Pouchoscopy

About: Pouchoscopy is a research topic. Over the lifetime, 99 publications have been published within this topic receiving 5745 citations.

Efficacy of Vedolizumab in Patients with Antibiotic and Anti-tumor Necrosis Alpha Refractory Pouchitis

Abstract: Refractory pouchitis is a risk factor for pouch failure and surgical excision. While TNFa inhibitors have been reported to be effective as treatment for pouchitis there is no data regarding the use of vedolizumab in refractory pouchitis. In this study we evaluated the clinical and endoscopic response to vedolizumab in refractory pouchitis. This is an open label case series. Three patients were identified as having refractory pouchitis with loss or lack of response to antibiotics, corticosteroids, and at least one TNFa inhibitor along with a variety of other modalities of therapy. Each patient underwent pouch endoscopy before initiation of vedolizumab and repeat endoscopy within 4 months of initiation of treatment. Vedolizumab was administered as per standard dosing regimen. The Pouch Disease Activity Index (PDAI) endoscopic subscore was evaluated by the 2 investigators independently and reported as an average. The clinical record was reviewed to determine patient reported response to therapy. Patient 1, a 54 year old male, had undergone colectomy and IPAA in 2000 for medically refractory ulcerative colitis (UC). He suffered from ankylosing spondylitis and chronic pouchitis. He had been treated serially with antibiotics, budesonide, infliximab, methotrexate, adalimumab, in combination with hyperbaric oxygen therapy with severe diarrhea. His pouchoscopy prior to initiation revealed confluent ulceration with PDAI endoscopic subscore of 4. Endoscopy 4 months after the initiation of vedolizumab therapy revealed visual improvement, with few small ulcers noted, with PDAI endoscopic subscore of 3. He experienced improvement in clinical symptoms and has avoided surgical resection of his pouch but did require maintenance therapy with budesonide. Patient 2, a 54 year old female underwent colectomy and IPAA in 1991 for medically refractory UC. She developed recurrent stricturing at the pouch inlet and afferent limb and pouchitis, treated with surgical stricturoplasty, antibiotics, thiopurines, mesalamine, intravenous immunoglobulin therapy, fecal microbiota transplant, and adalimumab. She continued to have symptoms of diarrhea and pain. Pouch endoscopy revealed chronic pouchitis with edema and loss of vascular pattern consistent with a PDAI score of 5, along with cuffitis, and ulcerated strictures in the neo-terminal ileum. She underwent pouchoscopy 4 months after the therapy with vedolizumab which revealed improvement in pouchitis, normal appearing mucosa and PDAI endoscopic subscore 1, but ongoing ulceration at cuff and inlet. Patient 3, a 54 year old female post restorative proctocolectomy for refractory UC in 2012 had required pouch redo surgery in 2014 for severe pouch dysfunction. She suffered from diarrhea requiring intravenous hydration despite use of antibiotics, infliximab with azathioprine, and mesalamine. Her pouchoscopy revealed pouchitis and ileitis with a PDAI score of 3. Pouch endoscopy 4 months after initiation of vedolizumab which revealed improved mucosa of the pouch with PDAI score of 1. She noted improvement in symptoms of diarrhea. All 3 patients had improved endoscopic scores and reported clinical improvement in terms of diarrhea and pain. Vedolizumab in open label use for chronic antibiotic- and anti- TNFα-refractory, chronic pouchitis demonstrated improvement in both symptoms and endoscopy scores.

Mid Pouch Strictureplasty for Crohn's Disease After Ileal Pouch-Anal Anastomosis: An Alternative to Pouch Excision

Abstract: A 33-year-old female developed an isolated stricture of the mid portion of her ileal pouch nine years after proctocolectomy and J-ileal pouch-anal anastomosis for ulcerative colitis. Repeated episodes of pouchitis and partial small-bowel obstruction led to pouchoscopy and pouchography, which demonstrated pouch inflammation and a long, tight, midpouch stricture. Her diagnosis was changed to Crohn's disease and she was treated with azathioprine, budesonide, and infliximab. Repeat pouchoscopy demonstrated mucosal healing but a persistent fibrotic stricture. Pouch reconstruction was performed with a midpouch strictureplasty alleviating her obstructive symptoms. One year after surgery, the patient has no clinical evidence of obstruction and repeat pouchography demonstrates a wider pouch lumen across the strictureplasty site. Strictureplasty is an alternative to pouch excision in the management of patients with Crohn's disease who have an isolated pouch stricture.

Endoscopic activity in asymptomatic patients with an ileal pouch is associated with an increased risk of pouchitis.

Abstract: Background The significance of endoscopic activity in asymptomatic ulcerative colitis (UC) patients with an ileal pouch is unknown. Aim To investigate the association of endoscopic pouch activity in asymptomatic patients with the subsequent development of pouchitis. Methods We analyzed a retrospective cohort of patients with UC or IBD-unspecified who underwent a total proctocolectomy with ileal pouch anal anastomosis (IPAA). Asymptomatic patients with a Pouchitis Disease Activity Index (PDAI) symptom sub-score of zero who underwent an index surveillance pouchoscopy were included. Endoscopic pouch body activity was graded as 0: normal, 1: mucosal inflammation, or 2: mucosal breaks (ulcers and/or erosions). The primary outcome was primary acute idiopathic pouchitis defined as PDAI score ≥ 7 with symptoms lasting less than four weeks and responsive to standard antibiotics, not otherwise meeting criteria for secondary pouchitis. The secondary outcome was chronic idiopathic pouchitis defined as PDAI score ≥ 7 with symptoms lasting greater than four weeks despite standard antibiotics. Predictors of pouchitis were analyzed using Kaplan-Meier and Cox regression methods with hazard ratios (HR) and 95% confidence intervals (CI) reported. Results 143 asymptomatic pouch patients were included. Index endoscopic pouch body activity was 0 in 86 (60.1%) patients, 1 in 26 (18.2%) and 2 in 31 (21.7%). The median length of follow-up after index surveillance pouchoscopy was 3.03 [IQR 1.24-4.60] years. Primary acute idiopathic pouchitis occurred in 44 (31%) patients and chronic idiopathic pouchitis in 12 (8.4%). Grade 2 endoscopic pouch activity was associated with the development of acute pouchitis (HR 2.39, 95% CI 1.23-4.67), although not chronic pouchitis (HR 1.76, 95% CI 0.53-5.87). Histologic inflammation in endoscopically normal pouch mucosa was not associated with acute or chronic pouchitis. Conclusions Mucosal breaks are present in nearly a quarter of asymptomatic patients with IPAA and are associated with an increased risk of acute pouchitis.