Management of Mucosal Complications: Pouchitis, Crohn Disease, and Cuffitis

Educational Objectives

The goal of this program is to treat patients with complications related to ileal pouch-anal anastomosis. After hearing and assimilating this program, the clinician will be better able to:

1.Diagnose complications related to ileal pouch-anal anastomosis using clinical and endoscopic findings.

2. Manage complications of ileal pouch-anal anastomosis using endoscopic findings and markers of inflammation.

Summary

Case: 30-yr-old woman reported having ulcerative colitis (UC) since 18 yr of age, with annual flares that required steroids despite maintenance using 5-aminosalicylic acid (5-ASA); 5 yr ago, she underwent total proctocolectomy with ileal pouch-anal anastomosis and loop ileostomy because of severe pancolitis refractory to steroid treatment; pathology studies found severe active disease of mucosa, indicating UC; loop ileostomy closed after 4 mo; after 6 mo, patient reported ≤12 loose bowel movements per day, with abdominal cramping and urgency for previous 10 days

Acute pouchitis

Treatment: small randomized clinical trial found metronidazole (Flagyl) more effective than placebo; another found efficacy of ciprofloxacin (Cipro) and metronidazole similar; focus on single-line therapy

Diagnosis: presence of symptoms alone insufficient for diagnosis; study found incidence of acute pouchitis in patients with symptomatic pouches ≈50%; others had irritable pouch syndrome or inflammation of rectal cuff (cuffitis); bleeding important indicator of cuffitis; pouchitis disease activity index (PDAI) — scoring system based on clinical, histologic, and endoscopic components; score >7 indicates acute pouchitis; modified PDAI — clinical symptoms and endoscopic findings assessed without biopsy findings; sensitivity 97% and specificity 100% for identifying pouchitis

Treatment (continued): empiric use of metronidazole as first-line therapy least expensive; if condition does not improve, perform endoscopy and treat based on findings; cost-effectiveness analysis found endoscopy without biopsy more expensive than treatment with metronidazole, but improvement in symptoms during 30 days after treatment greater; speaker recommends endoscopy without biopsy for patients with new symptoms related to ileal pouch; relapsing pouchitis — placebo-controlled trial found use of probiotic medical foods (VSL#3) effective, but findings not supported by subsequent research or clinical practice; long-term use of antibiotics (eg, metronidazole, ciprofloxacin, rifaximin, tinidazole) may help in control of relapsing chronic pouchitis

Case (continued): use of metronidazole led to resolution of symptoms, but patient developed increasingly frequent episodes of diarrhea over next few years and underwent multiple pouchoscopies that revealed inflammation of pouch; antibiotics eventually ineffective; review of original colectomy specimen found pancolitis and ulcerations that extended deep into muscularis externa; diagnosis indeterminate colitis due to deep transmural inflammation; pouchoscopy performed; x-ray indicated ulcers in afferent limb associated with Crohn disease

Ulcers in afferent limb: found in ≈80% of patients with Crohn disease in study of patients with ileal pouch-anal anastomosis; in patients with UC, presence limited to those who used nonsteroid anti-inflammatory drugs (NSAIDs)

Case (continued): symptoms decreased significantly after patient received azathioprine and prednisone; after tapering of steroids, maintenance with azathioprine effective

Algorithm for treatment of patient with ileal pouch and diarrhea: perform pouchoscopy without biopsy, and discontinue use of NSAIDs; differentiate cuffitis from pouchitis; cuffitis — topical 5-ASA or steroids; pouchitis — antibiotics; probiotics and long-term antibiotics for relapsing disease; Crohn disease with ulcers in afferent limb — anti-inflammatory therapy; irritable pouch syndrome — antidepressant or anticholinergic agents

Fecal markers of inflammation: study of 60 patients with ileal pouch-anal anastomosis found level of fecal lactoferrin low in patients with asymptomatic or noninflammatory disease and high in those with inflammatory conditions; at cutoff 7 µg/mL, sensitivity 100% and specificity 85% for identifying inflammatory conditions

Algorithm for treatment of symptomatic patient with ileal pouch-anal anastomosis: fecal lactoferrin <7 µg/mL — treat patient for irritable pouch syndrome; ≥7 µg/mL — treat patient according to results of endoscopy (without biopsy)

Readings

Murrell ZA et al: A prospective evaluation of the long-term outcome of ileal pouch-anal anastomosis in patients with inflammatory bowel disease-unclassified and indeterminate colitis. Dis Colon Rectum. 2009 May;52(5):872-8; Parsi MA et al: Fecal lactoferrin for diagnosis of symptomatic patients with ileal pouch-anal anastomosis. Gastroenterology. 2004 May;126(5):1280-6; Shen B et al: Modified pouchitis disease activity index: a simplified approach to the diagnosis of pouchitis. Dis Colon Rectum. 2003 Jun;46(6):748-53; Wolf JM et al: Afferent limb ulcers predict Crohn’s disease in patients with ileal pouch-anal anastomosis. Gastroenterology. 2004 Jun;126(7):1686-91.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Lashner was recorded at the 5th Annual Gastroenterology and Hepatology Symposium, held February 4-6, 2016, in Boca Raton, FL, and presented by the Cleveland Clinic Digestive Disease Institute. For information on future CME activities from this sponsor, please visit clevelandclinicmeded.com. The Audio Digest Foundation thanks the speakers and sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

GE310302

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.