Histologic predictors of pouchitis in patients with chronic ulcerative colitis

Normal Ileal Mucus Is Inadequate for Epithelial Protection in Ileal Pouch Mucosa

BACKGROUND

Clinical, nonspecific pouchitis is common after restorative proctocolectomy for ulcerative colitis, but its cause is unknown. A possible lack of protection for the ileal mucosa in its role as a reservoir for colonic-type bacteria may be the missing piece in defining the causes of pouchitis.

OBJECTIVE

The study aimed to review the causes of pouchitis and introduce the hypothesis that inadequate mucus protection in the pouch, combined with a predisposition to abnormal inflammation, is the most common cause of nonspecific pouchitis.

DATA SOURCES

Review of PubMed and MEDLINE for articles discussing pouchitis and intestinal mucus.

STUDY SELECTION

Studies published from 1960 to 2023. The main search terms were "pouchitis," and "intestinal mucus," whereas Boolean operators were used with multiple other terms to refine the search. Duplicates and case reports were excluded.

MAIN OUTCOME MEASURES

Current theories about the cause of pouchitis, descriptions of the role of mucus in the physiology of intestinal protection, and evidence of the effects of lack of mucus on mucosal inflammation.

RESULTS

The crossreference of "intestinal mucus" with "pouchitis" produced 9 references, none of which discussed the role of mucus in the development of pouchitis. Crossing "intestinal mucus" with "pouch" resulted in 32 articles, combining "pouchitis" with "barrier function" yielded 37 articles, and "pouchitis" with "permeability" yielded only 8 articles. No article discussed the mucus coat as a barrier to bacterial invasion of the epithelium or mentioned inadequate mucus as a factor in pouchitis. However, an ileal pouch produces a colonic environment in the small bowel, and the ileum lacks the mucus protection needed for this sort of environment. This predisposes pouch mucosa to bacterial invasion and chronic microscopic inflammation that may promote clinical pouchitis in patients prone to an autoimmune response.

LIMITATIONS

No prior studies address inadequate mucus protection and the origin of proctitis. There is no objective way of measuring the autoimmune tendency in patients with ulcerative colitis.

CONCLUSIONS

Studies of intestinal mucus in the ileal pouch and its association with pouchitis are warranted.

Characteristics and Outcomes of Left-sided Ulcerative Colitis With a Cecal/Periappendiceal Patch of Inflammation

Ulcerative colitis (UC) is characterized by continuous mucosal inflammation of the rectum, extending uninterrupted to a variable portion of the colon proximally. However, in some patients with distal colitis, a distinct pattern of skip inflammation (so-called patch) involves the cecum and/or appendiceal orifice, but data on this entity are contradictory, and its significance and prognosis are still debated. We identified 102 adult cases of left-sided UC with a cecal/periappendiceal patch and compared them to 102 controls (left-sided UC only) along clinicopathologic characteristics and disease outcomes. In multivariate analysis, patients with a patch were younger (median age: 31 vs. 41 y; P =0.004) and more likely to have rectosigmoid involvement only (58.8% vs. 28.4%; P <0.001), compared with patients without a patch. During follow-up, patients with a patch were more likely to be eventually diagnosed with Crohn disease (CD) (9.8% vs. 1.0%; P =0.022) and to show proximal extension of inflammation (35.6% vs. 10.0%; P =0.021), but showed no differences in rates of neoplasia, colectomy, or pharmacotherapy escalation. Kaplan-Meier analysis confirmed that patients with a biopsy diagnosis of cecal/periappendiceal patch were more likely to show proximal disease extension ( P <0.001) and to be diagnosed with CD ( P =0.008). In conclusion, cecal/periappendiceal skip inflammation in left-sided UC occurs more often in younger patients and in those with rectosigmoid involvement and is associated with proximal disease extension and, in a small fraction of cases, change of diagnosis to CD. However, it does not portend increased risk of neoplasia, pharmacotherapy escalation, or subsequent colectomy, compared with patients with left-sided UC only.

Histologic Diagnosis of Inflammatory Bowel Diseases

Inflammatory bowel disease, including ulcerative colitis and Crohn disease, is an idiopathic chronic inflammatory condition of the gastrointestinal tract. Since neither the clinical manifestations nor the morphologic features of inflammatory bowel disease are pathognomonic alone, the differential diagnosis to consider is relatively broad, and it relies on the synthesis of clinical, endoscopic, and microscopic features. Long-held histologic diagnostic principles include recognizing structural and inflammatory features of chronicity, that is, architectural distortion, basal plasmacytosis, and expansion of the lamina propria lymphoplasmacytic infiltrate. In addition, evaluation of the neutrophilic inflammation and related crypt and epithelial destruction is essential to gauge the activity of the disease. Nevertheless, these features can be difficult to confirm in special settings, including at the inception of the disease or in partially treated cases. This review will explore the classic morphologic features of ulcerative colitis and Crohn disease, followed by a detailed discussion of atypical and diagnostically challenging presentations and a brief review of the clinical aspects necessary for the daily practice of pathologists.

Appendiceal inflammation in colectomy is independently correlated with early pouchitis following ileal pouch anal anastomosis in ulcerative colitis and indeterminate colitis

BACKGROUND

Appendiceal inflammation in colectomy is one of the histologic predictors of pouchitis in ulcerative colitis (UC) following ileal pouch anal anastomosis (IPAA). Fecal calprotectin level has been shown to increase 2 months prior to the onset of pouchitis. We evaluated whether inflammation and calprotectin expression in appendiceal specimens correlate with early-onset pouchitis in UC and indeterminate colitis (IC).

MATERIALS AND METHODS

IPAA (2000-2018) cases with appendix blocks available in colectomy specimens were identified (n = 93, 90 UC, 3 IC). Histologic features thought to predict pouchitis were evaluated. The degree of appendiceal inflammation was scored. Calprotectin immunostain was performed on the appendix blocks and the extent of mucosal staining was quantified. Electronic medical records were reviewed for demographics, smoking history, clinical pouchitis, time of onset of pouchitis, and clinical and endoscopic components of the Pouchitis Disease Activity Index (PDAI) score. Follow-up pouch biopsies were reviewed and scored to generate histologic PDAI score, when available.

RESULTS

Among the patients with clinical pouchitis (n = 73), moderate to severe appendiceal inflammation independently correlated with earlier pouchitis compared to no/mild inflammation (median time to pouchitis 12.0 vs. 23.8, log rank p = 0.016). Calprotectin staining correlated with inflammatory scores of the appendix (Spearman's rho, r = 0.630, p < 0.001) but not with early pouchitis (p > 0.05).

CONCLUSIONS

The presence of moderate to severe appendiceal inflammation at the time of colectomy was associated with a shorter time to pouchitis following IPAA. Calprotectin immunostain may be used to demonstrate the presence of inflammation in the appendix but its role in predicting early pouchitis remains limited.

Predictors of pouchitis after ileal pouch-anal anastomosis in pediatric-onset ulcerative colitis

OBJECTIVES

Few studies have reported on the incidence and risk factors for pouchitis following colectomy and ileal pouch-anal anastomosis (IPAA) in patients with pediatric-onset ulcerative colitis (UC). We aimed to determine clinical predictors for the development of pouchitis following IPAA in this population.

PATIENTS AND METHODS

We performed a retrospective chart review of all pediatric UC cases that were diagnosed at the Schneider Children's Medical Center of Israel between 1981 and 2013 and who underwent colectomy during disease course. Potential predictors for pouchitis and chronic pouchitis including various demographic, clinical, endoscopic, and histological variables at diagnosis and at the time of surgery were assessed.

RESULTS

Of 188 patients with pediatric-onset UC, 33 (18%) underwent colectomy and IPAA surgery. During a median postsurgical follow-up of 7.6 (range: 1-21.5) years following IPAA, 20/33 (60%) patients developed pouchitis including 11/33 (33%) patients who developed chronic pouchitis. Kaplan-Meier survival estimates of the cumulative probability for pouchitis were 9% at 1 year and 36 and 55% at 5 and 10 years, respectively. Multivariate Cox models showed that older age at colectomy (hazard ratio: 0.86, P=0.024) was a protective factor, whereas preoperative vitamin-D deficiency (≤20 ng/ml) (hazard ratio: 4.4, P=0.021) increased the risk for pouchitis. Age at diagnosis, sex, disease extent, and preoperative therapeutic regimens did not affect the risk of pouchitis.

CONCLUSION

Long-term risk for pouchitis is significantly high in pediatric-onset UC after IPAA. Vitamin-D deficiency and younger age at colectomy may increase the risk for pouchitis.

Clinical Aspects of Idiopathic Inflammatory Bowel Disease: A Review for Pathologists

CONTEXT

-Idiopathic inflammatory bowel disease manifests with different clinical phenotypes showing varying behavior and risk for neoplasia. The clinical questions that are posed to pathologists differ depending on phase of the disease and the clinical circumstances. Understanding the clinical aspects of the dynamic disease process will enhance the role of pathology in optimizing the care of patients with inflammatory bowel disease.

OBJECTIVE

-To review clinical and surgical aspects of inflammatory bowel disease that are relevant to practicing pathologists.

DATA SOURCES

-The literature was reviewed.

CONCLUSIONS

-Diagnosis and management of inflammatory bowel disease require an integrated evaluation of clinical, endoscopic, radiologic, and pathologic features. Therefore, close interaction between clinicians and pathologists is crucial. Having this team approach improves understanding of the pertinent clinical and surgical aspects of the disease and assists in the recognition of unusual presentation of variants, as well as mimics of idiopathic inflammatory bowel disease, by pathologists.

Review article: the pathogenesis of pouchitis

BACKGROUND

A total proctocolectomy followed by ileal pouch-anal anastomosis is a potentially curative surgery for ulcerative colitis or familial adenomatous polyposis. About 5-35% of patients with ulcerative colitis and 0-11% of patients with familial adenomatous polyposis develop subsequent inflammation of the ileal pouch termed pouchitis.

AIM

To provide a comprehensive analysis of the research studying the possible pathogenesis of pouchitis. The goals were to identify promising areas of investigation, to help focus clinicians, researchers and patients on how to better understand and then potentially manage ileal pouchitis, and to provide avenues for future research investigations.

METHODS

This review examined manuscripts from 1981 to 2015 that discussed and/or proposed hypotheses with supportive evidence for the potential underlying pathogenic mechanism for pouchitis.

RESULTS

The pathogenesis of pouchitis is not definitively understood, but various hypotheses have been proposed, including (i) recurrence of ulcerative colitis, (ii) dysbiosis of the ileal pouch microbiota, (iii) deprivation of nutritional short-chain fatty acids, (iv) mucosal ischaemia and oxygen-free radical injury, (v) host genetic susceptibility and (vi) immune dysregulation. However, none of these alone are able to fully explain pouchitis pathogenesis.

CONCLUSIONS

Pouchitis, similar to inflammatory bowel disease, is a complex disorder that is not caused by any one single factor. More likely, pouchitis occurs through a combination of both dysregulated host inflammatory mechanisms and interaction with luminal microbiota.

Severity of inflammation as a risk factor for ileo-anal anastomotic leak after a pouch procedure in ulcerative colitis

PURPOSE

The pelvic pouch procedure (PPP) carries significant post-operative complication risks including a 4-14 % risk of ileo-anal anastomotic (IAA) leak [1-4]. The aim of this study is to evaluate the severity of disease at the distal resection margin as an independent risk factor for an IAA leak following the PPP for patients with ulcerative colitis (UC).

METHODS

A retrospective matched case-control study was undertaken. The distal margin of each subject's specimen was reviewed by a blinded pathologist and the degree of inflammation was scored using a modified histological activity index (mHAI)--a 0 to 5 graded scale with HAI of 5 representing ulcerations >25 % the depth of bowel wall.

RESULTS

Forty-nine patients with perioperative IAA leaks (mean 11 days ±0.92) were identified and matched for gender, age and year of surgery. The case cohort had 33 males (67 %) of mean age at time of surgery of 36.3 years (±1.42). The severity of distal inflammation did not increase the risk of IAA leak. The presence of a diverting ileostomy was associated with a decreased incidence of an IAA leak (p = 0.01).

CONCLUSION

Studies with greater power will be required to evaluate the association (if any) between histological severity of UC at the distal margin of a PPP procedure and IAA leak rate. This risk factor could influence preoperative management and post-operative outcome in patients requiring the PPP.

Appendiceal skip inflammation and ulcerative colitis

In recent decades, the appearance of inflammation near the appendix in patients with distal ulcerative colitis (UC) has been highlighted. Many epidemiological studies have confirmed the link between appendectomy and decreased incidence of UC. However, the clinical significance of appendiceal orifice inflammation (AOI) or peri-appendiceal red patch (PARP) as a "skip lesion" in UC has not been well elucidated. In this review, we summarized the literature regarding AOI/PARP and the role of this lesion in relation to UC. Since the appendiceal "skip area" in UC was first described in 1958, several reports using histologic examination of colectomy specimens and colonoscopy have been published. AOI/PARP has been more frequently associated with distal, mild UC than extensive, severe disease. Although it is still controversial, AOI/PARP seems to have little prognostic implication in the disease course of UC, including remission, relapse and proximal disease extension. However, some case reports have raised the possibility of a relationship between AOI/PARP and appendiceal neoplasms such as appendiceal cystadenoma and appendiceal adenocarcinoma. In addition, some investigators have treated UC patients who were resistant to conventional medical therapy with appendectomy and have reported inconsistent therapeutic effect. Further research may lead to the discovery of etiologic and pathogenic roles of appendiceal inflammation in UC.

The extent of inflammation is a predictor for pouch-related complications in ileal pouches in patients with ulcerative or indeterminate colitis

AIM

Limited data are available on the relationship between the histological features of the resected specimens in patients with ulcerative colitis (UC) or indeterminate colitis (IC) and the outcome of restorative proctocolectomy. The aim of our study was to determine if the histological features of the resected specimen in patients with UC and IC can predict ileal-pouch-related outcome.

METHOD

A review of all patients who had a restorative proctocolectomy created following completion proctectomy or proctocolectomy for UC and IC was performed.

RESULTS

Between 1992 and 2011, 142 patients (132 with UC and 10 with IC) were reviewed. After a median follow-up of 36 (3-149) months, 51 (35.9%) developed a pouch-related complication. Forty-two (29.7%) developed pouchitis while three (2.1%) developed a pouch-cutaneous fistula. Four (2.8%) had pouch failure, while stricture of the anastomosis was seen in three (2.1%) patients. The presence of extension of the inflammation into the muscularis propria of the resected specimen was associated with an increased risk of pouch-related complications (P = 0.01). The presence of submucosal oedema was also a significant risk factor (P = 0.03).

CONCLUSION

The extension of inflammation into the muscularis propria appears to predict pouch-related complications following restorative proctocolectomy for UC or IC.

Progress in histopathological diagnosis of ulcerative colitis

In recent years, the incidence of ulcerative colitis (UC) has been increasing year by year, which affect people's health and life seriously. Although UC is known as a clinical disease for more than a century, there is still a lack of specific diagnostic index for this disease. UC diagnosis is mainly based on clinical features, endoscopic findings and biopsy pathology as well as the exclusion of other diseases. Currently, histopathological diagnosis has become a research hot spot. Scholars around the world have attached great importance to the role of biopsy in the diagnosis of UC. This article will review recent progress in histopathological diagnosis of UC.

Ulcerative colitis or Crohn's disease? Pitfalls and problems

The interpretation of colorectal biopsies taken for the initial diagnosis of chronic idiopathic inflammatory bowel disease (IBD) is challenging. Subclassification of IBD as ulcerative colitis (UC) or Crohn's disease, which may be particularly difficult, is the subject of this review. Biopsies taken at first presentation are emphasised, partly because their features have not been modified by time or treatment. Aspects of longstanding disease and of resections are also mentioned. The first part of the review comprises background considerations and a summary of histological features that are discriminant, according to published evidence, between UC and Crohn's disease in initial biopsies. Pitfalls and problems associated with making the distinction between UC and Crohn's disease are then discussed. These include: mimics of IBD; inadequate clinical details; unreliable microscopic features; absence of histological changes in early IBD; discontinuity in UC; cryptolytic granulomas; differences between paediatric and adult UC; reliance on ileal and oesophagogastroduodenal histology; and atypical features in IBD resections. Avoidance by pathologists of known pitfalls should increase the likelihood of accurate and confident subclassification of IBD, which is important for optimum medical and surgical management.

Inflammatory bowel disease biopsies: updated British Society of Gastroenterology reporting guidelines

Accurate histopathological assessment of biopsies is important for the diagnosis, subclassification, and management of chronic idiopathic inflammatory bowel disease (IBD). British Society of Gastroenterology (BSG) guidelines for the initial histopathological diagnosis of IBD were published in 1997. Changes since then include: more widespread use of full colonoscopy; greater recognition of the effects of time and treatment; improved documentation of variations in anatomical distribution; better understanding of the mimics of IBD; significant progress in clinical management; and modifications of terminology. Accordingly, an update is required. These revised guidelines aim to optimise the quality and consistency of reporting of biopsies taken for the initial diagnosis of IBD by summarising the literature and making recommendations based on the available evidence. Advice from existing clinical guidelines is also taken into account. Among the subjects discussed are: distinguishing IBD from other colitides, particularly infective colitis; subclassification of IBD (as ulcerative colitis, Crohn's disease, or IBD unclassified); the discriminant value of granulomas; aspects of disease distribution, including discontinuity in ulcerative colitis; time-related changes; differences between paediatric and adult IBD; the role of ileal and upper gastrointestinal biopsies; differential diagnoses such as diverticular colitis and diversion proctocolitis; and dysplasia. The need to correlate the histological features with clinical and endoscopic findings is emphasised. An approach to the conclusion of an IBD biopsy report based on the acronym Pattern, Activity, Interpretation, Dysplasia (PAID) is suggested. The key recommendations are listed at the end of the document.

Risk factors for chronic pouchitis after ileal pouch-anal anastomosis: a prospective cohort study

AIM

The association between various demographic, clinical and pathological parameters and the evolution of chronic pouchitis was evaluated.

METHOD

All ulcerative colitis patients who underwent ileal pouch anal anastomosis (1981-2009) were followed prospectively in a comprehensive pouch clinic. We examined risk factors including the presence of appendiceal inflammation and backwash ileitis in the colonic specimen, gender, ethnicity, age at disease onset, disease duration, extent of colitis, presence of extraintestinal manifestations (e.g. primary sclerosing cholangitis), family history of inflammatory bowel disease, indication for surgery, medical treatment, age at operation, staged procedure, diverting ileostomy and length of follow-up. Univariate analysis was performed on all risk factors followed by logistic regression analysis.

RESULTS

The 201 enrolled patients (106 women, age at surgery 35 ± 15 years) were followed for a mean of 108 months. One hundred and thirty-eight (69%) had either a normal pouch or episodes of acute pouchitis and 63 (31%) developed chronic pouchitis. On univariate analysis the presence of an ileostomy (P = 0.017), pancolitis (P = 0.008), shorter disease duration (P = 0.04) and longer follow-up (P = 0.01) were identified as risk factors for chronic pouchitis. Multivariate analysis showed that patients with pancolitis (OR 3.26, 95% CI 1.20-8.85) and longer follow-up (OR 1.09, 95% CI 1.01-1.18) were more likely to develop chronic pouchitis. There was also an association to disease duration but this did not reach a level of significance.

CONCLUSIONS

Pancolitis and longer follow-up are directly related to the development of chronic pouchitis.

Pre-colectomy appendectomy and risk for Crohn's disease in patients with ileal pouch-anal anastomosis

BACKGROUND

A subset of patients with a pre-operative diagnosis of ulcerative colitis can develop Crohn's disease (CD) of the pouch after restorative proctocolectomy. While appendectomy has been implicated to be associated with an increased risk for CD, its impact on the development of de novo CD of the pouch in patients' ileal pouch-anal anastomosis (IPAA) has not been studied. The aims of the study were to assess the prevalence of CD of the pouch in patients with pre-colectomy appendectomy and to investigate the impact of appendectomy on the development of de novo CD of the pouch.

METHODS

All eligible patients with restorative proctocolectomy and IPAA for IBD who had available information on pre-colectomy appendectomy were studied. Demographic and clinical characteristics were evaluated. Cox regression analysis was performed.

RESULTS

The study included 434 patients (44.9 % male) with a mean age of 45.2 ± 4.4 years and follow-up of 4.6 ± 2.3 years. Forty patients (9.2 %) had had appendectomy prior to colectomy. Appendectomy was not shown to be associated with CD of the pouch or its phenotypes in both univariable and multivariable analyses. In the Cox model, independent risk factors associated with CD of the pouch were active smoking (hazard ratio [HR] =1.58; 95 % confidence interval [CI], 1.03-2.43) and family history of CD (HR=1.82; 95 % CI, 0.99-3.32).

CONCLUSIONS

While this study has shown no association between previous appendectomy and the development of CD of pouch, active smoking was an independent risk factor for development of CD of the pouch.

Backwash ileitis does not affect pouch outcome in patients with ulcerative colitis with restorative proctocolectomy

BACKGROUND & AIMS

There has been controversy over the significance of active inflammation of the terminal ileum (also known as backwash ileitis) in patients with ulcerative colitis (UC) and idiopathic inflammatory bowel disease of indeterminate type for diagnosis and pouch construction. We investigated the impact of backwash ileitis on pouch outcome after restorative proctocolectomy with ileoanal pouch anastomosis.

METHODS

Data from patients with backwash ileitis (n = 132) were compared with those from 132 matched controls without ileal inflammation for age, sex, and type of proctocolectomies with ileal pouch construction (1- or 2-stage). We evaluated terminal ileal sections from original colectomies of 2213 patients with either UC or idiopathic inflammatory bowel disease of indeterminate type, collected during a 21-year period, for extent and severity of chronic and active ileitis. Clinical pouch outcomes were assessed through a longitudinally maintained clinical outcome database that systematically catalogued all short-term and long-term pouch complications, including pouchitis, sepsis, impaired long-term pouch survival, and conversion to Crohn's disease.

RESULTS

Regardless of severity or extent, backwash ileitis was not correlated with any clinical outcome examined, short-term or long-term.

CONCLUSIONS

Ileal inflammation is not a contraindication for restorative proctocolectomy with ileal pouch construction in patients with UC or idiopathic inflammatory bowel disease of indeterminate type. Ileal inflammation with pancolitis is not a useful criterion for classifying otherwise typical UC as colitis of indeterminate type, because pouch outcomes are not affected.

Primary sclerosing cholangitis is associated with endoscopic and histologic inflammation of the distal afferent limb in patients with ileal pouch-anal anastomosis

BACKGROUND

We hypothesized that patients with primary sclerosing cholangitis (PSC) may have a higher risk for prepouch ileitis in the setting of ileal pouch-anal anastomosis (IPAA). The aim of this study was to compare endoscopic and histologic inflammation in the afferent limb (prepouch ileum) and pouch between IPAA patients with and without PSC.

METHODS

In all, 39 consecutive inflammatory bowel disease (IBD) and IPAA patients with PSC (study group) were identified and 91 IBD and IPAA patients without PSC (control group) were randomly selected with a 1:2 ratio. Demographic, clinical, endoscopic, and histologic variables were analyzed.

RESULTS

There were no significant differences in age, gender, and nonsteroidal antiinflammatory drug use between the study and control groups. Twelve (30.8%) patients in the IPAA-PSC group had coexisting autoimmune disorders, in contrast to five (5.5%) patients in the IPAA control group (P < 0.001). More patients in the study group had endoscopic inflammation as demonstrated by the higher Pouchitis Disease Activity Index (PDAI) endoscopic scores of the afferent limb and pouch body than those in the control group (P = 0.02 and P < 0.001, respectively). In addition, more patients with PSC had higher PDAI histologic scores of the afferent limb than those without PSC (P < 0.001). Multivariate analysis showed higher PDAI endoscopy and histology subscores were associated with risk for PSC, with odds ratio 1.34 (95% confidence interval [CI]: 1.34, 3.79) and 1.61 (95% CI: 1.00, 2.58), respectively.

CONCLUSIONS

Concurrent PSC appears to be associated with a significant prepouch ileitis on endoscopy and histology in patients with IPAA. Pouch patients with long segment of ileitis should be evaluated for PSC.

Surgical prophylaxis of pouchitis in ulcerative colitis

Ileal pouch-anal anastomosis (IPAA) is now the procedure of choice for most patients requiring proctocolectomy for ulcerative colitis. The J-shaped pouch, usually 15-20 cm in length, is easiest to construct and has functional outcomes identical to those of the more complex designs. IPAA is a complex procedure, and complications occur frequently. Despite the significant improvements this surgical advance has made on the quality of life in these patients, inflammation of the surgically created ileal pouch or pouchitis remains a major late postoperative complication that can often overshadow the benefits of this otherwise curative operation. Several inflammatory and noninflammatory complications can occur after IPAA. Pouchitis is the most common, occurring in ≈50% of patients. Whereas acute pouchitis can be treated rapidly and successfully in the majority of patients, refractory and chronic pouchitis remain therapeutic challenges to patients and physicians. The problem is believed to be caused by stasis of feces in the pouch with overgrowth of aerobic and anaerobic organisms. The size of the pouch has a significant influence on the incidence of pouchitis: a smaller pouch usually empties better than a larger pouch and so may be less susceptible to pouchitis.

Perioperative factors during ileal pouch-anal anastomosis predict pouchitis

PURPOSE

Pouchitis is the most common complication of IPAA. Identifying factors predictive of pouchitis may improve outcomes by modifying contributing factors and enhancing patient selection. The most objective means for confirming pouchitis is by histology because the clinical and endoscopic diagnoses rely on more subjective assessments. The importance of histological pouchitis in the absence of clinical or endoscopic findings is unknown.

METHODS

Prospectively collected data on patients with IPAA and pouch surveillance were evaluated. Patients who developed pouchitis, defined as symptoms of pouchitis confirmed by endoscopic biopsy (group B) were compared with those without any episode of clinical, endoscopic, or histological pouchitis (group A) for pre- and intraoperative factors and outcomes. Asymptomatic patients with histological pouchitis on surveillance biopsies (group C) were further compared with group A. Patients with Crohn's disease were excluded.

RESULT

Of the 673 patients with pouch biopsies, 422 (62.7%) were in group A, 161 (23.9%) in group B, and 90 (13.4%) in group C. Mean follow-up was 9.8 (±5.1), 12.4 (±5.4), and 13. (±4.7) years. Of the 43 preoperative factors evaluated, those associated with group B included leukocytosis (P < .001), rheumatologic extraintestinal disease (P < .001), disease proximal to splenic flexure (P = .001), pulmonary comorbidity (P = .004), prior steroid use (P = .006), and age at operation and diagnosis (P = .018 and .021). Of the 10 intraoperative factors evaluated, pouchitis was associated with S-pouch reconstruction (P < .001), transfusion (P < .001), and 2-stage instead of 3-stage operation (P = .05), all surrogates for operative complexity. On multivariate analysis, pulmonary comorbidity (OR 3.38, 95% CI 1.62-7.07), disease proximal to splenic flexure (OR 2.37, 95% CI 1.18-4.77), extraintestinal disease manifestations (OR 1.6, 95% CI 1.01-2.54), and S-pouch reconstruction (OR 1.59, 95% CI 0.99 - 2.54) were associated with pouchitis. Patients in group B had worse outcomes, including more strictures (P = .015), bowel obstructions (P = .019), fistulas (P = .18), and lower quality of life (P < .001). Group C patients had the same outcomes as those in group A and the finding was not predicted by the above-mentioned parameters.

CONCLUSION

Patients with symptomatic, biopsy-confirmed pouchitis have worse long-term outcomes than those without pouchitis. This complication is associated with specific pre- and intraoperative factors. Histological pouchitis incidentally found on surveillance biopsy in asymptomatic patients is of no clinical relevance and does not influence outcome. Identification of these preoperative factors associated with the subsequent development of pouchitis will strengthen patient counseling and may facilitate risk stratification.

Morphologic findings in upper gastrointestinal biopsies of patients with ulcerative colitis: a controlled study

INTRODUCTION

Upper gastrointestinal involvement, both gastric and duodenal, is known to occur in both Crohn disease and ulcerative colitis (UC). However, the frequency and types of inflammation in upper gastrointestinal biopsies in patients with UC has not been well studied, especially in a controlled study.

METHODS

Twenty-four esophageal, 59 gastric, and 40 duodenal biopsies from 69 UC patients were reviewed. These were compared with 35 esophageal, 66 gastric, and 46 duodenal biopsies from a control group of 97 consecutive patients of similar age and sex distribution. The pattern and extent of inflammation were noted in each biopsy.

RESULTS

There were 3 types of gastric inflammation that occurred more in UC patients than in controls, and the differences were statistically significant. The most common was an intense focal gastritis, present in 29% of UC gastric biospies, compared with 9% of controls. Twenty-two percent of UC patients had a basal mixed inflammation compared with 8% of controls, and 20% of the UC patients had superficial plasmacytosis compared with 6% of controls. There were no esophageal inflammations that occurred more commonly in UC than controls. Four UC patients and no controls had diffuse chronic duodenitis, also a statistically significant difference. All 4 UC-duodenitis patients were among the 10 with previous colectomies, and all 4 patients had pouchitis. Only 1 of the 4 UC-colectomy patients without duodenitis developed pouchitis.

CONCLUSIONS

Most UC patients have no upper gastrointestinal inflammation in biopsies, and most of the inflammations they have are not unique. The most common upper gastrointestinal inflammatory pattern in patients with UC is focal gastritis, followed by gastric basal mixed inflammation and superficial plasmacytosis. The one unique upper gastrointestinal inflammation in UC patients is diffuse chronic duodenitis, present in 10% of patients who had duodenal biopsies, and in 40% of UC patients who had colectomy and all of these patients had pouchitis. This association strongly suggests that diffuse chronic duodenitis in UC patients who have colectomy is a strong predictor of pouchitis.

Pathologic features of ulcerative colitis in patients with primary sclerosing cholangitis: a case-control study

BACKGROUND

The pathologic features of ulcerative colitis (UC) in patients with primary sclerosing cholangitis (PSC) are, essentially, unknown. One previous clinical study suggested that UC-PSC patients reveal a high rate of rectal sparing and backwash ileitis. The purpose of this study was to systematically evaluate the pathologic characteristics and distribution of colonic disease in UC-PSC patients and to compare the results with a matched control group of UC patients without PSC.

METHODS

Forty UC-PSC patients and 40 matched UC patients without PSC (controls) were identified from the files of 3 hospitals between the years 1989 and 2005. Clinical, endoscopic, and follow-up data (including incidence of pouchitis) were evaluated, and a detailed pathologic evaluation of biopsy and resection specimens (when available) was performed in a blinded fashion. The degree of activity and chronicity in mucosal biopsies and/or tissue from resection specimens was graded on a 5-point grading system (0 to 4), and each portion of the colon (cecum, ascending colon, transverse colon, descending colon, rectum) was assessed separately. Rectal sparing and patchiness of disease were evaluated, and scored as either absolute or relative depending on the complete absence of inflammatory disease in the former, or less inflammatory disease in the rectum compared with other parts of the colon in the latter.

RESULTS

In this matched case-control study, UC-PSC patients presented at a significantly earlier age (24.5 y), had a higher prevalence rate of pancolitis (85%), and an overall significantly lower grade of inflammation in the colon (mean grade: 2.09+/-0.085) compared with UC controls (mean age: 33.8 y, pancolitis: 45%, inflammation grade: 2.59+/-0.92, P<0.05 for all comparisons). The incidence rate of absolute and relative rectal sparing (27.5%) and of patchy inflammatory disease proximal to the rectum (5.7%) was not significantly different between the UC-PSC cases and the UC controls (25% and 7.9%, respectively). UC-PSC patients had a higher prevalence rate of ileitis (35.7%) and pouchitis (42.8%), but the values were not significantly different from controls (26.9% and 26.6%, respectively). The incidence rate of dysplasia was similar between the 2 patient groups.

CONCLUSIONS

UC patients with PSC show a propensity for more extensive, but less active, disease but are otherwise characterized by similar pathologic findings compared with UC patients without PSC. Rectal sparing and patchy disease activity is not characteristic of UC patients with PSC.

Comprehensive pouch clinic concept for follow-up of patients after ileal pouch anal anastomosis: report of 3 years' experience in a tertiary referral center

BACKGROUND

We designed and evaluated a novel concept in enhancing postoperative care of patients following restorative proctocolectomy (RPC) for ulcerative colitis (UC) and determined the risk factors, incidence, and nature of RPC-associated complications in this population.

METHODS

The study cohort consisted of consecutive UC patients post-RPC attending a comprehensive pouch clinic run by a gastroenterologist and a colorectal surgeon in a tertiary care medical center (from January 2003 to December 2005). Data were collected on their medical history, physical examination, laboratory tests, pouch endoscopy and biopsies, and anonymous in-house patient satisfaction questionnaires mailed to the first 90 patients. Assessment was also done on data regarding risk factors, incidence, and nature of RPC-associated complications.

RESULTS

A total of 120 UC patients with a functioning pouch visited the clinic: mean age 37 years, range 13-75; 57 males; mean disease duration 11 years; mean follow-up 65 months. Of the 55 patients who responded to the questionnaire, 48 (87%) felt that the comprehensive clinic significantly improved the quality of their care. The major complications were pouchitis (52%), extraintestinal manifestations, pouch-related fistula, and mechanical dysfunction. The risk factors for the development of pouchitis were time since surgery, >1-stage surgery, and reason for surgery (acute exacerbation/intractable disease more than dysplasia/cancer); the latter was the only independent risk factor.

CONCLUSIONS

The pouch clinic concept significantly enhanced patient satisfaction. The most common RPC-associated complication was pouchitis. Risk factors for developing pouchitis were duration since operation, >1-stage operation, and indication for surgery.

Predictors of pouchitis after ileal pouch-anal anastomosis: a retrospective review

PURPOSE

The primary end point of this study was to determine the risk factors that predict chronic pouchitis in those patients having ileal pouch-anal anastomosis.

METHODS

A total of 237 patients with ulcerative colitis and undergoing ileal pouch-anal anastomosis by one surgeon at Oregon Health & Science University from 1993 to 2003 were evaluated. Data were gathered via retrospective chart reviews and by a questionnaire administered by telephone in 2004. Patients were excluded if there was less than one-year follow-up documented in the chart or they could not be contacted by telephone (n = 62), postoperative diagnosis of Crohn's disease (n = 3), failed ileoanal procedure (n = 1), and one-stage ileal pouch-anal anastomosis (n = 3), leaving 167 patients for evaluation. Patients were defined as having chronic pouchitis (> 3 episodes of pouchitis) or no pouchitis (< or = 3 episodes of pouchitis). Potential risk factors included number of operations used to perform ileal pouch-anal anastomosis, fulminant ulcerative colitis with two-stage operation, duration of diverting ileostomy after pouch formation, primary sclerosing cholangitis, other extraintestinal manifestations of ulcerative colitis, preoperative liver function tests, duration of ulcerative colitis, and the occurrence of postoperative complications. Initial univariate analysis was performed on all risk factors. Multivariate analysis was performed on all univariate risk factors with P values < 0.2.

RESULTS

The prevalence of chronic pouchitis in our population was 46 percent. The following variables were identified during univariate analysis and entered into a multivariate model: preoperative serum albumin (P = 0.07), PSC (P = 0.126), duration of diverting ileostomy (P = 0.111), fulminant ulcerative colitis with two-stage operation, (P = 0.051), the presence of postoperative complications (P = 0.031), and the type of postoperative complications (anastomotic complications, P = 0.013). Patients who did not undergo diverting ileostomy at the time of their ileal pouch-anal anastomosis trended toward a lower likelihood of developing chronic pouchitis (P = 0.06). Multivariate analysis showed that patients with postoperative complications (53 percent, P = 0.042), specifically anastomotic complications, were more likely to develop chronic pouchitis (P = 0.005). Eight percent of patients had primary sclerosing cholangitis and 11 percent of patients had at least one extraintestinal manifestation of ulcerative colitis. Patients with primary sclerosing cholangitis were not more likely to develop chronic pouchitis (P = 0.168). Patients with extraintestinal manifestations also were not more likely to develop chronic pouchitis (P = 0.273).

CONCLUSIONS

Chronic pouchitis is a frequent complication after ileal pouch-anal anastomosis. In this study patients with primary sclerosing cholangitis or other extraintestinal manifestations of ulcerative colitis were not more likely to develop chronic pouchitis. Patients with postoperative complications, specifically anastomotic complications after ileal pouch-anal anastomosis, were more likely to develop chronic pouchitis and may benefit from early strategies to prevent pouchitis.

Mucosal inflammation in the terminal ileum of ulcerative colitis patients: endoscopic findings and cytokine profiles

BACKGROUND

Currently, published reports of mucosal inflammation in the terminal ileum of ulcerative colitis (UC) before colectomy are scarce.

AIM

To investigate inflammation in the terminal ileum of UC patients by endoscopic examinations and measurement of mucosal cytokine profiles.

METHODS

Fifty consecutive patients with active UC were studied. At ileocolonoscopy, mucosal biopsies were taken from the terminal ileum. As control, mucosal biopsies from 20 patients without inflammation were examined.

RESULTS

Thirty-eight patients showed endoscopically normal terminal ileum, four showed backwash ileitis, and eight showed non-backwash ileitis (ileitis with normal caecum). Pancolitis was observed in all of four patients with backwash ileitis, in 4 of 8 (50%) with non-backwash ileitis, and in 4 of 38 (11%) without ileal inflammation (P=0.0002). Extraintestinal manifestations were observed in none of 4 patients with backwash ileitis, in 6 of 8 (75%) with non-backwash ileitis, and in 3 of 38 (8%) without ileal inflammation (P<0.0001). In patients with backwash ileitis and non-backwash ileitis, ileal interleukin [IL]-1beta, IL-6, IL-8 and tumour necrosis factor-alpha levels were significantly elevated compared with the control group. Only extraintestinal manifestation was associated with higher ileal cytokine levels, whereas age, sex, and duration, extent and severity of UC did not show any apparent association.

CONCLUSIONS

In patients with backwash ileitis, elevated ileal cytokines might reflect a reaction to regurgitation of colonic content into the ileum, but in patients without backwash ileitis, alternative factors are expected to contribute to the aetiology of ileal inflammation. Patients with extraintestinal manifestations had elevated ileal cytokine levels.

Pitfalls in the interpretation of nonneoplastic mucosal biopsies in inflammatory bowel disease

This review provides a summary of common diagnostic problems encountered by both pathologists and gastroenterologists when evaluating patients with diarrhea and in whom inflammatory bowel disease (IBD) is suspected. The two most common forms of IBD, ulcerative colitis (UC) and Crohn's disease (CD), may, in certain settings, show overlapping endoscopic and pathologic features, potentially resulting in diagnostic confusion. For instance, some cases of UC may show unusual CD-like features, such as rectal sparing, discontinuous disease, aphthous ulceration, ileal or extracolonic involvement, and granulomatous inflammation, all of which may be evident in mucosal biopsy specimens. CD may also present as a diffuse, superficial pancolitis with ileal sparing that mimics the endoscopic and histologic appearance of UC. Furthermore, other forms of colitis, such as microscopic colitis, diverticulitis, diversion colitis, and nonsteroidal anti-inflammatory drug (NSAID)-induced colonic injury may also show IBD-like changes in mucosal biopsies. The potential diagnostic pitfalls faced by physicians, as well as features that aid in the distinction among these entities, are discussed in detail in this review.

Pouchitis and pre-pouch ileitis developed after restorative proctocolectomy for ulcerative colitis: A case report

We report a case of pouchitis and pre-pouch ileitis, and inflammation in the neo-terminal ileum proximal to the pouch, developed after restorative proctocolectomy for ulcerative colitis. A 35-year old female presented with fever and abdominal pain five weeks after ileostomy closure following proctocolectomy. Computed tomography showed collection of feces in the pouch and proximal ileum. A drainage tube was placed in the pouch perianally, and purulent feces were discharged. With antibiotic treatment, her symptoms disappeared, but two weeks later, she repeatedly developed fever and abdominal pain along with anal bleeding. Pouchscopy showed mucosal inflammation in both the pouch and the pre-pouch ileum. The mucosal cytokine production was elevated in the pouch and pre-pouch ileum. With antibiotic and corticosteroid therapy, her symptoms were improved along with improvement of endoscopic inflammation and decrease of mucosal cytokine production. The fecal stasis with bacterial overgrowth is the major pathogenesis of pouchitis and pre-pouch ileitis in our case.

Pouchitis in Ulcerative Colitis: Correlation between Predictors from Colectomy Specimens and Clinico-Histological Features

Pouchitis after restorative proctocolectomy for ulcerative colitis is usually of ill-defined etiology and is encountered with sclerosing cholangitis, bacterial overgrowth, and ischemia. Recently, appendiceal involvement, ileitis, and fissures in the colectomy specimen have been associated with short- and long-term development of pouchitis. To corroborate these recent findings, the histology of 40 colectomies (70% males; mean age 46.3 years, age range 20-70 years; mean follow-up period 3.7 years, range 1-13 years) with yearly follow-up biopsies was correlated with pouchitis and clinical symptoms. Appendicitis, fissures, and ileitis were present in 47, 45 and 5% of the patients, respectively. Pouchitis in patients with appendicitis or with fissures was noted in 44 and 50% at first biopsy and in 70 and 58% during follow-up (p = NS). Of the patients without appendicitis or without fissures, 33 and 33% demonstrated pouchitis at the first biopsy and 30 and 55% during follow-up (p = NS). Clinico-histological correlation revealed normal/near-normal biopsies with the lowest clinical severity score in 77% and with the highest clinical score in 43% (p < 0.025). The histological findings of appendiceal involvement, fissuring ulcers, and ileitis in colectomies for ulcerative colitis do not correlate with the finding of pouchitis in early or late pouch biopsies. A high clinical suspicion score is frequently not correlated with significant inflammation of the pouch.

Contemporary morphologic definition of backwash ileitis in ulcerative colitis and features that distinguish it from Crohn disease

Terminal ileum (TI) sections from 250 ulcerative colitis (UC) total colectomy specimens resected during 3 periods and endoscopic TI biopsy specimens from 100 contemporary chronic UC and 100 Crohn disease (CD) patients were reviewed. The respective proportions of cases resected during the 3 periods with moderately or markedly active cecal UC were 72%, 34%, and 2% and with moderate or marked backwash ileitis (BWI), 21%, 18%, and 0%. The activity level of BWI correlated with level of cecal UC. In contemporary initial endoscopic TI biopsy specimens, 6% of chronic UC patients had BWI, all with moderately to markedly active cecal chronic UC. In CD cases, 75% had chronic or active enteritis, consisting of patchy lamina propria edema containing mildly active inflammation, crypt disarray, and focally blunted or flattened villi. Mucous gland metaplasia was present in 27% of CD biopsy specimens. BWI should be restricted to active enteritis that involves the ileum in a contiguous pattern from the cecum that has a similar or greater degree of active inflammation. Mild BWI predominantly involves the superficial mucosa in a contiguous pattern. Focal isolated ileal erosions, mucous gland metaplasia, or patchy edema with mild active inflammation are features of CD.

Diagnostic difficulties in inflammatory bowel disease pathology

This review summarizes some of the common diagnostic problems encountered by pathologists when evaluating patients with chronic colitis and in whom inflammatory bowel disease (IBD) is either suspected or within the differential diagnosis. Both ulcerative colitis (UC) and Crohn's disease (CD) show characteristic, but non-specific, pathological features that may overlap and result in a diagnosis of 'indeterminate colitis' (IC). However, other reasons why pathologists may entertain a diagnosis of IC include failure to recognize or accept certain 'hardcore' histological features as indicative of CD, an attempt to classify cases of chronic colitis based on mucosal biopsy material or in the absence of adequate clinical and radiographic information, and the presence of other disease processes that mask, or mimic, IBD. In addition, some cases of UC may show unusual CD-like features, such as discontinuous or patchy disease, ileal inflammation, extracolonic inflammation, granulomatous inflammation in response to ruptured crypts, aphthous ulcers, or transmural inflammation. Furthermore, other forms of colitis, such as microscopic colitis, diverticulitis and diversion colitis may, on occasion, also show IBD-like changes. The clinical and pathological features that aid in the distinction between these entities, and others, are covered in detail in this review.

Prognostic Significance of Superficial Fissuring Ulceration in Patients With Severe “Indeterminate” Colitis

Some colectomy specimens from patients with severe colitis contain superficial fissuring-type ulcers but do not have any other features of Crohn's disease (CD). This finding may cause difficulty with regard to distinguishing ulcerative colitis (UC) from CD and, thus, lead to a diagnosis of "indeterminate" colitis. The aim of this study was to evaluate the clinical and pathologic features, and outcome, of a cohort of patients with colitis and superficial fissuring ulcers, but without any other features that may suggest a diagnosis of CD. We retrospectively identified 21 patients (male-to-female ratio, 10/11; mean age, 38 years) with severe chronic active colitis, all of whom had at least one (range, 1-3) superficial fissuring ulcer in their colectomy specimens (but without any other features of CD), as well as a control group of 18 patients (male-to-female ratio, 10/8; mean age, 41 years) with equally severe disease, but without fissuring ulcers. Both groups were evaluated for a variety of clinical and pathologic features, such as clinical presentation, degree, extent, and duration of colitis, and follow-up information, such as the development of pouchitis, pouch fistulae, and any other features of CD. Overall, 81% of the study patients presented clinically with fulminant colitis and underwent an emergent or urgent colectomy, compared with only 41% of the control patients (P = 0.02). Nine (43%) study patients had active serositis in their colectomy specimens, whereas only 1 (6%) control patient had this finding (P = 0.002). However, no significant differences were noted in either the extent or severity of disease or the presence of active ("backwash") ileitis, between the study and control groups. Upon follow-up (mean, 42 months; range, 4-121 months), the study patients with superficial fissuring ulcers developed pouchitis significantly more often (68% vs. 20%, P = 0.007) than the control group following an ileal pouch-anal anastomosis (IPAA) procedure. One patient from each group developed an anal fissure and another from each group developed an anastomotic stricture. In addition, 1 study patient developed a pouch-cutaneous fistula, and 1 control patient developed an enterocutaneous fistula to a loop ileostomy. Finally, 1 control patient ultimately had her pouch excised because of recurrent intractable pouchitis. However, none of the other study or control patients developed any clinical or pathologic manifestations of CD. We conclude that superficial fissuring ulcers may occur in patients with severe chronic active UC, particularly those who present with fulminant disease. Affected individuals should not be considered to have CD or "indeterminate" colitis and should not be denied an IPAA procedure. Nevertheless, the presence of superficial fissuring-type ulcers in patients with severe chronic active UC denotes a subgroup with a higher risk of pouchitis following surgical resection.

Pathologic features and clinical significance of "backwash" ileitis in ulcerative colitis

Patients with ulcerative colitis (UC) may develop inflammation in the distal ileum thought to be due to "backwash" of cecal contents ("backwash ileitis"). However, a systematic analysis of ileal changes in UC has never been performed, and the prevalence and criteria for "backwash" ileitis have not been defined. The aim of this study was to evaluate the prevalence and spectrum of inflammatory changes in the ileum in patients with UC and to correlate ileal changes with outcome after total proctocolectomy and ileal pouch-anal anastomosis. Routinely processed ileocolonic resection specimens from 200 consecutive patients with clinically and pathologically confirmed UC were evaluated for a wide variety of pathologic features in the ileum and colon. The ileal data were correlated with both the clinical features and the pathologic findings in the colon. Follow-up data were obtained to confirm absence of Crohn's disease and to evaluate outcome of ileo-anal pouches. Overall, 34 of 200 (17%) UC patients had inflammatory changes in the ileum (male/female ratio, 16/18; mean age, 42 years); 32 of 34 (94%) had pancolitis, which was significantly higher than the rate of pancolitis (39%) in patients without ileal disease (N = 166) (P < 0.001), but there were no other differences between patients with or without ileal pathology. In the colon, 22 of 34 (65%) patients had severe activity. Ileal changes included villous atrophy and crypt regeneration without increased inflammation (N = 3), increased neutrophilic and mononuclear inflammation in the lamina propria (N = 6), patchy cryptitis and crypt abscesses (N = 21) and focal superficial surface erosions (N = 4), some with pyloric metaplasia (N = 2 of 4). In general, the severity of ileal changes paralleled the severity of colonic activity. However, 2 of 4 (50%) patients with superficial erosions in the ileum had subtotal or left-sided colitis only, and had only mild colonic activity. Other cases showed only mild to moderate colonic activity and patchy or discontinuous involvement of the distal ileum. Upon follow-up of patients with erosions (mean, 48.5 months; range, 26-102 months), none developed manifestations of Crohn's disease anywhere in the gastrointestinal tract. The presence of inflammatory changes in the ileum had no effect on the prevalence of pouch complications or on the occurrence of dysplasia or cancer. Ileal changes in UC are not uncommon (prevalence, 17%), are generally mild in nature (villous atrophy, increased inflammation, scattered crypt abscesses), and are not associated with an increased rate of ileo-anal pouch complications, dysplasia, or carcinoma. In some cases, our findings are consistent with a backwash etiology. However, rarely, ileal erosions may occur in patients without cecal involvement, which may indicate that other pathogenetic mechanisms should be considered in the etiology of ileitis in UC patients.

Risk factors for diseases of ileal pouch-anal anastomosis after restorative proctocolectomy for ulcerative colitis

BACKGROUND & AIMS

Although pouchitis is considered the most common adverse sequela of ileal pouch-anal anastomosis (IPAA), inflammatory and noninflammatory conditions other than pouchitis are increasingly being recognized. The risk factors for these non-pouchitis conditions, including Crohn's disease (CD) of the pouch, cuffitis, and irritable pouch syndrome (IPS), have not been studied. The aim of this study was to assess risk factors for inflammatory and noninflammatory diseases of IPAA in a tertiary care setting.

METHODS

The study consisted of 240 consecutive patients who were classified as having healthy pouches (N = 49), pouchitis (N = 61), CD of the pouch (N = 39), cuffitis (N = 41), or IPS (N =50). Demographic and clinical features were assessed to determine risk factors for each of these conditions by using logistic regression analysis.

RESULTS

Risk factors remaining in the final logistic regression models were for pouchitis: IPAA indication for dysplasia (odds ratio [OR], 3.89; 95% confidence interval [CI], 1.69-8.98), never having smoked (OR, 5.09; 95% CI, 1.01-25.69), no use of anti-anxiety agents (OR, 5.19; 95% CI, 1.45-18.59), or use of NSAIDs (OR, 3.24; 95% CI, 1.71-6.13); for CD of the pouch: a long duration of IPAA (OR, 1.20; 95% CI, 1.12-1.30) and current smoking (OR, 4.77; 95% CI, 1.39-16.25); for cuffitis: arthralgias (OR, 4.13; 95% CI, 1.91-8.94) and younger age (OR, 1.16; 95% CI, 1.01-1.33); and for IPS: use of antidepressants (OR, 4.17, 95% CI, 1.95-8.92) or anti-anxiety agents (OR, 3.21; 95% CI, 1.34-7.47).

CONCLUSIONS

The majority of risk factors for the 4 inflammatory and noninflammatory conditions of IPAA are different, suggesting that each of these diseases has a different etiology and pathogenesis. The identification and modification of these risk factors might help patients and clinicians to make a preoperative decision for IPAA, reduce IPAA-related morbidity, and improve response to treatment.

A characterization of anaerobic colonization and associated mucosal adaptations in the undiseased ileal pouch

INTRODUCTION

The resolution of pouchitis with metronidazole points to an anaerobic aetiology. Pouchitis is mainly seen in patients with ulcerative colitis pouches (UCP). We have recently found that sulphate reducing bacteria (SRB), a species of strict anaerobe, colonize UCP exclusively. Herein, we aimed to correlate levels of different bacterial species (including SRB) with mucosal inflammation and morphology.

METHODS

Following ethical approval, fresh faecal samples and mucosal biopsies were taken from 9 patients with UCP and 5 patients with familial adenomatous polyposis pouches (FAPP). For the purposes of comparison, faecal samples and mucosal biopsies were also taken from the stomas of 7 of the 9 patients with UC (UCS). Colonization by four types of strict anaerobes (SRB, Clostridium perfringens, Bifidobacteria and Bacteroides) as well as by three types of facultative anaerobes (Enterococci, Coliforms and Lactobacilli) was evaluated. Inflammatory scores and mucosal morphology were assessed histologically in a blinded fashion by a pathologist.

RESULTS

In general, strict anaerobes predominated over facultative in the UCP (P = 0.041). SRB were present in UCP exclusively. Even after exclusion of SRB from total bacterial counts, strict anaerobes still predominated. In the UCS, facultative anaerobes predominated. Strict and facultative anaerobes were present at similar levels in the FAPP. Enterococci were present at significantly reduced levels in the UCP when compared with the UCS (P = 0.031). When levels of SRB and other anaerobic species were individually correlated with mucosal inflammation and morphology, no trends were observed.

CONCLUSION

We have previously identified that SRB exclusively colonize UCP. In addition we have now identified a novel increase in the strict/facultative anaerobic ratio within the UCP compared to UCS. These stark differences in bacterial colonization, however, appear to have limited impact on mucosal inflammation or morphology.

The impact of the fecal stream and stasis on immunologic reactions in ileal pouch after restorative proctocolectomy for ulcerative colitis: a prospective, pilot study

OBJECTIVE

The etiology of pouch inflammation after restorative proctocolectomy is unknown. The fecal stream and immunological reactions are potential pathological factors. This study was performed to examine the impact of the fecal stream and stasis on immunological reactions in the pouch.

METHODS

Patients who underwent a restorative proctocolectomy with a covering ileostomy for ulcerative colitis were studied. Mucosal biopsy specimens were obtained from both the pouch and the proximal ileum at the time of ileostomy closure, and 3, 6, and 12 months after ileostomy closure. As a control group, normal ileal biopsies were obtained from patients with colonic polyps.

RESULTS

At the time of ileostomy closure, mucosal interleukin-1beta, interleukin-6, interleukin-8, and tumor necrosis factor-alpha levels in the pouch and the proximal ileum were not significantly different from those in the normal control group. At 3 months after ileostomy closure, the mucosal cytokine levels in the pouch increased significantly compared with those at ileostomy closure, and their levels were significantly higher than those in the proximal ileum. At 6 and 12 months after ileostomy closure, the mucosal cytokine levels in the pouch did not change significantly compared with those at 3 months after ileostomy closure. The mucosal cytokine levels in the proximal ileum did not change significantly during the entire study.

CONCLUSIONS

The immunological reactions in the pouch occurred soon after ileostomy closure, and continued for at least 1 yr. The fecal stream and stasis play an important part in the pathogenesis of immunological reactions in the ileal pouch.

Skip inflammation of the appendiceal orifice: a prospective endoscopic study

OBJECTIVE

The purpose of the study was to evaluate the incidence of discontinuous inflammation of the appendiceal orifice in patients undergoing colonoscopy for diagnosis or surveillance of colonic disease.

MATERIAL AND METHODS

Consecutive and unselected patients subjected to colonoscopy over a 3-year period were included in a prospective study. Biopsies were taken within 2 cm of the orifice of the appendix, from the caecum and from predefined colonic segments. Discontinuous inflammation of the appendiceal orifice was defined as an area of macroscopic inflammatory changes distinct from a normal caecum of ascending colon. The biopsies were graded histologically for the presence and severity of inflammation by a pathologist without knowledge of the endoscopic findings.

RESULTS

A total of 271 patients were included. The final diagnoses were: ulcerative colitis (UC) (83 patients), Crohn's disease (CD) (54), indeterminate colitis (12), irritable bowel syndrome (IBS) (54), microscopic colitis (15) and other disease (53). Endoscopic discontinuous inflammation of the appendiceal orifice was found in 27% (95% CI: 17-38%) of patients with UC, 24% (95% CI: 13-39%) with CD, 40% (95% CI: 12-74%) with indeterminate colitis, 8% (95% CI: 0-36%) with microscopic colitis, 10% (95% CI: 3-24%) of patients with IBS and in 9% (95% CI: 2-021%) of other diseases (p<0.05). A correlation was found for endoscopic and histological discrimination between normal and inflamed mucosa (p<0.001). However, in 24% of patients, endoscopic inflammation was without histological signs of inflammation, primarily in an otherwise normal colon.

CONCLUSIONS

Discontinuous inflammation of the appendiceal orifice is common in patients with IBD irrespective of clinical activity. However, patients with otherwise normal colon may also show congestion of this area without or with minimal microscopic inflammation.