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Bo Shen - One of the best experts on this subject based on the ideXlab platform.
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reliability among central readers in the evaluation of endoscopic disease activity in Pouchitis
Gastrointestinal Endoscopy, 2018Co-Authors: Mark A Samaan, William J Sandborn, Bo Shen, Lisa M Shackelton, Mahmoud Mosli, Guangyong Zou, Sigrid Nelson, Larry Stitt, Stuart Bloom, Darrell S PardiAbstract:Background and Aims Pouchitis is a common adverse event after proctocolectomy with ileal pouch anal anastomosis for ulcerative colitis. Evaluation of Pouchitis disease activity and response to treatment requires use of validated indices. We assessed the reliability of items evaluating endoscopic Pouchitis disease activity. Methods Twelve panelists used a modified RAND appropriateness methodology to rate the appropriateness of items evaluating endoscopic Pouchitis disease activity derived from a systematic review and also identified additional potential endoscopic items based on expert opinion. Four central readers then evaluated 50 pouchoscopy videos in triplicate, in random order. Intra- and inter-rater reliability for each item was assessed by calculating and comparing intraclass correlation coefficients (ICCs). A Delphi process identified common sources of disagreement among the readers. Results Ten existing endoscopic items were identified from the systematic review and an additional 7 exploratory items from the panelists. ICCs for inter-rater reliability were highest for the existing item of pouch ulceration (.72; 95% confidence interval [CI], .60-.82) and for the exploratory item of ulcerated surface in the pouch body (.67; 95% CI, .53-.75). Inter-rater reliability for all other existing and exploratory items was “moderate” (ICC Conclusion Substantial reliability was observed only for the endoscopic items of ulceration and ulcerated surface in the pouch body. Future studies should assess responsiveness to treatment in the next stage toward development of an endoscopic Pouchitis disease activity index.
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management of Pouchitis and other common complications of the pouch
Inflammatory Bowel Diseases, 2018Co-Authors: Robin Dalal, Bo Shen, David A SchwartzAbstract:Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) has become the preferred surgical treatment for refractory or complicated ulcerative colitis (UC) and familial adenomatous polyposis (FAP). Pouchitis is the most common complication of this procedure and can occur in about 50% of patients. Treatment of Pouchitis depends on the phenotype of disease. Pouchitis can be classified as acute, chronic/refractory, or secondary Pouchitis, which includes Pouchitis occurring due to Crohn's disease (CD). CD of the pouch is becoming an increasingly recognized problem, and management is challenging. This article reviews the literature and offers treatment recommendations regarding management of Pouchitis and CD of the pouch.
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frequency and risk factors of clostridium difficile infection in hospitalized patients with Pouchitis a population based study
Inflammatory Bowel Diseases, 2017Co-Authors: Gaurav Kistangari, Rocio Lopez, Bo ShenAbstract:BACKGROUND Clostridium difficile infection (CDI) in patients with the ileal pouch after proctocolectomy has been increasingly recognized. We sought to evaluate the frequency and risk factors of CDI in patients with the primary or secondary discharge diagnosis of Pouchitis in the United States. METHODS We reviewed the National Inpatient Sample of the Healthcare Cost and Utilization Project and identified patients admitted for Pouchitis with underlying inflammatory bowel disease (IBD) or familial adenomatous polyposis (FAP), between 2010 and 2012. Cases with CDI were identified based on a concomitant primary or secondary discharge diagnosis for CDI. The frequency of CDI was estimated in patients with underlying IBD and FAP. Multivariable analysis was conducted to study the risk factors associated with CDI in those with Pouchitis with underlying IBD. RESULTS A total of 3566 eligible patients with Pouchitis were identified during the study period. Eighty-nine patients (2.5%) had CDI as a concomitant primary or secondary discharge diagnosis. CDI was identified in 2.6% (99.9% confidence interval [CI], 1.3-3.8) of Pouchitis patients with underling IBD. None of the patients with Pouchitis with underlying FAP were found to have CDI during the study period. Among Pouchitis patients with underlying IBD, the presence of nonalcoholic fatty liver disease (odds ratio = 5.4; 95% CI, 1.5-19.9), obesity (odds ratio = 5.5; 95% CI, 1.4-21.4), or obstructive sleep apnea (odds ratio = 10.3; CI, 2.0-53.7) was associated with an increased risk of CDI. CONCLUSIONS It seems that CDI was limited to Pouchitis with underlying IBD and rare in those with underlying FAP. Patients with nonalcoholic fatty liver disease, obesity, and obstructive sleep apnea are at an increased risk of C. difficile Pouchitis among patients with IBD.
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efficacy of vedolizumab in patients with antibiotic and anti tumor necrosis alpha refractory Pouchitis
Inflammatory Bowel Diseases, 2017Co-Authors: Jessica Philpott, Jean Ashburn, Bo ShenAbstract:Refractory Pouchitis is a risk factor for pouch failure and surgical excision. While TNFa inhibitors have been reported to be effective as treatment for Pouchitis there is no data regarding the use of vedolizumab in refractory Pouchitis. In this study we evaluated the clinical and endoscopic response to vedolizumab in refractory Pouchitis. This is an open label case series. Three patients were identified as having refractory Pouchitis with loss or lack of response to antibiotics, corticosteroids, and at least one TNFa inhibitor along with a variety of other modalities of therapy. Each patient underwent pouch endoscopy before initiation of vedolizumab and repeat endoscopy within 4 months of initiation of treatment. Vedolizumab was administered as per standard dosing regimen. The Pouch Disease Activity Index (PDAI) endoscopic subscore was evaluated by the 2 investigators independently and reported as an average. The clinical record was reviewed to determine patient reported response to therapy. Patient 1, a 54 year old male, had undergone colectomy and IPAA in 2000 for medically refractory ulcerative colitis (UC). He suffered from ankylosing spondylitis and chronic Pouchitis. He had been treated serially with antibiotics, budesonide, infliximab, methotrexate, adalimumab, in combination with hyperbaric oxygen therapy with severe diarrhea. His pouchoscopy prior to initiation revealed confluent ulceration with PDAI endoscopic subscore of 4. Endoscopy 4 months after the initiation of vedolizumab therapy revealed visual improvement, with few small ulcers noted, with PDAI endoscopic subscore of 3. He experienced improvement in clinical symptoms and has avoided surgical resection of his pouch but did require maintenance therapy with budesonide. Patient 2, a 54 year old female underwent colectomy and IPAA in 1991 for medically refractory UC. She developed recurrent stricturing at the pouch inlet and afferent limb and Pouchitis, treated with surgical stricturoplasty, antibiotics, thiopurines, mesalamine, intravenous immunoglobulin therapy, fecal microbiota transplant, and adalimumab. She continued to have symptoms of diarrhea and pain. Pouch endoscopy revealed chronic Pouchitis with edema and loss of vascular pattern consistent with a PDAI score of 5, along with cuffitis, and ulcerated strictures in the neo-terminal ileum. She underwent pouchoscopy 4 months after the therapy with vedolizumab which revealed improvement in Pouchitis, normal appearing mucosa and PDAI endoscopic subscore 1, but ongoing ulceration at cuff and inlet. Patient 3, a 54 year old female post restorative proctocolectomy for refractory UC in 2012 had required pouch redo surgery in 2014 for severe pouch dysfunction. She suffered from diarrhea requiring intravenous hydration despite use of antibiotics, infliximab with azathioprine, and mesalamine. Her pouchoscopy revealed Pouchitis and ileitis with a PDAI score of 3. Pouch endoscopy 4 months after initiation of vedolizumab which revealed improved mucosa of the pouch with PDAI score of 1. She noted improvement in symptoms of diarrhea. All 3 patients had improved endoscopic scores and reported clinical improvement in terms of diarrhea and pain. Vedolizumab in open label use for chronic antibiotic- and anti- TNFα-refractory, chronic Pouchitis demonstrated improvement in both symptoms and endoscopy scores.
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Pouchitis what every gastroenterologist needs to know
Clinical Gastroenterology and Hepatology, 2013Co-Authors: Bo ShenAbstract:Pouchitis is the most common complication among patients with ulcerative colitis who have undergone restorative proctocolectomy with ileal pouch–anal anastomosis. Pouchitis is actually a spectrum of diseases that vary in etiology, pathogenesis, phenotype, and clinical course. Although initial acute episodes typically respond to antibiotic therapy, patients can become dependent on antibiotics or develop refractory disease. Many factors contribute to the course of refractory Pouchitis, such as the use of nonsteroidal anti-inflammatory drugs, infection with Clostridium difficile, pouch ischemia, or concurrent immune-mediated disorders. Identification of these secondary factors can help direct therapy.
William J Sandborn - One of the best experts on this subject based on the ideXlab platform.
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disease activity indices for Pouchitis a systematic review
Inflammatory Bowel Diseases, 2021Co-Authors: Rocio Sedano, William J Sandborn, Claire E. Parker, Brian G. Feagan, Geert R Dhaens, Tran M Nguyen, Ahmed Almradi, Florian Rieder, Lisa M Shackelton, Vipul JairathAbstract:Background Several indices exist to measure Pouchitis disease activity; however, none are fully validated. As an initial step toward creating a validated instrument, we identified Pouchitis disease activity indices, examined their operating properties, and assessed their value as outcome measures in clinical trials. Methods Electronic databases were searched to identify randomized controlled trials including indices that evaluated clinical, endoscopic, or histologic Pouchitis disease activity. A second search identified studies that assessed the operating properties of Pouchitis indices. Results Eighteen randomized controlled trials utilizing 4 composite Pouchitis disease activity indices were identified. The Pouchitis Disease Activity Index (PDAI) was most commonly used (12 of 18; 66.7%) to define both trial eligibility (8 of 12; 66.7%), and outcome measures (12 of 12; 100%). In a separate search, 21 studies evaluated the operating properties of 3 Pouchitis indices; 90.5% (19 of 21) evaluated validity, of which 42.1% (8 of 19) evaluated the construct validity of the PDAI. Criterion validity (73.7%; 14 of 19) was evaluated through correlation of the PDAI with fecal calprotectin (FCP; r = 0.188 to 0.71), fecal lactoferrin (r = 0.570 to 0.582), and C-reactive protein (CRP; r = 0.584). Two studies assessed correlation of the modified PDAI (mPDAI) with FCP (r = 0.476 and r = 0.565, respectively). Fair to moderate inter-rater reliability of the PDAI (k = 0.440) and mPDAI (k = 0.389) was reported in a single study. Responsiveness of the PDAI pre-antibiotic and postantibiotic treatment was partially evaluated in a single study of 12 patients. Conclusions Development and validation of a specific Pouchitis disease activity index is needed given that existing instruments are not valid, reliable, or responsive.
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treatment and prevention of Pouchitis after ileal pouch anal anastomosis for chronic ulcerative colitis
Cochrane Database of Systematic Reviews, 2019Co-Authors: Siddharth Singh, William J Sandborn, Andrea M Stroud, Stefan D Holubar, Darrell S PardiAbstract:Background Pouchitis may occur following ileal pouch-anal anastomosis for chronic ulcerative colitis in approximately 30% of patients. Objectives The primary objective was to determine the efficacy of medical therapies for Pouchitis (including antibiotic, probiotic, and other agents) as substantiated by data from randomized controlled trials (RCTs). Search strategy A search for RCTs from 1966 to October 2009 was performed using the MEDLINE, Cochrane Library, EMBASE, Web of Science, and Scopus databases. Selection criteria Randomized controlled treatment or prevention trials of adult patients who underwent ileal pouch-anal anastomosis for ulcerative colitis who subsequently developed Pouchitis or were at risk for Pouchitis were considered for inclusion. Data collection and analysis Extracted data were converted to 2X2 tables and then synthesized in to a summary statistic using the Peto odds ratio (OR) and [95% confidence intervals], or weighted mean difference (WMD), using RevMan-5 for Mac OS 10.6. Main results Eleven RCTs fulfilled the inclusion criteria and were included in the review. The efficacy of 10 different pharmacologic agents was assessed. For the treatment of acute Pouchitis (4 RCTS, 5 agents), ciprofloxacin was more effective at inducing remission than metronidazole. Neither rifaximin nor lactobacillus GG were more effective than placebo, while budesonide enemas and metronidazole were similarly effective, for inducing remission of acute Pouchitis. For the treatment and maintenance of remission of chronic Pouchitis (4 RCTs, 4 agents), glutamine suppositories were not more effective than butyrate suppositories, and bismuth carbomer foam enemas were not more effective than placebo, while VSL#3 was more effective than placebo in maintaining remission of chronic Pouchitis in patients with chronic Pouchitis who achieved remission with antibiotics. For the prevention of Pouchitis (3 RCTs, 2 agents), in one study VSL#3 was more effective than placebo while in another study VSL#3 was not more effective than no treatment. Allopurinol was not more effective than placebo, while inulin was more effective than placebo but the results were not clinically significant. Authors' conclusions For acute Pouchitis, ciprofloxacin was more effective than metronidazole, while budesonide enemas and metronidazole were similarly effective. For chronic Pouchitis, VSL#3 was more effective than placebo. For the prevention of Pouchitis, VSL#3 was more effective than placebo. Larger RCTs are needed to determine the optimal agent(s) for the treatment and prevention of Pouchitis.
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reliability among central readers in the evaluation of endoscopic disease activity in Pouchitis
Gastrointestinal Endoscopy, 2018Co-Authors: Mark A Samaan, William J Sandborn, Bo Shen, Lisa M Shackelton, Mahmoud Mosli, Guangyong Zou, Sigrid Nelson, Larry Stitt, Stuart Bloom, Darrell S PardiAbstract:Background and Aims Pouchitis is a common adverse event after proctocolectomy with ileal pouch anal anastomosis for ulcerative colitis. Evaluation of Pouchitis disease activity and response to treatment requires use of validated indices. We assessed the reliability of items evaluating endoscopic Pouchitis disease activity. Methods Twelve panelists used a modified RAND appropriateness methodology to rate the appropriateness of items evaluating endoscopic Pouchitis disease activity derived from a systematic review and also identified additional potential endoscopic items based on expert opinion. Four central readers then evaluated 50 pouchoscopy videos in triplicate, in random order. Intra- and inter-rater reliability for each item was assessed by calculating and comparing intraclass correlation coefficients (ICCs). A Delphi process identified common sources of disagreement among the readers. Results Ten existing endoscopic items were identified from the systematic review and an additional 7 exploratory items from the panelists. ICCs for inter-rater reliability were highest for the existing item of pouch ulceration (.72; 95% confidence interval [CI], .60-.82) and for the exploratory item of ulcerated surface in the pouch body (.67; 95% CI, .53-.75). Inter-rater reliability for all other existing and exploratory items was “moderate” (ICC Conclusion Substantial reliability was observed only for the endoscopic items of ulceration and ulcerated surface in the pouch body. Future studies should assess responsiveness to treatment in the next stage toward development of an endoscopic Pouchitis disease activity index.
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rifaximin for the treatment of active Pouchitis a randomized double blind placebo controlled pilot study
Inflammatory Bowel Diseases, 2007Co-Authors: Kim L Isaacs, Robert S Sandler, Stephen B Hanauer, Maria T Abreu, Michael F Picco, Stephen J Bickston, Daniel H Present, Francis A Farraye, Douglas C Wolf, William J SandbornAbstract:Background: The efficacy of the nonabsorbable antibiotic rifaximin in patients with active acute or chronic Pouchitis is unknown. Methods: We performed a placebo-controlled pilot trial to evaluate the efficacy and safety of rifaximin in patients with active Pouchitis. Eighteen patients with active Pouchitis were randomized to receive oral rifaximin 400 mg or placebo 3 times daily for 4 weeks. Active Pouchitis was defined as a total Pouchitis Disease Activity Index (PDAI) score = 7 points. Clinical remission was defined as a PDAI score <7 points and a decrease in the baseline PDAI score = 3 points. The primary analysis was clinical remission at week 4. Results: Eight patients were randomized to rifaximin and 10 patients were randomized to placebo. One patient in the placebo group did not have a post-baseline efficacy evaluation and was excluded from the efficacy analysis. Two of 8 patients (25%) treated with rifaximin were in clinical remission at week 4 compared to 0 of 9 patients (0%) treated with placebo (P = 0.2059). None of 8 patients in the rifaximin group withdrew from the trial prior to week 4. Two of 9 patients in the placebo group withdrew prior to week 4 due to lack of efficacy and were categorized as treatment failures. Conclusions: Clinical remission occurred more frequently in patients treated with rifaximin 400 mg 3 times daily but the difference was not significant in this pilot study. A larger trial would be required to determine if rifaximin is effective for the treatment of active Pouchitis. Rifaximin was well tolerated. (Inflamm Bowel Dis 2007)
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systematic review the management of Pouchitis
Alimentary Pharmacology & Therapeutics, 2006Co-Authors: Darrell S Pardi, William J SandbornAbstract:Pouchitis is the most common complication following proctocolectomy and ileal pouch-anal anastomosis in patients with ulcerative colitis. We aim at discussing relevant information on epidemiology, clinical features, risk factors, diagnostic testing, differential diagnosis and treatment of this idiopathic inflammatory condition. A computerized search of PubMed was performed with the search term 'Pouchitis', limited to English papers on humans. This strategy identified 514 references. Relevant articles were selected from this list. In addition, the reference list for each of the selected articles was reviewed to identify any additional references. Pouchitis occurs in up to 60% of patients after ileal pouch-anal anastomosis for ulcerative colitis, and has characteristic clinical, endoscopic and histological features. The most important test for diagnosis is pouch endoscopy with biopsy. Antibiotics remain the mainstay of treatment, and other options are discussed for those patients who are refractory to antibiotic therapy.
Victor W. Fazio - One of the best experts on this subject based on the ideXlab platform.
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perioperative factors during ileal pouch anal anastomosis predict Pouchitis
Diseases of The Colon & Rectum, 2011Co-Authors: Jeremy M Lipman, Bo Shen, Feza H. Remzi, Ravi P Kiran, Victor W. FazioAbstract:PURPOSE: Pouchitis is the most common complication of IPAA. Identifying factors predictive of Pouchitis may improve outcomes by modifying contributing factors and enhancing patient selection. The most objective means for confirming Pouchitis is by histology because the clinical and endoscopic diagnoses rely on more subjective assessments. The importance of histological Pouchitis in the absence of clinical or endoscopic findings is unknown. METHODS: Prospectively collected data on patients with IPAA and pouch surveillance were evaluated. Patients who developed Pouchitis, defined as symptoms of Pouchitis confirmed by endoscopic biopsy (group B) were compared with those without any episode of clinical, endoscopic, or histological Pouchitis (group A) for pre- and intraoperative factors and outcomes. Asymptomatic patients with histological Pouchitis on surveillance biopsies (group C) were further compared with group A. Patients with Crohn's disease were excluded. RESULTS: Of the 673 patients with pouch biopsies, 422 (62.7%) were in group A, 161 (23.9%) in group B, and 90 (13.4%) in group C. Mean follow-up was 9.8 (±5.1), 12.4 (±5.4), and 13.5 (±4.7) years. Of the 43 preoperative factors evaluated, those associated with group B included leukocytosis (P < .001), rheumatologic extraintestinal disease (P < .001), disease proximal to splenic flexure (P = .001), pulmonary comorbidity (P = .004), prior steroid use (P = .006), and age at operation and diagnosis (P = .018 and .021). Of the 10 intraoperative factors evaluated, Pouchitis was associated with S-pouch reconstruction (P < .001), transfusion (P < .001), and 2-stage instead of 3-stage operation (P = .05), all surrogates for operative complexity. On multivariate analysis, pulmonary comorbidity (OR 3.38, 95% CI 1.62-7.07), disease proximal to splenic flexure (OR 2.37, 95% CI 1.18-4.77), extraintestinal disease manifestations (OR 1.6, 95% CI 1.01-2.54), and S-pouch reconstruction (OR 1.59, 95% CI 0.99 - 2.54) were associated with Pouchitis. Patients in group B had worse outcomes, including more strictures (P = .015), bowel obstructions (P = .019), fistulas (P = .18), and lower quality of life (P < .001). Group C patients had the same outcomes as those in group A and the finding was not predicted by the above-mentioned parameters. CONCLUSION: Patients with symptomatic, biopsy-confirmed Pouchitis have worse long-term outcomes than those without Pouchitis. This complication is associated with specific pre- and intraoperative factors. Histological Pouchitis incidentally found on surveillance biopsy in asymptomatic patients is of no clinical relevance and does not influence outcome. Identification of these preoperative factors associated with the subsequent development of Pouchitis will strengthen patient counseling and may facilitate risk stratification.
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asymmetric endoscopic inflammation of the ileal pouch a sign of ischemic Pouchitis
Inflammatory Bowel Diseases, 2010Co-Authors: Bo Shen, Feza H. Remzi, Victor W. Fazio, Thomas Plesec, Erick M Remer, Pokala R Kiran, Rocio Lopez, John R. GoldblumAbstract:Background: Pouchitis is associated with dysbiosis and dysregulated mucosal immunity, although secondary Pouchitis with special etiologic factors, such as ischemia, can occur. The aim was to describe a disease phenotype of the ileal pouch with an endoscopic appearance suggestive of ischemia. Methods: We identified consecutive patients with endoscopic asymmetric inflammation of the pouch (inflammation of side of the pouch with a completely normal other limb of the pouch one limb and a sharp demarcation along the staple suture line). Patients with Crohn's disease (CD) of the pouch or antibiotic-responsive Pouchitis, matched for duration of the pouch, served as controls. Histology slides of mucosal biopsies were re-reviewed independently by 2 blinded gastrointestinal pathologists. Demographic, clinical, endoscopic, histologic, and imaging characteristics were compared between the groups. Results: Ten patients with “ischemic” Pouchitis, 15 with CD of the pouch, and 15 with antibiotic-responsive Pouchitis were studied. Pyloric gland metaplasia was observed only in the groups with CD of the pouch (23.1%) or antibiotic-responsive Pouchitis (13.3%). Of patients with “ischemic” Pouchitis, 80% had extracellular hemosiderin or hematoidin deposits (versus 30.8% those with CD of the pouch and 13.3% of those with Pouchitis, P = 0.003). The majority of patients (80%) with “ischemic” Pouchitis did not respond to conventional antibiotic therapy. It appeared that subsequent abdominal surgeries after pouch construction and a history of postoperative portal vein thrombi were associated with “ischemic” Pouchitis. Conclusions: Endoscopic asymmetric inflammation of the pouch may represent an ischemia-associated Pouchitis with characteristic clinical, radiographic, and histologic features. Its hemodynamic, cellular, and molecular basis of mechanism warrants further study. Inflamm Bowel Dis 2010
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effect of withdrawal of nonsteroidal anti inflammatory drug use on ileal pouch disorders
Digestive Diseases and Sciences, 2007Co-Authors: Bo Shen, Feza H. Remzi, Ana E. Bennett, Victor W. Fazio, Aaron Brzezinski, Rocio Lopez, Kerry Sherman, Ian C Lavery, Bret A LashnerAbstract:NSAID use has been shown to exacerbate disease activity of inflammatory bowel disease. The detrimental effect of NSAIDs on the ileal pouch has not been characterized. To study the effect of withdrawal of NSAID use on ileal pouch disorders. The study consisted of a cohort of 17 symptomatic patients seen in the Pouchitis Clinic who had ulcerative colitis and ileal pouch-anal anastomosis with chronic (>6 months) daily use of NSAIDs. The patients were treated by withdrawing NSAID use. The Pouchitis Disease Activity Index (PDAI) consisting of symptom, endoscopy and histology scores, and Cleveland Global Quality of Life, Irritable Bowel Disease Quality of Life, and Short Inflammatory Bowel Disease Questionnaire scores were measured before and after a 4-week intervention. The cohort consisted of 11 patients with chronic refractory Pouchitis (65%), 2 with acute Pouchitis (12%), 1 with cuffitis (6%), 1 with cuffitis and chronic refractory Pouchitis (6%), and 2 with irritable pouch syndrome (12%). The withdrawal of NSAID use alone resulted in a significant reduction in the mean PDAI scores of −3.6 ± −3.0 (p<0.02) and a significant improvement in mean quality-of-life scores (p<0.05). Patients with pouch disorders who regularly used NSAIDs appeared to benefit from the complete cessation of such agents, suggesting an association between NSAID use and pouch disorders.
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combined ciprofloxacin and tinidazole therapy in the treatment of chronic refractory Pouchitis
Diseases of The Colon & Rectum, 2007Co-Authors: Bo Shen, Feza H. Remzi, Ana E. Bennett, Victor W. Fazio, Aaron Brzezinski, Rocio Lopez, Ioannis Oikonomou, Kerry Sherman, Bret A LashnerAbstract:Management of chronic refractory Pouchitis, a common cause for pouch failure with pouch resection or diversion, is often challenging. The aim of this study was to assess the efficacy and safety of a combination therapy of ciprofloxacin and tinidazole in patients with chronic refractory Pouchitis compared with mesalamine therapy. Sixteen consecutive ulcerative colitis patients with chronic refractory Pouchitis (disease>4 weeks and failure to respond to>4 weeks of single-antibiotic therapy) were treated with a four-week course of ciprofloxacin 1 g/day and tinidazole 15 mg/kg/day. A historic cohort of ten consecutive patients with chronic refractory Pouchitis treated with oral (4 g/day), enema (8 g/day), or suppository (1 g/day) mesalamine served as controls. The Pouchitis Disease Activity Index, clinical remission, clinical response, the Cleveland Global Quality of Life, the Irritable Bowel Syndrome-Quality of Life, and the Short Inflammatory Bowel Disease Questionnaires scores were calculated before and after therapy and compared between the two treatment groups. Patients taking ciprofloxacin and tinidazole had a significant reduction in the total Pouchitis Disease Activity Index scores and subscores and a significant improvement in quality-of-life scores (P < 0.002). For patients in the mesalamine group, there was a significant reduction in the total Pouchitis Disease Activity Index scores only. Patients in the antibiotic group had a greater reduction in the total Pouchitis Disease Activity Index scores and a greater improvement in the quality-of-life scores than those in the mesalamine group (P ≤ 0.03). The rate of clinical remission and clinical response for the antibiotic group was 87.5 percent and 87.5 percent, respectively, and for the mesalamine group it was 50 percent and 50 percent, respectively (P = 0.069). Two patients in the antibiotic group (peripheral neuropathy and dysgeusia) developed adverse effects. Combination therapy with ciprofloxacin and tinidazole was generally well tolerated and was effective in treating patients with chronic refractory Pouchitis.
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Clostridium Difficile-Associated Pouchitis
Digestive Diseases and Sciences, 2006Co-Authors: Bo Shen, John R. Goldblum, Tracy L. Hull, Feza H. Remzi, Ana E. Bennett, Victor W. FazioAbstract:Pouchitis is the most common long-term sequela of ileal pouch-anal anastomosis (IPAA) following total proctocolectomy. No single pathogen is identified as being solely responsible for the pathogenesis of the disease. Here we describe a case of Clostridium difficile-associated Pouchitis that was successfully treated with ciprofloxacin and tinidazole. Diagnosis and management of a patient with medically refractory Pouchitis associated with Clostridium difficile infection is described. A 63-year-old male with underlying ulcerative colitis and IPAA presented with increased stool frequency and seepage for 2 months, which partially responded to oral metronidazole. While on the antibiotic therapy, pouch endoscopy was performed and showed severe Pouchitis. Assays for Clostridium difficile toxins in stool specimens were positive. He was treated with a 4-week course of ciprofloxacin 500 mg BID and tinidazole 500 mg TID. His symptoms resolved within several days from the initiation of therapy. A repeat pouch endoscopy at week 5 showed a complete resolution of mucosal inflammation of the pouch, while tests for Clostridium difficile toxins became negative. Clostridium difficile-associated Pouchitis is rare. However, Clostridium difficile infection should be excluded in patients with chronic refractory Pouchitis.
Feza H. Remzi - One of the best experts on this subject based on the ideXlab platform.
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perioperative factors during ileal pouch anal anastomosis predict Pouchitis
Diseases of The Colon & Rectum, 2011Co-Authors: Jeremy M Lipman, Bo Shen, Feza H. Remzi, Ravi P Kiran, Victor W. FazioAbstract:PURPOSE: Pouchitis is the most common complication of IPAA. Identifying factors predictive of Pouchitis may improve outcomes by modifying contributing factors and enhancing patient selection. The most objective means for confirming Pouchitis is by histology because the clinical and endoscopic diagnoses rely on more subjective assessments. The importance of histological Pouchitis in the absence of clinical or endoscopic findings is unknown. METHODS: Prospectively collected data on patients with IPAA and pouch surveillance were evaluated. Patients who developed Pouchitis, defined as symptoms of Pouchitis confirmed by endoscopic biopsy (group B) were compared with those without any episode of clinical, endoscopic, or histological Pouchitis (group A) for pre- and intraoperative factors and outcomes. Asymptomatic patients with histological Pouchitis on surveillance biopsies (group C) were further compared with group A. Patients with Crohn's disease were excluded. RESULTS: Of the 673 patients with pouch biopsies, 422 (62.7%) were in group A, 161 (23.9%) in group B, and 90 (13.4%) in group C. Mean follow-up was 9.8 (±5.1), 12.4 (±5.4), and 13.5 (±4.7) years. Of the 43 preoperative factors evaluated, those associated with group B included leukocytosis (P < .001), rheumatologic extraintestinal disease (P < .001), disease proximal to splenic flexure (P = .001), pulmonary comorbidity (P = .004), prior steroid use (P = .006), and age at operation and diagnosis (P = .018 and .021). Of the 10 intraoperative factors evaluated, Pouchitis was associated with S-pouch reconstruction (P < .001), transfusion (P < .001), and 2-stage instead of 3-stage operation (P = .05), all surrogates for operative complexity. On multivariate analysis, pulmonary comorbidity (OR 3.38, 95% CI 1.62-7.07), disease proximal to splenic flexure (OR 2.37, 95% CI 1.18-4.77), extraintestinal disease manifestations (OR 1.6, 95% CI 1.01-2.54), and S-pouch reconstruction (OR 1.59, 95% CI 0.99 - 2.54) were associated with Pouchitis. Patients in group B had worse outcomes, including more strictures (P = .015), bowel obstructions (P = .019), fistulas (P = .18), and lower quality of life (P < .001). Group C patients had the same outcomes as those in group A and the finding was not predicted by the above-mentioned parameters. CONCLUSION: Patients with symptomatic, biopsy-confirmed Pouchitis have worse long-term outcomes than those without Pouchitis. This complication is associated with specific pre- and intraoperative factors. Histological Pouchitis incidentally found on surveillance biopsy in asymptomatic patients is of no clinical relevance and does not influence outcome. Identification of these preoperative factors associated with the subsequent development of Pouchitis will strengthen patient counseling and may facilitate risk stratification.
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asymmetric endoscopic inflammation of the ileal pouch a sign of ischemic Pouchitis
Inflammatory Bowel Diseases, 2010Co-Authors: Bo Shen, Feza H. Remzi, Victor W. Fazio, Thomas Plesec, Erick M Remer, Pokala R Kiran, Rocio Lopez, John R. GoldblumAbstract:Background: Pouchitis is associated with dysbiosis and dysregulated mucosal immunity, although secondary Pouchitis with special etiologic factors, such as ischemia, can occur. The aim was to describe a disease phenotype of the ileal pouch with an endoscopic appearance suggestive of ischemia. Methods: We identified consecutive patients with endoscopic asymmetric inflammation of the pouch (inflammation of side of the pouch with a completely normal other limb of the pouch one limb and a sharp demarcation along the staple suture line). Patients with Crohn's disease (CD) of the pouch or antibiotic-responsive Pouchitis, matched for duration of the pouch, served as controls. Histology slides of mucosal biopsies were re-reviewed independently by 2 blinded gastrointestinal pathologists. Demographic, clinical, endoscopic, histologic, and imaging characteristics were compared between the groups. Results: Ten patients with “ischemic” Pouchitis, 15 with CD of the pouch, and 15 with antibiotic-responsive Pouchitis were studied. Pyloric gland metaplasia was observed only in the groups with CD of the pouch (23.1%) or antibiotic-responsive Pouchitis (13.3%). Of patients with “ischemic” Pouchitis, 80% had extracellular hemosiderin or hematoidin deposits (versus 30.8% those with CD of the pouch and 13.3% of those with Pouchitis, P = 0.003). The majority of patients (80%) with “ischemic” Pouchitis did not respond to conventional antibiotic therapy. It appeared that subsequent abdominal surgeries after pouch construction and a history of postoperative portal vein thrombi were associated with “ischemic” Pouchitis. Conclusions: Endoscopic asymmetric inflammation of the pouch may represent an ischemia-associated Pouchitis with characteristic clinical, radiographic, and histologic features. Its hemodynamic, cellular, and molecular basis of mechanism warrants further study. Inflamm Bowel Dis 2010
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effect of withdrawal of nonsteroidal anti inflammatory drug use on ileal pouch disorders
Digestive Diseases and Sciences, 2007Co-Authors: Bo Shen, Feza H. Remzi, Ana E. Bennett, Victor W. Fazio, Aaron Brzezinski, Rocio Lopez, Kerry Sherman, Ian C Lavery, Bret A LashnerAbstract:NSAID use has been shown to exacerbate disease activity of inflammatory bowel disease. The detrimental effect of NSAIDs on the ileal pouch has not been characterized. To study the effect of withdrawal of NSAID use on ileal pouch disorders. The study consisted of a cohort of 17 symptomatic patients seen in the Pouchitis Clinic who had ulcerative colitis and ileal pouch-anal anastomosis with chronic (>6 months) daily use of NSAIDs. The patients were treated by withdrawing NSAID use. The Pouchitis Disease Activity Index (PDAI) consisting of symptom, endoscopy and histology scores, and Cleveland Global Quality of Life, Irritable Bowel Disease Quality of Life, and Short Inflammatory Bowel Disease Questionnaire scores were measured before and after a 4-week intervention. The cohort consisted of 11 patients with chronic refractory Pouchitis (65%), 2 with acute Pouchitis (12%), 1 with cuffitis (6%), 1 with cuffitis and chronic refractory Pouchitis (6%), and 2 with irritable pouch syndrome (12%). The withdrawal of NSAID use alone resulted in a significant reduction in the mean PDAI scores of −3.6 ± −3.0 (p<0.02) and a significant improvement in mean quality-of-life scores (p<0.05). Patients with pouch disorders who regularly used NSAIDs appeared to benefit from the complete cessation of such agents, suggesting an association between NSAID use and pouch disorders.
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combined ciprofloxacin and tinidazole therapy in the treatment of chronic refractory Pouchitis
Diseases of The Colon & Rectum, 2007Co-Authors: Bo Shen, Feza H. Remzi, Ana E. Bennett, Victor W. Fazio, Aaron Brzezinski, Rocio Lopez, Ioannis Oikonomou, Kerry Sherman, Bret A LashnerAbstract:Management of chronic refractory Pouchitis, a common cause for pouch failure with pouch resection or diversion, is often challenging. The aim of this study was to assess the efficacy and safety of a combination therapy of ciprofloxacin and tinidazole in patients with chronic refractory Pouchitis compared with mesalamine therapy. Sixteen consecutive ulcerative colitis patients with chronic refractory Pouchitis (disease>4 weeks and failure to respond to>4 weeks of single-antibiotic therapy) were treated with a four-week course of ciprofloxacin 1 g/day and tinidazole 15 mg/kg/day. A historic cohort of ten consecutive patients with chronic refractory Pouchitis treated with oral (4 g/day), enema (8 g/day), or suppository (1 g/day) mesalamine served as controls. The Pouchitis Disease Activity Index, clinical remission, clinical response, the Cleveland Global Quality of Life, the Irritable Bowel Syndrome-Quality of Life, and the Short Inflammatory Bowel Disease Questionnaires scores were calculated before and after therapy and compared between the two treatment groups. Patients taking ciprofloxacin and tinidazole had a significant reduction in the total Pouchitis Disease Activity Index scores and subscores and a significant improvement in quality-of-life scores (P < 0.002). For patients in the mesalamine group, there was a significant reduction in the total Pouchitis Disease Activity Index scores only. Patients in the antibiotic group had a greater reduction in the total Pouchitis Disease Activity Index scores and a greater improvement in the quality-of-life scores than those in the mesalamine group (P ≤ 0.03). The rate of clinical remission and clinical response for the antibiotic group was 87.5 percent and 87.5 percent, respectively, and for the mesalamine group it was 50 percent and 50 percent, respectively (P = 0.069). Two patients in the antibiotic group (peripheral neuropathy and dysgeusia) developed adverse effects. Combination therapy with ciprofloxacin and tinidazole was generally well tolerated and was effective in treating patients with chronic refractory Pouchitis.
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Clostridium Difficile-Associated Pouchitis
Digestive Diseases and Sciences, 2006Co-Authors: Bo Shen, John R. Goldblum, Tracy L. Hull, Feza H. Remzi, Ana E. Bennett, Victor W. FazioAbstract:Pouchitis is the most common long-term sequela of ileal pouch-anal anastomosis (IPAA) following total proctocolectomy. No single pathogen is identified as being solely responsible for the pathogenesis of the disease. Here we describe a case of Clostridium difficile-associated Pouchitis that was successfully treated with ciprofloxacin and tinidazole. Diagnosis and management of a patient with medically refractory Pouchitis associated with Clostridium difficile infection is described. A 63-year-old male with underlying ulcerative colitis and IPAA presented with increased stool frequency and seepage for 2 months, which partially responded to oral metronidazole. While on the antibiotic therapy, pouch endoscopy was performed and showed severe Pouchitis. Assays for Clostridium difficile toxins in stool specimens were positive. He was treated with a 4-week course of ciprofloxacin 500 mg BID and tinidazole 500 mg TID. His symptoms resolved within several days from the initiation of therapy. A repeat pouch endoscopy at week 5 showed a complete resolution of mucosal inflammation of the pouch, while tests for Clostridium difficile toxins became negative. Clostridium difficile-associated Pouchitis is rare. However, Clostridium difficile infection should be excluded in patients with chronic refractory Pouchitis.
Bret A Lashner - One of the best experts on this subject based on the ideXlab platform.
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effect of withdrawal of nonsteroidal anti inflammatory drug use on ileal pouch disorders
Digestive Diseases and Sciences, 2007Co-Authors: Bo Shen, Feza H. Remzi, Ana E. Bennett, Victor W. Fazio, Aaron Brzezinski, Rocio Lopez, Kerry Sherman, Ian C Lavery, Bret A LashnerAbstract:NSAID use has been shown to exacerbate disease activity of inflammatory bowel disease. The detrimental effect of NSAIDs on the ileal pouch has not been characterized. To study the effect of withdrawal of NSAID use on ileal pouch disorders. The study consisted of a cohort of 17 symptomatic patients seen in the Pouchitis Clinic who had ulcerative colitis and ileal pouch-anal anastomosis with chronic (>6 months) daily use of NSAIDs. The patients were treated by withdrawing NSAID use. The Pouchitis Disease Activity Index (PDAI) consisting of symptom, endoscopy and histology scores, and Cleveland Global Quality of Life, Irritable Bowel Disease Quality of Life, and Short Inflammatory Bowel Disease Questionnaire scores were measured before and after a 4-week intervention. The cohort consisted of 11 patients with chronic refractory Pouchitis (65%), 2 with acute Pouchitis (12%), 1 with cuffitis (6%), 1 with cuffitis and chronic refractory Pouchitis (6%), and 2 with irritable pouch syndrome (12%). The withdrawal of NSAID use alone resulted in a significant reduction in the mean PDAI scores of −3.6 ± −3.0 (p<0.02) and a significant improvement in mean quality-of-life scores (p<0.05). Patients with pouch disorders who regularly used NSAIDs appeared to benefit from the complete cessation of such agents, suggesting an association between NSAID use and pouch disorders.
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combined ciprofloxacin and tinidazole therapy in the treatment of chronic refractory Pouchitis
Diseases of The Colon & Rectum, 2007Co-Authors: Bo Shen, Feza H. Remzi, Ana E. Bennett, Victor W. Fazio, Aaron Brzezinski, Rocio Lopez, Ioannis Oikonomou, Kerry Sherman, Bret A LashnerAbstract:Management of chronic refractory Pouchitis, a common cause for pouch failure with pouch resection or diversion, is often challenging. The aim of this study was to assess the efficacy and safety of a combination therapy of ciprofloxacin and tinidazole in patients with chronic refractory Pouchitis compared with mesalamine therapy. Sixteen consecutive ulcerative colitis patients with chronic refractory Pouchitis (disease>4 weeks and failure to respond to>4 weeks of single-antibiotic therapy) were treated with a four-week course of ciprofloxacin 1 g/day and tinidazole 15 mg/kg/day. A historic cohort of ten consecutive patients with chronic refractory Pouchitis treated with oral (4 g/day), enema (8 g/day), or suppository (1 g/day) mesalamine served as controls. The Pouchitis Disease Activity Index, clinical remission, clinical response, the Cleveland Global Quality of Life, the Irritable Bowel Syndrome-Quality of Life, and the Short Inflammatory Bowel Disease Questionnaires scores were calculated before and after therapy and compared between the two treatment groups. Patients taking ciprofloxacin and tinidazole had a significant reduction in the total Pouchitis Disease Activity Index scores and subscores and a significant improvement in quality-of-life scores (P < 0.002). For patients in the mesalamine group, there was a significant reduction in the total Pouchitis Disease Activity Index scores only. Patients in the antibiotic group had a greater reduction in the total Pouchitis Disease Activity Index scores and a greater improvement in the quality-of-life scores than those in the mesalamine group (P ≤ 0.03). The rate of clinical remission and clinical response for the antibiotic group was 87.5 percent and 87.5 percent, respectively, and for the mesalamine group it was 50 percent and 50 percent, respectively (P = 0.069). Two patients in the antibiotic group (peripheral neuropathy and dysgeusia) developed adverse effects. Combination therapy with ciprofloxacin and tinidazole was generally well tolerated and was effective in treating patients with chronic refractory Pouchitis.
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maintenance therapy with a probiotic in antibiotic dependent Pouchitis experience in clinical practice
Alimentary Pharmacology & Therapeutics, 2005Co-Authors: Bo Shen, Feza H. Remzi, Ana E. Bennett, Victor W. Fazio, Jean Paul Achkar, Aaron Brzezinski, K Sherman, Bret A LashnerAbstract:SUMMARY Background: Management of antibiotic-dependent Pouchitis is often challenging. Oral bacteriotherapy with probiotics (such as VSL #3) as maintenance treatment has been shown to be effective in relapsing Pouchitis in European trials. However, this agent has not been studied in the US, and its applicability in routine clinical practice has not been evaluated. Aim: To determine compliance and efficacy of probiotic treatmentinpatientswithantibiotic-dependentPouchitis. Methods: Thirty-one patients with antibiotic-dependent Pouchitis were studied. VSL #3 is a patented probiotic preparation of live freeze-dried bacteria. All patients received 2 weeks of ciprofloxacin 500 mg b.d. followed by VSL #3 6 g/day for 8 months. Baseline Pouchitis Disease Activity Index scores were calculated. Patients’ symptoms were reassessed at week 3 when VSL #3 therapy was initiated and at the end of the 8-month trial. Some patients underwent repeat pouch endoscopy at the end of the trial. Results: All 31 patients responded to the 2-week ciprofloxacin trial with resolution of symptoms and they were subsequently treated with VSL #3. The mean duration of follow-up was 14.5 ± 5.3 months (range: 8‐26 months). At the 8-month follow-up, six patients were still on VSL #3 therapy, and the remaining 25 patients had discontinued the therapy due to either recurrence of symptoms while on treatment or development of adverse effects. All six patients who completed the 8-month course with a mean treatment period of 14.3 ± 7.2 months (range: 8‐26 months) had repeat clinical and endoscopic evaluation as out-patients. At the end of 8 months, these six patients had a mean Pouchitis Disease Activity Index symptom score of 0.33 ± 0.52 and a mean Pouchitis Disease Activity Index endoscopy score of 1.83 ± 1.72, which was not statistically different from the baseline Pouchitis Disease Activity Index endoscopy score of 2.83 ± 1.17 (P ¼ 0.27). Conclusion: This study was conducted to evaluate bacteriotherapy in routine care. The use of probiotics has been adopted as part of our routine clinical practice with only anecdotal evidence of efficacy. Our review of patient outcome from the treatment placebo showed that only a minority of patients with antibiotic-dependent Pouchitis remained on the probiotic therapy and in symptomatic remission after 8 months.
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differentiating risk factors for acute and chronic Pouchitis
Clinical Gastroenterology and Hepatology, 2005Co-Authors: Jean Paul Achkar, Bo Shen, Feza H. Remzi, Mohammad A Alhaddad, Bret A Lashner, Aaron Brzezinski, Farah Khandwala, Victor W. FazioAbstract:Background & Aims: Pouchitis is the most common complication of ileal pouch anal anastomosis in patients with ulcerative colitis. In some cases the inflammation becomes chronic and requires long-term medical therapy. The clinical course and medical therapy are different between acute Pouchitis and chronic Pouchitis. The aim of this study was to determine if there are predictors of risk for acute vs. chronic Pouchitis. Methods: Patients with acute Pouchitis (N = 40) and patients with chronic Pouchitis (N = 40) were matched with a control group who never had Pouchitis (N = 40). Data were collected for multiple pre-, peri-, and postoperative factors and follow-up telephone calls were performed. Case-control univariable analyses and multivariate logistic regression were used to measure the association between covariates and Pouchitis. Results: Multivariate logistic regression showed that extensive colonic disease (odds ratio [OR], 2.99; P = .045 for acute Pouchitis; and OR, 4.61; P = .010 for chronic Pouchitis) and extraintestinal manifestations (OR, 2.88; P = .037 for acute Pouchitis; and OR, 2.69; P = .047 for chronic Pouchitis) were associated with both acute and chronic Pouchitis. Postoperative nonsteroidal anti-inflammatory drug (NSAID) use was associated with chronic Pouchitis, but less so with acute Pouchitis. Patients with fulminant colitis as an indication for surgery had a decreased risk for developing chronic Pouchitis (OR, 0.22; P = .036), but no such association was seen for acute Pouchitis. Conclusions: Extensive colonic disease and preoperative extraintestinal manifestations are associated with increased risk for both acute and chronic Pouchitis. Fulminant colitis leading to colectomy is protective from development of chronic Pouchitis. Postoperative use of NSAIDS is a risk factor for chronic Pouchitis and possibly for acute Pouchitis, and thus should be discouraged for patients who undergo ileal pouch anal anastomosis.
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modified Pouchitis disease activity index a simplified approach to the diagnosis of Pouchitis
Diseases of The Colon & Rectum, 2003Co-Authors: Bo Shen, Feza H. Remzi, Victor W. Fazio, Jean Paul Achkar, Aaron Brzezinski, Jason T Connor, Adrian H Ormsby, Charles L Bevins, Marlene L Bambrick, Bret A LashnerAbstract:PURPOSE: Pouchitis is the most common complication of ileal pouch-anal anastomosis for ulcerative colitis. Our previous study suggested that symptoms alone are not reliable for the diagnosis of Pouchitis. The most commonly used diagnostic instrument is the 18-point Pouchitis disease activity index consisting of three principal component scores: symptom, endoscopy, and histology. Despite its popularity, the Pouchitis disease activity index has mainly been a research tool because of costs of endoscopy (especially with histology), complexity in calculation, and time delay in determining histology scores. It is not known whether pouch endoscopy without biopsy can reliably diagnose Pouchitis in symptomatic patients. The aim of the present study was to determine whether omitting histologic evaluation from the Pouchitis disease activity index significantly affects the sensitivity and specificity of diagnostic criteria for Pouchitis. METHODS: Ulcerative colitis patients with an ileal pouch-anal anastomosis and symptoms suggestive of Pouchitis were evaluated. Patients with chronic refractory Pouchitis and Crohn’s disease were excluded. Patients with Pouchitis disease activity index scores of seven or more were diagnosed as having Pouchitis. Different diagnostic criteria were compared on the basis of the Pouchitis disease activity index component scores. Nonparametric receiver-operating-characteristic curves were used to measure proposed Pouchitis scores’ diagnostic accuracy compared with diagnosis from the Pouchitis disease activity index. The receiver-operating-characteristic area under the curve measured how much these diagnostic strategies differed from each other. RESULTS: Fifty-eight consecutive symptomatic patients were enrolled; 32 (55 percent) patients were diagnosed with Pouchitis. With the use of the Pouchitis disease activity index as a criterion standard, the use of only symptom and endoscopy scores (modified Pouchitis disease activity index) produced an area under the curve of 0.995. Establishing a cut-point of five or more for diseased patients resulted in a sensitivity equal to 97 percent and specificity equal to 100 percent. CONCLUSIONS: Diagnosis based on the modified Pouchitis disease activity index offers similar sensitivity and specificity when compared with the Pouchitis disease activity index for patients with acute or acute relapsing Pouchitis. Omission of endoscopic biopsy and histology from the standard Pouchitis disease activity index would simplify Pouchitis diagnostic criteria, reduce the cost of diagnosis, and avoid delay associated with determining histology score, while providing equivalent sensitivity and specificity.
