Pouchitis

Pouchitis, defined as nonspecific inflammation of the ileal pouch, is the most common long-term compli cation of IPAA in UC patients [54]. Aetiology is poorly understood, and several mechanisms have been suggested, such as genetic susceptibility, immune alterations, faecal stasis resulting in bacterial overgrowth, lack of mucosal nutrients, ischaemia and missed diagnosis of Crohn's disease, none of which have been proved. Pouchitis may be a form of IBD that recurs in the pouch or a novel third form of IBD. It tends to occur in equal frequency irrespective of the pouch configuration. A number of factors have been studied as potential predictors for the development of pouchitis. A positive association was found between the presence of EIM and PSC and the risk of developing pouchitis [55, 56]. Smoking appears to protect from developing pouchitis [57]. Data regarding other predictive factors are more controversial and include previous course of extensive colonic disease, backwash ileitis and serum perinuclear anti-neutrophil cytoplasmic antibody (pANCA) staining pattern [58]. The true incidence of pouchitis in patients operated for UC is difficult to determine as it depends on diagnostic criteria used to define the syndrome, accuracy and intensity of evaluation as well as length and method of follow-up. Reported incidence varies between 5% and 59% [59-61]. Diagnosis should be based on clinical, endoscopic and histolog-ic criteria [62]. To address this issue, a pouchitis disease activity index (PDAI) was developed taking into account clinical symptoms, endoscopic findings and histological changes, with pouchitis defined as a score greater than or equal to 7 points [63]. The use of clinical symptoms alone leads to overdiagnosis of pouchitis and unnecessary antibiotic use [62]. Pou-chitis may appear late in the postoperative course, and its incidence increases with increased length of follow-up [64].

Clinically, patients present with a marked increase of stool frequency, usually watery but occasionally bloody, urgency and incontinence. Abdominal pain and pelvic discomfort, fever, fatigue, anorexia and malaise are often present. Pouchitis is a heterogeneous disease and can be classified depending on the activity (remission, mild to moderate or severe) and pattern (acute, acute relapsing and chronic persistent). It is usually well controlled with medical therapy and a variety of agents have been used. For the majority of patients, 10-14 days of antibiotic treatment will rapidly control symptoms [65]. Metronidazole is probably the most commonly used first-line agent and has been shown to be effective for active chronic pouchitis in a meta-analysis [66]. However, long-term use of metronidazole may be hazardous and cause peripheral neuropathy. Ciprofloxacin has been widely used as an alternative or in combination with metronidazole [67].

Relapse is common. About 60% of patients who experience one episode of acute pouchitis will develop recurrent attacks [68]. In patients with chronic pouchitis who respond to antibiotic treatment and are in remission, the use of probiotics seems to be effective in the prevention of further episodes. Gionchetti et al. [69] in a double blind, placebo-controlled trial found that oral administration of a mixture of probiotic bacterial strains (VSL3) was effective in secondary prevention of pouchitis. In total, about 4.5-21.5% of UC patients develop chronic pou-chitis, which is defined as symptoms that persistent for more than 3 months or chronic antibiotic treatment [59, 70]. Chronic pouchitis may eventually lead to persistent use of anti-inflammatory agents, corticosteroids or immunosuppressive therapy [71]. A recent study found that patients who had suffered from chronic pouchitis had poorer functional results and general health perception when compared with patients with no or acute pouchitis [72]. About 1% of the patients develop chronic persistent pouchitis refractory to any medical treatment. In these patients, pouch excision is thus the only alternative since no other surgical approach has proved to alleviate symptoms and prevent recurrent pouchitis [60].

In our group of patients, the cumulative risk of developing at least one episode of pouchitis (that is, PDAI ^7) was 50%. Of the patients who developed pouchitis, 28% had a single acute episode that responded to antibiotics, 45% had recurrent acute attacks and 27% had chronic pouchitis that required long-term maintenance antibiotic therapy. Patients with pouchitis were followed for a statistically significantly longer period of time compared with patients without pouchitis. This finding supports the observation that the incidence of pouchitis tends to increase with time. Thus, we recommend that patients be followed up on a regular basis after the operation.

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