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Barnes EL, Dunn MS, Ashburn J, Barto A, Bloomfeld R, Cairns A, Mehta K, Patel P, Dziwis J, Esckilsen S, Rahbar R, Sadiq TS, Hanson JS, Herfarth HH. Extraintestinal Manifestations and Family History of Inflammatory Bowel Disease Increase the Risk of Pouchitis in a State-Level Epidemiology Study. Clin Transl Gastroenterol 2024; 15:e00670. [PMID: 38146854 PMCID: PMC10887435 DOI: 10.14309/ctg.0000000000000670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 12/14/2023] [Indexed: 12/27/2023] Open
Abstract
INTRODUCTION Our understanding of the epidemiology of inflammatory conditions of the pouch and effectiveness of treatment is largely based on selected populations. We created a state-level registry to evaluate the incidence of pouchitis and the effectiveness of treatments used in an initial episode of pouchitis. METHODS In a state-level retrospective cohort of all patients undergoing proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis between January 1, 2018, and December 31, 2020, we evaluated the incidence of pouchitis and compared the proportion of patients developing recurrent pouchitis and chronic antibiotic-dependent pouchitis according to initial antibiotic therapy. RESULTS A total of 177 patients underwent surgery with 49 (28%) developing pouchitis within the 12 months after the final stage of IPAA. Patients with extraintestinal manifestations of inflammatory bowel disease (IBD) were significantly more likely to develop pouchitis within the first 12 months after IPAA (adjusted odds ratio 2.45, 95% confidence interval 1.03-5.81) after adjusting for family history of IBD (adjusted odds ratio 3.50, 95% 1.50-8.18). When comparing the proportion of patients who developed recurrent pouchitis or chronic antibiotic-dependent pouchitis with those who experienced an isolated episode of pouchitis, there were no significant differences among the initial antibiotic regimens used. DISCUSSION In a state-level examination of outcomes after IPAA for ulcerative colitis, patients with extraintestinal manifestations of IBD were more likely to develop pouchitis; however, the initial antibiotic regimen chosen did not seem to affect long-term outcomes.
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Affiliation(s)
- Edward L. Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
- Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Michael S. Dunn
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jean Ashburn
- Division of Colon and Rectal Surgery, Atrium Health at Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Amy Barto
- Division of Gastroenterology and Hepatology, Duke University, Durham, North Carolina, USA
| | - Richard Bloomfeld
- Section of Gastroenterology, Atrium Health at Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Ashley Cairns
- Division of Colon and Rectal Surgery, Atrium Health at Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Kurren Mehta
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Pooja Patel
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Jennifer Dziwis
- Section of Gastroenterology, Atrium Health at Wake Forest Baptist, Winston-Salem, North Carolina, USA
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Scott Esckilsen
- University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Reza Rahbar
- North Carolina Surgery, Raleigh, North Carolina, USA
| | | | - John S. Hanson
- Division of Gastroenterology and Hepatology, Atrium Health, Charlotte, North Carolina, USA
| | - Hans H. Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
- Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, North Carolina, USA
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Fadel MG, Geropoulos G, Warren OJ, Mills SC, Tekkis PP, Celentano V, Kontovounisios C. Risks Factors Associated with the Development of Crohn's Disease After Ileal Pouch-Anal Anastomosis for Ulcerative Colitis: A Systematic Review and Meta-Analysis. J Crohns Colitis 2023; 17:1537-1548. [PMID: 36961323 PMCID: PMC10588783 DOI: 10.1093/ecco-jcc/jjad051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND Following ileal pouch-anal anastomosis [IPAA] for ulcerative colitis [UC], up to 16% of patients develop Crohn's disease of the pouch [CDP], which is a major cause of pouch failure. This systematic review and meta-analysis aimed to identify preoperative characteristics and risk factors for CDP development following IPAA. METHODS A literature search of the MEDLINE, EMBASE, EMCare and CINAHL databases was performed for studies that reported data on predictive characteristics and outcomes of CDP development in patients who underwent IPAA for UC between January 1990 and August 2022. Meta-analysis was performed using random-effect models and between-study heterogeneity was assessed. RESULTS Seven studies with 1274 patients were included: 767 patients with a normal pouch and 507 patients with CDP. Age at UC diagnosis (weighted mean difference [WMD] -2.85; 95% confidence interval [CI] -4.39 to -1.31; p = 0.0003; I2 54%) and age at pouch surgery [WMD -3.17; 95% CI -5.27 to -1.07; p = 0.003; I2 20%) were significantly lower in patients who developed CDP compared to a normal pouch. Family history of IBD was significantly associated with CDP (odds ratio [OR] 2.43; 95% CI 1.41-4.19; p = 0.001; I2 31%], along with a history of smoking [OR 1.80; 95% CI 1.35-2.39; p < 0.0001; I2 0%]. Other factors such as sex and primary sclerosing cholangitis were found not to increase the risk of CDP. CONCLUSIONS Age at UC diagnosis and pouch surgery, family history of IBD and previous smoking have been identified as potential risk factors for CDP post-IPAA. This has important implications towards preoperative counselling, planning surgical management and evaluating prognosis.
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Affiliation(s)
- Michael G Fadel
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Georgios Geropoulos
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Oliver J Warren
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Sarah C Mills
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Paris P Tekkis
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Department of Colorectal Surgery, Royal Marsden NHS Foundation Trust, London, UK
| | - Valerio Celentano
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Christos Kontovounisios
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Department of Colorectal Surgery, Royal Marsden NHS Foundation Trust, London, UK
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Connelly TM, Lincango E, Holubar SD. Crohn's of the Pouch: Now What? Clin Colon Rectal Surg 2022; 35:475-486. [PMID: 36591396 PMCID: PMC9797285 DOI: 10.1055/s-0042-1758139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Total proctocolectomy and ileal pouch anal anastomosis (IPAA) is the gold standard surgical treatment for the majority (∼90%) of ulcerative colitis (UC) patients. In cases of carefully selected Crohn's colitis patients without small bowel or perianal involvement an "intentional IPAA" may be a viable option for disease resection and restoration of intestinal continuity. More commonly, Crohn's is incidentally found either in the resection specimen or, more commonly, when inflammatory complications subsequently arise after pouch construction for UC or indeterminate colitis. These incidental Crohn's pouches may be diagnosed early or late period post-IPAA. Crohn's may manifest within the pouch, in the proximal small bowel, and/or distally in the rectal cuff or anus. Like intestinal Crohn's, Crohn's disease of the pouch may be of an inflammatory, fibrostenosing, or fistulizing phenotype. Treatment depends on the phenotype and includes medical treatment, most commonly in the form of tumor necrosis factor inhibitor medications; however, the newer small molecules offer a potential treatment for these patients. Surgery first entails treating the sequelae of Crohn's and is typically staged. In up to 60% of Crohn's pouches, particularly in fistulizing disease and/or recalcitrant perianal disease, the pouch fails and must be defunctioned or excised. In patients with Crohn's pouches in situ long term, outcomes including quality of life are comparable to patients who underwent IPAA for UC.
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Affiliation(s)
- Tara M. Connelly
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eddy Lincango
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Stefan D. Holubar
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
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Shehab M, Alrashed F, Charabaty A, Bessissow T. Biologic Therapies for the Treatment of Post-ileal Pouch Anal Anastomosis Surgery Chronic Inflammatory Disorders: Systematic Review and Meta-analysis. J Can Assoc Gastroenterol 2022; 5:287-296. [DOI: 10.1093/jcag/gwac026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Background
Chronic inflammatory disorders after ileal pouch-anal anastomosis (IPAA) surgery are common. These include chronic pouchitis (CP), Crohn’s disease (CD) of the pouch, prepouch ileitis (PI) and rectal cuff inflammation (cuffitis). The aim of this study was to evaluate the efficacy of biologic therapies in treating these disorders.
Method
Systematic review of all published studies from inception to August 1, 2021 was performed to investigate the efficacy of biologic therapies for post-IPAA chronic inflammatory disorders. The primary outcome was the efficacy of biologic therapies in achieving complete clinical response in patients with IPAA.
Results
A total of 26 studies were identified including 741 patients. Using a random-effect model, the efficacy of infliximab in achieving complete clinical response in patients with CP was 51% (95% CI, 36 to 66), whereas the efficacy of adalimumab was 47% (95% CI, 31 to 64). The efficacies of ustekinumab and vedolizumab were 41% (95% CI, 06 to 88) and 63% (95% CI, 35 to 84), respectively. In patients with CD/PI, the efficacy of infliximab in achieving complete clinical response was 52% (95% CI, 33 to 71), whereas the efficacy of adalimumab was 51% (95% CI, 40 to 61). The efficacies of ustekinumab and vedolizumab were 42% (95% CI, 06 to 90) and 67% (95% CI, 38 to 87), respectively. Only one study involved patients with cuffitis.
Conclusion
Ustekinumab, infliximab, vedolizumab and adalimumab are effective in achieving complete clinical response in post-IPAA surgery chronic inflammatory disorders. More studies are needed to determine the efficacy of biologics in cuffitis.
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Affiliation(s)
- Mohammad Shehab
- Division of Gastroenterology, Department of Internal Medicine, Mubarak Alkabeer University Hospital, Kuwait University , Aljabreyah , Kuwait
| | - Fatema Alrashed
- Department of Pharmacy Practice, Faculty of Pharmacy, Health Science Center, Kuwait University , Aljabreyah , Kuwait
| | - Aline Charabaty
- Division of Gastroenterology, Johns Hopkins School of Medicine , Washington, DC , USA
| | - Talat Bessissow
- Division of Gastroenterology, School of Medicine, McGill University Health Center , Montreal, Quebec , Canada
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Barnes EL, Deepak P, Beniwal-Patel P, Raffals L, Kayal M, Dubinsky M, Chang S, Higgins PDR, Barr JI, Galanko J, Jiang Y, Cross RK, Long MD, Herfarth HH. Treatment Patterns and Standardized Outcome Assessments Among Patients With Inflammatory Conditions of the Pouch in a Prospective Multicenter Registry. CROHN'S & COLITIS 360 2022; 4:otac030. [PMID: 36082341 PMCID: PMC9446900 DOI: 10.1093/crocol/otac030] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Much of our understanding about the natural history of pouch-related disorders has been generated from selected populations. We designed a geographically diverse, prospective registry to study the disease course among patients with 1 of 4 inflammatory conditions of the pouch. The primary objectives in this study were to demonstrate the feasibility of a prospective pouch registry and to evaluate the predominant treatment patterns for pouch-related disorders.
Methods
We used standardized diagnostic criteria to prospectively enroll patients with acute pouchitis, chronic antibiotic-dependent pouchitis (CADP), chronic antibiotic refractory pouchitis (CARP), or Crohn’s disease (CD) of the pouch. We obtained detailed clinical and demographic data at the time of enrollment, along with patient-reported outcome (PRO) measures.
Results
We enrolled 318 patients (10% acute pouchitis, 27% CADP, 12% CARP, and 51% CD of the pouch). Among all patients, 55% were on a biologic or small molecule therapy. Patients with CD of the pouch were more likely to use several classes of therapy (P < .001). Among patients with active disease at the time of enrollment, 23% with CARP and 40% with CD of the pouch were in clinical remission at 6 months after enrollment.
Conclusions
In a population where most patients had refractory inflammatory conditions of the pouch, we established a framework to evaluate PROs and clinical effectiveness. This infrastructure will be valuable for long-term studies of real-world effectiveness for pouch-related disorders.
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Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina , Chapel Hill, North Carolina , USA
- Center for Gastrointestinal Biology and Disease, University of North Carolina , Chapel Hill, North Carolina , USA
| | - Parakkal Deepak
- Division of Gastroenterology, Washington University School of Medicine in St. Louis , St. Louis, Missouri , USA
| | - Poonam Beniwal-Patel
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin , Milwaukee, Wisconsin , USA
| | - Laura Raffals
- Division of Gastroenterology and Hepatology, Mayo Clinic , Rochester, Minnesota , USA
| | - Maia Kayal
- Division of Gastroenterology, The Icahn School of Medicine at Mount Sinai , New York, New York , USA
| | - Marla Dubinsky
- Division of Pediatric Gastroenterology, The Icahn School of Medicine at Mount Sinai , New York, New York , USA
| | - Shannon Chang
- Division of Gastroenterology and Hepatology, NYU Langone Health , New York, New York , USA
| | - Peter D R Higgins
- Division of Gastroenterology and Hepatology, University of Michigan , Ann Arbor, Michigan , USA
| | - Jennifer I Barr
- Center for Gastrointestinal Biology and Disease, University of North Carolina , Chapel Hill, North Carolina , USA
| | - Joseph Galanko
- Center for Gastrointestinal Biology and Disease, University of North Carolina , Chapel Hill, North Carolina , USA
| | - Yue Jiang
- Trinity College of Arts and Sciences, Duke University , Durham, North Carolina , USA
| | - Raymond K Cross
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine , Baltimore, Maryland , USA
| | - Millie D Long
- Division of Gastroenterology and Hepatology, University of North Carolina , Chapel Hill, North Carolina , USA
- Center for Gastrointestinal Biology and Disease, University of North Carolina , Chapel Hill, North Carolina , USA
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina , Chapel Hill, North Carolina , USA
- Center for Gastrointestinal Biology and Disease, University of North Carolina , Chapel Hill, North Carolina , USA
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Sriranganathan D, Kilic Y, Nabil Quraishi M, Segal JP. Prevalence of pouchitis in both ulcerative colitis and familial adenomatous polyposis: A systematic review and meta-analysis. Colorectal Dis 2022; 24:27-39. [PMID: 34800326 DOI: 10.1111/codi.15995] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 11/03/2021] [Accepted: 11/14/2021] [Indexed: 12/13/2022]
Abstract
AIM Pouchitis is a clinically significant complication of ileal pouch-anal anastomosis with its prevalence varying in the literature. Pouchitis is thought to occur more commonly in patients with ulcerative colitis (UC) than in patients with familial adenomatous polyposis (FAP). We conducted a systematic review with meta-analysis of all published literature to report the prevalence of pouchitis in all pouch patients as well as specifically in UC and FAP. We also investigated the prevalence of acute and chronic pouchitis in UC and FAP. METHODS A meta-analysis was conducted by searching the Embase, Embase Classic and PubMed databases between 1978 and 2021 exploring the prevalence of pouchitis in UC and FAP. We then performed a random effects model in order to find the pooled prevalence of pouchitis and used odds ratios to report differences in the prevalence of pouchitis in UC and FAP. RESULTS Fifty-nine full papers and conference abstracts were included in the meta-analysis comprising 18 117 patients with UC and 860 with FAP. The prevalence of pouchitis in UC was 0.32 (95% CI 0.27-0.37) and in FAP was found to be 0.06 (95% CI 0.03-0.15). The odds ratio of pouchitis in UC patients compared with FAP patients was 4.95 (95% CI 3.17-7.72, P < 0.0001). CONCLUSIONS Our findings support the consensus that the prevalence of pouchitis is higher in UC than in FAP. More significantly our findings suggest that the true prevalence of pouchitis is higher than commonly reported in the literature. This literature may help counsel patients prior to undergoing restorative proctocolectomy.
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Affiliation(s)
| | - Yakup Kilic
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Mohammed Nabil Quraishi
- Department of Gastroenterology, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jonathan P Segal
- Department of Gastroenterology, Hillingdon Hospitals NHS Foundation Trust, Uxbridge, UK
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