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Pouchitis After Ileal Pouch-Anal Anastomosis for Ulcerative Colitis Occurs with Increased Frequency Cholangitis

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Pouchitis After Ileal Pouch-Anal Anastomosis for Ulcerative Colitis Occurs with Increased Frequency Cholangitis 234 Gut 1996; 38: 234-239 Pouchitis after ileal pouch-anal anastomosis for ulcerative colitis occurs with increased frequency in patients with associated primary sclerosing Gut: first published as 10.1136/gut.38.2.234 on 1 February 1996. Downloaded from cholangitis C Penna, R Dozois, W Tremaine, W Sandborn, N LaRusso, C Schleck, D Ilstrup Abstract of concomitant primary sclerosing cholangitis Primary sclerosing cholangitis (PSC), (PSC), a chronic cholestatic syndrome of present in 5% of patients with ulcerative unknown cause characterised by fibrosing colitis, may be associated with pouchitis obliteration of the bile ducts, seems to be a after ileal pouch-anal anastomosis. The significant risk factor for the development of cumulative frequency of pouchitis in pouchitis.7 patients with and without PSC who To further explore the association between underwent ileal pouch-anal anastomosis PSC and pouchitis, the aims ofthis study were: for ulcerative colitis was determined. A (a) to determine if PSC represents an indepen- total of 1097 patients who had an ileal dent risk factor for pouchitis; (b) to compare pouch-anal anastomosis for ulcerative clinical, endoscopic, and pathological findings colitis, 54 with associated PSC, were of pouchitis in a subset of patients without studied. Pouchitis was defined by clinical PSC; and (c) to search for correlations criteria in all patients and by clinical, between the risk of pouchitis and status of endoscopic, and histological criteria in liver disease. 83% of PSC patients and 85% of their matched controls. PSC was defined by clinical, radiological, and pathological Methods findings. One or more episodes of pouchitis occurred in 32% of patients Patients without PSC and 63% of patients with Between January 1981 and April 1993, 1097 PSC. The cumulative risk of pouchitis at patients underwent ileal J pouch-anal anasto- one, two, five, and 10 years after ileal mosis for UC at the Mayo Medical Center in http://gut.bmj.com/ pouch-anal anastomosis was 15.5%0 Rochester, Minnesota. All pouches were con- 22/5%, 36%/ and 45.5% for the patients structed according to a technique previously without PSC and 22%/ 43%, 61%, and 79% described,8 and patients with indeterminate for the patients with PSC. In the PSC colitis or with other designs of reservoir were group, the risk of pouchitis was not excluded. The following information was related to the severity of liver disease. In retrieved from the medical records of all conclusion, the strong correlation patients: duration of UC calculated from the on September 24, 2021 by guest. Protected copyright. between PSC and pouchitis suggest a date of onset of colonic symptoms to the date common link in their pathogenesis. of IPAA; extent of UC (rectal, sigmoid, left (Gut 1996; 38: 234-239) sided, and pancolonic) and indication for IPAA. Keywords: pouchitis, ulcerative colitis, primary Fifty four of these patients were identified as sclerosing cholangitis. having associated PSC. The diagnosis of PSC Division of Colon and Rectal Surgery was based on established clinical or bio- C Penna chemical evidence of cholestasis of more than R Dozois Restorative proctocolectomy with ileal reser- six months' duration and characteristic cholan- Division of voir is now a widely accepted procedure in the giographic9 or typical hepatic histological find- Gastroenterology surgical treatment of ulcerative colitis (UC). ings, or both.10 For those patients with PSC, W Tremaine The operation cures the gastrointestinal symp- the following information was retrieved from W Sandbom N LaRusso toms and eliminates the potential for malig- the medical record: (1) Duration of PSC nant degeneration while preserving anorectal determined by the date of earliest suggested Section of Biostatistics functions. evidence of liver disease. (2) Specific symp- C Schleck Non-specific inflammation of the reservoir toms and of liver such as D Ilstrup signs disease, jaun- or pouchitis is the principal longterm compli- dice, fever, cholangitis, encephalopathy, Mayo Clinic and Mayo cation of ileal pouch-anal anastomosis (IPAA). variceal bleeding, ascites, hepatomegaly, Foundation, The clinical problem, dominated by diarrhoea, splenomegaly, and oesophageal varices. (3) Rochester, Minnesota, USA sometimes containing blood, and abdominal Biochemical testing, including serum alkaline discomfort, varies between 7 and 47% of phosphatase, total bilirubin, aspartate amino- Correspondence to: Dr RR Dozois, Mayo Clinic, patientsl4 depending on the duration of transferase, prothrombin time, and serum 200 First Street SW, follow up. Pouchitis usually occurs in patients protein electrophoresis. (4) Cholangiographic Rochester, Minnesota 55905, USA. operated on for UC5 and has been associated appearance of the biliary tree was classified as Accepted for publication with the presence of extraintestinal manifesta- normal, extrahepatic changes, or intra and 9 August 1995 tions of the disease.6 In particular, the presence extrahepatic changes.' Small duct PSC was Pouchitis and primary sclerosing cholangitis 235 defined as histological evidence of PSC episode per week with interruption of activi- (pericholangitis) with a normal cholangiogram ties). The use of drugs was defined by the need in a patient with a history ofUC. 12 Histological for more than four days per week of anti- changes were classified according to the diarrhoeal agents or antibiotics to control the criteria of Ludwig et al 13: cholangitis or portal frequency of defecation. Gut: first published as 10.1136/gut.38.2.234 on 1 February 1996. Downloaded from hepatitis (stage I), periportal fibrosis or peri- portal hepatitis (stage II), septal fibrosis or bridging necrosis, or both (stage III), and Statistical methods biliary cirrhosis (stage IV). Likelihood of The association of pouchitis with nominal risk patient survival (with regard to PSC) was factors was assessed with x2 tests, the associa- based on serum bilirubin concentration, histo- tion with ordinal risk factors was assessed with logical stage on liver biopsy, age, and the rank sum tests, and the association with con- presence of splenomegaly14 was also deter- tinuous variables was assessed with t tests or, mined for each patient. when necessary, rank sum tests. The occur- rence of pouchitis was estimated as a function of time since surgery using the Kaplan-Meier Definition ofpouchitis and classification of method. Log rank tests were used to compare clinical course the curves with nominal risk factors. The diagnosis of pouchitis was based on clinical criteria including watery diarrhoea, haematochezia, urgency, abdominal or pelvic Results discomfort, malaise, and fever. The occurrence of pouchitis in patients with or without PSC Cumulative risk ofpouchitis after IPAA in UC was determined by the date of the first episode with or without PSC after IPAA retrieved from a computerised Overall, pouchitis occurred at least once in 370 registry. This registry was also used to deter- patients (35.7%) after IPAA. Among the 1043 mine the length of time between IPAA and the patients without PSC, pouchitis occurred in first episode of pouchitis, the symptoms of 336 patients (32%) and in 34 of 54 patients pouchitis, and the number of episodes of with associated PSC (63%) (p<0 001, x2). pouchitis (less than or equal to two, more than The estimated risk of pouchitis at one, two, two, or chronic pouchitis). five, and 10 years after IPAA was 1 5.5%, A more detailed comparison of the clinical, 22.5%, 36%, and 45.5%, respectively, in endoscopic, and histological features of all the patients without PSC; and 22%, 43%, 61%, patients with pouchitis and PSC (n=34) were and 79% in patients with PSC, respectively. compared with a group of patients with Figure 1 shows the occurrence of pouchitis estimated as a function of time. The risk pouchitis but without PSC (n=33) retrieved http://gut.bmj.com/ from the computerised registry and matched was significantly greater in PSC patients for age, sex, extraintestinal manifestations (p<0.0001, log rank). other than PSC, date of IPAA, and length of follow up after closure of the temporary ileostomy. This more detailed evaluation was Pouchitis disease course after IPAA for UC with performed to assess whether the severity of and without PSC in pouchitis was similar in patients with and Chronic pouchitis was more frequent the on September 24, 2021 by guest. Protected copyright. without PSC. Clinical evaluation included the group of patients with PSC (60% v 15%, length of time between IPAA and the first p<0001), and acute pouchitis in those episode of pouchitis, the symptoms of patients with less than or equal to two pouchitis, and the number of episodes of episodes, occurred more often in patients pouchitis as defined above. The following without PSC (36% v 6%, p<0.001) (Fig 2). endoscopic findings of inflammation were Clinical, endoscopic, and histological pre- recorded as present or absent: oedema; granu- sentation of pouchitis in 34 patients with PSC larity; friability; erythema; loss of the vascular (group 1) were compared with a group of 33 pattern; mucus exudate; and mucosal ulcera- matched UC patients without PSC (group 2). tion. 15 16 The severity of endoscopic inflamma- As Table I shows, both groups were com- tion was then classified according to the parable with regard to demographic character- following definition: mild (discrete oedema of istics. the mucosa); moderate (erythema, muco- The mean interval between ileostomy purulent exudate, and small ulcerations); or closure and the occurrence of the first episode severe (deep ulcerations, diffuse erythema, and of pouchitis was 12 months (range one to 96 extensive mucosa necrosis). Histopathological months) in group 1 and 13 months (range two changes were classified according to the to 60 months) in group 2 (p=0.8). Diarrhoea criteria of Shepherd et al.'6 17 The pouchitis was the most common symptom and was disease activity index as described by present in 94 and 97% of each group respec- Sandborn18 was also used to quantitate pouch- tively. Abdominal cramping (79% v 44%, itis disease severity.
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