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Pouchitis and Functional Complications of the Pelvic Pouch
Introduction
Despite recent advances in medical therapy, approximately 25% to 30% of patients with ulcerative colitis (UC) will need surgery for refractory colitis or colitis-associated neoplasia. For these patients, a total proctocolectomy with ileal pouch–anal anastomosis (IPAA) is the standard surgical option. During the past four decades, IPAA has been constantly shown to reduce the risk of UC-associated neoplasia and to improve quality of life. On the other hand, construction of an IPAA is technically demanding, with mechanical, inflammatory, and functional sequelae that can be minimized by good technique, but not completely avoided. Pouchitis and irritable pouch syndrome are the most common inflammatory and functional disorders of the pelvic pouch and will be discussed in this chapter.
Pouchitis
Pouchitis is inflammation of an ileal pouch. It can be specific (with an identifiable cause) or nonspecific. Cumulative frequencies of pouchitis after IPAA range from 23% to 46% over 10 to 11 years of follow-up. In a small clinical drug trial of prophylaxis of pouchitis with a probiotic agent, the incidence was 40% within the first 12 months after ileostomy closure.
Etiology and Pathogenesis
It is intriguing that pouchitis occurs almost exclusively in patients with underlying UC and is rarely seen in patients with a pouch who have familial adenomatous polyposis, suggesting causative factors in common with UC that may be genetic and/or systemic. In general, pouchitis results from alterations in commensal luminal microflora (dysbiosis) and subsequent abnormal mucosal immune response in genetically susceptible hosts.
Genetic Factors
Immunogenetic studies have shown that polymorphisms in genes such as those coding for interleukin-1 receptor antagonist NOD2/CARD15 or a combined carrying of TLR9-1237C and CD14-260T alleles are associated with an increased risk of chronic pouchitis.
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