. 22.2%; p = 0.99), hepatic artery thrombosis (10.8% vs. 0; p = 0.58), acute rejection (32.6% vs. 44.4%; p = 0.7), chronic rejection (4.3% vs. 11.1%; p = 0.42), recurrence of primary sclerosing cholangitis (23.9% vs. 22.2%; p = 0.99), and biliary strictures (19.6% vs. 33.3%; p = 0.36) were similar between the ileal pouch-anal anastomosis and end ileostomy groups, respectively. None of the end ileostomy patients developed parastomal varices. The log-rank tests for graft (p = 0.97), recipient (p = 0.3), and combined graft/recipient survival (p = 0.73) were similar.

CONCLUSION

Ileal pouch-anal anastomosis did not negatively affect graft, recipient, and combined graft/recipient survival, or the long-term complications, compared to end ileostomy.

Altered Bile Acid and Pouch Microbiota Composition in Patients With Chronic Pouchitis

BACKGROUND

Patients with ulcerative colitis and total abdominal proctocolectomy with ileal pouch-anal anastomosis have a 50% risk of pouchitis and a 5% to 10% risk of chronic pouchitis.

AIMS

The goal of the study was to compare pouch microbiota and stool bile acid composition in patients with chronic pouchitis, chronic pouchitis and primary sclerosing cholangitis, and normal pouch.

METHODS

Patients with ulcerative colitis and ileal pouch-anal anastomosis were recruited from March 20, 2014, to August 6, 2019, and categorized into normal pouch, chronic pouchitis, and chronic pouchitis/primary sclerosing cholangitis groups. Stool samples were subjected to bile acid quantification and 16S rRNA gene sequencing. Statistical comparisons of absolute bile acid abundance and pouch microbiota α-diversity, β-diversity, and taxa abundance were performed among the patient groups.

RESULTS

A total of 51 samples were analyzed. Both α-diversity (P = .01, species richness) and β-diversity (P = .001) significantly differed among groups. Lithocholic acid was significantly lower in patients with chronic pouchitis/primary sclerosing cholangitis than in those with chronic pouchitis (P = .01) or normal pouch (P = .03). Decreased α-diversity was associated with an increased primary to secondary bile acid ratio (P = .002), which was also associated with changes in β-diversity (P = .006).

CONCLUSIONS

Pouch microbiota α- and β-diversity differed among patients with normal pouch, chronic pouchitis, and chronic pouchitis/primary sclerosing cholangitis. Lithocholic acid level and primary to secondary bile acid ratio were highly associated with pouch microbiota richness, structure, and composition. These findings emphasize the associations between pouch microbiota and bile acid composition in dysbiosis and altered metabolism, suggesting that secondary bile acids are decreased in chronic pouchitis.

Management of Primary Sclerosing Cholangitis and Extraintestinal Disorders in Patients With Ileal Pouches: A Systematic Review

BACKGROUND

Restorative proctocolectomy with IPAA improves the quality of life in patients with ulcerative colitis by the removal of diseased large bowel and preservation of the natural route of defecation. Although the surgery may improve preexisting extraintestinal manifestations in the joints, skin, and eyes, extraintestinal manifestations, particularly primary sclerosing cholangitis, can persist after colectomy.

OBJECTIVES

A systematic review of diagnosis and treatment of liver, joint, skin, and eye manifestations in patients with restorative proctocolectomy and IPAA for ulcerative colitis.

DATA SOURCES

PubMed, Google Scholar, and Cochrane database.

STUDY SELECTION

Relevant articles on primary sclerosing cholangitis and extraintestinal manifestations in ileal pouches published between January 2001 and July 2023 in English were included on the basis of Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

INTERVENTION

Diagnosis and treatment of primary sclerosing cholangitis and extraintestinal manifestations in patients with restorative proctocolectomy and IPAA were included.

MAIN OUTCOME MEASURES

Association between primary sclerosing cholangitis, extraintestinal manifestations, and inflammatory disorders of the pouch and their management.

RESULTS

Primary sclerosing cholangitis and extraintestinal manifestations are associated with pouchitis, particularly chronic pouchitis. Primary sclerosing cholangitis is associated with chronic pouchitis, enteritis, and possible pouch neoplasia. However, the disease severity and course of primary sclerosing cholangitis and pouchitis do not appear to be parallel. Despite the fact that oral vancomycin or budesonide have been used to treat primary sclerosing cholangitis-associated pouchitis, their impact on the disease course of primary sclerosing cholangitis is not known. Biological therapy for chronic inflammatory disorders of the pouch may also be beneficial for the concurrent extraintestinal manifestations of the joints, skin, and eyes. However, studies on the correlation between the severity of inflammatory pouch disorders and the severity of joint, skin, and eye diseases are lacking.

LIMITATIONS

This is a qualitative, not quantitative, review of case series and case reports.

CONCLUSIONS

Primary sclerosing cholangitis and extraintestinal manifestations of the joints, skin, and eyes appear to be associated with inflammatory disorders of the ileal pouch. Although the treatment of pouchitis does not seem to affect the disease course of primary sclerosing cholangitis, effective therapy of inflammatory pouch disorders, particularly with biologics, likely benefits concurrent disorders of the joints, skin, and eyes. See video from the symposium .

Surgical management of colon cancer in ulcerative colitis patients with orthotopic liver transplant for primary sclerosing cholangitis. A systematic review

INTRODUCTION

Colon cancer in ulcerative colitis patients with liver transplant (UCCOLT) due to primary sclerosing cholangitis carries significant treatment challenges. Aim of this literature search is to review management strategies and provide a framework to facilitate the decisional process in this clinical setting.

METHODS

PRISMA-compliant systematic search was followed by critical expert commentary of the results and development of a surgical management algorithm. Endpoints included surgical management, operative strategies, functional and survival outcomes. Technical and strategics aspects with particular regard to the choice of reconstruction were evaluated to tentatively develop an integrated algorithm.

RESULTS

Ten studies reporting treatment of 20 UCCOLT patients were identified after screening. Nine patients underwent proctocolectomy and end-ileostomy (PC) and eleven had restorative ileal pouch-anal anastomosis (IPAA). Reported results for perioperative outcomes, oncological outcomes, and graft loss were comparable for both procedures. There were no reports of subtotal colectomies and ileo-rectal anastomosis (IRA).

CONCLUSIONS

Literature in the field is scarce and decision-making is particularly complex. PC and IPAA have been reported with good results. Nevertheless, IRA may also be considered in UCCOLT patients in selected cases, reducing the risks of sepsis, OLT and pouch failure; furthermore, in young patients, it has the advantage of preserving fertility or sexual function. The proposed treatment algorithm may represent a valuable support in guiding surgical strategy.

Hepatobiliary Impairments in Patients with Inflammatory Bowel Diseases: The Current Approach

Inflammatory bowel disease (IBD) refers to chronic conditions with a low mortality but high disability. The multisystemic nature of these diseases can explain the appearance of some extraintestinal manifestations, including liver damage. Abnormal liver biochemical tests can be identified in approximately one third of patients with IBD and chronic liver disease in 5% of them. Among the liver diseases associated with IBD are primary sclerosing cholangitis, cholelithiasis, fatty liver disease, hepatic amyloidosis, granulomatous hepatitis, drug-induced liver injury, venous thromboembolism, primary biliary cholangitis, IgG4-related cholangiopathy, autoimmune hepatitis, liver abscesses or the reactivation of viral hepatitis. The most common disease is primary sclerosing cholangitis, a condition diagnosed especially in patients with ulcerative colitis. The progress registered in recent years in the therapeutic management of IBD has not eliminated the risk of drug-induced liver disease. Additionally, the immunosuppression encountered in these patients increases the risk of opportunistic infections, including the reactivation of viral hepatitis. Currently, one of the concerns consists of establishing an efficiency and safety profile of the use of direct-acting antiviral agents (DAA) among patients with hepatitis C and IBD. Early diagnosis and optimal treatment of liver complications can improve the prognoses of these patients.

Primary Sclerosing Cholangitis-Associated Pouchitis: A Distinct Clinical Phenotype

BACKGROUND & AIMS

Patients with primary sclerosing cholangitis (PSC) commonly undergo ileal pouch-anal anastomosis (IPAA) for medically-refractory ulcerative colitis (UC) or colorectal dysplasia. Pouchitis develops more frequently in patients with PSC, potentially leading to increased morbidity. We aimed to assess clinical characteristics and treatment outcomes for pouchitis in patients with PSC compared to a matched, non-PSC cohort.

METHODS

All patients with PSC who underwent IPAA and were diagnosed with pouchitis (PSC-pouchitis) were identified. A matched cohort composed of non-PSC patients who underwent IPAA for UC and subsequently developed pouchitis (UC-pouchitis) was developed. Relevant demographic, clinical, endoscopic, histologic, and treatment data were collected and compared between groups.

RESULTS

Of those with PSC-pouchitis (n=182), 53.9% and 46.1% underwent IPAA for medically-refractory disease and dysplasia, respectively, compared to 88.7% and 11.3% in the UC-pouchitis group (P < .001). Patients with PSC-pouchitis were more likely to develop chronic pouchitis (68.1% vs 34.1%; P < .001), have moderate-to-severe pouch inflammation (54.9% vs 32.4%; P < .001), and prepouch ileitis (34.1% vs 11.5%; P < .001) compared to UC-pouchitis. Of those with PSC-pouchitis, 50.6% and 17.6% developed chronic antibiotic-dependent or antibiotic-refractory pouchitis, respectively, compared to 25.8% and 7.7% with UC-pouchitis. There was no difference in treatment response between the two groups with use of thiopurines, anti-tumor necrosis factor agents, and newer biologics.

CONCLUSIONS

PSC-associated pouchitis presents with a unique clinical phenotype, characterized by increased risk of chronic pouchitis, moderate-to-severe pouch inflammation, prepouch ileitis, and less response to conventional antimicrobial therapy.

Predication of post-operative outcome of colectomy in ulcerative colitis patients using Model of End-Stage Liver Disease Score

PURPOSE

Model of End-Stage Liver Disease (MELD) score was developed to predict mortality in patients with liver disease. The aim of this study was to investigate the relationship between preoperative MELD score and 30-day surgical outcomes using the American College of Surgeons National Surgical Quality Improvement Program.

METHODS

Patients with ulcerative colitis (UC) (ICD: 556.X) who underwent colectomy were identified from NSQIP 2005 to 2013. The primary outcomes were bleeding complications, and overall morbidity and mortality.

RESULTS

A total of 7534 UC patients undergoing colectomy were identified. Patients with a higher MELD score had a longer hospital stay; more bleeding; and cardiac, respiratory, renal, thromboembolic, and septic complications as well as mortality. Patients were stratified into 4 groups by MELD score: < 7, 7-11, 12-15, and > 15 and a stratified multivariate analysis was done. Patients with a MELD score 12-15 (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.1-1.3) and MELD > 15 (OR 2.6, 95%CI 1.5-4.7) were at significant risk for bleeding complication. Apart from the MELD score, the presence of ascites (OR 2.5, 95%CI 1.2-5.1) or varices (OR 1.0, 95%CI 1.01-1.03) was also significantly associated with post-operative bleeding complication. MELD 12-15 and MELD > 15 were also found to be risk factors for overall morbidity (OR 5.3, 95%CI 1.8-15.7; OR 10.3, 95%CI 3.6-29.7, respectively) and mortality (OR 3.3, 95%CI 1.3-8.4; OR 5.9, 95%CI 2.4-14.6, respectively).

CONCLUSION

UC patients with a higher MELD score were associated with a higher post-colectomy morbidity and mortality. MELD score > 11 was an independent indicator for post-operative bleeding, and overall complications and mortality.

The impact of ileal pouch-anal anastomosis on graft survival following liver transplantation for primary sclerosing cholangitis

BACKGROUND

Liver transplantation is the only life-extending intervention for primary sclerosing cholangitis (PSC). Given the co-existence with colitis, patients may also require colectomy; a factor potentially conferring improved post-transplant outcomes.

AIM

To determine the impact of restorative surgery via ileal pouch-anal anastomosis (IPAA) vs retaining an end ileostomy on liver-related outcomes post-transplantation.

METHODS

Graft survival was evaluated across a prospectively accrued transplant database, stratified according to colectomy status and type.

RESULTS

Between 1990 and 2016, 240 individuals with PSC/colitis underwent transplantation (cumulative 1870 patient-years until first graft loss or last follow-up date), of whom 75 also required colectomy. A heightened incidence of graft loss was observed for the IPAA group vs those retaining an end ileostomy (2.8 vs 0.4 per 100 patient-years, log-rank P = 0.005), whereas rates between IPAA vs no colectomy groups were not significantly different (2.8 vs 1.7, P = 0.1). In addition, the ileostomy group experienced significantly lower graft loss rates vs. patients retaining an intact colon (P = 0.044). The risks conferred by IPAA persisted when taking into account timing of colectomy as related to liver transplantation via time-dependent Cox regression analysis. Hepatic artery thrombosis and biliary strictures were the principal aetiologies of graft loss overall. Incidence rates for both were not significantly different between IPAA and no colectomy groups (P = 0.092 and P = 0.358); however, end ileostomy appeared protective (P = 0.007 and 0.031, respectively).

CONCLUSION

In PSC, liver transplantation, colectomy + IPAA is associated with similar incidence rates of hepatic artery thrombosis, recurrent biliary strictures and re-transplantation compared with no colectomy. Colectomy + end ileostomy confers more favourable graft outcomes.

Hepatobiliary Manifestations and Complications in Inflammatory Bowel Disease: A Review

Liver and biliary track diseases are common extraintestinal manifestations of inflammatory bowel disease (IBD), reported both in Crohn’s disease and ulcerative colitis, and may occur at any time during the natural course of the disease. Their etiology is mainly related to pathophysiological changes induced by IBD, and secondary, due to drugs used in IBD. Fatty liver is considered as the most frequent hepatobiliary manifestation in IBD, while primary sclerosing cholangitis (PSC) is the most correlated hepatobiliary disorder and is more prevalent in patients with ulcerative colitis. PSC can cause serious complications from the liver, biliary tree, and gallbladder and can lead to liver failure. Less frequently, IBD-associated hepatobiliary manifestations include cholelithiasis, granulomatous hepatitis, portal vein thrombosis, IgG4-related cholangiopathy, pyogenic liver abscess, hepatic amyloidosis and primary biliary cirrhosis. Most of the drugs used for IBD treatment may cause liver toxicity. Methotrexate and thiopurines carry the higher risk for hepatotoxicity, and in many cases, dose adjustment may normalize the liver biochemical tests. Reactivation of hepatitis B and C virus during immunosuppressive use, especially during use of biological agents, is a major concern, and adequate screening, vaccination and prophylactic treatment is warranted.

Hepatic manifestations of inflammatory bowel diseases

Inflammatory bowel diseases are associated with various hepatobiliary disorders, reported both in Crohn's disease and ulcerative colitis. They may occur at any moment in the natural course of the disease. The prevalence of liver dysfunction rises from 3% to 50% accordingly to definitions used in different studies. Fatty liver is considered as the most common hepatobiliary complication in inflammatory bowel diseases while primary sclerosing cholangitis is the most specific one. Less frequently, inflammatory bowel diseases-associated hepatobiliary disorders include: autoimmune hepatitis/ primary sclerosing cholangitis overlap syndrome, IgG4-associated cholangiopathy, primary biliary cholangitis, hepatic amyloidosis, granulomatous hepatitis, cholelithiasis, portal vein thrombosis and liver abscess. The spectrum of these manifestations varies according to the type of inflammatory bowel diseases. Treatments of inflammatory bowel diseases may cause liver toxicity, although incidence of serious complications remains low. However, early diagnosis of drug-induced liver injury is of major importance as it affects future clinical management. When facing abnormal liver tests, clinicians should undertake a full diagnostic work-up in order to determine whether the hepatic abnormalities are related to the inflammatory bowel diseases or not. Management of hepatic manifestations in inflammatory bowel diseases usually involves both hepatologists and gastroenterologists because of the complexity of some situations.

Evolving strategies to reduce colectomy rates in primary sclerosing cholangitis-inflammatory bowel disease: clinical remission of corticosteroid refractory colitis post-liver transplant with vedolizumab

Primary sclerosing cholangitis (PSC) is associated with inflammatory bowel disease (IBD) in approximately 70% of patients, with ulcerative colitis (UC) being the most common subtype of IBD identified. There is a paucity of data on the optimum management strategy for IBD flares in the post-liver transplant patient, particularly when refractory to conventional treatments. Vedolizumab is a novel gut-specific monoclonal antibody, which has recently been approved for use by National Institute for Health and Care Excellence for moderate-to-severe UC. We present an exemplar case of successful use of vedolizumab in the management of corticosteroid refractory PSC-IBD after liver transplantation.

Increased risk of colorectal neoplasia in patients with primary sclerosing cholangitis and inflammatory bowel disease: a meta-analysis of 16 observational studies

Ulcerative colitis (UC) patients with concomitant primary sclerosing cholangitis (PSC) carry an increased risk of colorectal neoplasia (dysplasia and cancer), whereas the association between PSC and the development of colorectal neoplasia in Crohn's disease (CD) is controversial. A meta-analysis was carried out to compare the risk of this neoplasia in patients with inflammatory bowel disease (IBD) with and without PSC. A systematic research of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials was performed to identify studies that compared the risk of colorectal neoplasia (dysplasia and cancer) in patients with IBD with and without PSC. Quality assessment was performed using the Newcastle-Ottawa Scale. Pooled odds ratio (OR) was calculated using the random-effects model by STATA 12.0. A total of 16 studies (four cohort studies, 12 case-control studies; nine prospective studies and seven retrospective studies) were selected for further study. These studies included 13 379 IBD patients, of whom 1022 also had PSC. Patients with IBD and PSC were at an increased risk of colorectal dysplasia and cancer compared with patients with IBD alone [OR 3.24; 95% confidence interval (CI): 2.14-4.90]. This increased risk was present even when the risk of colorectal cancer alone was analysed (OR 3.41; 95% CI: 2.13-5.48). Data only from patients with UC showed that PSC was associated with an increased risk for the development of colorectal neoplasia and cancer in patients with UC (OR 2.98; 95% CI: 1.54-5.76) (OR 3.01; 95% CI: 1.44-6.29), but there were high heterogeneity among studies (I=76.9 and 62.8%, respectively). Heterogeneity of the studies was affected by the study design (prospective or retrospective). The OR of colorectal neoplasia was 2.32 (95% CI: 0.70-7.70, P=0.133) and that of cancer was 2.91 (95% CI: 0.84-10.16, P=0.388) for patients with CD and concurrent PSC. Patients with IBD and PSC have a markedly higher risk for the development of colorectal neoplasia than patients with IBD, but not PSC. Stratification by IBD type show that the presence of PSC is associated with an increased risk for the development of colorectal neoplasia in patients with UC; however, there is a nonsignificant association in CD patients. When the risk of colorectal cancer alone is analysed, the conclusion does not change.

The Gut-Liver Axis in Primary Sclerosing Cholangitis

Dysregulation of the key genetic, immunologic, and microbiome compounds of the gut-liver axis is the basis for inflammatory bowel disease (IBD) and primary sclerosing cholangitis (PSC). This creates opportunities to accelerate therapies that have been traditionally developed for IBD to be used in PSC to the benefit of both diseases. Shared genetic susceptibility loci has yielded important clues into the pathogenesis of PSC-IBD. Understanding of the critical links between PSC and IBD are essential in designing clinical care pathways for these complex patients.

Management of ulcerative colitis pre- and post-liver transplant for primary sclerosing cholangitis: two case reports and review of literature

INTRODUCTION

Management of ulcerative colitis (UC) pre- and post-liver transplant for primary sclerosing cholangitis (PSC) can be challenging and complex. There are no formal guidelines, but there is a plethora of data regarding the use of medical and surgical treatment options, mainly from case series, retrospective data, and experience from transplant centers.

DISCUSSION

We present two cases of UC-PSC with variable severity of liver disease and discuss the available data on the management of UC pre- and post-liver transplant. A PubMed search was conducted using various keyword combinations looking for studies involving patients with UC-PSC pre- and post-liver transplant. We reviewed and summarized the available literature on the course of UC in patients with PSC-related cirrhosis pre- and post-transplant and risk of colorectal neoplasia post-transplant. Finally, we summarize the available data on the medical and surgical management of UC pre- and post-liver transplant and the effect of transplant on pouchitis. Current literature supports the use of medical therapies, including immunomodulators and biologic agents, following liver transplant. There is also literature supporting surgical management including total colectomy. A multidisciplinary, patient-centered approach is important when managing UC pre- and post-liver transplantation.

The longitudinal and interactive effects of HIV status, stimulant use, and host genotype upon neurocognitive functioning

Both human immunodeficiency virus (HIV)-1 infection and illicit stimulant use can adversely impact neurocognitive functioning, and these effects can be additive. However, significant variability exists such that as-of-yet unidentified exogenous and endogenous factors affect one's risk for neurocognitive impairment. Literature on both HIV and stimulant use indicates that host genetic variants in immunologic and dopamine-related genes are one such factor. In this study, the individual and interactive effects of HIV status, stimulant use, and genotype upon neurocognitive functioning were examined longitudinally over a 10-year period. Nine hundred fifty-two Caucasian HIV+ and HIV- cases from the Multicenter AIDS Cohort Study were included. All cases had at least two comprehensive neurocognitive evaluations between 1985 and 1995. Pre-highly active antiretroviral therapy (HAART) data were examined in order to avoid the confounding effect of variable drug regimens. Linear mixed models were used, with neurocognitive domain scores as the outcome variables. No four-way interactions were found, indicating that HIV and stimulant use do not interact over time to affect neurocognitive functioning as a function of genotype. Multiple three-way interactions were found that involved genotype and HIV status. All immunologically related genes found to interact with HIV status affected neurocognitive functioning in the expected direction; however, only C-C chemokine ligand 2 (CCL2) and CCL3 affected HIV+ individuals specifically. Dopamine-related genetic variants generally affected HIV-negative individuals only. Neurocognitive functioning among HIV+ individuals who also used stimulants was not significantly different from those who did not use stimulants. The findings support the role of immunologically related genetic differences in CCL2 and CCL3 in neurocognitive functioning among HIV+ individuals; however, their impact is minor. Being consistent with findings from another cohort, dopamine (DA)-related genetic differences do not appear to impact the longitudinal neurocognitive functioning of HIV+ individuals.

Clinical management of inflammatory bowel disease in the organ recipient

There was estimated a higher incidence of de novo inflammatory bowel disease (IBD) after solid organ transplantation than in the general population. The onset of IBD in the organ transplant recipient population is an important clinical situation which is associated to higher morbidity and difficulty in the medical therapeutic management because of possible interaction between anti-reject therapy and IBD therapy. IBD course after liver transplantation (LT) is variable, but about one third of patients may worsen, needing an increase in medical therapy or a colectomy. Active IBD at the time of LT, discontinuation of 5-aminosalicylic acid or azathioprine at the time of LT and use of tacrolimus-based immunosuppression may be associated with an unfavorable outcome of IBD after LT. Anti-tumor necrosis factor alpha (TNFα) therapy for refractory IBD may be an effective and safe therapeutic option after LT. The little experience of the use of biological therapy in transplanted patients, with concomitant anti-rejection therapy, suggests there be a higher more careful surveillance regarding the risk of infectious diseases, autoimmune diseases, and neoplasms. An increased risk of colorectal cancer (CRC) is present also after LT in IBD patients with primary sclerosing cholangitis (PSC). An annual program of endoscopic surveillance with serial biopsies for CRC is recommended. A prophylactic colectomy in selected IBD/PSC patients with CRC risk factors could be a good management strategy in the CRC prevention, but it is used infrequently in the majority of LT centers. About 30% of patients develop multiple IBD recurrence and 20% of patients require a colectomy after renal transplantation. Like in the liver transplantation, anti-TNFα therapy could be an effective treatment in IBD patients with conventional refractory therapy after renal or heart transplantation. A large number of patients are needed to confirm the preliminary observations. Regarding the higher clinical complexity of this subgroup of IBD patients, a close multidisciplinary approach between an IBD dedicated gastroenterologist and surgeon and an organ transplantation specialist is necessary in order to have the best clinical management of IBD after transplantation.

Liver transplantation and autoimmune liver diseases

Liver transplantation (LT) is an effective treatment for patients with end-stage autoimmune liver diseases such as primary biliary cirrhosis, primary sclerosing cholangitis, and autoimmune hepatitis. Indications for LT for these diseases do not differ substantially from those used for other acute or chronic liver diseases. Despite the good outcomes reported, the recurrence of autoimmune liver disease is relatively common in the allograft. In addition, it has become apparent that autoimmunity and autoimmune liver disease can arise de novo after transplantation for nonautoimmune liver disorders. An awareness of the existence of recurrent autoimmune liver diseases and de novo autoimmune hepatitis after LT has important clinical implications because their management differs from the standard antirejection treatment and is similar to the management of classic autoimmune liver diseases in the native liver.

Inflammatory bowel disease after liver transplantation for primary sclerosing cholangitis

The course of inflammatory bowel disease (IBD) after liver transplantation (LT) for primary sclerosing cholangitis (PSC) is complex, with several IBD-, PSC-, and transplant-related factors interplaying with each other. Approximately one-third of patients with known IBD improve, and one-third paradoxically worsen, after LT for PSC. Active IBD, discontinuation of 5-aminosalicylates (5-ASA) at time of LT and tacrolimus-based immunosuppression may be associated with an unfavorable course of IBD after LT. Approximately 14-30% patients with PSC may develop de novo IBD 10 years after LT. LT confers a high risk of pouchitis after ileal pouch-anal anastomosis, although it may not be higher than baseline rates for PSC patients. The risk of colorectal cancer continues to be high after LT for PSC, and is higher in this cohort of patients with PSC-IBD, compared with patients undergoing LT for other indications. IBD does not adversely affect patient survival after LT, although the risk of recurrent PSC in the allograft may be higher in patients with IBD and an intact colon at time of LT. Standard therapy with 5-ASA and/or azathioprine may be appropriate for treatment of active IBD after LT and maintenance of remission. Anti-tumor necrosis factor-α agents are effective, but should be used with caution because of high risk of adverse events. The management of IBD after LT requires close coordination between transplant hepatologists and IBD experts.

Impact of ileal pouch-anal anastomosis on the surgical outcome of orthotopic liver transplantation for primary sclerosing cholangitis

BACKGROUND

The definitive treatment for patients with primary sclerosing cholangitis (PSC) is orthotopic liver transplantation (OLT), while the surgical treatment of choice for UC is restorative protocolectomy with ileal pouch-anal anastomosis (IPAA). While studies to date show that OLT may impact the outcome of IPAA, the effect of IPAA on the surgical outcome of OLT is not known.

METHODS

All eligible patients (those with PSC and OLT) from our prospectively maintained OLT and Pouch Databases were included. Patient and OLT graft survivals along with surgical outcomes were assessed. Univariable and multivariable analyses were performed.

RESULTS

Seventy-nine patients with OLT for PSC were studied, including those with UC (PSC+OLT+UC, n=27) or without UC (PSC+OLT, n=30), and with UC and IPAA (PSC+OLT+UC+IPAA, n=22). In the PSC+OLT+UC group, 23 (85.2%) had UC before OLT and 4 (14.8%) had UC diagnosed after OLT. In the PSC+OLT+UC+IPAA group, 9 (40.9%) had IPAA-then-OLT and 13 (59.1%) had OLT-then-IPAA, while 21 (95.5%) had UC before OLT and 1 (4.5%) had UC diagnosed after OLT. Kaplan-Meier survival curve showed no statistical differences in patient and graft survivals between the 3 groups. In univariable analysis, there was no statistical difference for acute and chronic rejection, hepatic artery thrombosis, stricture, bile leak and acute and chronic renal failure for the 3 groups. In multivariable analysis, no factors were found to be associated with bacteremia or intra-abdominal abscess.

CONCLUSIONS

The presence of the IPAA in OLT for PSC patients appears not to have a negative impact on patient and graft survivals and post-operative complications.

PSC, AIH and overlap syndrome in inflammatory bowel disease

Primary sclerosing cholangitis (PSC) is a progressive, cholestatic disorder characterised by chronic inflammation and stricture formation of the biliary tree. Symptoms include pruritus, fatigue and in advanced cases ascending cholangitis, cirrhosis and end-stage hepatic failure. Patients are at an increased risk of malignancy arising from the bile ducts, gallbladder, liver and colon. The majority (>80%) of Northern European patients with PSC also have inflammatory bowel disease (IBD), usually ulcerative colitis (UC). IBD commonly presents before the onset of PSC, although the opposite can occur and the onset of both conditions can be separated by many years. The colitis associated with PSC is characteristically mild although frequently involves the whole colon. Despite the majority of patients having relatively inactive colonic disease, paradoxically the risk of colorectal malignancy is substantially increased. Patients may also develop dominant, stenotic lesions of the biliary tree which may be difficult to differentiate from cholangiocarcinoma and the coexistence of IBD may influence the development of this complication. Ursodeoxycholic acid may offer a chemoprotective effect against colorectal malignancy and improve liver biochemical indices. Evidence of any beneficial effect on histological progression of hepatobiliary disease is less clear. High doses (∼25-30 mg/kg/d) may be harmful and should be avoided. Autoimmune hepatitis (AIH) is less common in patients with IBD than PSC, however, an association has been observed. A small subgroup may have an overlap syndrome between AIH and PSC and management should be individualised dependant on liver histology, serum immunoglobulin levels, autoantibodies, degree of biochemical cholestasis and cholangiography.

Acute and chronic pouchitis--pathogenesis, diagnosis and treatment

Restorative proctocolectomy with ileal pouch-anal anastomosis has become the procedure of choice for the majority of patients with ulcerative colitis who require surgical treatment. Pouchitis, the most common long-term complication of the procedure, involves a spectrum of disease processes with heterogeneous risk factors, clinical features, disease courses and prognoses. In addition, clinical symptoms of pouchitis are not specific and often overlap with those of other inflammatory and functional pouch disorders, such as Crohn's disease of the pouch and irritable pouch syndrome. Pouchoscopy and biopsy, along with laboratory and radiographic evaluations, are often required for accurate diagnosis in patients with symptoms indicative of pouchitis. Dysbiosis has been implicated as a triggering factor for pouchitis, and concurrent infection with pathogens, such as Clostridium difficile, might contribute to disease relapse and exacerbation. Antibiotic therapy is the main treatment modality. However, the management of antibiotic-dependent and antibiotic-refractory pouchitis remains challenging. Secondary causes of pouchitis, such as ischaemia, NSAID use, the presence of concurrent primary sclerosing cholangitis and other systemic immune-mediated disorders, should be evaluated and properly managed.

Liver transplantation in autoimmune liver diseases

Liver transplantation is indicated for terminal phases of autoimmune hepatitis, primary biliary cirrhosis and primary sclerosing cholangitis. Indications for transplantation in autoimmune liver diseases are similar to those used in other acute or chronic liver diseases. Therapeutic advances have reduced the need for transplantation for autoimmune hepatitis and primary biliary cirrhosis but not for primary sclerosing cholangitis. Overall, outcomes of transplantation for autoimmune liver diseases are excellent. However, recurrence of autoimmune liver diseases in the allograft has variable impacts on graft and patient survivals. Treatment of recurrent diseases requires changes in immunosuppression or addition of ursodeoxycholic acid. Among autoimmune liver diseases, only autoimmune hepatitis occurs de novo in recipients transplanted for other diseases. Patients transplanted for autoimmune hepatitis or primary sclerosing cholangitis are at risk for reactivation or de novo onset of ulcerative colitis. Better understanding of the pathogenesis of recurrent autoimmune liver diseases is needed to devise effective means of prevention and treatment.

Hepatobiliary disorders and complications of inflammatory bowel disease

One of typical examples of liver-gut cross talk is the interaction and impact of inflammatory bowel disease (IBD) and hepatobiliary (HB) abnormalities on each other's disease course. There are several layers of association between IBD and HB diseases: (i) HB diseases and IBD share pathogenetic mechanisms; (ii) HB diseases parallel structural and pathophysiological changes seen with IBD; and (iii) hepatic toxicity is associated with medical therapy for IBD. Interdisciplinary approach, involving gastroenterologists, hepatologists and, in advanced cases, general, colorectal, and liver transplant surgeons, is advocated.

Short- and long-term surgical outcomes in patients undergoing proctocolectomy with ileal pouch-anal anastomosis in the setting of primary sclerosing cholangitis

BACKGROUND

Primary sclerosing cholangitis occurs in approximately 10% of patients with ulcerative colitis, but studies involving IPAA in patients with cholangitis have been reported in limited numbers.

OBJECTIVE

This study aimed to examine surgical outcomes in patients with ulcerative colitis and sclerosing cholangitis undergoing total proctocolectomy with IPAA and to identify variables associated with surgical complications.

DESIGN

This is a retrospective cohort study.

SETTINGS

This study was conducted at a single tertiary referral institution.

PATIENTS

Included were all patients with cholangitis and ulcerative colitis who underwent proctocolectomy with IPAA from 1994 to 2005.

MAIN OUTCOME MEASURES

Perioperative morbidity, long-term pouch function, and pouch survival were the main outcome measures.

RESULTS

One hundred patients (62 male) were studied. Forty-three percent were on steroids. There was no perioperative mortality, and 51 30-day complications occurred in 39 patients (39%). Median follow-up time was 5.9 years (range, 0.14-16.2 y). Pouch failure occurred in 3 patients (3%). The single variable that predicted 30-day morbidity was previous abdominal surgery (P = .03). Prednisone use, body mass index, age, ASA score, preoperative Model for End Stage Liver Disease score, and year of surgery were not significantly associated with short-term complications.

CONCLUSIONS

IPAA can be performed safely in the setting of sclerosing cholangitis. The preoperative Model for End-stage Liver Disease Score and the use of preoperative immunosuppressive agents are not associated with an increased risk of complications. The likelihood of long-term pouch survival is excellent.

The clinical impact of primary sclerosing cholangitis in patients with an ileal pouch-anal anastomosis for ulcerative colitis

INTRODUCTION

Primary sclerosing cholangitis (PSC), a chronic inflammatory disease affecting the liver, is associated with ulcerative colitis (UC) in up to 75% of Northern European patients. These patients are at increased risk for the development of colorectal cancer, and the operation of choice is restorative proctocolectomy with an ileal pouch-anal anastomosis. However, complications such as pouchitis can occur, and studies have suggested that PSC is an independent risk factor for the development of pouchitis.

AIM

The aim of this study is to review and discuss the available literature on the effect of PSC on clinical outcomes of patients who undergo pouch surgery for UC. The outcomes reviewed comprise the incidence of pouchitis and pouch dysplasia/cancer and quality of life, including sexual function in UC patients with or without PSC.

METHODS

Pubmed/Medline and Embase searches were undertaken to obtain papers in English between 1966 and 2008. The keywords used were primary sclerosing cholangitis, ulcerative colitis, ileal pouch-anal anastomosis, quality of life, sexual function, dysplasia or cancer, pouchitis and orthotopic liver transplantation.

RESULTS

The incidence of pouchitis, pouch mucosal atrophy and risk of dysplasia appear to be greater in patients with associated PSC than in UC patients without PSC. Quality of life does not appear to be worse than in patients without PSC. Sexual function has not been studied in this subgroup of patients.

CONCLUSION

Pouchitis appears to be more common in the subset of UC patients with PSC, although there is clearly a need for further well-designed studies.

Rectal non-Hodgkin's lymphoma in an infliximab treated patient with ulcerative colitis and primary sclerosing cholangitis

A 20-year old man with ulcerative colitis (UC) and primary sclerosing cholangitis (PSC) was diagnosed with a rectal non-Hodgkin's lymphoma (NHL) at surveillance endoscopy while being in remission on infliximab therapy. Further staging identified a diffuse large B-cell NHL, EBV negative restricted to the rectal submucosa (stage IA). Until now, there has not been any evidence of an increased risk of NHL in patients with UC nor of an increased risk of lymphoproliferative disorders in IBD patients. Hence, the role of concomitant PSC in the pathogenesis of intestinal NHL is unclear. However, IBD patients treated with purine analogues and with anti-TNF are at risk of NHL, especially hepatosplenic T-cell lymphoma. The management of this particular young patient is further complicated by the possibility of a future colectomy due to intractable disease which compromises the use of radiotherapy for this localized disease.

Hepatopancreatobiliary manifestations and complications associated with inflammatory bowel disease

Diseases involving the hepatopancreatobiliary (HPB) system are frequently encountered in patients with inflammatory bowel disease (IBD). Hepatobiliary manifestations constitute some of the most common extraintestinal manifestations of IBD. They appear to occur with similar frequency in patients with Crohn's disease or ulcerative colitis. HPB manifestations may occur in following settings: 1) disease possibly associated with a shared pathogenetic mechanism with IBD including primary sclerosing cholangitis (PSC), small-duct PSC/pericholangitis and PSC/autoimmune hepatitis overlap, acute and chronic pancreatitis related to IBD; 2) diseases which parallel structural and physiological changes seen with IBD, including cholelithiasis, portal vein thrombosis, and hepatic abscess; and 3) diseases related to adverse effects associated with treatment of IBD, including drug-induced hepatitis, pancreatitis (purine-based agents), or liver cirrhosis (methotrexate), and reactivation of hepatitis B, and biologic agent-associated hepatosplenic lymphoma. Less common HPB manifestations that have been described in association with IBD include autoimmune pancreatitis (AIP), IgG4-associated cholangitis (IAC), primary biliary cirrhosis (PBC), fatty liver, granulomatous hepatitis, and amyloidosis. PSC is the most significant hepatobiliary manifestation associated with IBD and poses substantial challenges in management requiring a multidisciplinary approach. The natural disease course of PSC may progress to cirrhosis and ultimately require liver transplantation in spite of total proctocolectomy with ileal-pouch anal anastomosis. The association between AIP, IAC, and elevated serum IgG4 in patients with PSC is intriguing. The recently reported association between IAC and IBD may open the door to investigate these complex disorders. Further studies are warranted to help understand the pathogenesis of HPB manifestations associated with IBD, which would help clinicians better manage these patients. An interdisciplinary approach, involving gastroenterologists, hepatologists, and, in advanced cases, general, colorectal, and transplant surgeons is advocated.

Treatment options for primary sclerosing cholangitis

Primary sclerosing cholangitis is a cholestatic liver disease characterized by inflammation and fibrosis of intra-/extrahepatic bile ducts, leading to multifocal strictures. Primary sclerosing cholangitis exhibits a progressive course resulting in cirrhosis and the need for liver transplantation over a median period of 12 years. The disease is frequently associated with inflammatory bowel disease and carries an increased risk of colorectal cancer and cholangiocarcinoma. Despite extensive research, there is currently no effective medical treatment. Multiple drugs are shown to be ineffective in halting disease progression, including ursodeoxycholic acid, the most widely evaluated drug. High-dose ursodeoxycholic acid (28-30 mg/kg/day) was recently shown to increase the adverse events rate. Endoscopic or radiological dilatation of a 'dominant' stricture may lead to symptomatic and biochemical improvement. However, liver transplantation is the only life-prolonging treatment for patients with end-stage disease. Studies with promising drugs, such as antibiotics, antifibrotic agents and bile acid derivatives, are eagerly awaited.

Pouchitis and pouch dysfunction

Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical treatment of choice for most patients with ulcerative colitis who require surgery. Although the surgical procedure offers a cure in some patients, postoperative inflammatory and noninflammatory complications are common. Pouchitis is the most common long-term complication of the procedure. Pouchitis represents a spectrum of disease processes with heterogeneous risk factors, clinical phenotypes, natural history, and prognosis. Accurate diagnosis and classification are important for proper treatment and prognosis.

Pouchitis and pouch dysfunction

Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical treatment of choice for most patients with ulcerative colitis who require surgery. Although the surgical procedure offers a cure in some patients, postoperative inflammatory and noninflammatory complications are common. Pouchitis is the most common long-term complication of the procedure. Pouchitis represents a spectrum of disease processes with heterogeneous risk factors, clinical phenotypes, natural history, and prognosis. Accurate diagnosis and classification are important for proper treatment and prognosis.

Primary sclerosing cholangitis: outcome of patients undergoing restorative proctocolecetomy for ulcerative colitis

PURPOSE

The prevalence of primary sclerosing cholangitis (PSC) among patients with ulcerative colitis needing proctocolectomy is about 12%. The study aim was to evaluate the progression of the liver disease after surgery.

METHODS

PSC progression in 68 patients with UC after restorative proctocolectomy was evaluated after a median follow-up of 11 years (range 0 to 21). Magnetic resonance imaging (MRI) of the liver, histological examination of a core needle liver specimen, and liver function tests were used in addition to clinical history.

RESULTS

Of the 68 patients, 30 participated in follow-up examinations. Ductal changes in MRI suggesting a diagnosis of PSC occurred in 21 (72%) of them. One carcinoma of the gallbladder was found in MRI. Histopathologic changes suggesting PSC were observable in 15 (50%) patients. Compared to stage in peroperative biopsies taken at proctocolectomy, PSC stage increased in four (13%) patients, decreased in 15 (50%), and remained unchanged in 11 (37%). Immunohistochemical staining for cytoceratin-7 in hepatocytes was positive in nine (30%) indicating cholestasis. After IPAA surgery, five patients underwent liver transplantation at 1, 1, 5, 6, and 11 years, respectively. Of the 68, six patients have, to date, developed cholangiocarcinoma.

CONCLUSIONS

Progression of PSC in patients with minor ductal changes at the time of restorative proctocolectomy is unlikely. Those patients with more advanced disease at surgery are at risk for disease progression and liver transplantation. We lack accurate diagnostic methods to detect premalignant changes of the biliary epithelium.