1. Understanding Pouch Problems (in context) Kangaroo Club
Dr Oliver Brain DPhil
Consultant Gastroenterologist
7th Oct 2017

2. Overview Normal pouch function Pouchitis
Structured approach to pouch dysfunction

3. ‘Normal’ pouch function?
6-8 bowel movements per 24 h
1-2 bowel movements per night (approx 50% of patients)
Lack of urgency / able to defer for 1 h
Loose or semi-formed
Occasional seepage at night
Pouch function stabilises 1 year post surgery
Fazio V etal Ann Surg 1995;222: Sagar PM, Pemberton JH Dig Dis 1997;15:

4. What is normal?

5. What is normal?
80% people BO 1-2x per day

6. What is normal?

7. 58 had constipation (IBS-C) Urgency 16%-31% Straining 5-23%
278 women
Age 60
146 were ‘normal’
72 had diarrhoea (IBS-D)
58 had constipation (IBS-C)
Urgency 16%-31%
Straining 5-23%
Postprandial BO 25-34%
Incomplete evacuation 13-32%
Bharucha A et al Am J Gastroenterol 2008;103:692–698

8. 58 had constipation (IBS-C) Urgency 16%-31% Straining 5-23%
278 women
Age 60
146 were ‘normal’
72 had diarrhoea (IBS-D)
58 had constipation (IBS-C)
Urgency 16%-31%
Straining 5-23%
Postprandial BO 25-34%
Incomplete evacuation 13-32%
NB Prevalence of IBS ≈ 15%
Bharucha A et al Am J Gastroenterol 2008;103:692–698

9. Problems Specific to the Pouch
Pouchitis

10. What is pouchitis? What is pouchitis? Inflammation of the pouch
Suggested by: stool frequency
urgency
bleeding
incontinence
Diagnosis confirmed by:
Pouchoscopy
Histology

11. PDAI
Pouchitis is defined as a total score ≥7

12. Patterns of pouchitis Acute: ≤ 4 weeks Chronic: > 4 weeks
Infrequent
Relapsing
Continuous
Treatment responsive
Treatment refractory

13. Pouchitis prevalence 50% of UC patients will have ≥1 acute episode1
Up to 60% suffer recurrent episodes pouchitis
Prevalence of chronic pouchitis is 5-10%1
Pouch failure
At 20 years pouch failure rates are 10-15%2
Pouchitis accounts for 10% of pouch failure3
1. Simchul et al World J Surg Stahlberg et al Dis Colon Rectum Lohmuller et al Ann Surg Salemans et al Dig Dis Sci Tekkis et al Colorectal Dis Hahnloser et al Br J Surg Leowardi et al Lengenbecks Arch Surg Tulchinsky et al Ann Surg 2003

14. Why does pouchitis occur?
Idiopathic
Occurs in up to 50% of UC patients
Rarely seen in FAP patients
Genetic risk?
Microbial risk / dysbiosis?

15. } Genetics of pouchitis Small, underpowered studies. IL1RA1 NOD22
TLR93
CD143 }
Chronic relapsing pouchitis
1. Brett et al EJGH 1996; Carter et al Gastroenterology Seghal et al Dis Colon Rectum 2010; Tyler et al Gastroenterology Lammers et al World J Gastroenterol 2005

16. } } Other Risk Factors Extensive / severe UC
Pre-colectomy thrombocytosis
Backwash ileitis
Extra-intestinal manifestations
pANCA positivity
Non-smokers
NSAID use
Reflection of disease severity }
Reflect PSC association
Reviewed in Landy J et al Inflamm Bowel Dis 2012

17. Risk Factors
PSC
Associated with a 2-fold increase in risk of pouchitis1
Also associated with pre-pouch ileitis
IgG4 may be associated with a subset of chronic pouchitis patients2
1.Zins BJ et al Am J Gastroetnerol Penna C et al Gut Navaneethan U et al Gastrointestin Surg 2011

18. Aetiology Pouch mucosal adaptation and colonic metaplasia
Part of a normal adaptive response
Altered short chain fatty acid metabolism
Anaerobic fermentation of PSAs
Bile acids
Conflicting data
Microbiome

19. Microbiome Pouchitis only occurs once ileostomy closed
Pouch is exposed to concentrations >106 times the TI1,2
Evidence of an altered microbial signature in pouchitis3, but there is significant study heterogeneity
Antibiotics
Probiotics
1. Nicholls et al Gut Santavirta et al Int J Colorectal Dis Landy J et al Inflamm Bowel Dis 2012

20. Dysfunctional pouch
What does this mean?

21. What does ‘dysfunctional pouch’ mean?
Answers:
a) Dysfunctional pouch = poorly functioning pouch from any cause
b) Dysfunctional pouch = poor pouch function in absence of demonstrable pouchitis / inflammation
c) Dysfunctional pouch = irritable pouch

22. Dysfunctional Pouch Obstruction: Stricture Functional obstruction
Peri-pouch sepsis: Acute or historic
Small volume pouch
Irritable pouch – symptoms with a PDAI <7

23. Risk Factors for Pouch Dysfunction
Patient-dependent
IBS
Weak sphincters
Disease-dependent
PSC
Surgery-dependent
Peri-pouch sepsis / anastomotic leak
Anastomosis formation
Small pouch volume

24. Patient 28 year old man Background UC and PSC diagnosed 6 years ago
Colectomy for refractory colitis 3 years ago
Post-operative anastomotic leak
Best pouch function:
6x per day, 2x nocte
Minimal urgency, occasional nocturnal accidents
Currently
12x per day, 3x nocte
Severe urgency, incontinence every other day
Minimal response to antibiotics

25. Basic rationale for pouch assessment

26. Approach to Pouch Dysfunction
Examination
Diagnosis
Therapy
Refractory
DRE
Stricture
Dilatation
Hegar
auto-dilatation
Revision surgery
Weak sphincter
Loperamide
Codeine
End ileostomy
Ano-rectal USS
Pouchoscopy
Inflammation

27. Approach to Dysfunctional Pouch
Examination
Diagnosis
Therapy
Refractory
Revision
surgery
Pouch inlet / outlet obstruction
Dilatation
Pouchoscopy
Small volume
pouch
Normal
Revision
surgery / ileostomy
Poucho-defaecogram
Functional outlet
obstruction
Medina catheter
Bio-feedback
Normal

28. Approach to Dysfunctional Pouch
Examination
Diagnosis
Therapy
Refractory
Revision pouch surgery
Pelvic MRI
Pelvic collection
Drainage
Reassurance
Dietary modification
Anti-diarrhoeal meds
Anti-spasmodic meds
Anti-depression meds
Irritable pouch
syndrome
Normal
Ileostomy

29. Patient Pouch-anal anastomotic stricture (moderate)
Dilated endoscopically
MRI peri-pouch fibrosis
Recovery of reasonable pouch function

30. Summary
Many people with and without pouches have GI symptoms when surveyed.
Pouch dysfunction can be due to both pouch-related and unrelated causes
A structured approach to investigation and management is required