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Djalal A, Wong SY, Colombel JF, Ungaro R, Kayal M. Problem with Hookups: Perianal Fistula After Ileal Pouch-Anal Anastomosis. Dig Dis Sci 2024; 69:1102-1104. [PMID: 38446307 DOI: 10.1007/s10620-024-08344-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 02/06/2024] [Indexed: 03/07/2024]
Affiliation(s)
- Arafa Djalal
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Serre-Yu Wong
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jean-Frédéric Colombel
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ryan Ungaro
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Maia Kayal
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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2
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Anto VP, Ramos AE, Mollen KP. Ouch, my pouch! a clinician's guide to pouchitis. Semin Pediatr Surg 2024; 33:151406. [PMID: 38636151 DOI: 10.1016/j.sempedsurg.2024.151406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
Pouchitis is defined as inflammation of the ileal pouch created during a restorative proctocolectomy with ileal pouch-anal anastomosis. Although the incidence of this inflammatory condition is high, the exact etiology often remains unclear and the management challenging. In this review, we summarize the clinical presentation, pathogenesis, diagnosis, and management of this common complication.
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Affiliation(s)
- Vincent P Anto
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Anna E Ramos
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Kevin P Mollen
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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3
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Barnes EL, Desai A, Kochhar GS. Response to Lin and Wei. Am J Gastroenterol 2024:00000434-990000000-01087. [PMID: 38534001 DOI: 10.14309/ajg.0000000000002740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/28/2024]
Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Aakash Desai
- Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Gursimran S Kochhar
- Division of Gastroenterology, Hepatology & Nutrition, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
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4
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Posner H, Lombard R, Akiyama S, Cohen NA, Rubin DT, Dubinsky MC, Dalal S, Kayal M. Extensive Disease and Exposure to Multiple Biologics Precolectomy Is Associated with Endoscopic Cuffitis Post-Ileal Pouch-Anal Anastomosis in Patients With Ulcerative Colitis. Inflamm Bowel Dis 2024:izae029. [PMID: 38521548 DOI: 10.1093/ibd/izae029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Indexed: 03/25/2024]
Abstract
INTRODUCTION To better inform the risk of cuffitis in patients with ulcerative colitis (UC), we aimed to identify its occurrence and associated precolectomy factors in a large multicenter cohort of patients who underwent restorative proctocolectomy (RPC) with stapled ileal pouch-anal anastomosis (IPAA). METHODS This study was a retrospective cohort analysis of individuals diagnosed with UC or indeterminate colitis who underwent RPC with IPAA for refractory disease or dysplasia at Mount Sinai Hospital or the University of Chicago followed by at least 1 pouchoscopy with report of the pouch-anal anastomosis. The primary outcome was cuffitis defined as ulceration of the cuff as reported in each pouchoscopy report. RESULTS The pouch-anal anastomosis was mentioned in the pouchoscopy reports of 674 patients, of whom 525 (77.9%) had a stapled anastomosis. Among these, cuffitis occurred in 313 (59.6%) patients a median of 1.51 (interquartile range 0.59-4.17) years after final surgical stage. On multivariable analysis, older age (hazard ratio [HR], 1.01; 95% confidence interval [CI], 1.01-1.02), extensive disease (HR, 1.34; 95% CI, 1.01-1.78), exposure to biologics before colectomy (HR, 2.51; 95% CI, 1.93-3.27), and exposure to at least 2 or more biologics before colectomy (HR, 2.18; 95% CI, 1.40-3.39) were significantly associated with subsequent cuffitis. CONCLUSIONS In this multicenter study of patients who underwent RPC with stapled IPAA and at least 1 follow-up pouchoscopy, cuffitis occurred in approximately 60% and was significantly associated with extensive disease and exposure to multiple biologics precolectomy.
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Affiliation(s)
- Hannah Posner
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Rachel Lombard
- University of Chicago Inflammatory Bowel Disease Center, Chicago, Illinois, USA
| | - Shintaro Akiyama
- University of Chicago Inflammatory Bowel Disease Center, Chicago, Illinois, USA
- Department of Gastroenterology, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Nathaniel A Cohen
- University of Chicago Inflammatory Bowel Disease Center, Chicago, Illinois, USA
| | - David T Rubin
- University of Chicago Inflammatory Bowel Disease Center, Chicago, Illinois, USA
| | - Marla C Dubinsky
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sushila Dalal
- University of Chicago Inflammatory Bowel Disease Center, Chicago, Illinois, USA
| | - Maia Kayal
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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5
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Mesonero F, Zabana Y, Fernández-Clotet A, Leo-Carnerero E, Caballol B, Núñez-Ortiz A, García MJ, Bertoletti F, Mínguez A, Suris G, Casis B, Ferreiro-Iglesias R, Calafat M, Jiménez I, Miranda-Bautista J, Lamuela LJ, Fajardo I, Torrealba L, Nájera R, Sáiz-Chumillas RM, González I, Vicuña M, García-Morales N, Gutiérrez A, López-García A, Benítez JM, Rubín de Célix C, Tejido C, Brunet E, Hernández-Camba A, Suárez C, Rodríguez-Lago I, Piqueras M, Castaño A, Ramos L, Sobrino A, Rodríguez-Grau MC, Elosua A, Montoro M, Baltar R, Huguet JM, Hermida B, Caballero-Mateos A, Sánchez-Guillén L, Bouhmidi A, Pajares R, Baston-Rey I, López-Sanromán A, Albillos A, Barreiro-de Acosta M. Effectiveness and safety of azathioprine for inflammatory pouch disorders: results from the RESERVO study of GETECCU. Therap Adv Gastroenterol 2024; 17:17562848241234476. [PMID: 38445247 PMCID: PMC10913517 DOI: 10.1177/17562848241234476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 02/02/2024] [Indexed: 03/07/2024] Open
Abstract
Background The usefulness of thiopurines has been poorly explored in pouchitis and other pouch disorders. Objective To evaluate the effectiveness and safety of azathioprine as maintenance therapy in inflammatory pouch disorders. Design This was a retrospective and multicentre study. Methods We included patients diagnosed with inflammatory pouch disorders treated with azathioprine in monotherapy. Effectiveness was evaluated at 1 year and in the long term based on normalization of stool frequency, absence of pain, faecal urgency or fistula discharge (clinical remission), or any improvement in these symptoms (clinical response). Endoscopic response was evaluated using the Pouchitis Disease Activity Index (PDAI). Results In all, 63 patients were included [54% males; median age, 49 (28-77) years]. The therapy was used to treat pouchitis (n = 37) or Crohn's disease of the pouch (n = 26). The rate of clinical response, remission and non-response at 12 months were 52%, 30% and 18%, respectively. After a median follow-up of 23 months (interquartile range 11-55), 19 patients (30%) were in clinical remission, and 45 (66%) stopped therapy. Endoscopic changes were evaluated in 19 cases. PDAI score decreased from 3 (range 2-4) to 1 (range 0-3). In all, 21 patients (33%) presented adverse events and 16 (25%) needed to stop therapy. Conclusion Azathioprine may be effective in the long term for the treatment of inflammatory pouch disorders and could be included as a therapeutic option.
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Affiliation(s)
- Francisco Mesonero
- Inflammatory Bowel Disease Unit, Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Cra. Colmenar km 9.1, Madrid 28034, Spain
| | - Yamile Zabana
- Hospital Universitario Mútua Terrassa, Terrassa, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Agnès Fernández-Clotet
- Hospital Clínic Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | | | - Berta Caballol
- Hospital Clínic Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | | | - María José García
- Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | | | | | - Gerard Suris
- Hospital Universitario de Bellvitge, Barcelona, Spain
| | - Begoña Casis
- Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - Margalida Calafat
- Hospital Universitario Germans Trias i Pujol, Badalona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Itxaso Jiménez
- Hospital Universitario de Galdakao, Biocruces Bizkaia Health Research Institute, Galdakao, Spain
| | | | | | | | | | | | | | | | | | | | - Ana Gutiérrez
- Hospital General Universitario Alicante Doctor Balmis (Alicante), Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Alicia López-García
- Hospital del Mar i Institut Mar d’Investigacions Mediques (IMIM), Barcelona, Spain
| | | | - Cristina Rubín de Célix
- Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Coral Tejido
- Complejo Hospitalario Universitario Ourense, Ourense, Spain
| | - Eduard Brunet
- Hospital Universitari Parc Taulí, Sabadell, Spain Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | | | - Cristina Suárez
- Hospital Universitario La Paz, Instituto de Investigación Sanitaria del Hospital Universitario La Paz (IdiPAZ), Madrid, Spain
| | - Iago Rodríguez-Lago
- Hospital Universitario de Galdakao, Biocruces Bizkaia Health Research Institute, Galdakao, Spain
| | | | | | - Laura Ramos
- Hospital Universitario de Canarias, Santa Cruz, Spain
| | - Ana Sobrino
- Hospital General Universitario Ciudad Real, Ciudad Real, Spain
| | | | | | | | - Ruth Baltar
- Hospital Universitario Álava, Vitoria, Spain
| | | | | | | | | | | | - Ramón Pajares
- Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Spain
| | - Iria Baston-Rey
- Hospital Clínico Universitario Santiago, Santiago de Compostela, Spain
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Macleod A, Parks MA, Cook CN, Petras RE, Galandiuk S. Long-term behavior and functional outcomes of ileal-pouch anal anastomosis in inflammatory bowel disease with changing phenotype. Surgery 2024; 175:765-775. [PMID: 37802743 DOI: 10.1016/j.surg.2023.07.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/24/2023] [Accepted: 07/08/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND Ileal-pouch-anal anastomosis is the operation of choice after proctocolectomy for ulcerative colitis; some patients will develop Crohn's disease. We aim to determine long-term behavior and outcomes of inflammatory bowel disease-ileal-pouch-anal anastomosis after colectomy, where a specialist gastrointestinal pathologist re-evaluated the initial colectomy specimen. METHODS Patients with inflammatory bowel disease-ileal-pouch-anal anastomosis were identified from a single-surgeon prospective database containing 1,165 patients accrued from 1991 to 2017 and invited to complete pouch-function and quality-of-life assessments. Medical records were used to obtain clinical outcomes and subjective functional assessments for those unable to be contacted. Data were compared between patients with and without histological assessment disagreement and subsequent inflammatory bowel disease behavior subgroups. RESULTS For 138 patients included in the analysis, the median follow-up was 22.5 (range: 5-39) years. A total of 39.1% of patients had histologic diagnostic change after gastrointestinal pathologist review, and 19% and 39% developed Crohn's disease-like disease behavior at 10- and 20-year follow-ups. Pouch function and quality-of-life scores were similar across diagnostic change subgroups. Pouch failure was higher in Crohn's-like disease (31.1 vs 13.0%, P < .05). Intestinal continuity was maintained in 68.9% of Crohn's disease-like patients, 57.9% required biologics. Gastrointestinal pathologist review did not alter the time to new diagnosis (P = .419) or time to pouch failure (P = .320), mean: 11.0 and 11.41 years, respectively. CONCLUSION We describe equivocal patient-reported outcomes in patients with ileal-pouch-anal anastomosis and changing histologic and clinical diagnosis. Although pouch excision and biologic use rates are higher, many Crohn's disease-like patients maintain their pouch. Diagnostic change and pouch failure often occur >10 years after ileal-pouch-anal anastomosis creation. This supports the consideration of ileal-pouch-anal anastomosis after colectomy in carefully selected patients with inflammatory bowel disease, even those with ambiguous histology and the need for close long-term follow-up.
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Affiliation(s)
- Anne Macleod
- Price Institute of Surgical Research, University of Louisville, KY
| | - Mary Alex Parks
- Price Institute of Surgical Research, University of Louisville, KY
| | - Cheyenne N Cook
- Price Institute of Surgical Research, University of Louisville, KY
| | | | - Susan Galandiuk
- Price Institute of Surgical Research, University of Louisville, KY; Division of Colon & Rectal Surgery, Hiram C Polk Jr MD Department of Surgery, University of Louisville, KY.
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7
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Abstract
There is abundant literature reporting about the use of antibiotics in inflammatory bowel disease (IBD), but their role in the management of IBD is not entirely clear. Diverse infectious organisms have been implicated in the pathogenesis of Crohn's disease. Also, infections are believed to be a trigger for flares of ulcerative colitis. The benefit of the routine use of antibiotics in IBD is equivocal. However, there are certain situations, where antibiotics have a clear role and evidence of benefit: perianal fistula, intra-abdominal abscesses in Crohn's disease, acute pouchitis and infection-related flares. However, there is a lack of supportive evidence for the routine use of antibiotics in all disease-related flares. Evidence indicates a lack of benefit of intravenous antibiotics in acute severe ulcerative colitis and only limited benefit in active ulcerative colitis. Limited evidence suggests the role of a combination of oral antibiotics in pediatric ulcerative colitis. Certain targeted antibiotic regimens have been used in IBD. In ulcerative colitis, limited evidence suggests the benefit of the use of an antibiotic cocktail directed against Fusobacterium varium. Therapy directed against Escherichia coli does not seem to have a benefit in inflammatory Crohn's disease. In Crohn's disease, antimycobacterial therapy may result in symptomatic improvement but no durable benefit. Antitubercular therapy (ATT), on the contrary, may result in fibrotic transformation, suggesting a need to avoid misdiagnosis and limit the duration of ATT in Crohn's disease. This review assesses the published literature with respect to antibiotic use and provides guidance to clinicians in appropriate antibiotic use in various situations in the setting of IBD.
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Affiliation(s)
- Daya K Jha
- Indian Navy, Visakhapatnam, 530 014, India
| | | | - Usha Dutta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India.
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8
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Hill L, Roofigari N, Faraz M, Popov J, Moshkovich M, Figueiredo M, Hartung E, Talbo M, Lalanne-Mistrih ML, Sherlock M, Zachos M, Timmons BW, Obeid J, Pai N. Physical Activity in Pediatric Inflammatory Bowel Disease: A Scoping Review. Pediatr Exerc Sci 2024; 36:44-56. [PMID: 37487582 DOI: 10.1123/pes.2022-0078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 04/10/2023] [Accepted: 04/18/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Inflammatory bowel disease (IBD) is a chronic, systemic condition affecting the gastrointestinal tract. IBD can be severe and are associated with impairment in growth, school absences, abdominal pain, and fatigue. Physical activity (PA) could have an anti-inflammatory effect in addition to other benefits. It is important to address the possible risks, physiological effects of PA, and potential barriers, and facilitators for PA participation in pediatric IBD. However, potential barriers and facilitators to PA have yet to be adequately described. METHODS We conducted a scoping review to map and describe the current literature on PA in pediatric IBD populations between 1980 and April 2022 using Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines for Scoping reviews. RESULTS Nineteen articles were identified including 10 descriptive, 6 interventional, and 3 physiological responses to PA studies. Patients and healthy controls demonstrated similar responses to exercise. Barriers to participation were low self-esteem, body image, and active IBD symptoms. Facilitators included personal interest, activity with friends, and support from family. CONCLUSION This review highlighted that PA participation may reduce in children with IBD-related symptoms. Short- and medium-term impacts of PA on immune modulation require further study; it is possible that regular PA does not negatively affect biomarkers of disease activity.
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Affiliation(s)
- Lee Hill
- Division of Gastroenterology & Nutrition, Department of Pediatrics, McMaster University, Hamilton, ON,Canada
- Department of Endocrinology, Research Institute of the McGill University Health Center, Montreal, QC,Canada
| | | | - Maria Faraz
- Department of Pathology, Albany Medical Center, Albany, NY,USA
| | - Jelena Popov
- Division of Gastroenterology & Nutrition, Department of Pediatrics, McMaster University, Hamilton, ON,Canada
| | - Michal Moshkovich
- Division of Gastroenterology & Nutrition, Department of Pediatrics, McMaster University, Hamilton, ON,Canada
- Faculty of Health Sciences, McMaster University, Hamilton, ON,Canada
| | - Melanie Figueiredo
- Division of Gastroenterology & Nutrition, Department of Pediatrics, McMaster University, Hamilton, ON,Canada
- Faculty of Health Sciences, McMaster University, Hamilton, ON,Canada
| | - Emily Hartung
- Division of Gastroenterology & Nutrition, Department of Pediatrics, McMaster University, Hamilton, ON,Canada
| | - Meryem Talbo
- School of Human Nutrition, McGill University, Montreal, QC,Canada
| | - Marie-Laure Lalanne-Mistrih
- Montreal Clinical Research Institute, Montreal, QC,Canada
- Department of Nutrition, University Hospital of Guadeloupe, Pointe-à-Pitre,France
- UFR of Medicine, University of French West Indies, Abymes, Guadeloupe,France
| | - Mary Sherlock
- Division of Gastroenterology & Nutrition, Department of Pediatrics, McMaster University, Hamilton, ON,Canada
- Department of Nutrition, University Hospital of Guadeloupe, Pointe-à-Pitre,France
| | - Mary Zachos
- Division of Gastroenterology & Nutrition, Department of Pediatrics, McMaster University, Hamilton, ON,Canada
- Department of Nutrition, University Hospital of Guadeloupe, Pointe-à-Pitre,France
| | - Brian W Timmons
- Child Health and Exercise Medicine Program, McMaster University, Hamilton, ON,Canada
| | - Joyce Obeid
- Child Health and Exercise Medicine Program, McMaster University, Hamilton, ON,Canada
| | - Nikhil Pai
- Division of Gastroenterology & Nutrition, Department of Pediatrics, McMaster University, Hamilton, ON,Canada
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON,Canada
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Barnes EL, Agrawal M, Syal G, Ananthakrishnan AN, Cohen BL, Haydek JP, Al Kazzi ES, Eisenstein S, Hashash JG, Sultan SS, Raffals LE, Singh S. AGA Clinical Practice Guideline on the Management of Pouchitis and Inflammatory Pouch Disorders. Gastroenterology 2024; 166:59-85. [PMID: 38128971 DOI: 10.1053/j.gastro.2023.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
BACKGROUND & AIMS Pouchitis is the most common complication after restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis. This American Gastroenterological Association (AGA) guideline is intended to support practitioners in the management of pouchitis and inflammatory pouch disorders. METHODS A multidisciplinary panel of content experts and guideline methodologists used the Grading of Recommendations Assessment, Development and Evaluation framework to prioritize clinical questions, identify patient-centered outcomes, conduct an evidence synthesis, and develop recommendations for the prevention and treatment of pouchitis, Crohn's-like disease of the pouch, and cuffitis. RESULTS The AGA guideline panel made 9 conditional recommendations. In patients with ulcerative colitis who have undergone ileal pouch-anal anastomosis and experience intermittent symptoms of pouchitis, the AGA suggests using antibiotics for the treatment of pouchitis. In patients who experience recurrent episodes of pouchitis that respond to antibiotics, the AGA suggests using probiotics for the prevention of recurrent pouchitis. In patients who experience recurrent pouchitis that responds to antibiotics but relapses shortly after stopping antibiotics (also known as "chronic antibiotic-dependent pouchitis"), the AGA suggests using chronic antibiotic therapy to prevent recurrent pouchitis; however, in patients who are intolerant to antibiotics or who are concerned about the risks of long-term antibiotic therapy, the AGA suggests using advanced immunosuppressive therapies (eg, biologics and/or oral small molecule drugs) approved for treatment of inflammatory bowel disease. In patients who experience recurrent pouchitis with inadequate response to antibiotics (also known as "chronic antibiotic-refractory pouchitis"), the AGA suggests using advanced immunosuppressive therapies; corticosteroids can also be considered in these patients. In patients who develop symptoms due to Crohn's-like disease of the pouch, the AGA suggests using corticosteroids and advanced immunosuppressive therapies. In patients who experience symptoms due to cuffitis, the AGA suggests using therapies that have been approved for the treatment of ulcerative colitis, starting with topical mesalamine or topical corticosteroids. The panel also proposed key implementation considerations for optimal management of pouchitis and Crohn's-like disease of the pouch and identified several knowledge gaps and areas for future research. CONCLUSIONS This guideline provides a comprehensive, patient-centered approach to the management of patients with pouchitis and other inflammatory conditions of the pouch.
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Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Manasi Agrawal
- The Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York; Center for Molecular Prediction of Inflammatory Bowel Disease, Department of Clinical Medicine, Aalborg University, Copenhagen, Denmark
| | - Gaurav Syal
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Ashwin N Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Benjamin L Cohen
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases Institute, Cleveland Clinic, Cleveland, Ohio
| | - John P Haydek
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Elie S Al Kazzi
- Division of Gastroenterology, Case Western Reserve University, Cleveland, Ohio
| | - Samuel Eisenstein
- Division of Colorectal Surgery, Department of Surgery, University of California San Diego, La Jolla, California
| | - Jana G Hashash
- Inflammatory Bowel Disease Center, Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
| | - Shahnaz S Sultan
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota; Veterans Affairs Healthcare System, Minneapolis, Minnesota
| | - Laura E Raffals
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Siddharth Singh
- Division of Gastroenterology, University of California San Diego, La Jolla, California
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Xu S, Zhang L, Li Z, Wang K, Liu F, Cao B. Enhancing surgical precision: unveiling the impact of preoperative colonoscopy in anal fistula patients. BMC Gastroenterol 2023; 23:442. [PMID: 38102560 PMCID: PMC10722667 DOI: 10.1186/s12876-023-03066-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 11/28/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Anal fistula is a common benign anorectal disease that often requires surgical intervention for effective treatment. In recent years, preoperative colonoscopy as a diagnostic tool in patients with anal fistula has garnered increasing attention due to its potential clinical application value. By investigating underlying inflammatory bowel disease (IBD), polyps, and other abnormalities, preoperative colonoscopy can offer insights to refine surgical strategies and improve patient outcomes. METHODS This retrospective study focused on 1796 patients with various benign anorectal diseases who underwent preoperative intestinal endoscopy and met surgical criteria within the preceding three years at the First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine. Among these patients, 949 diagnosed with anal fistula comprised group A, while 847 patients without anal fistula were assigned to group B for comparison. The investigation encompassed an analysis of general patient information, endoscopic findings, polyp histopathology, distribution of bowel inflammation sites, and results of inflammatory bowel disease assessments between the two patient cohorts. A subgroup analysis was also conducted on 2275 anal fistula patients with no surgical contraindications. This subgroup was categorized into Group A (949 patients who underwent preoperative intestinal endoscopy) and Group C (1326 patients who did not undergo preoperative colonoscopy). The study compared the rates of detecting endoscopic lesions and IBD-related findings between the two subgroups. RESULTS The study initially confirmed the comparability of general patient information between groups A and B. Notably, the abnormal detection rate in group A was significantly higher than in group B (P < 0.01). In terms of endoscopic findings, the anal fistula group (group A) exhibited higher rates of detecting bowel inflammation, inflammatory bowel disease, and polyps compared to the non-anal fistula group (group B) (P < 0.05). The distribution of inflammation locations indicated higher detection rates in the terminal ileum, ileocecal region, and ascending colon for group A compared to group B (P < 0.05). Although the incidence of IBD in group A was higher than in group B, this difference did not reach statistical significance (P > 0.05). Subsequently, the analysis of the subgroup (groups A and C) revealed a significant disparity in intestinal endoscopic detection rates (P < 0.01) and statistically significant differences in detecting IBD (P < 0.05) and Crohn's disease (P < 0.05) between the two anal fistula subgroups. CONCLUSIONS The findings of this study underscore the substantial clinical value of preoperative colonoscopy in the comprehensive evaluation of patients with anal fistula. Preoperative colonoscopy aids in ruling out localized perianal lesions caused by underlying inflammatory bowel disease, thereby mitigating the likelihood of missed diagnoses and enhancing treatment outcomes. This research highlights the importance of incorporating preoperative colonoscopy as a valuable diagnostic tool in managing anal fistula patients.
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Affiliation(s)
- Shumin Xu
- Department of Anorectal Surgery, Guizhou Province, The First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, No. 71, Baoshan North Road, Guiyang, 550000, P. R. China
| | - Luo Zhang
- Dental Department, Guizhou Provincial People's Hospital, Guiyang, 550000, P. R. China
| | - Zhi Li
- Department of Anorectal Surgery, Guizhou Province, The First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, No. 71, Baoshan North Road, Guiyang, 550000, P. R. China
| | - Kaiping Wang
- Department of Anorectal Surgery, Guizhou Province, The First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, No. 71, Baoshan North Road, Guiyang, 550000, P. R. China
| | - Fang Liu
- Department of Anorectal Surgery, Guizhou Province, The First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, No. 71, Baoshan North Road, Guiyang, 550000, P. R. China.
| | - Bo Cao
- Department of Anorectal Surgery, Guizhou Province, The First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, No. 71, Baoshan North Road, Guiyang, 550000, P. R. China.
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11
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Bousvaros A, Zalieckas JM, Zimmerman L. Endoscopy of the Ileal Pouch Anal Anastomosis. J Pediatr Gastroenterol Nutr 2023; 77:691-694. [PMID: 37621012 DOI: 10.1097/mpg.0000000000003933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Affiliation(s)
- Athos Bousvaros
- From Boston Children's Hospital, Department of Gastroenterology and Nutrition, Boston, MA
| | | | - Lori Zimmerman
- From Boston Children's Hospital, Department of Gastroenterology and Nutrition, Boston, MA
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12
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Otero-Piñeiro AM, Hull T, Holubar S, Pedersen KE, Aykun N, Obi M, Butler R, Steele SR, Lightner AL. Surgical Options for the Treatment of Perianal and Anovaginal Fistulas in the Setting of Ileoanal Pouch Crohn's Disease: Experience of a Tertiary Center. J Gastrointest Surg 2023; 27:2867-2875. [PMID: 37985619 DOI: 10.1007/s11605-023-05603-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 01/03/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND The leading cause of pouch failure following ileal pouch-anal anastomosis are peri-pouch fistulas and pelvic sepsis. OBJECTIVE Determine the overall efficacy of current surgical therapy for the treatment of perianal and anovaginal fistulizing disease related to Crohn's disease phenotype of the pouch. DESIGN Retrospective cohort study of a prospectively maintained, IRB-approved database. SETTINGS/PATIENTS Ninety-one (2.3%) patients of 3058 patients with an original diagnosis of ulcerative colitis who underwent proctocolectomy with ileal pouch-anal anastomosis between 2000 and 2021 at the Cleveland Clinic and underwent postoperative surgery for Crohn's-related perianal disease. INTERVENTIONS Two hundred thirty-one operations for perianal or anovaginal fistula(s). MAIN OUTCOME AND MEASURES Healing rate of surgical therapy for peri-pouch fistulizing disease, impact of recurrent interventions on outcomes, and predictors of surgical failure. RESULTS Overall mean age was 39.1 (± 11.6) years, with a BMI of 25.3 (± 6.3) kg/m2. More than half of the patients were female (n = 52, 57.1%). Sixty-three patients (69.2%) had a perianal fistula, 25 (27.5%) had an anovaginal fistula, and 3 (3.3%) patients had both. Overall success rate for healing was 59.3% (n = 54/91) at a mean follow-up of 6.4 (± 4.8) years. Seventeen (18.7%) patients underwent a concomitant diverting loop ileostomy. Among them, eight (47.0%) patients had the ileostomy closure after a mean time of 9.7 (± 2.8) months. In the multivariable logistic regression model, patients who had seton insertions in any operation were significantly less likely to heal (OR 0.11 95%, CI 0.03-0.43, p = 0.001). Overall pouch failure rate was 12.1%. LIMITATIONS Retrospective single-center study which lacks a control arm and consistent long-term follow-up specific to a population-based dataset. CONCLUSIONS Pouch patients who develop perianal disease are difficult to treat, sometimes requiring pouch excision. However, when medical treatment alone is not effective, a multidisciplinary approach including surgical intervention can result in complete fistula healing in more than half of the cases.
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Affiliation(s)
- Ana M Otero-Piñeiro
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Tracy Hull
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Stefan Holubar
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Karina E Pedersen
- College of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Nihal Aykun
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Megan Obi
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Robert Butler
- Department of General Surgery, Statistics, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Scott R Steele
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
- College of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
- Department of General Surgery, Statistics, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA.
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13
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Chang S, Hong S, Hudesman D, Remzi F, Sun K, Cao W, Kani HT, Axelrad J, Sarkar SA. Histologic Predictors of Clinical Outcomes and Healthcare Utilization in Patients With Ileal Pouch-Anal Anastomosis. Inflamm Bowel Dis 2023; 29:1769-1777. [PMID: 36702534 PMCID: PMC10628915 DOI: 10.1093/ibd/izac277] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND The prognostic significance of histology in ileal pouch-anal anastomosis (IPAA) remains unclear. The aim of this study was to evaluate if histologic variables are predictive of IPAA clinical outcomes and healthcare utilization. METHODS This was a retrospective cohort study of patients with IPAA undergoing surveillance pouchoscopy at a tertiary care institution. Pouch body biopsies were reviewed by gastrointestinal pathologists, who were blinded to clinical outcomes, for histologic features of acute or chronic inflammation. Charts were reviewed for clinical outcomes including development of acute pouchitis, chronic pouchitis, biologic or small molecule initiation, hospitalizations, and surgery. Predictors of outcomes were analyzed using univariable and multivariable logistic and Cox regression. RESULTS A total of 167 patients undergoing surveillance pouchoscopy were included. Polymorphonuclear leukocytes (odds ratio [OR], 1.67), ulceration and erosion (OR, 2.44), chronic inflammation (OR, 1.97), and crypt distortion (OR, 1.89) were associated with future biologic or small molecule initiation for chronic pouchitis. Loss of goblet cells was associated with development of chronic pouchitis (OR, 4.65). Pyloric gland metaplasia was associated with hospitalizations (OR, 5.24). No histologic variables were predictive of development of acute pouchitis or surgery. In an exploratory subgroup analysis of new IPAA (<1 year), loss of goblet cells was associated with acute pouchitis (OR, 14.86) and chronic pouchitis (OR, 12.56). Pyloric gland metaplasia was again associated with hospitalizations (OR, 13.99). CONCLUSIONS Histologic findings may be predictive of IPAA outcomes. Pathologists should incorporate key histologic variables into pouchoscopy pathology reports. Clinicians may need to more closely monitor IPAA patients with significant histologic findings.
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Affiliation(s)
- Shannon Chang
- Division of Gastroenterology, New York University Grossman School of Medicine, New York, NY, USA
| | - Simon Hong
- Division of Gastroenterology, New York University Grossman School of Medicine, New York, NY, USA
| | - David Hudesman
- Division of Gastroenterology, New York University Grossman School of Medicine, New York, NY, USA
| | - Feza Remzi
- Department of Colorectal Surgery, New York University Langone Health, New York, NY, USA
| | - Katherine Sun
- Department of Pathology, New York University Langone Health, New York, NY, USA; and
| | - Wenqing Cao
- Department of Pathology, New York University Langone Health, New York, NY, USA; and
| | - H Tarik Kani
- Division of Gastroenterology, New York University Grossman School of Medicine, New York, NY, USA
- Department of Gastroenterology, School of Medicine, Marmara University, Istanbul, Turkey
| | - Jordan Axelrad
- Division of Gastroenterology, New York University Grossman School of Medicine, New York, NY, USA
| | - Suparna A Sarkar
- Department of Pathology, New York University Langone Health, New York, NY, USA; and
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14
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Abstract
Total abdominal proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) is associated with substantial complications despite the benefits of managing refractory and/or neoplasia-associated disease. For the purpose of this review, we focused on the diagnosis of some of the most common inflammatory and structural pouch disorders and their respective management. Pouchitis is the most common complication, and it is typically responsive to antibiotics. However, chronic antibiotic refractory pouchitis (CARP) has been increasingly recognized, and biologic therapies have emerged as the mainstay of therapy. Crohn's-like disease of the pouch (CLDP) can affect up to 10% of patients with UC after IPAA. Medical options are similar to CARP therapies, including biologics with immunomodulators. Studies have shown higher efficacy rates of biologics for CLDP when compared with those for CARP. In addition, managing stricturing and fistulizing CLDP is challenging and often requires interventional endoscopy (balloon dilation and/or stricturotomy) and/or surgery. The implementation of standardized diagnostic criteria for inflammatory pouch disorders will help in advancing future therapeutic options. Structural pouch disorders are commonly related to surgical complications after IPAA. We focused on the diagnosis and management of anastomotic leaks, strictures, and floppy pouch complex. Anastomotic leaks and anastomotic strictures occur in approximately 15% and 11% of patients with UC after IPAA, respectively. Further complications from pouch leaks include the development of sinuses, fistulas, and pouch sepsis requiring excision. Novel endoscopic interventions and less invasive surgical procedures have emerged as options for the management of these disorders.
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Affiliation(s)
- Priscila Santiago
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Laura E Raffals
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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15
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Barnes EL, Desai A, Kochhar GS. The Comparative Effectiveness of Ciprofloxacin and Metronidazole for an Initial Episode of Pouchitis: A Propensity-Matched Study. Am J Gastroenterol 2023; 118:1989-1996. [PMID: 37463438 PMCID: PMC10841309 DOI: 10.14309/ajg.0000000000002412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 07/14/2023] [Indexed: 07/20/2023]
Abstract
INTRODUCTION There is minimal evidence regarding the comparative effectiveness of individual antibiotics in the treatment of pouchitis. We sought to evaluate the comparative effectiveness of ciprofloxacin monotherapy, metronidazole monotherapy, and combination therapy (ciprofloxacin and metronidazole) in the treatment of an initial episode of pouchitis after ileal pouch-anal anastomosis for ulcerative colitis (UC). METHODS We performed a retrospective cohort study in TriNetX, a global federated research network of electronic health records. Primary outcomes were failure of initial antibiotic therapy and the development of recurrent pouchitis in the first 12 months after an initial episode of pouchitis. One-to-one propensity score matching was performed for age, sex, race, primary sclerosing cholangitis, nicotine dependence, obesity, and previous exposure to tumor necrosis factor inhibitors between the cohorts. RESULTS Among 271 patients who developed pouchitis (mean age at ileal pouch-anal anastomosis 35.8 years, male sex 57%) and were treated with ciprofloxacin, metronidazole, or combination therapy, 190 (70%) developed recurrent pouchitis. After propensity score matching, there was no significant difference in the odds of early relapse or nonresponse with ciprofloxacin compared with metronidazole monotherapy (adjusted odds ratio 0.56, 95% confidence interval 0.23-1.34) or when either monotherapy was compared with combination therapy. There was also no significant difference in odds of recurrent pouchitis when comparing patients treated with ciprofloxacin with metronidazole monotherapy (adjusted odds ratio 0.86, 95% confidence interval 0.40-1.84) or either monotherapy with combination therapy. DISCUSSION In this retrospective cohort study, we demonstrated no significant difference in the real-world effectiveness of ciprofloxacin, metronidazole, or combination therapy for the initial episode of pouchitis.
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Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Aakash Desai
- Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Gursimran S Kochhar
- Division of Gastroenterology, Hepatology & Nutrition, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
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16
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Quera R, Núñez P, Sicilia B, Flores L, Gomollón F. Corticosteroids in inflammatory bowel disease: Are they still a therapeutic option? Gastroenterol Hepatol 2023; 46:716-726. [PMID: 36375697 DOI: 10.1016/j.gastrohep.2022.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 10/26/2022] [Accepted: 10/30/2022] [Indexed: 11/13/2022]
Abstract
Despite the development and incorporation of new therapeutic strategies, such as biologic therapy and small molecules, corticosteroids still play an important role in inducting inflammatory bowel diseases (IBD) remission. Variables like indicating the right doses at the right time, in adequate intervals, the security of these drugs and the pharmacological alternatives available must be considered by the providers when they are indicated to patients with IBD. Although the use of corticosteroids is considered as a marker of quality of care in patients with IBD, the use of these drugs in the clinical practice of IBD is far from being the correct one. This review article is not intended to be just a classic review of the indications for corticosteroids. Here we explain the scenarios in which, in our opinion, steroids would not be an appropriate option for our patients, as well as the most frequent mistakes we make in our daily practice when using them.
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Affiliation(s)
- Rodrigo Quera
- Programa Enfermedad Inflamatoria Intestinal, Centro de Enfermedades Digestivas, Universidad de los Andes, Santiago, Chile
| | - Paulina Núñez
- Programa Enfermedad Inflamatoria Intestinal, Centro de Enfermedades Digestivas, Universidad de los Andes, Santiago, Chile; Sección de Gastroenterología, Departamento de Medicina Interna, Hospital San Juan de Dios, Facultad Medicina Occidente, Universidad de Chile, Santiago, Chile
| | - Beatriz Sicilia
- Unidad de Enfermedad Inflamatoria Intestinal, Servicio de Aparato Digestivo, Hospital Universitario de Burgos, Burgos, España
| | - Lilian Flores
- Programa Enfermedad Inflamatoria Intestinal, Centro de Enfermedades Digestivas, Universidad de los Andes, Santiago, Chile
| | - Fernando Gomollón
- Facultad de Medicina, Hospital Clínico Universitario, Instituto de Investigación Sanitaria de Aragón, CIBEREHD, Zaragoza, España.
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17
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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18
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O'Shea D, Picoraro JA. De Novo Crohn's Disease in the Pediatric Pouch. Inflamm Bowel Dis 2023:izad231. [PMID: 37815461 DOI: 10.1093/ibd/izad231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Indexed: 10/11/2023]
Abstract
Children who undergo ileal pouch anal anastomosis (IPAA) surgery for refractory ulcerative colitis (UC) may ultimately develop a Crohn's disease (CD) phenotype. This de novo CD is open to broad interpretation and misattribution, and its manifestation in children is poorly understood. The surgically altered environment of the ileal pouch is at risk of a spectrum of ileal pouch disorders, which have limited description in children. In this issue of Inflammatory Bowel Diseases, a multicenter, retrospective study of children with UC who underwent IPAA and developed de novo CD highlights the challenges and opportunities of ileal pouch characterization in children.
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Affiliation(s)
- Delia O'Shea
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Joseph A Picoraro
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
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19
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Fortuny M, Gutiérrez-Rios L, Vayreda E, Mañosa M, Domènech E. Tofacitinib for the treatment of inflammatory condition of the ileoanal pouch refractory to infliximab. Gastroenterol Hepatol 2023; 46:629-630. [PMID: 36115629 DOI: 10.1016/j.gastrohep.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/10/2022] [Accepted: 08/27/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Marta Fortuny
- Servicio de Aparato Digestivo, Hospital Universitari Germans Trias i Pujol, Badalona, España
| | - Laura Gutiérrez-Rios
- Servicio de Aparato Digestivo, Hospital Universitari Germans Trias i Pujol, Badalona, España
| | - Eva Vayreda
- Servicio de Aparato Digestivo, Hospital Universitari Germans Trias i Pujol, Badalona, España
| | - Míriam Mañosa
- Servicio de Aparato Digestivo, Hospital Universitari Germans Trias i Pujol, Badalona, España; Centro de Investigación Biomédica En Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), España
| | - Eugeni Domènech
- Servicio de Aparato Digestivo, Hospital Universitari Germans Trias i Pujol, Badalona, España; Centro de Investigación Biomédica En Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), España.
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Uchino M, Horio Y, Kuwahara R, Kusunoki K, Nagano K, Ikeuchi H. Associations between Pouchitis and Fecal Calprotectin after Restorative Proctocolectomy in Patients with Ulcerative Colitis. Inflamm Intest Dis 2023; 8:77-83. [PMID: 37901341 PMCID: PMC10601934 DOI: 10.1159/000531654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/17/2023] [Indexed: 10/31/2023] Open
Abstract
Introduction Recently, fecal calprotectin has been identified and used as an assessment tool for the confirmation of disease activity in ulcerative colitis. Although a meta-analysis suggested the usefulness of fecal calprotectin for the assessment of pouchitis, the number of participants was still insufficient. Therefore, we prospectively measured fecal calprotectin levels during pouchoscopy and analyzed their associations with pouchitis. Methods Patients who underwent pouchoscopy after total proctocolectomy and ileal pouch-anal anastomosis for ulcerative colitis were included. Fecal samples were collected for the measurement of calprotectin during pouchoscopy. Patients either with or without suspicious pouchitis were included. Pouchitis was defined as a modified pouchitis disease activity index (m-PDAI) score of ≥5. The associations between the development of pouchitis and the m-PDAI score and fecal calprotectin and serum markers, including C-related protein, albumin, and white blood cells, were assessed. Results A total of 170 patients were included. Seventy-two patients were diagnosed with pouchitis with an m-PDAI score of 7.3 ± 1.5. The values of fecal calprotectin were 1,500 ± 1,544 μg/g in patients with pouchitis and 259 ± 402 μg/g in patients without pouchitis (p < 0.01). The correlation coefficient between calprotectin and the m-PDAI score was significant (r2 = 0.279, p < 0.001). The cutoff value of fecal calprotectin in receiver operating characteristic analysis was 246 μg/g (area under curve 0.85, sensitivity 83.9%, specificity 71.0%). Fecal samples were able to be collected from 6 patients. The levels of fecal calprotectin significantly decreased from 2,101.3 ± 880.3 μg/g to 284.2 ± 96.9 μg/g in response to the treatment. Conclusions Elevated fecal calprotectin appeared to be significantly correlated with pouchitis. We should consider the alteration of this marker during treatments in further studies.
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Affiliation(s)
- Motoi Uchino
- Division of Inflammatory Bowel Disease Surgery, Department of Gastroenterological Surgery, Hyogo Medical University, Nishinomiya, Japan
| | - Yuki Horio
- Division of Inflammatory Bowel Disease Surgery, Department of Gastroenterological Surgery, Hyogo Medical University, Nishinomiya, Japan
| | - Ryuichi Kuwahara
- Division of Inflammatory Bowel Disease Surgery, Department of Gastroenterological Surgery, Hyogo Medical University, Nishinomiya, Japan
| | - Kurando Kusunoki
- Division of Inflammatory Bowel Disease Surgery, Department of Gastroenterological Surgery, Hyogo Medical University, Nishinomiya, Japan
| | - Kentaro Nagano
- Division of Inflammatory Bowel Disease Surgery, Department of Gastroenterological Surgery, Hyogo Medical University, Nishinomiya, Japan
| | - Hiroki Ikeuchi
- Division of Inflammatory Bowel Disease Surgery, Department of Gastroenterological Surgery, Hyogo Medical University, Nishinomiya, Japan
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21
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Maspero M, Hull TL. Clinical approach to patients with an ileal pouch. Abdom Radiol (NY) 2023; 48:2918-2929. [PMID: 37005915 DOI: 10.1007/s00261-023-03888-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/13/2023] [Accepted: 03/13/2023] [Indexed: 04/04/2023]
Abstract
Restorative proctocolectomy with ileal pouch-anal anastomosis is the procedure of choice to maintain intestinal continuity when a total proctocolectomy is a required. It is a technically challenging operation that may be burdened by several nuanced complications both in the immediate postoperative period and in the long term. Most patients with a pouch and any kind of complication will undergo radiological studies, thus multidisciplinary collaboration between surgeons, gastroenterologists, and radiologists is paramount to their timely and accurate diagnosis. When treating pouch patients, radiologists should be familiar with regular pouch anatomy and its appearance in imaging studies, as well as with the most common complications that can occur in this population. In this review, we examine the clinical decision-making process at each step before and after pouch creation, as well as the most common complications associated with pouch surgery, their diagnosis, and their management.
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Affiliation(s)
- Marianna Maspero
- Department of Colorectal Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Tracy L Hull
- Department of Colorectal Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44195, USA.
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22
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Esckilsen S, Kochar B, Weaver KN, Herfarth HH, Barnes EL. Very Early Pouchitis Is Associated with an Increased Likelihood of Chronic Inflammatory Conditions of the Pouch. Dig Dis Sci 2023:10.1007/s10620-023-07947-9. [PMID: 37148442 DOI: 10.1007/s10620-023-07947-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 04/03/2023] [Indexed: 05/08/2023]
Abstract
INTRODUCTION Chronic inflammatory conditions of the pouch are common after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC). AIMS We aimed to investigate the relationship between acute pouchitis within 180 days of the final stage of IPAA surgery (very early pouchitis) and the future development of chronic antibiotic dependent pouchitis (CADP) and Crohn's-like disease of the pouch (CLDP). METHODS We performed a retrospective cohort study, evaluating patients who underwent proctocolectomy with IPAA between January 1, 2004 and December 31, 2016. Multivariable logistic regression was used to evaluate the relationship between very early pouchitis and the development of CADP and CLDP. RESULTS Among 626 patients undergoing IPAA for UC, 137 (22%) developed very early pouchitis, 75 (12%) developed CADP, and 59 (9%) developed CLDP in a median follow-up of 5.18 years (interquartile range 0.94-10.8 years). Very early pouchitis was associated with a significant increase in the odds of developing CADP (adjusted odds ratio [aOR3.65, 95% CI 2.19-6.10) as was primary sclerosing cholangitis (aOR 3.97, 95% CI 1.44-11.0). Very early pouchitis was associated with increased odds for developing CLDP (aOR 2.77, 95% CI 1.54-4.98) along with a family history of inflammatory bowel disease (aOR 2.10, 95% CI 1.11-3.96). CONCLUSION In this cohort, very early pouchitis was associated with an increased risk of developing CADP and CLDP. These findings highlight very early pouchitis as a unique risk factor for chronic inflammatory conditions of the pouch and the need for future studies evaluating potential strategies for secondary prophylaxis strategies in this population.
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Affiliation(s)
- Scott Esckilsen
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Bharati Kochar
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
- Clinical Translational Epidemiology Unit, The Mongan Institute, Boston, MA, USA
| | - Kimberly N Weaver
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, 130 Mason Farm Road, Campus Box #7080, Chapel Hill, NC, 27599-7080, USA
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, 130 Mason Farm Road, Campus Box #7080, Chapel Hill, NC, 27599-7080, USA
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, 130 Mason Farm Road, Campus Box #7080, Chapel Hill, NC, 27599-7080, USA.
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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23
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Prentice RE, Wright EK, Flanagan E, Kamm MA, Goldberg R, Ross AL, Burns M, Bell SJ. Evaluation and management of ileal pouch-anal anastamosis (IPAA) complications in pregnancy, and the impacts of an IPAA on fertility. Eur J Gastroenterol Hepatol 2023; 35:609-612. [PMID: 36966753 DOI: 10.1097/meg.0000000000002538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) remains the preferred surgical option for medically refractory ulcerative colitis. Management of individuals with an IPAA prior to and during pregnancy presents challenges that can have serious consequences. Infertility, mechanical obstructive and inflammatory pouch complications are frequently encountered in pregnant women with an IPAA. Mechanical obstructions occur due to a variety of underlying aetiologies, including stricturing disease, adhesions and pouch twists. Conservative management of such obstructions often results in resolution of symptoms without a need for endoscopic or surgical intervention, although endoscopic decompression may be attempted in isolation or as a bridge to definitive surgical intervention. Parenteral nutrition, and early delivery, may also be necessary. Faecal calprotectin and intestinal ultrasound, both of which are accurate in pregnancy, are useful in the setting of suspected inflammatory pouch complications, in some circumstances allowing for avoidance of pouchoscopy. Penicillin-based antimicrobials can be considered first line in pregnancy for the management of pouchitis and pre-pouch ileitis, and biologics can be safely instituted in the setting of refractory disease or suspected Crohn's disease-like inflammation of the pouch or pre-pouch ileum. Pragmatism, clear patient communication and multidisciplinary discussion are essential in approaching pregnant women with complications of an IPAA, particularly given the lack of definitive evidence to guide therapeutic decisions.
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Affiliation(s)
- Ralley E Prentice
- Department of Gastroenterology, St Vincent's Hospital, Melbourne
- Department of Gastroenterology, Monash Health, Clayton, Victoria
- Monash University, Clayton
| | - Emily K Wright
- Department of Gastroenterology, St Vincent's Hospital, Melbourne
- University of Melbourne, Melbourne, Australia
| | - Emma Flanagan
- Department of Gastroenterology, St Vincent's Hospital, Melbourne
- University of Melbourne, Melbourne, Australia
| | - Michael A Kamm
- Department of Gastroenterology, St Vincent's Hospital, Melbourne
- University of Melbourne, Melbourne, Australia
| | - Rimma Goldberg
- Department of Gastroenterology, Monash Health, Clayton, Victoria
- Monash University, Clayton
| | - Alyson L Ross
- Department of Gastroenterology, St Vincent's Hospital, Melbourne
| | - Megan Burns
- Department of Gastroenterology, Monash Health, Clayton, Victoria
| | - Sally J Bell
- Department of Gastroenterology, Monash Health, Clayton, Victoria
- Monash University, Clayton
- University of Melbourne, Melbourne, Australia
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Carman N, Picoraro JA. Advances in Endoscopy for Pediatric Inflammatory Bowel Disease. Gastrointest Endosc Clin N Am 2023; 33:447-461. [PMID: 36948755 DOI: 10.1016/j.giec.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
Endoscopic characterization of pediatric inflammatory bowel disease (IBD) has developed in accordance with advances in treatment and improved understanding of disease progression and complications. Reliable and consistent endoscopic reporting practices and tools continue to evolve. The roles of endoscopic ultrasonography, capsule endoscopy, and deep enteroscopy in the care of children and adolescents with IBD are beginning to be clarified. Opportunities for therapeutic intervention with endoscopy in pediatric IBD, including endoscopic balloon dilation and electroincision therapy, require further study. This review discusses the current utility of endoscopic assessment in Pediatric Inflammatory Bowel Disease, as well as emerging and evolving techniques to improve patient care.
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Affiliation(s)
- Nicholas Carman
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, CHEO Inflammatory Bowel Disease Centre, Children's Hospital of Eastern Ontario, University of Ottawa, Ontario, Canada; Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, Sickkids Inflammatory Bowel Disease Centre, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada.
| | - Joseph A Picoraro
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Irving Medical Center, 622 West 168th Street, PH17-105, New York, NY 10032, USA; NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY 10032, USA
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25
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He X, Lv X, Zhang B, Ying X, Hu C, Zhou X, Hu J. Adenoma Detection Rate in Average-Risk Population: An Observational Consecutive Retrospective Study. Cancer Control 2023; 30:10732748231193243. [PMID: 37528552 PMCID: PMC10399273 DOI: 10.1177/10732748231193243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 06/06/2023] [Accepted: 07/11/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND Although colonoscopy is considered the most effective tool for reducing colorectal cancer-related morbidity, the age at which average-risk individuals begin colonoscopic screening is undetermined. This study aimed to compare the adenoma and advanced adenoma detection rates according to age and sex in a large average-risk population in the rural areas of Eastern China. METHODS This observational, single-center, retrospective study included patients with average colorectal cancer risk and examined the adenoma and advanced adenoma detection rates using age intervals of 5 years. We also compared the size and age of patients with and without advanced adenoma. RESULTS We included 18 928 patients with a median age of 54 years (range 15-90 years), including 10 143 men and 8785 women. The adenoma and advanced adenoma detection rates were 17.08% and 5.24%, respectively, and increased with age in the whole population. The adenoma detection rates increased from 8.97% (aged 40-44) to 14.98% (aged 45-49) and 6.24% (aged 45-49) to 11.00% (aged 50-54) in men and women (both P < .001), respectively. The advanced adenoma detection rates increased from 2.19% (aged 40-44) to 4.76% (aged 45-49) and 1.89% (aged 45-49) to 3.13% (aged 50-54) in men (P = .002) and women (P = .056), respectively. Patients with advanced adenomas were significantly older than those with non-advanced adenomas (P < .001). The tumors in the advanced adenoma group were significantly larger than those in the non-advanced adenoma group (P < .001). CONCLUSION The adenoma and advanced adenoma detection rates increased significantly in average-risk population aged 45 years and older, especially in men.
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Affiliation(s)
- Xiaoyan He
- Department of Gastroenterology, Dongyang Hospital affiliated to Wenzhou Medical University, Dongyang, China
| | - Xiangyin Lv
- Department of Gastroenterology, Dongyang Hospital affiliated to Wenzhou Medical University, Dongyang, China
| | - Binbin Zhang
- Department of Gastroenterology, Dongyang Hospital affiliated to Wenzhou Medical University, Dongyang, China
| | - Xiaoxuan Ying
- Department of Gastroenterology, Dongyang Hospital affiliated to Wenzhou Medical University, Dongyang, China
| | - Chiyu Hu
- Department of Gastroenterology, Dongyang Hospital affiliated to Wenzhou Medical University, Dongyang, China
| | - Xiaoying Zhou
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jianwen Hu
- Department of Gastroenterology, Dongyang Hospital affiliated to Wenzhou Medical University, Dongyang, China
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26
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Lee WS, Arai K, Alex G, Treepongkaruna S, Kim KM, Choong CL, Mercado KS, Darma A, Srivastava A, Aw MM, Huang J, Ni YH, Malik R, Tanpowpong P, Tran HN, Ukarapol N. Medical Management of Pediatric Inflammatory Bowel Disease (PIBD) in the Asia Pacific Region: A Position Paper by the Asian Pan-Pacific Society for Pediatric Gastroenterology, Hepatology, and Nutrition (APPSPGHAN) PIBD Working Group. J Gastroenterol Hepatol 2022; 38:523-538. [PMID: 36574956 DOI: 10.1111/jgh.16097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 11/08/2022] [Accepted: 12/25/2022] [Indexed: 12/29/2022]
Abstract
Pediatric inflammatory bowel disease (PIBD) is rising rapidly in many industrialised and affluent areas in the Asia Pacific region. Current available guidelines, mainly from Europe and North America, may not be completely applicable to clinicians caring for children with PIBD in this region due to differences in disease characteristics and regional resources constraints. This position paper is an initiative from the Asian Pan-Pacific Society for Pediatric Gastroenterology, Hepatology and Nutrition (APPSPGHAN) with the aim of providing an up-to-date, evidence-based approach to PIBD in the Asia Pacific region, taking into consideration the unique disease characteristics and financial resources available in this region. A group of pediatric gastroenterologists with special interest in PIBD performed an extensive literature search covering epidemiology, disease characteristics and natural history, management and monitoring. Gastrointestinal infections, including tuberculosis, need to be excluded before diagnosing IBD. In some populations in Asia, the Nudix Hydrolase 15 (NUD15) gene is a better predictor of leukopenia induced by azathioprine than thiopurine-S-methyltransferase (TPMT). The main considerations in the use of biologics in the Asia Pacific region are high cost, ease of access, and potential infectious risk, especially tuberculosis. Conclusion: This position paper provides a useful guide to clinicians in the medical management of children with PIBD in the Asia Pacific region.
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Affiliation(s)
- Way Seah Lee
- Department of Paediatrics, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Katsuhiro Arai
- Center for Pediatric Inflammatory Bowel Disease, National Center for Child Health and Development, Tokyo, Japan
| | - George Alex
- Department of Gastroenterology and Nutrition, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Suporn Treepongkaruna
- Division of Gastroenterology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kyung Mo Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Chee Liang Choong
- Department of Paediatrics, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Karen Sc Mercado
- Makati Medical Center and The Medical City, Philippine Society for Pediatric Gastroenterology, Hepatology and Nutrition, Manila, Philippines
| | - Andy Darma
- Department of Child Health, Dr. Soetomo General Hospital, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Anshu Srivastava
- Department of Paediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Marion M Aw
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - James Huang
- Division of Paediatric Gastroenterology, Nutrition, Hepatology and Liver Transplantation, Department of Paediatrics, National University Hospital, Singapore
| | - Yen Hsuan Ni
- National Taiwan University College of Medicine, Taiwan
| | - Rohan Malik
- Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Pornthep Tanpowpong
- Department of Pediatrics, Faculty of Medicine Ramathibodi, Mahidol University, Bangkok, Thailand
| | - Hong Ngoc Tran
- Department of Gastroenterology, Children's Hospital # 1, Ho Chi Minh City, Vietnam
| | - Nuthapong Ukarapol
- Department of Pediatric Gastroenterology and Hepatology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Chen SL, Faye AS, Chang S. Ileal Pouch-Anal Anastomosis in the Older Adult: a Review of Postoperative Outcomes and Pouchitis Treatment. Curr Treat Options Gastroenterol 2022; 20:564-581. [PMID: 36844648 PMCID: PMC9957085 DOI: 10.1007/s11938-022-00405-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/12/2022] [Indexed: 06/18/2023]
Abstract
PURPOSE OF REVIEW Ileal pouch-anal anastomosis (IPAA) has become the preferred surgical treatment for patients with medically refractive ulcerative colitis (UC). Previous studies have suggested that outcomes of this procedure may be worse in older patients; however, more recent reports have suggested that IPAA in select patients is safe, feasible, and results in good quality of life. In this review, we discuss the recent literature surrounding clinical considerations and treatment management of IPAA in older adults. RECENT FINDINGS IPAA complication rates and adverse events are similar in the older adult population, as compared to the younger adult patient population. Although fecal urgency and incontinence may be more common among older adults, chronological age alone is not a contraindication for IPAA surgery, as good quality of life can still be achieved. In this review, we will also discuss the development of pouchitis after IPAA, particularly among older adults, as the emergence of newer biologic drugs has shifted the treatment landscape. SUMMARY IPAA can be a safe and effective treatment modality for older adults with UC, with high self-reported patient satisfaction. Patient optimization and careful case selection are vital to achieving these outcomes, and specialized preoperative assessments and counseling can help facilitate the proper treatment.
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Affiliation(s)
- Sabrina L. Chen
- Department of Gastroenterology, New York University Grossman School of Medicine, 305 East 33rd Street, NY 10016 New York, USA
| | - Adam S. Faye
- Department of Gastroenterology, New York University Grossman School of Medicine, 305 East 33rd Street, NY 10016 New York, USA
| | - Shannon Chang
- Department of Gastroenterology, New York University Grossman School of Medicine, 305 East 33rd Street, NY 10016 New York, USA
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Akiyama S, Dyer EC, Rubin DT. Diagnostic and Management Considerations for the IPAA With Crohn's Disease-Like Features. Dis Colon Rectum 2022; 65:S77-84. [PMID: 35867686 DOI: 10.1097/DCR.0000000000002547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Patients with ulcerative colitis often develop medically refractory colonic inflammation or colorectal neoplasia, and approximately 10% to 15% of patients require surgery. The most common surgical procedure is a restorative proctocolectomy with IPAA. Even if the preoperative diagnosis is ulcerative colitis, approximately 10% of patients can develop inflammatory pouch conditions resembling a Crohn's disease phenotype. OBJECTIVE This study aimed to review the diagnostic approach, prognosis, and management of IPAA with Crohn's disease-like features. DATA SOURCES The data sources include search in electronic databases. STUDY SELECTION This narrative review included studies focusing on pouches with Crohn's disease-like features. MAIN OUTCOME MEASURES The main topics in this review included the pathogenesis, risk factors, diagnosis, phenotypes, prognosis, and medications of pouches with Crohn's disease-like features. RESULTS A diagnostic approach for the pouch conditions resembling a Crohn's disease phenotype should be based on history-taking to evaluate its risk factors and endoscopic assessment of the pouch. Prior disease history and pathology, location of pouch complications, and timing of complications offer clues for the differential diagnosis of this phenotype. We advocate for the more descriptive term "pouch with Crohn's disease-like features" and reserve the term "Crohn's disease of the pouch" for patients who undergo IPAA and have a precolectomy diagnosis of Crohn's disease or whose colectomy pathology revealed Crohn's disease. Medications, which are often used for traditional Crohn's disease, show efficacy in pouches with Crohn's disease-like features as well. The poor prognosis associated with pouches with Crohn's disease-like features, particularly the fistulizing phenotype, underscores the importance of proactive monitoring and therapeutic intervention. LIMITATIONS The limitations include no explicit criteria for article selection. CONCLUSIONS This review suggests future research should seek to understand the natural history and meaningful shorter and longer term therapeutic targets for these types of pouch phenotypes. Long-term follow-up and prospective preoperative and postoperative interventional trials of treatments and prevention strategies are needed.
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Abstract
BACKGROUND In patients with ulcerative colitis or familial adenomatous polyposis who develop neoplasia or fail medical therapy and require colectomy, restorative proctocolectomy with IPAA is often indicated. Although often well tolerated, IPAA can be complicated by cuffitis or inflammation of the remaining rectal cuff. Although much has been published on this subject, there is no clear and comprehensive synthesis of the literature regarding cuffitis. METHODS Our systematic literature review analyzes 34 articles to assess the frequency, cause, pathogenesis, diagnosis, classification, complications, and treatment of cuffitis. RESULTS Cuffitis occurs in an estimated 10.2% to 30.1% of pouch patients. Purported risk factors include rectal cuff length >2 cm, pouch-rectal anastomosis, stapled anastomosis, J-pouch configuration, 2- or 3-stage IPAA, preoperative Clostridium difficile infection, toxic megacolon, fulminant colitis, preoperative biologic use, medically refractory disease, immunomodulator/steroids use within 3 months of surgery, extraintestinal manifestations of IBD, and BMI <18.5 kg/m2 at the time of colectomy. Adverse consequences associated with cuffitis include decreased quality-of-life scores, increased risk for pouchitis, pouch failure, pouch excision, and pouch neoplasia. CONCLUSIONS Given the similarities between pouchitis and cuffitis, diagnosis and treatment of cuffitis should proceed according to the International Ileal Pouch Consortium guidelines. This review found that the majority of the current literature fails to distinguish between classic cuffitis (a form of reminant ulcerative proctitis) and nonclassic cuffitis (resulting from other causes). Further work is needed to distinguish the unique risk factors and endoscopic characteristics associated with each subtype, and further randomized clinical trials should be conducted to strengthen the evidence for treatment options.
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30
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Shaffer SR, Bernstein CN. Controversies in Crohn's Disease Before and After Pouch Surgery. Dis Colon Rectum 2022; 65:S45-9. [PMID: 35895863 DOI: 10.1097/DCR.0000000000002550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND IPAA is rarely performed in patients with a known diagnosis of Crohn's disease, although it may be done in highly selected patients with an absence of perianal disease or small bowel inflammation. Patients with a preoperative diagnosis of Crohn's disease are, however, at increased risk of developing Crohn's disease of the pouch. Crohn's disease of the pouch can also occur in people with a preoperative diagnosis of ulcerative colitis; however, it is unknown whether this phenotype is similar to classic Crohn's disease involving an intact bowel, or whether it is a distinct entity. OBJECTIVE This study aimed to describe Crohn's disease of the pouch, including luminal inflammation, and fibrostenotic and perforating phenotypes, as well as management of these conditions. RESULTS Crohn's disease of the pouch can present in similar ways as classic Crohn's disease, classified as either inflammatory, fibrostenotic, or penetrating. Criteria involving the diagnosis of Crohn's disease of the pouch are stringent to prevent unnecessary treatments, because a diagnosis of Crohn's disease after IPAA for presumed ulcerative colitis can cause mental anguish. Treatment of Crohn's disease of the pouch depends on the presenting phenotype, although therapies are similar to classic Crohn's disease. Endoscopic, or even surgical treatment, may be required for fibrostenotic and fistulizing diseases. LIMITATIONS Crohn's disease of the pouch is a newly described disease of patients who undergo an ileoanal pouch anastomosis; and therefore, most of the evidence comes from retrospective trials in patients with an initial diagnosis of ulcerative colitis. CONCLUSIONS While Crohn's disease of the pouch is controversial and perhaps a distinct disease within the spectrum of inflammatory bowel diseases, it nonetheless requires long-term medical therapy and close follow-up.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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32
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Bakes D, Kiran RP. Overview of Common Complications in Inflammatory Bowel Disease Surgery. Gastrointest Endosc Clin N Am 2022; 32:761-776. [PMID: 36202515 DOI: 10.1016/j.giec.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The complication rate after surgery in patients with inflammatory bowel disease is high owing to chronic inflammatory and suboptimal physiologic state, the effect of steroids and immunosuppressive medication, and the inherent complexity of the surgical procedures. Although some of the complications after surgery are similar for Crohn disease and ulcerative colitis, others are specific to the diagnosis. Complications are divided into early postoperative and late complications. Specific complications are related to more extensive surgery such as a proctocolectomy or reoperative procedures or with complex reconstructive procedures such as the ileoanal pouch and continent ileostomy.
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Affiliation(s)
- Debbie Bakes
- Division of Colorectal Surgery, Columbia University Medical Center, New York Presbyterian Hospital, 161 Fort Washington Avenue, 8th Floor, Herbert Irving Pavilion, New York, NY 10032, USA
| | - Ravi Pokala Kiran
- Division of Colorectal Surgery, Columbia University Medical Center, New York Presbyterian Hospital, 161 Fort Washington Avenue, 8th Floor, Herbert Irving Pavilion, New York, NY 10032, USA.
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Li DF, Yang MF, Xu J, Xu HM, Zhu MZ, Liang YJ, Zhang Y, Tian CM, Nie YQ, Shi RY, Wang LS, Yao J. Extracellular Vesicles: The Next Generation Theranostic Nanomedicine for Inflammatory Bowel Disease. Int J Nanomedicine 2022; 17:3893-3911. [PMID: 36092245 PMCID: PMC9462519 DOI: 10.2147/ijn.s370784] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 08/25/2022] [Indexed: 12/02/2022] Open
Abstract
The recent rapid development in the field of extracellular vesicles (EVs) based nanotechnology has provided unprecedented opportunities for nanomedicine platforms. As natural nanocarriers, EVs such as exosomes, exosome-like nanoparticles and outer membrane vesicles (OMVs), have unique structure/composition/morphology characteristics, and show excellent physical and chemical/biochemical properties, making them a new generation of theranostic nanomedicine. Here, we reviewed the characteristics of EVs from the perspective of their formation and biological function in inflammatory bowel disease (IBD). Moreover, EVs can crucially participate in the interaction and communication of intestinal epithelial cells (IECs)-immune cells-gut microbiota to regulate immune response, intestinal inflammation and intestinal homeostasis. Interestingly, based on current representative examples in the field of exosomes and exosome-like nanoparticles for IBD treatment, it is shown that plant, milk, and cells-derived exosomes and exosome-like nanoparticles can exert a therapeutic effect through their components, such as proteins, nucleic acid, and lipids. Moreover, several drug loading methods and target modification of exosomes are used to improve their therapeutic capability. We also discussed the application of exosomes and exosome-like nanoparticles in the treatment of IBD. In this review, we aim to better and more clearly clarify the underlying mechanisms of the EVs in the pathogenesis of IBD, and provide directions of exosomes and exosome-like nanoparticles mediated for IBD treatment.
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Affiliation(s)
- De-Feng Li
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, People's Republic of China
| | - Mei-Feng Yang
- Department of Hematology, Yantian District People's Hospital, Shenzhen, People's Republic of China
| | - Jing Xu
- Department of Gastroenterology and Hepatology, Guangzhou Digestive Disease Center, Guangzhou First People's Hospital (School of Medicine of South China University of Technology), Guangzhou, People's Republic of China
| | - Hao-Ming Xu
- Department of Gastroenterology and Hepatology, Guangzhou Digestive Disease Center, Guangzhou First People's Hospital (School of Medicine of South China University of Technology), Guangzhou, People's Republic of China
| | - Min-Zheng Zhu
- Department of Gastroenterology and Hepatology, Guangzhou Digestive Disease Center, Guangzhou First People's Hospital (School of Medicine of South China University of Technology), Guangzhou, People's Republic of China
| | - Yu-Jie Liang
- Department of Child and Adolescent Psychiatry, Shenzhen Kangning Hospital, Shenzhen, People's Republic of China
| | - Yuan Zhang
- Department of Medical Administration, Huizhou Institute of Occupational Diseases Control and Prevention, Huizhou, People's Republic of China
| | - Cheng-Mei Tian
- Department of Emergency, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, People's Republic of China
| | - Yu-Qiang Nie
- Department of Gastroenterology and Hepatology, Guangzhou Digestive Disease Center, Guangzhou First People's Hospital (School of Medicine of South China University of Technology), Guangzhou, People's Republic of China
| | - Rui-Yue Shi
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, People's Republic of China
| | - Li-Sheng Wang
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, People's Republic of China
| | - Jun Yao
- Department of Gastroenterology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, People's Republic of China
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Gabbiadini R, Dal Buono A, Correale C, Spinelli A, Repici A, Armuzzi A, Roda G. Ileal Pouch–Anal Anastomosis and Pouchitis: The Role of the Microbiota in the Pathogenesis and Therapy. Nutrients 2022; 14:2610. [PMID: 35807791 PMCID: PMC9268595 DOI: 10.3390/nu14132610] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 06/15/2022] [Accepted: 06/22/2022] [Indexed: 11/20/2022] Open
Abstract
Inflammatory bowel diseases, Crohn’s disease and ulcerative colitis, are life-long disorders characterized by the chronic relapsing inflammation of the gastrointestinal tract with the intermittent need for escalation treatment and, eventually, even surgery. The total proctocolectomy with ileal pouch–anal anastomosis (IPAA) is the surgical intervention of choice in subjects affected by ulcerative colitis (UC). Although IPAA provides satisfactory functional outcomes, it can be susceptible to some complications, including pouchitis as the most common. Furthermore, 10–20% of the pouchitis may develop into chronic pouchitis. The etiology of pouchitis is mostly unclear. However, the efficacy of antibiotics in pouchitis suggests that the dysbiosis of the IPAA microbiota plays an important role in its pathogenesis. We aimed to review the role of the microbiota in the pathogenesis and as a target therapy in subjects who develop pouchitis after undergoing the surgical intervention of total proctocolectomy with IPAA reconstruction.
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Le Cosquer G, Buscail E, Gilletta C, Deraison C, Duffas JP, Bournet B, Tuyeras G, Vergnolle N, Buscail L. Incidence and Risk Factors of Cancer in the Anal Transitional Zone and Ileal Pouch following Surgery for Ulcerative Colitis and Familial Adenomatous Polyposis. Cancers (Basel) 2022; 14:cancers14030530. [PMID: 35158797 PMCID: PMC8833833 DOI: 10.3390/cancers14030530] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 01/17/2022] [Accepted: 01/18/2022] [Indexed: 12/29/2022] Open
Abstract
Proctocolectomy with ileal pouch-anal anastomosis is the intervention of choice for ulcerative colitis and familial adenomatous polyposis requiring surgery. One of the long-term complications is pouch cancer, having a poor prognosis. The risk of high-grade dysplasia and cancer in the anal transitional zone and ileal pouch after 20 years is estimated to be 2 to 4.5% and 3 to 10% in ulcerative colitis and familial polyposis, respectively. The risk factors for ulcerative colitis are the presence of pre-operative dysplasia or cancer, disease duration > 10 years and severe villous atrophy. For familial polyposis, the risk factors are the number of pre-operative polyps > 1000, surgery with stapled anastomosis and the duration of follow-up. In the case of ulcerative colitis, a pouchoscopy should be performed annually if one of the following is present: dysplasia and cancer at surgery, primary sclerosing cholangitis, villous atrophy and active pouchitis (every 5 years without any of these factors). In the case of familial polyposis, endoscopy is recommended every year including chromoendoscopy. Even if anal transitional zone and ileal pouch cancers seldom occur following proctectomy for ulcerative colitis and familial adenomatous polyposis, the high mortality rate associated with this complication warrants endoscopic monitoring.
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Affiliation(s)
- Guillaume Le Cosquer
- Department of Gastroenterology and Pancreatology, CHU Toulouse-Rangueil (University Hospital Centre) and Toulouse University, UPS, 31059 Toulouse, France; (G.L.C.); (C.G.); (B.B.)
| | - Etienne Buscail
- Department of Surgery, CHU Toulouse-Rangueil and Toulouse University, UPS, 31059 Toulouse, France; (E.B.); (J.-P.D.); (G.T.)
- IRSD, Toulouse University, INSERM 1022, INRAe, ENVT, UPS, 31300 Toulouse, France; (C.D.); (N.V.)
| | - Cyrielle Gilletta
- Department of Gastroenterology and Pancreatology, CHU Toulouse-Rangueil (University Hospital Centre) and Toulouse University, UPS, 31059 Toulouse, France; (G.L.C.); (C.G.); (B.B.)
| | - Céline Deraison
- IRSD, Toulouse University, INSERM 1022, INRAe, ENVT, UPS, 31300 Toulouse, France; (C.D.); (N.V.)
| | - Jean-Pierre Duffas
- Department of Surgery, CHU Toulouse-Rangueil and Toulouse University, UPS, 31059 Toulouse, France; (E.B.); (J.-P.D.); (G.T.)
| | - Barbara Bournet
- Department of Gastroenterology and Pancreatology, CHU Toulouse-Rangueil (University Hospital Centre) and Toulouse University, UPS, 31059 Toulouse, France; (G.L.C.); (C.G.); (B.B.)
| | - Géraud Tuyeras
- Department of Surgery, CHU Toulouse-Rangueil and Toulouse University, UPS, 31059 Toulouse, France; (E.B.); (J.-P.D.); (G.T.)
| | - Nathalie Vergnolle
- IRSD, Toulouse University, INSERM 1022, INRAe, ENVT, UPS, 31300 Toulouse, France; (C.D.); (N.V.)
| | - Louis Buscail
- Department of Gastroenterology and Pancreatology, CHU Toulouse-Rangueil (University Hospital Centre) and Toulouse University, UPS, 31059 Toulouse, France; (G.L.C.); (C.G.); (B.B.)
- Centre for Clinical Investigation in Biotherapy, CHU Toulouse-Rangueil and INSERM U1436, 31059 Toulouse, France
- Correspondence: ; Tel.: +33-5613-23055
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Kayal M, Dubinsky MC. Medical management of chronic pouch inflammation. Current Research in Pharmacology and Drug Discovery 2022; 3:100095. [PMID: 35281692 PMCID: PMC8913311 DOI: 10.1016/j.crphar.2022.100095] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 01/03/2022] [Accepted: 02/28/2022] [Indexed: 12/29/2022] Open
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