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Pouchitis
This article discusses the definition, symptoms, diagnosis, possible causes, treatment (including the probiotic prepar- ation VSL#3), and patient concerns regarding pouchitis.
• Article added April 30, 2004
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What is Pouchitis?
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The ileo-anal pouch (pelvic pouch) and the continent ileostomy (Koch pouch) are alternatives to the standard ileostomy and are the surgical procedures of choice for the management of ulcerative colitis and familial adenomatous polyposis (FAP). Both eliminate the need to wear an external ostomy appliance. In each case, the colon and rectum are removed and the small intestine is formed into a pouch, which acts as a reservoir for waste. Some- times the lining of this internal pouch becomes inflamed. This complication is known as "pouchitis". [Top] |
What are the Symptoms?
Pouchitis may cause mild or severe symptoms and may be acute (sudden and severe but lasts only a short time) or chronic (long-lasting and recurrent). It can cause diarrhea and crampy, abdominal pain with increased frequency of stool, rectal bleeding, a sense of "urgency" before having a bowel movement, and may also produce effects such as fever, dehydration and joint pain.
How is Pouchitis Diagnosed?
Patients who have any of the symptoms listed above could have pouchitis. But other conditions could cause similar symptoms. These include irritable bowel syndrome (IBS), irritable pouch syndrome, small-bowel obstruction from scar tissue, narrowing of the connection between the anus and the pouch (regarding ileo-anal pouches), an intestinal infection with bacteria or parasites, and Crohn's disease.
For this reason, patients whose symptoms suggest pouchitis should have a flexible sigmoidoscopy and tissue samples of the pouch should be obtained. A flexible sigmoidoscopy exam will reveal inflammation in the lining of the pouch. When examined under the microscope, the tissue samples will also show inflam- mation. If inflammation is not present, then other causes for the symptoms would then be considered. [Top]
What Causes Pouchitis?
The cause of pouchitis is not known. Medical researchers have suggested several theories: an excess of bacteria in the pouch; a recurrence of inflammatory bowel disease (IBD) in the pouch; and misdiagnosis of ulcerative colitis (before surgery) in a patient who really has Crohn's disease.
One of the factors that may contribute to chronic pouchitis is that the pouch may not be emptying adequately with each bowel movement. This incomplete emptying causes stasis of the stool – in other words, stool lying in the pouch for prolonged periods of time, lending itself to overgrowth of certain bacteria causing pouchitis.
Research is being done to identify the cause of pouchitis. Some investigators are looking for "triggering" bacteria or disease markers, such as antibodies. The most likely cause is two-fold: a genetic susceptibility to both ulcerative colitis and pouchitis, combined with a "trigger," such as bacteria, within the stool in the pouch. [Top]
How is Pouchitis Treated?
The usual treatment for pouchitis is antibiotics, often a combin- ation of Metronidazole and Ciprofloxacin. Patients often report an improvement in their symptoms in as little as 48 hours. The antibiotics are usually prescribed for 10-14 days. If the pouchitis returns, the same treatment is often used. If there are frequent relapses or chronic pouchitis, long-term antibiotics may be required.
Recently, there has been interest in the use of probiotics to treat pouchitis. Research has shown that certain bacteria in the bowel may promote inflammation while others may have a more protec- tive role. Probiotics are an attempt to reintroduce the protective bacteria into the bowel.
Unfortunately, the studies and the preparations that are often referred to are European, and similar preparations are not yet available in Canada. Some probiotics may be available through health food stores or a pharmacy, but as they are not yet regulated, they will vary in their quality and in the viability of the bacteria and positive outcomes cannot be guaranteed.
Source • Mount Sinai Hospital Toronto, Canada
Probiotic VSL#3 Maintains Remission from Pouchitis FT. LAUDERDALE, FL • January 5, 2004 • Press Release Further evidence that manipulating the intestinal flora with a highly concentrated probiotics may be an effective therapeutic strategy for patients with inflammatory bowel disease (IBD) was reported in this month's issue of the medical journal, Gut In the year-long, placebo-controlled study, once daily treatment with the probiotic preparation VSL#3 was shown to be highly effective in maintaining antibiotic-induced remission of a post-surgical complication called pouchitis in patients with ulcerative colitis (UC) who have had their colons surgically removed. Additionally, patients in the study who took VSL#3 reported improved quality of life compared with a marked deterioration in quality of life seen in the patients who received placebo. According to the Crohn's and Colitis Foundation of America, approximately 25 percent to 40 percent of the 500,000 patients with UC will need their colon removed and an internal pouch created to store stool using a portion of the small intestine. Pouchitis, often considered to be a form of chronic UC, is the most frequent and serious long-term complication of this surgery and is characterized by increased stool frequency and fluidity, rectal bleeding, abdominal cramping, incontinence and fever. "About 5 to 15 percent of patients experience recurrent or refractory pouchitis, which is associated with a severe decline in quality of life for patients," said lead investigator Toshiki Mimura, MD, PhD, Lecturer, School of Medicine, Teikyo University, Japan. "These individuals require contin- uous doses of antibiotics, which are not without side-effects and place them at risk for developing an antibiotic-resistant infection. Some patients do not respond to any treatments and have little choice but to suffer with their symptoms." The double-blind study conducted at St. Mark's Hospital in the United Kingdom and a center in Bologna, Italy examined 36 patients with recurrent (occurrence at least twice in the previous year) or refractory (requiring continuous use of anti- biotics) pouchitis as defined by the Pouchitis Disease Activity Index (PDAI). Remission had been induced in all patients by a four-week course of the antibiotics Metronidazole (400 mg or 500 mg twice daily) and Ciprofloxacin (500 mg twice daily). Twenty patients were given VSL#3 (6 g once daily), while 16 patients received placebo. Remission, the primary endpoint, was maintained at one year in 17 patients (85 percent) taking VSL#3 and in only one (6 percent) patient who received placebo. Health-related quality of life and patients' general satisfaction with treatment were secondary endpoints in the study. The Inflammatory Bowel Disease Questionnaire (IBDQ) was used to assess quality of life examining bowel, systemic and emotional symptoms and social function of patients, with a score of 32 being worst and 224 being best. At the beginning of the study, IBDQ scores were high (190 in the VSL#3 group and 169 in the placebo patients). However, at 12 months or time of relapse, the VSL#3 group score was 205 versus 105 for placebo. Similarly, patient satisfaction scores remained high for the VSL#3 treated group, but deteriorated significantly for the placebo group. In past studies of probiotic therapies, quality of life has not been effectively assessed. However, the Gut study confirms that VSL#3 is an effective once daily maintenance therapy that sustains patient satisfaction and quality of life. NOTE • This is a press release issued by VSL Pharmaceu- ticals, Inc., so it may be biased and omit some of the negative aspects of the study. VSL Pharmaceuticals, Inc. is a new company that has been recently established in North America to oversee the development, production, distribution and use of the probiotic preparation, VSL#3. Source of Press Release • IBD Answers.com Probiotic Study in Prevention of Endoscopic Recurrence of Crohn's Disease After Ileo-colonic Surgical Resection The following is a summary of a trial currently underway at Mount Sinai Hospital
About VSL#3 VSL#3 can be mixed in yogurt, ice cream, apple sauce or any other cold food or non-carbonated drink; stir contents and ingest immediately. It should not be mixed or taken with hot foods or hot drinks because the high heat inactivate the lactic acid bacteria. For additional consumer information, visit the VSL Frequently Asked Questions The patented probiotic therapy VSL#3 has been evaluated in more clinical trials of serious gastrointestinal disorders than any probiotic on the market. VSL#3 is different from other probiotic therapies in that it contains numerous strains of bacteria at high concentrations (450 billion). The formulation is marketed by VSL Pharmaceuticals, Inc. and is only avail- able to consumers through the VSL web site. |
What Happens to Patients With Pouchitis?
Studies show that out of 100 patients with the ileo-anal pouch, 68 will never get pouchitis. Of the 32 persons who do develop this condition, 12 will have a single episode that improves with a short course of treatment (1-2 weeks) with antibiotics, and they will never get pouchitis again. For these patients, having a single episode of pouchitis is not much different from having a urinary infection or the flu. Fifteen patients will have recurrent flare-ups, which will occur anywhere from once a year to once every three months. This pattern is a nuisance and, in some respects, is like having ulcerative colitis again. The majority of these patients, however, are easily treated with antibiotics or other safe medications. Though not ideal, this is better than the original ulcerative colitis, which often required treatment with oral steroids and which carried the risk of colon cancer.
Chronic symptoms of pouchitis will occur in five out of 100 persons. These patients often do not respond to treatment. For this small group, pouchitis has a major negative impact on the quality of life, and they may choose to have the pouch converted to a permanent ileostomy. [Top]
Should Concerns About Getting Pouchitis
Discourage One From Having Ileo-Anal Pouch Surgery?
Based on the most recent information available, the answer is no. Most patients with the ileo-anal pouch or the Koch pouch never get pouchitis. Even people who do develop pouchitis find that their quality of life is better than when they had ulcerative colitis, and better than it would be with an ileostomy. Only a small number of patients suffer from chronic pouchitis. In virtually all cases, the problem can be eliminated by converting to a standard ileostomy.
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