Pouchitis

Pouchitis is an inflammation of the pelvic pouch that can result in a number of symptoms, including increased bowel movements, abdominal cramping and bloating, generalized fatigue/malaise, fever, and sometimes blood in the stools. In some cases, it can also result in joint pain and weight loss.

The etiology or cause of pouchitis is unknown, although it is believed to be related to an overgrowth of bacteria in the pouch. Approximately 30 to 50 per cent of individuals with the pelvic pouch will develop pouchitis at some point in their life. A small minority of individuals (less than one per cent) will develop chronic pouchitis and may require long-term treatment. The development of pouchitis also appears to be related to the underlying cause for the surgery itself. The incidence of pouchitis tends to be greater in those with a diagnosis of ulcerative colitis than in those with familial polyposis. The main symptom for most individuals with pouchitis is an abnormally large number of stools. An increase from four to six (on average) stools may occur. Individuals may also experience rectal bleeding, abdominal cramping, a sense of "urgency" before having a bowel movement, and fever.

Individuals who have any of the above symptoms listed above could have pouchitis. However, several other conditions could also cause similar symptoms. These include irritable bowel syndrome, small bowel obstruction from scar tissue, narrowing of the join (anastomosis) between the anus and the pouch, an intestinal infection with bacterial or parasites, and Crohn's disease. For this reason, individuals whose symptoms suggest pouchitis should be seen by either their colorectal surgeon or gastroenterologist to have a flexible sigmoidoscopy (examination of the pouch with a flexible lighted instrument). At this time, biopsies (tissue samples) of the pouch should also be obtained.

At Mount Sinai Hospital , approximately 40 per cent of our patients with the Pelvic Pouch will develop pouchitis at some point in their life. As more time passes since the creation of the pouch, the more likely it is that pouchitis will occur.

The cause of pouchitis is not known. Several theories have been suggested, including: an excess of bacteria in the pouch; a recurrence of inflammatory bowel disease in the pouch and misdiagnosis of ulcerative colitis. In a minority of patients, it may be difficult to differentiate between Crohn's disease and Colitis. Problems that may occur post-operatively could be related to the fact that the patient has Crohn's disease.

Individuals with pouchitis often improve with antibiotics, suggesting that bacteria are an important factor in the development of this condition. Pouchitis occurs more commonly in people with extraintestinal problems associated with ulcerative colitis (e.g. arthritis or abnormalities of the liver, skin, or eyes). These findings suggest that pouchitis may be a new type of IBD, which occurs in the pouch. The majority of individuals with pouchitis do not have Crohn's disease.

Research is being done to identify the cause of pouchitis. Some investigators are looking for "triggering" bacteria or disease markers, such as antibodies. One early finding is that pouchitis is more common in ulcerative colitis patients who have antineutrophil cytoplasmic antibodies (ANCA) in their blood. Not everyone who has ANCA will get pouchitis. 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.

Antibiotics are the most common treatment for pouchitis. The most common prescription is a combination of Ciprofloxin and metronidazole (Flagyl). Most, if not all, individuals initially improve after taking metronidazole, usually within one or two days. The length of treatment is usually one to two weeks. A small minority of individuals may require continual treatment for chronic pouchitis.

Italian researchers are reporting that high doses of probiotics (healthy bacteria) appear to be an effective therapy for maintaining remission in patients with chronic pouchitis. Other studies have shown that 5-aminosalicylates, steroids, immunomodulators, anti-TNF-alpha therapies, may also be effective in treating recurrent or chronic pouchitis.

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 protective role. Probiotics are an attempt to reintroduce protective bacteria into the bowel. Some probiotics may be available through health food stores or a pharmacy, but as they are not yet regulated. Probiotics will vary in their quality and in the viability of the bacteria and positive outcomes cannot be guaranteed.

Helpful suggestions that may reduce the risk of pouchitis include:

• Include a liberal intake of fluids to keep your system flushed.

• Include yogurt that contains the healthy bacteria acidophilus. Look for yogurts that contain the living strains of L. bulgaricus and S. thermophilus.

• Do not allow stool to stay inside the pouch for long periods of time. Going to the bathroom prior to sleep is recommended.

Pouchitis does not affect everyone with a pelvic pouch. Even people who do develop pouchitis report that their quality of life is better than when they had ulcerative colitis. In almost all cases, having an ileostomy can eliminate the problem of chronic pouchitis.