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Diversion Colitis and Pouchitis: a Mini-Review

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Submit a Manuscript: http://www.f6publishing.com World J Gastroenterol 2018 April 28; 24(16): 1734-1747 DOI: 10.3748/wjg.v24.i16.1734 ISSN 1007-9327 (print) ISSN 2219-2840 (online) MINIREVIEWS Diversion colitis and pouchitis: A mini-review Kentaro Tominaga, Kenya Kamimura, Kazuya Takahashi, Junji Yokoyama, Satoshi Yamagiwa, Shuji Terai Kentaro Tominaga, Kenya Kamimura, Kazuya Takahashi, Published online: April 28, 2018 Junji Yokoyama, Satoshi Yamagiwa, Shuji Terai, Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8510, Japan ORCID number: Kentaro Tominaga (0000-0001-6792-1005); Abstract Kenya Kamimura (0000-0001-7182-4400); Kazuya Takahashi Diversion colitis is characterized by inflammation of (0000-0002-3097-9841); Junji Yokoyama (0000-0002-1810 the mucosa in the defunctioned segment of the colon -7709); Satoshi Yamagiwa (0000-0003-4791-6107); Shuji Terai after colostomy or ileostomy. Similar to diversion colitis, (0000-0002-5439-635X). diversion pouchitis is an inflammatory disorder occurring Author contributions: Tominaga K and Kamimura K wrote the in the ileal pouch, resulting from the exclusion of the manuscript; Takahashi K, Yokoyama J, Yamagiwa S and Terai fecal stream and a subsequent lack of nutrients from S collected information; all authors read and approved the final luminal bacteria. Although the vast majority of patients version of the manuscript. with surgically-diverted gastrointestinal tracts remain asymptomatic, it has been reported that diversion Conflict-of-interest statement: The authors declare that they colitis and pouchitis might occur in almost all patients have no current financial arrangement or affiliation with any with diversion. Surgical closure of the stoma, with organization that may have a direct influence on their work. reestablishment of gut continuity, is the only curative Open-Access: This article is an open-access article which was intervention available for patients with diversion disease. selected by an in-house editor and fully peer-reviewed by external Pharmacologic treatments using short-chain fatty reviewers. It is distributed in accordance with the Creative acids, mesalamine, or corticosteroids are reportedly Commons Attribution Non Commercial (CC BY-NC 4.0) license, effective for those who are not candidates for surgical which permits others to distribute, remix, adapt, build upon this reestablishment; however, there are no established work non-commercially, and license their derivative works on assessment criteria for determining the severity of different terms, provided the original work is properly cited and diversion colitis, and no management strategies to the use is non-commercial. See: http://creativecommons.org/ date. Therefore, in this mini-review, we summarize licenses/by-nc/4.0/ and review various recently-reported treatments for Manuscript source: Invited manuscript diversion disease. We are hopeful that the information summarized here will assist physicians who treat Correspondence to: Kenya Kamimura, MD, PhD, Lecturer, patients with diversion colitis and pouchitis, leading to Division of Gastroenterology and Hepatology, Graduate School better case management. of Medical and Dental Sciences, Niigata University, 1-757 Asahimachi-dori, Chuo-ku, Niigata 951-8510, Key words: Diversion colitis; Diversion pouchitis; Ileitis; Japan. [email protected] Inflammatory bowel disease Telephone: +81-25-2272207 Fax: +81-25-2270776 © The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved. Received: March 12, 2018 Peer-review started: March 13, 2018 First decision: March 30, 2018 Core tip: Diversion colitis is characterized by inflam­ Revised: April 1, 2018 mation of the mucosa in the defunctioned segment Accepted: April 16, 2018 of the colon after colostomy or ileostomy. The vast Article in press: April 16, 2018 majority of diverted patients remain asymptomatic, WJG|www.wjgnet.com 1734 April 28, 2018|Volume 24|Issue 16| Tominaga K et al . Diversion colitis and pouchitis however diversion colitis occurs in almost all diverted the first time by Triantafillidis et al[31] in 1991; Glotzer patients. Pharmacologic treatment using short-chain et al[2] reported the efficacy of steroid enemas in patients fatty acids, mesalamine, or corticosteroids are reportedly with diversion colitis in 1984, and similar results were effective for those who are not candidates for surgical subsequently reported by Lim et al[32] and Jowett et al[33]. reestablishment; however, there are no established Nonsurgical treatments include short-chain fatty acids, assessment criteria for determining the severity of 5-aminosalicylic acids, glucocorticoids, antibiotics, and diversion colitis, and no management strategies to date. so on. However, due to the lack established assessment In this mini-review, we summarize and review various methods, the efficacy of these treatments has not been recently-reported diversion disease treatments. We clearly confirmed. Consequently, surgical re-anastomosis hope this review will be useful for future treatment. remains the most reliable and effective treatment option. There is an unmet need for a summary of these therapeutic options and information regarding the Tominaga K, Kamimura K, Takahashi K, Yokoyama J, Yamagiwa S, Terai S. Diversion colitis and pouchitis: A mini-review. World disease assessment, and this need informed the present J Gastroenterol 2018; 24(16): 1734-1747 Available from: URL: literature review. We believe that the information http://www.wjgnet.com/1007-9327/full/v24/i16/1734.htm DOI: summarized in this mini-review will help physicians treat http://dx.doi.org/10.3748/wjg.v24.i16.1734 cases and, by increasing the number of treated cases, we will support the establishment of novel criteria for disease assessments and therapeutic decision trees. INTRODUCTION LITERATURE ANALYSIS Diversion colitis was first described by Morson et al[1] in A literature search was conducted using PubMed and 1974 as a non-specific inflammation in the diverted colon. Ovid, with the terms “diversion colitis” or “diversion Glotzer et al[2] labeled this inflammation “diversion colitis” proctitis” and “diversion pouchitis” used to extract in 1981. Since then, the disease has been reported in studies published over the preceding 45 years. All both retrospective[3-20] and prospective studies[21-27] which appropriate English-language publications from relevant have described the characteristic clinical, endoscopic, and journals were selected. We summarized the available pathological findings. Surprisingly, the prospective study information on demographics, clinical symptoms, reported that almost all cases exhibit colitis, evidenced by endoscopic and histological findings, treatment, and endoscopic analyses, 3 to 36 mo after the colostomy[21]. the clinical course. Symptomatic cases make up only around 30% of all cases diagnosed via endoscopic studies, and the precise pathogenesis of this condition remains unclarified. CLINICAL CHARACTERS Although a wide range of symptoms are reportedly asso- ciated with the disease, including abdominal discomfort, Epidemiology A total of 69 articles, including 25 case reports, were tenesmus, anorectal pain, mucous discharge, and rectal [3,4] matched to our definition of diversion colitis and bleeding , there are no established diagnostic criteria pouchitis assessment; this information is summarized for assessing disease severity. Diversion pouchitis is similar to diversion colitis, featuring inflammation of the in Tables 1 and 2. Based on our review, the prevalence ileal pouch that results from fecal stream exclusion and estimates of these conditions appear extremely high, the subsequent lack of nutrients from luminal bacteria. reaching almost the entire population of interest if Therefore, the difference between the pouchitis and the phenomenon is followed prospectively, beginning [21] diversion puchitis is whether the lesion is exposed to at 3 to 36 mo after colostomy . In a recent study, [3] the fecal stream or not. Patients generally present with Szczepkowski et al described more than 90% varying symptoms such as tenesmus, bloody or mucus- incidence of diversion colitis on endoscopy in a series like discharge, and abdominal pain[28]. The incidence of of 145 patients. The study further reported that there diversion pouchitis is unknown; however, it appears more were no significant associations between diversion commonly in patients with underlying inflammatory colitis and age, sex, type of stoma, or mode of surgery bowel disease (IBD). Nonsurgical approaches for the performed. The frequency of disease occurrence ranged [22] treatment of diversion pouchitis include the use of short from 70%-74% in patients without pre-existing IBD [6,21] chain fatty acids (SCFA), topical 5-aminosalicylic acids, and 91% in patients with pre-existing IBD . In and topical glucocorticoids. Unfortunately, efficacy study patients with histories of Crohn’s disease chronic severe outcomes are conflicting, and the only curative approach inflammation, often with transmural disease, has been is surgical re-anastomosis with the reestablishment of described after defunctioning colostomies[34]. It has also gut continuity[28-30]. been hypothesized that diversion colitis may be a risk In their 1989 examination of non-surgical treatment factor for ulcerative colitis in predisposed individuals, options procedure, Harig et al[5] reported the efficacy and that ulcerative colitis
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