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Pouch Dysfunction in Colitis
Published in Peter Sagar, Andrew G. Hill, Charles H. Knowles, Stefan Post, Willem A. Bemelman, Patricia L. Roberts, Susan Galandiuk, John R.T. Monson, Michael R.B. Keighley, Norman S. Williams, Keighley & Williams’ Surgery of the Anus, Rectum and Colon, 2019
Mariangela Allocca, Silvio Danese, Tom Øresland, Michael R.B. Keighley
A stapled anastomosis is the preferred technique to create the ileoanal pouch anastomosis,2 provided it is located no more than 1 to 2 cm from the dentate line. No more than a 1 to 2 cm of anal canal involving the anal transitional zone should remain. Cuffitis is inflammation of the mucosa of the rectal remnant, which has been left above the desired transection site usually because of technical difficulty in resecting the entire rectum in fat short males. In a large cohort of 931 UC patients undergoing IPAA, the prevalence of cuffitis was 13% (see Figure 68.1).2,70
A pragmatic stepwise approach to the diagnosis and management of refractory acute pouchitis
Published in Expert Opinion on Pharmacotherapy, 2021
Zaid S. Ardalan, Miles P. Sparrow
Pouch symptoms of increased frequency, urgency and abdominal cramps are not specific to idiopathic pouchitis and can be seen in secondary pouchitis and non-inflammatory pouch complications. Therefore, objective evaluation with pouchoscopy is needed. This is particularly crucial when managing a first episode of pouch dysfunction or when an empiric course of antibiotic fails. In fact, pouchoscopy is considered more cost-effective than an empiric trial of antibiotics for episodes of acute pouchitis [4]. It will help diagnose isolated cuffitis, prepouch ileitis and ischemic pouchitis (asymmetric sharply demarcated inflammation within the pouch body). Furthermore, the degree of pouch body inflammation on pouchoscopy can help distinguish pouchitis from irritable pouch syndrome. Using the Pouchitis Disease Activity Index (PDAI), which consists of symptom (0–6 points), endoscopy (0–6 points), and histology (0–6 points) sub-scores, a PDAI score of ≥7 points is diagnostic for pouchitis [5]. Second, while the PDAI allows diagnosis of pouchitis, it does not distinguish idiopathic pouchitis from secondary causes of pouchitis or other causes of diarrhea such as celiac disease. Hence, this approach should be coupled with a fecal sample tested for C. difficile toxin, a review of NSAID intake and celiac serology. Importantly, special attention should be made to the onset of pouch symptoms in relation to stoma closure. Those whose symptoms started immediately after stoma closure should be suspected of and investigated for a pouch leak or sinus. Third, and particularly in patients with antibiotic refractory pouchitis, Crohn’s-like disease of the pouch (CLDP) needs to be ruled out. In the absence of defining Crohn’s-like features, such as complex peri-pouch fistulas or proximal small bowel strictures, the distinction may be difficult. This is particularly true since granulomas are only seen in 12–13% of CLDP cases. A diagnosis of CLDP is suggested by the presence of deep ulcerations in the pouch body combined with risk factors for CD such as a preoperative diagnosis of indeterminate colitis, active smoking, and positive anti-Saccharomyces cerevisiae antibodies (ASCA).
Biologics and immunomodulators for treating Crohn’s disease developing after surgery for an initial diagnosis of ulcerative colitis: a review of current literature
Published in Scandinavian Journal of Gastroenterology, 2018
Abhijeet Yadav, Joshua Foromera, Kenneth R. Falchuk, Joseph D. Feuerstein
Finally, it is imperative that more common conditions including: pouchitis, cuffitis, irritable pouch syndrome, and surgical leaks/fistula are all excluded prior to considering a diagnosis of CD or CDL conditions of the pouch [13,14].