What Is Pouchitis?
Pouchitis is related to the inflammation and swelling that occurs in the J- pouch provided during the ileal pouch-anal anastomosis surgery; this leads to an inflamed and irritated pouch. This increased inflammation of the pouch can cause increased bowel movements, frequent visits to the bathroom, blood in stools, severe abdominal pain, cramping, and bloating. This may also result due to underlying ulcerative colitis and inflammatory bowel disease.
Pouchitis is classified on the basis of its activity:
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Remission pouchitis (dormant or inactive stage).
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Mild to moderately active (associated with symptoms like urgency, increased stool frequency, and infrequent incontinence).
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Severely active (needs hospitalization for frequent incontinence and dehydration).
The duration of pouchitis is further divided into acute or chronic, acute pouchitis is less than or equal to four weeks, and chronic pouchitis is four weeks or more. They are further also classified under the pattern of occurrence like infrequent, relapsing, or continuous.
What Is Proctocolectomy?
Proctocolectomy is a surgical technique that removes the infected part of the colon or rectum. The colon and rectum are major parts of the large intestine. Through this procedure, the healthcare provider eliminates these parts of the intestine and creates a new pathway to excrete the poop. A colostomy, ileostomy, or an internal ileal pouch known as a J pouch is given to create a new pathway.
How Common Is Pouchitis?
Pouchitis is common in about half of the individuals who undergo ileal pouch-anal anastomosis surgery for ulcerative colitis at least once in their lifetime. Around 40 % of individuals develop pouchitis every year. Males and females are equally affected. Habits and risk factors have a great impact on the occurrence.
What Causes Pouchitis?
The exact trigger for pouchitis is unknown. It may occur in individuals with ulcerative colitis and those with a genetically inherited condition like polyp of the colon and FAP(familial adenomatous polyposis). Bowel movement changes after IPAA (ileal pouch-anal anastomosis) surgery may play a key role in causing pouchitis. The mucous membrane or the inner lining of the ilium launches an immune response as a reaction to different bacteria exposed, leading to inflammation. But more suspension is related to gut health and gut health has a great impact on pouchitis. A theory supports that a mix of bad and good bacteria in the intestine paves the way for fungal, bacteria, and viral infections that lead to pouchitis.
Other risk factors include:
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Weak blood flow to the area.
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Smoking.
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Genetics.
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Inflamed or hardened bile ducts in the liver.
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Consumption of non-steroidal anti-inflammatory drugs.
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Extensive ulcerative colitis.
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Inflammatory polyps, or growth in the pouches.
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Increased platelet count after a proctocolectomy.
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Presence of certain antibodies in the blood.
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Diabetes or heart disease.
What Are the Signs and Symptoms of Pouchitis?
Around one in five people suffer from pouchitis after successful surgery, and have them after ten years. This happens when the immune system defends or turns against itself and inflames the pouch. The signs and symptoms differ in each individual. They include:
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Diarrhea.
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Belly cramps.
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Incontinence (leaking poop or losing control).
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Urge to poop more often.
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Blood in stool.
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Unintentional weight loss.
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Fever and chills.
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Malnourishment.
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Dehydration.
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Anemia - that may require emergency medical care.
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Severe joint pain.
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Fatigue.
How Is the Diagnosis Done for Pouchitis?
Followed by the symptoms revealed by the individual, an endoscopy (examination of the pouch with an endoscope instrument) is done. This endoscopy of the pouch is known as pouchoscopy. This test reveals inflammation, and how it spreads and detects if the ileum is irritated or not or if the individual has any Crohn's disease pouch.
The endoscopy of the pouch can reveal if the individual has cuffitis (inflammation of the anal, transition zone, and cuff), or any abnormalities. Individuals with cuffitis (inflammation of the anal transition zone) often suffer from bright red blood in the stool.
In some cases, a biopsy is done, during endoscopy, and other abnormalities like infections, polyps, and any inflamed granulated tissue, or restricted blood supply are checked.
Imaging tests and other tests like:
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Contrast Photography: Known as contrast-enhanced imaging, is a medical imaging technique that uses contrast agents to enhance the visibility of certain structures in the body. Contrast agents are substances that are injected into the body, swallowed, or applied externally to the skin, and they absorb or scatter X-rays or other types of radiation, making certain tissues or structures more visible on the resulting images
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CT scan (Computed Tomography Scan): A medical imaging test that uses X-rays and computer technology to produce detailed images.
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MRI (Magnetic Resonance Imaging): A imaging technique that uses a powerful magnetic field, radio waves, and a computer to produce detailed images of the internal structures of the body
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Barium Defecography: It is a medical imaging test that uses a special form of contrast called barium sulfate to evaluate the function of the rectum and anus during bowel movements.
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Gastrografin Enema: A medical imaging test used to examine the small intestine.
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Anorectal Manometry: A medical procedure used to evaluate the function of the rectum and anal sphincter muscles.
What Is the Treatment Provided for Pouchitis?
Treatment of pouchitis is usually done by giving a 14-day antibiotic course. Healthcare providers may also recommend probiotics like Bifidobacterium, Lactobacillus, and Thermophilus (these bacterias normally reside in the gastrointestinal tract).
Chronic pouchitis is treated by a low carbohydrate and a low fiber diet and a high protein diet, these help in relieving the symptoms, individuals may also require anti-inflammatory therapy by biological and anti-inflammatory agents. Antidiarrheal agents are used to treat loose and frequent bowel movements.
What Is the Prognosis for the Individual With Pouchitis?
The prognosis of the individual depends on the individual's illness and their body's response:
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Individuals who require antibiotics will have long-term therapy with either probiotics or antibiotics.
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When antibiotics fail, looking for other causes of pouchitis is important, like using NSAIDs (nonsteroidal anti-inflammatory drugs), infections, reduced blood flow to the pouch, and autoimmune disease.
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The pouchitis that are antibiotic resistant can be tough to treat and is the main reason for organ failure. Removal of the pouch or permanent diversion is necessary in such cases.
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Individuals without an obvious cause of pouchitis require treatment possibilities like immunosuppressants, biological therapy, and combination with corticosteroids. Due to the long-term use of antibiotics, the bacteria may turn resistant to the antibiotics.
Conclusion
Pouchitis is the most common long-term complication of restorative proctocolectomy that affects individuals who have undergone IPAA surgery. The individuals present with a wide range of symptoms, disease course, and prognosis. Avoiding the causative risk factors and making appropriate dietary changes and lifestyle modifications can prevent such consequent conditions. Regular follow-up after the surgery looking for any new symptoms immediately can rule out the condition and immediate care can be provided. Though antibiotic therapy is largely used in the management of the condition, antibiotic-dependent and antibiotic-refractory pouchitis remain challenging conditions for health professionals.
