Before treatment is started, it is important to exclude other less frequent causes of pouch dysfunction or pouch inflammation, and this is particularly necessary in the case of a refractory patient. An anasto-motic stricture, with consequent outlet obstruction and faecal stasis, is a common complication of IPAA; this increases stool frequency, makes the defecation painful with an incomplete evacuation predisposing to pouchitis. Diagnosis could be made by evacuation pouchography, while the stricture can usually be dilated with a finger or a rubber dilator.
Infectious etiology, caused by intestinal pathogens such as Shigella, Escherichia coli, Salmonella, Clostridi-
um difficile, should be ruled out by microbiology analysis and pouch biopsy. Multiple cases of cytomegalovirus infection have been reported showing the need for using monoclonal immunofluorescent staining for CMV for the examination of pouch biopsies when treatment with antibiotics has proven unsuccessful. In these patients the CMV infection must be excluded before starting immune modifier therapy [28-29].
Cuffitis is the inflammation of the retained rectal mucosa (columnar cuff) above the anal transitional zone (ATZ) after stapled anastomosis between the pouch and the top of the anal canal; this kind of inflammation, usually mild and not related to inflammation of the pouch, can cause anal discomfort, perianal irritation and pouch dysfunction. Clinically significant cuffitis should be defined using a triad of diagnostic criteria including clinical symptoms, endo-scopic inflammation and acute histologic inflammation . This syndrome rarely reaches dramatic proportions and clinical improvement can be obtained with topical corticosteroid, mesalazine suppositories and lidocaine gel applications. Scintigraphic pelvic pouch emptying scans can be used to evaluate patients who have inadequate pouch evacuation.
Fistulae and perianal abscesses should be suspected as being the expression of misdiagnosed Crohn's disease. Review of the proctocolectomy specimen and new biopsy samples are needed to make a correct diagnosis. If Crohn's disease is suspected, a small-bowel follow-through x-ray will rule out disease above the pouch. Approximately 5% of IPAA surgery is performed in patients whose primary diagnosis of UC is revised at some point after surgery to a definitive diagnosis of Crohn's disease. Other disorders that are able to mimic pouchitis symptoms are bile acid malabsorption, irritable pouch syndrome , and chronic pelvic sepsis.
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