Risk Factors for Diseases of Ileal Pouch–Anal Anastomosis After Restorative Proctocolectomy for Ulcerative Colitis

doi:10.1016/j.cgh.2005.10.004

Clinical Gastroenterology and Hepatology

Volume 4, Issue 1, January 2006, Pages 81-89

https://doi.org/10.1016/j.cgh.2005.10.004 Get rights and content

Background & Aims: Although pouchitis is considered the most common adverse sequela of ileal pouch–anal anastomosis (IPAA), inflammatory and noninflammatory conditions other than pouchitis are increasingly being recognized. The risk factors for these non-pouchitis conditions, including Crohn’s disease (CD) of the pouch, cuffitis, and irritable pouch syndrome (IPS), have not been studied. The aim of this study was to assess risk factors for inflammatory and noninflammatory diseases of IPAA in a tertiary care setting. Methods: The study consisted of 240 consecutive patients who were classified as having healthy pouches (N = 49), pouchitis (N = 61), CD of the pouch (N = 39), cuffitis (N = 41), or IPS (N =50). Demographic and clinical features were assessed to determine risk factors for each of these conditions by using logistic regression analysis. Results: Risk factors remaining in the final logistic regression models were for pouchitis: IPAA indication for dysplasia (odds ratio [OR], 3.89; 95% confidence interval [CI], 1.69–8.98), never having smoked (OR, 5.09; 95% CI, 1.01–25.69), no use of anti-anxiety agents (OR, 5.19; 95% CI, 1.45–18.59), or use of NSAIDs (OR, 3.24; 95% CI, 1.71–6.13); for CD of the pouch: a long duration of IPAA (OR, 1.20; 95% CI, 1.12–1.30) and current smoking (OR, 4.77; 95% CI, 1.39–16.25); for cuffitis: arthralgias (OR, 4.13; 95% CI, 1.91–8.94) and younger age (OR, 1.16; 95% CI, 1.01–1.33); and for IPS: use of antidepressants (OR, 4.17, 95% CI, 1.95–8.92) or anti-anxiety agents (OR, 3.21; 95% CI, 1.34–7.47). Conclusions: The majority of risk factors for the 4 inflammatory and noninflammatory conditions of IPAA are different, suggesting that each of these diseases has a different etiology and pathogenesis. The identification and modification of these risk factors might help patients and clinicians to make a preoperative decision for IPAA, reduce IPAA-related morbidity, and improve response to treatment.

Section snippets

Study Subjects

The Cleveland Clinic Foundation Institutional Review Board approved this study, and written informed consent was obtained from all participants. A total of 240 consecutive adult (>18 years old) patients who underwent IPAA for an original diagnosis of UC between March 2002 and October 2004 were identified from our Pouchitis Clinic. These patients were classified as having healthy pouches (N = 49), antibiotic-dependent or antibiotic-refractory pouchitis (N = 61), CD of the pouch (N = 39),

Results

During the 30-month study period, 289 consecutive patients were seen in the Pouchitis Clinic, of whom 240 patients met the inclusion criteria. Forty-nine patients did not meet inclusion criteria and were excluded from the study; 35 patients had antibiotic-responsive pouchitis, 5 patients had concurrent pouchitis and cuffitis, 1 patient had antibiotic-refractory pouchitis with CMV viremia and viral inclusion bodies in mucosal biopsy of the pouch, and 8 patients had surgery-related complications

Discussion

This study is the first of its kind to evaluate and compare risk factors between patients with pouchitis, CD of the pouch, cuffitis, and IPS. In this study, we combined outpatient comprehensive evaluation with database analysis by using a standard protocol in a consecutive patient population. Logistic regression analysis revealed risk factors for each of the 4 disease conditions: for pouchitis—IPAA for dysplasia, never having smoked, use of NSAIDs, and non-use of anti-anxiety agents; for CD of

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Cited by (178)

Increasing Incidence of Pouchitis Between 1996 and 2018: A Population-Based Danish Cohort Study
2023, Clinical Gastroenterology and Hepatology
Current knowledge regarding the epidemiology of pouchitis is based on highly selected, mostly single-center, patient cohorts. Our objective was to prospectively determine the population-based incidence of pouchitis in patients with ulcerative colitis in the first 2 years after ileal pouch–anal anastomosis and analyze time trends of the incidence of pouchitis.
Using national registries, we established a population-based cohort of all Danish patients undergoing proctocolectomy with ileal pouch–anal anastomosis for ulcerative colitis between 1996 and 2018. The primary outcome was the development of pouchitis within the first 2 years after surgery, evaluated by time period. We used Kaplan–Meier and Cox proportional hazard modeling to evaluate the time to development of pouchitis.
Overall, 1664 patients underwent an ileal pouch–anal anastomosis. The cumulative incidence of pouchitis in the 2 years after ileal pouch–anal anastomosis increased throughout the study period, from 40% in the period from 1996 to 2000 (95% CI, 35%–46%) to 55% in the period from 2015 to 2018 (95% CI, 48%–63%). Patients undergoing surgery between 2015 and 2018 also showed an increased risk of pouchitis compared with the earliest study period (1996–2000) after adjusting for sex, age, and socioeconomic status (hazard ratio, 1.57; 95% CI, 1.20–2.05).
This population-based study showed a 15% absolute and 38% relative increase in the incidence of pouchitis among patients undergoing surgery between 1996 and 2018, with the greatest cumulative incidence of pouchitis shown in the most recent era (2015–2018). The striking increase in the incidence of pouchitis highlights the need for further research into causes and prevention of pouchitis.
Chronic pouchitis and Crohn's disease of the pouch after ileal pouch-anal anastomosis: Incidence and risk factors
2021, Digestive and Liver Disease
Restorative proctocolectomy with ileal-pouch anal-anastomosis (IPAA) is the operation of choice for patients with ulcerative colitis (UC) or with inflammatory bowel diseases unclassified (IBDU).
to assess the incidence and risk factors of chronic pouchitis (CP) and Crohn's disease of the pouch (CDP) in patients with UC or IBDU.
We conducted a retrospective study. We included consecutive patients who underwent IPAA between 2011 and 2019. The main outcome was the occurrence of CP or CDP. We looked for risk factors with multivariable and a least absolute shrinkage and selection operator (LASSO) Cox models.
247 patients were included. The 5-year cumulative incidence of CP or CDP was 35.3% (95%CI: 26.2–43.2). In multivariable analysis, diagnosis of IBDU, age less than 35 years at surgery and extra-intestinal manifestations other than articular and primary sclerosing cholangitis were associated with higher incidence. The LASSO analysis identified these three prognostic factors and articular manifestations. In patients with two or more prognostic factors, 5-year cumulative incidence, was 65.2% (95%CI: 41.8–79.2).
Five years after IPAA, approximately one-third of patients had either CP or CDP. Risk factors were IBDU, an age less than 35 years at surgery, articular manifestations and other extra-intestinal manifestations.
Incidence, Risk Factors, and Outcomes of Pouchitis and Pouch-Related Complications in Patients With Ulcerative Colitis
2021, Clinical Gastroenterology and Hepatology
Acute pouchitis is the most common non-surgical complication after restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC). We used validated case-finding definitions for pouchitis to search administrative claims data and determine the incidence of pouchitis in the first 2 years after IPAA.
We identified all patients who underwent proctocolectomy with IPAA for UC in the IQVIA Legacy PharMetrics Adjudicated Claims Database, from January 1, 2007 through June 1, 2016. The primary outcome was the development of pouchitis within 2 years after IPAA. Secondary outcomes included isolated acute vs recurrent pouchitis, immunosuppressive therapy, further surgery, and admission to the hospital.
Among 594 patients, the cumulative incidence of pouchitis within 2 years of IPAA was 48% (95% CI, 44%–52%). The cumulative incidence of isolated acute pouchitis was 29% (95% CI, 26%–33%). Compared to patients with isolated acute pouchitis, patients who received a diagnosis of recurrent pouchitis (cumulative incidence, 19%: 95% CI, 16%–22%) demonstrated increased outpatient visits, emergency department visits, and inpatient admissions (all P < .001). Patients who developed pouchitis were more likely to have a history of primary sclerosing cholangitis (adjusted odds ratio [aOR], 3.94; 95% CI, 1.05–14.8) and anti-tumor necrosis factor alpha therapy prior to colectomy (aOR 1.63; 95% CI, 1.09–2.45). Among patients with pouchitis, the cumulative frequency of new immunosuppressive therapy was 40% (95% CI, 35%–46%) and the cumulative incidence of pouch excision was 1.0% (95% CI, 0.4%–3.0%). The cumulative incidence of a new diagnosis of Crohn’s disease after IPAA for UC was 9.0% (95% CI, 7.2%–11%).
In a geographically diverse population, 48% of patients with UC developed pouchitis within the first 2 years after IPAA. Patients with pouchitis had greater use of healthcare resources, indicating a significant burden of disease.
Pyloric gland metaplasia: Potential histologic predictor of severe pouch disease including Crohn's disease of the pouch in ulcerative colitis
2021, Pathology Research and Practice
Crohn’s disease of the pouch (CDP) is seen in a subset of ulcerative colitis (UC) patients following ileal pouch-anal anastomosis (IPAA). Histologic or clinical predictors of CDP are unknown. UC patients with subsequent CDP diagnosis were identified. The rationales for the diagnosis, the interval from the initial signs of CDP to the diagnosis, family history and smoking history were reviewed. Archived pathology materials were reviewed for the presence of pyloric gland metaplasia (PGM) and compared with those from UC with similar severity of pouchitis with CDP (matched UC controls), random UC controls, and ileocolectomies from primary CD patients. CDP diagnosis was made in 26 (18.1%) of 144 patients; all of them met commonly used diagnostic criteria for CDP. The diagnosis was rendered on average 15 months after the initial CD-like signs. PGM was found in 58% of CDP, more common than random UC controls but no different from primary CD and matched UC controls. PGM preceded first signs of CD in a subset. Patients with a family history of CD were more likely to develop CDP than those without a family history of any type of inflammatory bowel disease. Smoking status did not affect the likelihood of developing CDP. Finding PGM in proctocolectomy, ileostomy and follow-up biopsies in UC patients post IPAA may warrant close follow up for the potential development of pouchitis. Some of these patients, especially those with family history of CD, may further progress and develop severe disease meeting the clinical diagnostic criteria for CDP.
Exposing the Achilles Heel of Antibiotic Therapy for Pouchitis Using Microbial Function and Composition
2020, Gastroenterology
The Safety of Dilation of Ileoanal Strictures With Mechanical or Balloon Dilation Is Similar Among Patients After Ileal Pouch-Anal Anastomosis
2024, Inflammatory Bowel Diseases

View all citing articles on Scopus

: Supported by NIH R03 DK 067275 and an American College of Gastroenterology Junior Faculty Development Grant (to B.S.).

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Original articleRisk Factors for Diseases of Ileal Pouch–Anal Anastomosis After Restorative Proctocolectomy for Ulcerative Colitis

Section snippets

Study Subjects

Results

Discussion

Gastroenterology

Clin Gastroenterol Hepatol

Am J Gastroenterol

Am J Gastroenterol

Mayo Clin Proc

Gastroenterology

Immunopharmacology

Life Sci

Lancet

Gastroenterology

Am J Med

Clin Gastroenterol Hepatol

Ileal pouch-anal anastomosiscomplications and function in 1005 patients

Ann Surg

Comprehensive evaluation of inflammatory and non-inflammatory sequelae of ileal pouch-anal anastomosis

Am J Gastroenterol

Prospective study of the incidence, timing, and treatment of pouchitis in 104 consecutive patients after restorative proctocolectomy

Arch Surg

J ileal pouch-anal anastomosis from chronic ulcerative colitiscomplications and long-term outcome in 1310 patients

Br J Surg

Pouchitis after ileal pouch-anal anastomosis for ulcerative colitis occurs with increased frequency in patients with associated primary sclerosing cholangitis

Gut

Risk factors and true incidence of pouchitis in patients after ileal pouch-anal anastomosis

World J Surg

Preoperative terminal ileal and colonic resection histopathology predicts risk of pouchitis in patients after ileoanal pull-through procedure

Ann Surg

Workshoppouchitis

Int J Colorectal Dis

Original article
Risk Factors for Diseases of Ileal Pouch–Anal Anastomosis After Restorative Proctocolectomy for Ulcerative Colitis