Gut: first published as 10.1136/gut.24.3.193 on 1 March 1983. Downloaded from

Gut, 1983, 24, 193-201

Dysfunction of the continent ileostomy: clinical features and bacteriology*

DARLENE G KELLY, S F PHILLIPS. K A KELLY, W M WEINSTEIN, AND MARY J R GILCHRIST From the Unit and Department of Laboratorv Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, and the Departmlent of Medicine, University of California, Los Angeles, California, USA

SUMMARY The pathogenesis and treatment of dysfunction of the continent ileostomy was investigated in 12 patients, five of whom had asymptomatic and seven of whom had acute complaints. The number of anaerobic bacteria in jejunal aspirates was increased in patients with pouch malfunction (range 103 to 108/g aspirate), but the microbiology of ileal effluent and the morphology of the ileal mucosa could not be correlated with dysfunction. acid breath tests and lactose tolerance tests were not, however, reliable indicators of jejunal bacterial overgrowth. The symptoms, the malabsorption, and the number of jejunal and ileal anaerobic bacteria decreased in patients during treatment with , implicating overgrowth of anaerobic bacterial flora in the pathogenesis of the syndrome.

The continent ileostomy (ileal pouch), devised by vitamin B12,9 12 proliferation of anaerobic bacteria http://gut.bmj.com/ Kock,' has been used as an alternative to con- in the pouch,9 inflammation in the pouch,7 ventional ileostomy for selected patients with incontinence,"' difficulty with intubation,1' and ulcerative and familial polyposis.2-5 The bloody discharge.5 We previously reported reservoir functions satisfactorily in most patients, diarrhoea with some features of malabsorption in but malfunction of the 'nipple valve' may occur in up approximately one-third of asymptomatic patients to a third of patients and lead to incontinence. with continent ileostomies. 12 Here, we extend these

Improved surgical techniques appear, however, to studies to include patients with symptoms of on September 25, 2021 by guest. Protected copyright. have decreased the incidence of valvular ileostomy dysfunction; we also examined the dysfunction ;2 5 furthermore, better selection of possible mechanisms for dysfunction and the patients should decrease the need for revision of symptomatic response to metronidazole. prolapsed valves.6 Because Crohn's disease may recur after construction of a pouch,2 5 we believe Methods that this diagnosis is a contraindication to the operation.2 5 T PATIENTS WITH POUCH DYSFUNCTION (Table 1) More recently other syndromes of ileostomy These patients were selected on the basis of docu- dysfunction have been reported. These are mented malabsorption and/or symptoms of a described variably as: 'stafnant loop syndrome',9 malfunctioning pouch. Five subjects (nos 1-5) with '' ,7 '', " and 'non-specific diarrhoea and malabsorption had been identified '. 5 "I The corresponding clinical features may earlier. 12 Their pouches were 'mature' (32-51 include diarrhoea,5 l0l2 malabsorption of fat and months postoperative, mean 40 months). On restudy, these five still had excess outputs of volume * Supported in part by grants from the National Foundation for lleitis and (>1000 g/day) and/or fat (Table 1). Seven patients Colitis. and the National Institutes of Health. Bethesda. Maryland (AM 69(08. AM 2(06(15. AM (16342-Il1. RR 585). A preliminary report of this work was (nos 6-12) had symptoms of dysfunction of the presented at the American Gastroenterological Association annual meeting. pouch (Table 1); these included bleeding from the May 198(1. Address for correspondence: Dr S F Phillips. Gastroenterology Unit. Mayo pouch, diarrhoea, peristomal discomfort, minor Clinic. Rochester. MN 559(05. USA. leakage, and difficulties with intubation. In five, the Received for publication 2(0 August 1982 onset of symptoms was during the first year after 193 Gut: first published as 10.1136/gut.24.3.193 on 1 March 1983. Downloaded from

194 Kelly, Phillips, Kelly, Weinstein, and Gilchrist

Table 1 C'linic(allfatures of pantient.s with ileostomrv dvsflulntioino Schilling tie.vt$ After lleuomn Faecal wit/i intrinsic Age operatiotn resected wveight IieI' t fiictor Patienti (vr) Sex (montls) (cm) (g/24 hi ('/,241i('I in uirinte) SSymptomns I 61) F 51 22 898 23 6 Bone pain; otherwise asymptomatic 2 39 F 35 14 1508 20 9 Asymptomatic 3* 48 M 36 70 1785 10 12 Asymptomaitic 4 33 M 35 8 994 15 32 Asymptomiatic 5 72 M 50 6 763 11 6 Asymptomatic 6 24 F 32 4 905 5 18 Blceding from pouch. RLQ pain 7* 32 F 33 1(-2() 1166 6 12 Difficult intuhation. pouch pain 8 18 F 8 10)32 4 2 Bleeding from pouch. RLQ paiin 9* 19 F 9 5 1052 9 12 . diarrhoea. abdominal craimps 10 21 M 8 3 1485 11 26 Difficult intubation. pouch pain. diarrhoea 11* 35 F 6 <10 1332 5 24 Bleeding from pouch. cramps. diarrhoea 12 46 F 1 4 856 8 3 Nausea. diarrhoea. RLQ pain Secondary conversion of Brooke ilcostomy. t Expressed as pcrcentage dietary intake, approximate fait was l (N) g/day. Upper limit of normal. 7'ih. t Normal >9%. operation (range, one to nine months; mean, five ileostomies constructed 2() to 58 months (mean, 38 months). Two were studied 32 and 33 months after months) previously. operation. All patients in the study had proctocolectomies performed for chronic . All gave CONTROL PATIENTS (Table 2) written, informed consent for the protocol that had In five patients (nos 13-17) with continent been approved by the Human Studies Committee of ileostomies, we had documented in a previous Mayo Clinic. The patients were hospitalised in the study12 normal pouch effluents (weight <1000 g/24 h Clinical Research Center. They were given constant http://gut.bmj.com/ and faecal fat <7 gl24 h), both of which were diets of known composition, designed to be similar confirmed. These subjects had had their pouches for to the usual dietary pattern at home, and including 35 to 63 months (mean, 50 months). A second 100 g fat. None was taking medication. One patient control group (Table 2) consisted of eight patients (no. 4), who was taking salicylazosulphapyridine, (nos 18-25) who had conventional (Brooke) discontinued the drug two weeks before the study. on September 25, 2021 by guest. Protected copyright. Table 2 Clinicalfeatures ofpatients in control groups Schilling te.stt with intrinsic Age After operation lleum resected Faecal weight Faecalfat* factor Patient (yr) Sex (months) (cm) (g/24 h) (Cc/24 h) (Mc in urine) lleal pouch - normal function 13 38 F 51 1() 743 4 16 14 27 F 61 2 267 1 36 15 28 F 63 0 546 4 16 16 51 F 35 7 453 2 23 17 43 F 40 4 543 3 17 Conventional ileostomy 18 72 M 58 38 1073 5 24 19 52 M 31 6 629 4 21 20 20 M 30 17 613 2 27 21 25 F 54 3 355 3 23 22 50 M 20 8 603 2 16 23 35 M 22 30 958 3 31 24 49 M 36 5 719 2 17 25 37 M 55 6 424 2 24 * Expressed as percentage dietary intake excreted per day; approximate dietary fat was 100 g/day. Upper limit of normal. 7%. t Normal >9%. Gut: first published as 10.1136/gut.24.3.193 on 1 March 1983. Downloaded from

Di.stu, ( tiott ofc(oltinlelt ileostootin1 195

STUDIES OF II.EOSTOMY EFFILUENT agar, and colistin-nalidixic acid agar plates were lleostomy effluent was collected for 48 hours, and inoculated and incubated at 35°C. For isolation of the weight of the specimen was recorded. All anaerobes, phenethylalcohol agar, rabbit blood agar specimens were frozen immediatelv upon collection with gentamicin and vancomycin, and laked sheep and thawed only for homogenisation and blood agar were inoculated and incubated in Gas preparation of aliquots, which were processed Pak jars (Baltimore Biological Laboratories) without delay. The fat content of effluents was containing catalyst and Gas Pak envelopes for the determined by the method of van de Kamer' 3and an generation of hydrogen and carbon dioxide. After output of <7% of the daily fat intake was con- 48, 72, and 96 hours of incubation at 35°C, colonies sidered normal. were picked to aerobic and anaerobic conditions so that strict anaerobes could. be differentiated and VITAMIN B12 ABSORPTION TEST further identified to the genus or species level. Standard Schilling tests were performed by simul- Statistical comparisons of numbers of organisms taneous jngestion of 0(25 ,ug cyanocobalamin con- were made between groups using the Wilcoxon's taining 0O8 MCi '8Co cyanocobalamin and of 0.25 1ug rank sum test for unpaired data. cyanocobalamin containing 0.5 ,Ci 57Co cyano- The intestinal contents were examined for faecal cobalamin bound to human gastric juice (Amersham pathogens by appropriate enrichment techniques. Corporation Dicopac Kit). A loading dose of 1 mg Campylobacter fetus ssp jejuni, Salmonella, and unlabelled vitamin B12 was given intramuscularly 1, Shigella were sought specifically. Direct visual to two hours after the oral dose. Urinary excretion examination for presence of parasites was of >9%/24 h of each isotope was taken as normal. performed on each specimen. Faecal samples from nine of the patients with stomal dysfunction were JEJUNAL BIOPSIES examined for Clostridium difficile toxin (tests Jejunal biopsies were obtained from the region of performed in the laboratory of Drs J W Chang and the ligament of Treitz with the Quinton Multi- S L Gorbach). purpose Biopsy Tube. Biopsies were oriented, fixed in modified Bouin's fixative (1% glacial acetic acid), BREATH TESTS Bile acid breath tests were performed according to and processed for light microscopy (haematoxylin http://gut.bmj.com/ and eosin) as previously described.'4 Jejunal the method of Fromm and Hofmann. '6 Patients histology was evaluated by one of us (WMW) were fasted for 12 hours before receiving an oral without previous knowledge of the clinical features dose of 5 uCi 1-4C-cholyl glycine in 240 ml Ensure of the patients. Histological findings were (Ross Laboratories). Expired air was collected in categorised into normal , abnormal hydroxide of hyamine before administration of the architecture (villous blunting). and the presence or isotopes and then hourly for four hours after the bile absence of mucosal inflammation. Mucosal inflam- acid was given. Trapped 14C02 was suspended in a mation was defined as an unequivocal increase in Perma-fluor, Carbasoda (Packard Instruments) and on September 25, 2021 by guest. Protected copyright. lymphocytes and plasma cells ('round' cells) and/or quantified by counting against an external gamma the presence of polymorphonuclear leucocytes. standard in a Beckman LS 250 Scintillation Counter Mucosal biopsy samples were also frozen for subse- (Beckman Instruments). quent determination of mucosal sucrase and lactase Hydrogen breath tests were carried out after an activity. ' oral dose of 50 g lactose in distilled water.'5 17 Expired air was collected for five minutes before and MICROBIOLOGICAL ANALYSIS OF BOWEL at hourly intervals for four hours after adminis- CONTENTS tration of lactose. Breath hydrogen was determined After an overnight (12 hour) fast, aspirates of by gas chromatography. Simultaneous capillary proximal small intestinal content were obtained blood samples were obtained before and at 15, 30, from the region of the ligament of Treitz, using a and 60 minutes after lactose. Glucose concen- sterile tube. In addition, ileostomy effluent was trations were measured using the hexokinase assay collected from ileal pouches or appliances (Brooke (Hexokinase Kit, Beckman Instruments). ileostomies), approximately 14 hours after the previous evacuation. Bowel contents were ENDOSCOPY AND BIOPSY OF ILEOSTOMY immediately transferred to C02-filled vials for Ileal pouches and their valves were examined using quantitative microbiological studies. Ten-fold a Fujinon model FG, QBF fibreoptic endoscope. dilutions through 10-8 were made using sterile Biopsies were obtained under direct vision at several Ringer's lactate as a diluent. For isolation of aerobic separate sites with an ACMI 7035A biopsy forceps. organisms, sheep blood agar, eosin methylene blue The posterior wall of the pouch directly opposite the Gut: first published as 10.1136/gut.24.3.193 on 1 March 1983. Downloaded from

1'96 Kellv, Phillips, Kelly, Weinstein, and Gilchrist valve was avoided, as it is the region most likely to 1fl10r*v suffer trauma from the catheter used to empty the pouch. Tissue for histology was prepared as described for jejunal biopsies and was also 108 - 0 evaluated by WMW. -E RESPONSE TO TREATMENT Patients with pouch dysfunction were treated with metronidazole (250 mg tid) and measurements of EU)W 104 faecal weight, faecal fat, and the Schilling test with a intrinsic factor were repeated at the end of a seven 0 or 14 day course of the antimicrobial. Results 100 CLINICAL FEATURES (Tables 1 and 2) Patients 1-5 had laboratory features of malabsorp- tion but were essentially asymptomatic. Even on specific questioning, only minor or no symptoms 0g Continent ileostomy could be elicited. Except for one patient (no. 6), with dystunction patients with symptoms (nos 6-12) had high faecal Fig. 1 Total anaerobic bacteria (l3acteroides, Clostridium, weights (>1000 g/24 h) and/or excessive faecal fat. Peptostreptococcus. Fusobacterium. Veillonella, Propiontic All control patients (Table 2) had normal faecal bacterium. Euibacterium) in jejutnal aspirates fromt1 patients weights and fat excretions except patient no. 18 who with conventional (Brooke) and continent (Kock) had an increased faecal Four 1, ileostomies. Control continent were asvtnptoimatic wit/lola weight. patients (nos evidence ofdysfunction. treatment given was mnetronidazole 5, 8, 12) had abnormal Schilling tests (<9% ingested 250 mg tid. Shaded area represents upper limit of normal in dose). All patients had normal serum vitamin B12 healthy subjects. Values are expressed as nuiimbers of levels. Other laboratory tests were normal or organisms per gram or millilitre ofaspirate. http://gut.bmj.com/ showed changes expected after proctocolectomy (mild systemic acidosis, mild hyperchloraemia). Two patients (nos 2 and 4) had abnormalities pharyngeal origin - that is, Streptococcus viridans, compatible with a diagnosis of Bacteroides oralis, Veillonella parvula, Neisseria associated with ulcerative colitis; these were long- species - with a notable absence of characteristic standing and antedated proctocolectomy. 'faecal' flora. While aerobic bacteria are normally was normal in all from found in the proximal bowel in concentrations Jejunal histology patients on September 25, 2021 by guest. Protected copyright. whom tissue was available for interpretation, with of 102-104/g,'8 the numbers of such organisms one exception. Patient no. 2 had normal villous which were observed in patients with dysfunction architecture but a mild increase of inflammatory (105-109/g) exceeded the numbers usually encoun- (round) cells in the lamina propria and a single crypt tered in the upper . abscess. Jejunal histology was not evaluated from On the other hand, no major differences were three control patients (nos 17, 19, 24) and two in the seen among groups when bacteria in the stomal dysfunction group (nos 8 and 11). effluents were quantified (Fig. 2). Flora in ileostomy effluent was primarily colonic in nature (Bacteroides MICROBIOLOGY OF JEJUNUM AND ILEAL EFFLUENT fragilis, Escherichia coli, group D streptococci) in In jejunal aspirates the numbers of total bacteria, the three groups of patients with no apparent aerobic and anaerobic, were larger for the patients qualitative or quantitative differences being with dysfunction than for either of the control recognised among groups. Faecal bacterial groups. Numbers of anaerobic bacteria are shown in pathogens, parasites, and Clostridium difficile Fig. 1; patients with pouch dysfunction differed cytotoxin were universally absent. from those with normally functioning continent (p<005), or conventional ileostomies (p=0.05). BILE ACID BREATH TESTS (Fig. 3) Counts of aerobic organisms reached 10 -109/g in Eight of the 12 patients with malfunctioning subjects with malfunctioning ileostomies, 0-104/g in ileostomies had bile acid breath tests within normal patients with conventional ileostomies (p<005), limits (<50 Fromm-Hofmann units) at two hours, and 102-107/g in controls with ileal pouches (NS). and 10/12 had normal levels (<150 Fromm- The major bacteria identified were of oral and Hofmann units) at four hours. Two patients (nos 1 Gut: first published as 10.1136/gut.24.3.193 on 1 March 1983. Downloaded from

D'.sfunticutlioI of (Onltinenllt illeostoiv197 19)7 ileal pouches (nos 13 and 17) and two with conven- tional ileostoniles (ilos 18 and 19) had levels conisidcered to be abnormnal at either two or four hours.

1 E1S 01 C\RBOIIYDRA1EC TO1FRANCE After a lactose load. excretion of hvdrogen in the breath was normal (less than 0(2 mllmin) in the second hour in all patients. Lactose tolerance to the 50 g dose was abnormal in one patient in the dysfunction group (no. 7. peak rise of 12 mg/dl at 6(0 minutes) and borderline in another (no. 3. peak rise of 21 mg/dl at 15 minutes). All other patients had a normal peak rise (>25 mg/dl).'' Lactase activitv in jejunal biopsies was abnormal in the same two patients with dysfunction (nos 3 and 7) and in two controls (nos 16 and 18). The values were 0(3. 0(6, & 0)*6, and 0( 1 U/mg wet weight respectively; all other Continern ileostomy levels were within the normal ralnge (0.7-1 11 with dysfunction U mg).' Fig. 2 Total anaerobic bacteril (Bacteroides. Clostridium. II.EAI MORPHOLOGY (Table 3) Peptostreptococcus. Fulsobacterium. Veillonella, Propionic Endoscopic appearances were normail in aill control bacterium, Eubacterium) in stomnal effluent fromti patietits patients and in four patients with ileostomy with conventional (Brooke) and contitnent (Kock) 5) had ileostomies. Control continent were as! mptomati( without dysfunction; these individuals (nos 1. 2. 3. evidence of dvsfuinction, treatment given was metronid.azole malabsorption, but no symptoms of dysfunction. 250 mg tid. Abnormal endoscopic findings included mild to friability without discrete moderate erythema. http://gut.bmj.com/ lesions (nos 8 and 10), and pinpoint erosions (nos 6, 9. 1 1). Correct postoperative anatomy of the 'nipple and 3) displayed clearly abnormal curves throughout valve' was confirmed in all patients. the test. A common finding (10/12 patients), Tissue fr-om the ileal pouch was adequate for however, was a high level of 14CO0 in expired air at interpretation in 11112 patients (17 biopsies) with one hour, which in eight patient represented the pouch dvsfunction. Seven patients had an abnormal peak value for the test. Control patients exhibited architecture (characterised by villous blunting) and similar patterns with a peak value at one hour being nine of 11 showed mild to moderate inflammatory on September 25, 2021 by guest. Protected copyright. observed in five patients (two with continent changes. The inflammatory cells were predominantly ileostomies and three with conventional round cells (plasma cells and lymphocytes), but ileostomies). In addition, two control patients with polymorphonuclear leucocytes were often present as

Control groups Dysfunction group

Fig. 3 Bile acid breath tests for patients with continent ileostomies (-) andfor those with conventional ileostomies (----). Normal levels are 14CCO2 expired demonstrated bv the shaded (Fromm Hofrr.nn Uf areas (16). Most patients exhibited a peak `CO, expiration at one hour regardless ofclinical status.

0 1 2 3 4 1 2 3 Time (hours) Time (hours) Gut: first published as 10.1136/gut.24.3.193 on 1 March 1983. Downloaded from

198 KellY, Phillips, KellY, Weltistein, and Gilchrist TIiblc 3 M1orpholog of'ilell/in

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well (nos 1, 2, 5. 6. 8, 9). Granulation tissue was presented with complaints of pouch dysfunction. In prominent in two patients (nos 2 and 7). Crypt all instances there was relief of pain, cramps. or abscesses were identified in two (nos 6 and 9). nausea, correction of the difficulty with intubation. Ten biopsies were available from the five 'pouch and cessation of bleeding. All patients had a controls' and tissue was obtained'from seven con- reduction in faecal weight, and, in addition, faecal ventional ileostomies. Four of the 12 controls had fat decreased to normal or near normal values in abnormal architecture and three of 12 showed patients 4. 5, and 1(; three of the four patients with inflammatory changes. In neither control group, an abnormally low Schilling test returned to the however, was the frequency and severity of morpho- normal range. logical features significantly different (X2 test) from As expected, metronidazole decreased the biopsies obtained from patients with dysfunction. number of anaerobic organisms in both jejunal and Moreover, histological change was certainly not a stomal specimens (Figs 1 and 2). Aerobic bacteria reliable indication of ileostomy dysfunction in any diminished in jejunal aspirates but increased in ileal individual (Fig. 4). Normal tissue was obtained from effluent. malfunctioning ileostomies and, conversely, Eleven biopsies of pouch mucosa were obtained abnormal appearances were seen in controls. from eight patients after metronidazole. One patient http://gut.bmj.com/ Furthermore, examination of serial sections (no. 1) whose pretreatment mucosal biopsy revealed revealed variability of morphological change within inflammation had a normal biopsy after treatment. individual biopsies, emphasising the patchy nature All others were unchanged by treatment. of abnormalities. FOLLOW-UP RESPONSE TO TREATMENT (Table 4) Responses to a follow-up questionnaire indicated After metronidazole there was symptomatic that four of 12 patients (nos 3. 4, 5. 8) had on September 25, 2021 by guest. Protected copyright. improvement in all patients (nos 6-12) who maintained a decreased ileal output without further

Fig. 4 A. Case3 (Table 1). Normal villous architecture in biopsyfrom ilealpouch. This patient had diarrhoea and mildsteatorrhoea. B. Case 16 (Table2). Marked villous blunting in biopsyfrom ilealpouch. Thispatient had normalpouchfunction. Both Hand E, x 120 (originalmagnification). Gut: first published as 10.1136/gut.24.3.193 on 1 March 1983. Downloaded from l)!s/uieuio .(0f eo icl i/eosti,nvl19 199 'ldhlcrlt 4 ,AbI.tti,Ut ti/c liFUietill /1o1 iul( *l /te absorption or pouch dysfunction develops. The identities of the predominant organisms in our studv did not reveal a specific micro-organism which could account for the difference. The response to /'lti (ifiii1('i ZIt I (iei (lii/(i I ii ii1 it/i //' 2)4 hi iii,!'iti(C li I' i lrilli) metronlidazole with its anaerobic spectrum of activity suggests that anaerobes or their byproducts I)iitii'nlt I/c/we4¢ Iut(J I/i(/inc( I8/et} I/c/toi -I/rl might be responsible for the clinical effects. Patients who have required subsequent treatment, however, I 2 S7)0S'(tS 1007t11)07? 2)) 4343RA99) I)0s have responded to a variety of antibiotics. 1'S' 1A'- It4 12 12 17 commonly ampicillin. Thus, an antibiotic with a 4 9(4 941 1 9 2 Is broader spectrum might have been even more 7(6 IS 1 S ( ') necessity for 6 9)1' 41) IS 30t useful. Follow-up has indicated the 7 11 '6(4( 6 6 . 1I repeated courses of antibiotics, a feature consistent .S 1B_ (C' 4 _ _ 13 with the diagnosis of 'contaminated bowel Itt 145' 1090) 6 26 NL) svndrome'. II 1332 664 ND 24 NI) 12 6 5 4 Among other groups that have observed ' S, o4; S 3 diarrhoea or dysfunction in patients with ileal NI) = l donett)1t pouches, Schj0nsby" and Loeschke` impli- cated bacterial overgrowth in the pouch itself. Our bacterial counts in ileostomy effluent were not courses of antimicrobials. Eight have required different among patients with pouch dysfunction. additional treatment with various antibiotics, and and those with normally functioning pouches or two have also been treated with salicylazosulpha- conventional ileostomies. The results reported here pvridine. All control patients have continued to for conventional ileostomies are comparable with have no symptoms with their ileal pouches. those of Gorbach et a121 and Finegold.2' Our bacterial counts from conventional and continent Discussion ileostomies are. however, one to two log units lower than those of Schj0nsby.' Thus, our findings do not http://gut.bmj.com/ Dvsfunction of ileal pouches is due most often to suggest that quantitative microbiology of ileostomy partial or complete reduction of the 'nipple valve`; effluent is of value diagnostically. valve prolapse leads to a characteristic svndrome of It should be noted that the jejunal flora was incontinence and difficult intubationis.' Although qualitatively that of the proximal gut, and did not improvements in operative techniques and better reflect the content of the pouch. Factors responsible selection of patients- have lowered the incidence for jejunal bacterial overgrowth are uncertain, but of valve failure. 5-10%7r of patients will still develop reflux of pouch contents' into the (and this complication. Pouch dvsfunction which is due to beyond) seem unlikely. Altered motility of the on September 25, 2021 by guest. Protected copyright. non-mechanical causes can. however, produce proximal intestine, secondary to distension of the similar symptoms and it is important clinically to pouch, is suggested by the finding of slowed transit distinguish between these causes. Anatomical of a liquid meal.22 Reduced motility in the proximal definition of the valve. by endoscopy and a barium small bowel might well impair clearance of .pouchogram'. will usually suffice. Our patients with oropharyngeal organisms from the jejunum. pouch dysfunction all had normal anatomy but were In an attempt to identify other associations with otherwise a mixed and unselected group. some with bacterial overgrowth, we examined jejunal histology a spectrum of symptoms and others having and disaccharidase activity and sought evidence of asymptomatic diarrhoea and/or malabsorption. bile acid deconjugation. Bile acid breath tests were We observed an impressive response to metronid- of limited benefit in predicting bacterial overgrowth azole in the patients with dysfunction of the of the proximal small intestine. Patients with both continent ileostomv. In part this mav be explained continent and conventional ileostomies, regardless by the unexpected finding of bacterial overgrowth of of clinical status, had abnormal breath tests at the the proximal small bowel. Even some patients with end of the first and second hours, suggesting rapid normal pouch function. however. had an apparent contact of bile acids with a flora capable of increase in jejunal flora. Thus, the presence of a deconjugation. The test did not separate from stagnant reservoir within the pouch may predispose controls the patients with increased numbers of to bacterial overgrowth in the jejunum in all bacteria in the proximal small bowel. The presence patients. and it is possible that a subtle qualitative of faecal flora in the ileum would be expected to difference in the flora determines whether mal- produce this pattern, making the application of Gut: first published as 10.1136/gut.24.3.193 on 1 March 1983. Downloaded from

200 KellY, Phillips, K/llY, Weinstein, alnd Gichrist traditional normal values obtained from healthy though efficacy should be monitored by repeating subjects of questionable validity. Only two of the 12 appropriate studies after treatment. If one antibiotic patients with pouch dysfunction had clearly faills, another may succeed and some patients will abnormal bile acid breath tests throughout the four require repeated courses of antibiotics. Given that a hour test. lifetime with an ileal pouch is to be expected, the The apparent discrepancy of the various indices of occurrence of evenl borderline malabsorption cannot lactose absorption is, perhaps. not surprising in be ignored though the significance is still uncertain. these patients who lack a colon. The failure of breath hydrogen excretion to increase may reflect The authors are grateful to Anne Haddad. Jennifer the absence of a faecal flora able to metabolise Bouska. an(l Carol McLimans of the Mayo Clinic, unabsorbed lactose. This possibility is supported by Colleen Murdoch of the Universitv of Alberta, and the presence of flat lactose tolerance curves and Esther Braden of UCLA for technical assistance, decreased jejunal lactase activity in two patients and to the staff of the Clinical Research Center, who had normal hydrogen breath tests. Depletion of Mayo Clinic, for care of the sublijects. Dr Sherwood mucosal lactase and are con- Gorbach's laboratory performed assays for sistent with a diagnosis of bacterial overgrowth, -3 clostridial toxins. Mary' I lancnberger provided but are not prerequisites. These biochemical expert secretarial help. abnormalities were infrequent and not associated with an abnormal morphology in our patients. Only one patient (no. 2) had a definite, but mild. non-specific histological lesion in the jejunum. Many have reported a non-specific inflammation of the pouch mucosa associated with symptomatic malabsorption. 71(') II> We found a poor correla- References tion between the endoscopic appearances of the 1 Kock NGi. Intra-abdominal reservoir in patients with pouch and the presence or absence of abnormalities permanent ileostomy. Agrchmg 1969. 99: 223-31. on light microscopy. Thus, an abnormal endoscopic 2 Dozois RR. Kelly KA. Beart RW. Beahrs OH.

appearance of a pouch, though dramatic, may be of Improved results with continenlt ilcostonmy. Anini Slmg http://gut.bmj.com/ little significance. Mucosal histology was also of 1980; 192: 3 19-24. little help diagnostically; tissue was abnormal in 3 King SA. Qualitv of life - the continent ileostomn. Anini some patients with well-functioning pouches and Surg 1975: 182: 29-32. normal in some with dysfunction. In part, these 4 Kock NG. Darle N. Kewenter J. Mvrvold H. Philipson B. The quality of life after proctocolectomy and findings may reflect patchy changes and the ileostomy: a study of patients with conventional problems of obtaining representative samples. Our ileostomies converted to continent ileostomies. Di.s findings are in agreement with Nilsson and Colon 1974; 17: 287-9'2. on September 25, 2021 by guest. Protected copyright. colleagues26 who reported slight to moderate inflam- 5 Kock NG. Darle N. Hulten L. Kewenter J. Mvrvold HI. matory reaction in the lamina propria of pouches in Philipson B. Ileostomv Clurr Prob Suirg 1977; 14: 1-52. seven of 13 patients, even though histochemically 6 Dozois RR. Kelly KA. llstrup D, Beart RW. Beahrs the mucosa was normal. OH. Factors influencing revision rate after continent There are several practical implications of the ileostomy. Arch Su,rg 1981; 116: 610-3. present study. When pouch function is disturbed, 7 King SA. Enteritis and continent ileostomy. C(onn Medl 1977; 41: 477-9. mechanical failure of the 'nipple valve' should be 8 Myrvold HE. Kock NG. Continent ilcostomy in sought by endoscopy and barium studies. A positive patients with Crohn's disease. (Abstract.) Gastro- diagnosis requires corrective re-operation. Endo- enterology 1981; 80: 1237. scopy might also suggest an alternative aetiology 9 Schjonsby H. Halvorsen JF. Hofstad T. Hovdenak N. and, although histology is not a reliable guide to Stagnant loop syndrome in patients with continent inflammation in the pouch, biopsies should be ileostomy (intra-abdominal ileal reservoir). Guit 1977; obtained to look for recurrent Crohn's disease. 18: 795-9. Quantitative faecal outputs of fat and volume should 10 Gelernt IM. Continent ileostomy forum. OstomYn Q be performed to document malabsorption if present. 1979; 16: 56-9. 11 Halvorsen JF, Hermann P, Hoel R, Nygaard K. The Faecal cultures and microscopy will be needed to continent reservoir ileostomy: review of a collective exclude specific pathogens27 and/or toxins but we series of thirty-six patients from three surgical found that the identification of faecal ecology was departments. Surgery 1978; 83: 252-8. unhelpful in contrast with the experience of 12 Kelly DG. Branon ME. Phillips SF. Kelly KA. others.9 9 Empirical treatment of pouch Diarrhoea after continent ileostomv. G(ut 1980: 21: dysfunction with antimicrobials may be reasonable, 711-6. Gut: first published as 10.1136/gut.24.3.193 on 1 March 1983. Downloaded from

D)'sfiuntionI of onitineni ilco.Sto,x. 20()1 13 Van der Kamer JiH, ten Bokkell. Iluininkl.\[C\r nornial llora oiol antdurxaid ransxerscolostom 5 HA. Rapid method for determination o ffats in eces. J etllticnts. .1 InlI/c 1)1% 197): 122: 376-81 Biol Chem 1949: 177: 347-55. 22 Kelly 1)DK. S'hillipsSF. Kelly KA. Weinstein WM1. 14 Perera DR. Weinstein WM, Rubin CE. Smill hosel (iiillierist NiR.] Bacterial overcrowth in the jejunumn ot biopsy. Huim Pathol 1975: 6: 157-217. 1;ti.'lts sit h il.al pouches. (Abstract. ) Goairo- 15 Newcomer AD, McGill DB. Thomras PJ. 1lofwonn i'nirolog 1'(0I9) 78: 1 193. AF. Prospective comparison of indlirect methorlslo 23 (jianineilla RA. Rout WR. loskes PP. Jelunal brush detecting lactase deficiency. EngI J M/cd 1(75: 293: border ilnjury ind impaired sugar and arnino acid 1232-6. uptake in blind loop syndrome. ((i.siroetiterologv 1974: 16 Fromm H, Hofmrann AF. Breatlh test for altered 67: 965-74. bile-acid metabolism. Lanmet 1971: 2: -S 4 l3loeh R. Menge H. Lorenz-Meseer H. Stockert H(. 17 Levitt MD. Donaldson RM. UJs of respiratorx Riecken EO. Functional. biochemical and morpho- hydrogen (H,) excretion to detect carbohydrate 1m;al- lowical alterations in the intestines of rats with experi- absorption. J Lab (Clin Md 197(1: 75: 937-45. mental blind-loop svndrome. Re.s Exp Me(l 1975: 166: 18 Donaldson RM Jr. The relation of cnteric bacterial 67-78. populations to gastrointestinal function and disease. In: 25 Bonello JC. Thow GB. Manson RR. Mucosail enteritis: SIcisinger MH. Fordtran JS. eds. GJ.%iroi,ucshild a complication of the continent ileostomy. Dis Coln Disease, 2nd edn. Philadelphia: Saunders. 1978. Recutlatn 1981; 24: 37-41. 19 Loeschke K. Bolkert T. Kieflhaber P. Ruckdeschel G. 26 Nilsson LO. Kock NG. Lindgren 1. Myrvold [HG. Lohrs V. Bark, S. Schaudig A. Bacterial overgrowth in Philipson BM. Ahren C. Morphological aind histo- ilcal reservoirs (Kock pouch): extended functional chemical changes in the mucosa of the continent studies. Hepao-Gia.stroentierol 19801; 27: 31(1-6. ileostomy reservoir 6-1( vears after its construction. 2(0 Gorbach SL. Nahas L. Weinstein L. Studies of S'cand J Gastroeniterol 1980(: 15: 737-47. intestinal microflora. IV. The microflora of' ilcostomv 27 Drake AA. Huizenga KA. Van Scoy RE. Campvlo- effluent: a unique microbial ecology. Ga,stroemterolog-x, bacter fetus s.s. jejuni: a caIuse of' in a patient 1976: 53: 874-80. with a continent ileostomr. Dig Dis Sci 1982: 27: 21 Finegold SM. Sutter VL. Bolc JD. Shimnada K. The 1(037-8. http://gut.bmj.com/ on September 25, 2021 by guest. Protected copyright.