1. Oxford Colorectal Crohn’s disease and Pouches Bruce George Kangaroo Club 31-5-14

2. Oxford Colorectal Crohn’s disease and Pouches Why is this a question? Pre-pouch surgery –Crohn’s disease is a contra-indication to pouch surgery –What about indeterminate colitis? –Is it ever reasonable to make a pouch for known Crohn’s? Post pouch surgery –If pouch function is poor/complication, could this be due to Crohn’s –What happens if you develop Crohn’s in a pouch?

3. Oxford Colorectal They are very different diseases UC –mucosa only –continuous from top of anal canal upwards

4. Oxford Colorectal If you don’t want to see pictures of bowels and bottoms: –Look away now!!

5. Oxford Colorectal Crohn’s disease

6. Oxford Colorectal The problem Pouch surgery for Crohn’s disease highly likely to fail –Small bowel and anal disease –Deep inflammation: fistulae, leaks, strictures But sometimes Crohn’s can mimic UC –Isolated to colon –Similar histology

7. Oxford Colorectal Pre-pouch work-up Review pathology available Review distribution of disease –skip lesions –small bowel pathology –anal pathology Indeterminate UC, but minor features of CD Effects of therapy patchy Ordinary anal pathology piles tears

8. Oxford Colorectal Cleveland Clinic Over 3000 pouches 204 for Crohn’s –20 intentional –97 immediate diagnosis on colon pathology –87 delayed diagnosis Outcome –29% failure rate at 10 years (71% functioning) –Delayed group worse Metton et al 2008

9. Oxford Colorectal Policy in Oxford Not to offer pouch surgery for known Crohn’s disease Minimise surprise finding of Crohn’s disease on proctocolectomy specimen Review of all available pathology Colectomy first approach Slow lane for indeterminate Increased risks Delay in case features of Crohn’s develop

10. Oxford Colorectal Pouches behaving badly What is normal? Acute deterioration usually called pouchitis and treated with ciprofloxacin or metronidazole

11. Oxford Colorectal Pouchitis Symptoms increased stool frequency looseness blood urgency incontinence abdominal pain fever arthralgia Endoscopy oedema granularity contact bleeding loss of vascularity haemorrhage ulceration Histology acute inflammation + chronic inflammation villous atrophy crypt hyperplasia chronic inflammatory infiltrate

12. Oxford Colorectal Treatment Cochrane meta-analysis of 11 RCTs Acute pouchitis (4RCT, 5 agents) Rifaximin and lactobacillus GG not significantly different to placebo Budesonide enemas = metronidazole

13. Oxford Colorectal Cochrane meta-analysis Chronic pouchitis (4 RCT, 4 agents) VSL3 better than placebo in maintaining remission after treatment with antibiotics

14. Oxford Colorectal It’s probably not that simple Many other causes of poor pouch function –many of which may respond to antibiotics –many patients fulfilling definition of pouchitis may have poor pouch function due to other causes

15. Oxford Colorectal Assessment of pouch dysfunction Identification of –True pouchitis –Other causes of pouch inflammation (secondary) Pathogens (C diff, cmv) Adjacent inflammation (sepsis, ischaemia, intussusception) Drugs (NSAIDS) Crohn’s disease –Other causes of poor pouch function

16. Oxford Colorectal Phase 1 assessment of poor pouch function History of poor function –Always bad –Recent deterioration Review histology Review peri-operative course Clinical examination PR Pouchoscopy + biopsy Stool culture

17. Oxford Colorectal Common problems Acute pouchitis –ciprofloxacin Pouch-anal anastomotic stricture –EUA + gentle dilatation Cuffitis topical steroids or mesalazine

18. Oxford Colorectal Phase 2 Assessment of persistent poor pouch function Inside –Flexible pouchoscopy + biopsy –pouchogram Outside –CT or MR pelvis Below –Sphincter physiology and ultrasound –Pouchogram –EUA, pouch and cuff biopsies Above –MRE –endoscopy Emptying the pouch –Dynamic evacuating “proctography”

19. Oxford Colorectal INSIDE THE POUCH Chronic pouchitis Irritable pouch Small volume/non compliant pouch Cmv/c diff

20. Oxford Colorectal OUTSIDE THE POUCH Pelvic abscess/induration Fistula Unrelated pathology –Fibroid, desmoid

21. Oxford Colorectal Below the pouch Narrowing at anastomosis Pouch fistula Sphincter weakness Cuffitis Long rectal cuff

22. Oxford Colorectal ABOVE THE POUCH Adhesions Bacterial overgrowth Crohn’s disease Pre-pouch ileitis NSAIDs coeliac

23. Oxford Colorectal EMPTYING THE POUCH Internal pouch prolapse Anismus

24. Oxford Colorectal Treatment Dependant on identification of cause of poor pouch function Emerging concept: –Inflammation in/around pouch/fistula. Suspicion but no proof of Crohn’s –Leuven group: 88% improvement with infliximab/adalimumab

25. Oxford Colorectal Surgical options for the failing pouch Indefinite diversion –with pouch excision –with pouch left in-situ Re-do pouch reconstruction Kock pouch

26. Oxford Colorectal and finally... Summary of problems Weather –20 mph headwind Under-estimating the task Separation of cyclists and cyclists from van –Swanley underpass Getting lost –Maidstone at 04.15 Different speeds –Non-chain gang Food and drink Strategy when problems occur Negotiating skills –22.00, 45 miles from Paris

27. Oxford Colorectal

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