Managing Pouchitis in Ulcerative Colitis
Pouchitis is a common chronic complication of restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA) surgery among patients with inflammatory bowel disease (IBD) or familial adenomatous polyposis (FAP). The incidence of pouchitis ranges from 23% to 60% among individuals with IBD and 0% to 11% among individuals with FAP.1
Consultant360 caught up with Edward L. Barnes, MD, MPH, an assistant professor of medicine in the Division of Gastroenterology and Hepatology at the University of North Carolina at Chapel Hill School of Medicine, about the current management of pouchitis in ulcerative colitis (UC), a topic he discussed during his session at the Advances in Inflammatory Bowel Diseases (AIBD) Regional Meeting in Baltimore.
Consultant360: Why is pouchitis becoming an increasingly difficult complication for gastroenterologists to manage?
Dr Barnes: Pouchitis is the most common complication after restorative proctocolectomy with IPAA surgery, which is the most common surgery among individuals with UC. Acute pouchitis affects a number of patients in the first year after IPAA surgery, but we also see complications such as chronic antibiotic-dependent pouchitis (CADP) and chronic antibiotic-refractory pouchitis (CARP). The rate of colectomy for UC appears to be decreasing to some degree, although a significant number of patients still require colectomy and are at risk of developing acute or chronic pouchitis. Typically, antibiotics work well for managing acute pouchitis, but the difficulty in managing pouchitis is driven in part by the fact that we do not have an optimal treatment regimen. Also, if patients progress to more chronic pouchitis, we have to find the lowest effective dose of antibiotics for CADP or try new therapies for CARP.
C360: What are the 2 biggest management challenges?
Dr Barnes: One of the biggest challenges is our lack of ability to consistently predict who will develop chronic inflammatory conditions of the pouch after IPAA, including CADP, CARP, and Crohn-like disease of the pouch. This significantly hampers our ability to advise patients in the preoperative period on future potential outcomes. Additionally, our lack of ability to predict the development of these conditions, along with a lack of consistent, evidence-based guidance for prophylactic therapy to prevent acute pouchitis or the development of these chronic pouch-related conditions, leaves us with few options to intervene in a preventive manner at the time of colectomy.
C360: What are the most important remaining research needs in this area?
Dr Barnes: In addition to identifying predictors for these conditions, I believe that we should investigate the comparative effectiveness of therapies for chronic pouch-related conditions. Although the emerging data on the use of biologics in the treatment of CARP and Crohn-like disease of the pouch would suggest that many patients may benefit from use of these therapies, we do not have good comparative effectiveness studies to know which therapies might be most beneficial for these conditions and in which particular presentations. This limits our understanding of the proper sequencing of biologic therapies for CARP and Crohn-like disease of the pouch.
C360: What are 3 key takeaways for gastroenterologists from your presentation at the AIBD Regional in Baltimore on pouchitis complications?
Dr Barnes: First, it is important to know that pouchitis and inflammatory conditions of the pouch are common; a number of patients will develop acute pouchitis within the first year after IPAA and some will develop Crohn-like disease of the pouch after undergoing restorative proctocolectomy with IPAA for UC. Second, standardizing the approach to inflammatory conditions of the pouch can guide both the diagnostic evaluation and treatment choices. Lastly, the emerging data on newer biologic therapies for CARP and Crohn-like disease of the pouch is promising, but durability evaluations and larger scale studies, including comparative effectiveness, are warranted.
Szeto W, Farraye FA. Incidence, prevalence, and risk factors for pouchitis. Semin Colon Rectal Surg. 2017;28(3):116-120. doi:10.1053/j.scrs.2017.05.002.