Preoperative Endoscopic Activity Predicts the Occurrence of Pouchitis After Ileal Pouch–Anal Anastomosis in Ulcerative Colitis: A Multicenter Retrospective Study in China

Background: Pouchitis is the most common long-term complication after ileal pouch–anal anastomosis (IPAA) in patients with ulcerative colitis (UC). Ulcerative colitis endoscopic index of severity (UCEIS) and Mayo endoscopic score (MES) are widely used indices to evaluate endoscopic activity. This study aimed to clarify the predictive value of preoperative endoscopic activity on the occurrence of pouchitis after IPAA.Methods: Data of patients with UC who underwent IPAA from January 2008 to January 2020 were collected retrospectively. UCEIS and MES were based on the preoperative colonoscopy findings of two independent endoscopists.Results: A total of 102 patients with a median follow-up of 5 (interquartile range, 2–9) years were included in the study. Among them, 21.6% developed pouchitis. Compared with MES, UCEIS had a stronger correlation with pouchitis disease activity index. UCEIS ≥ 7 had the most significant receiver-operating characteristic (ROC) curve area of 0.747 with a sensitivity of 68.2% and specificity of 81.2% in predicting pouchitis, which outperformed MES of 3 with an ROC area of 0.679 with a sensitivity of 54.5% and specificity of 81.2%. Furthermore, we found that UCEIS ≥ 7 was an independent risk factor for post-IPAA pouchitis [odds ratio (OR), 8.860; 95% CI, 1.969–39.865, p < 0.001] with a higher risk than MES of 3 (OR, 5.200; 95% CI, 1.895–14.273; p = 0.001).Conclusion: Ulcerative colitis endoscopic index of severity performed better in predicting pouchitis after IPAA than MES. Earlier and more frequent postoperative colonoscopic surveillance should be considered in patients with preoperative UCEIS ≥ 7 to detect the occurrence of pouchitis earlier.

Disease Activity Indices for Pouchitis: A Systematic Review

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.

Prevention and Medical Treatment of Pouchitis In Ulcerative Colitis

Approximately 50% of patients who have undergone IPAA surgery for Ulcerative Colitis (UC) develop at least 1 episode of pouchitis. Patients with pouchitis have a wide range of symptoms, endoscopic and histologic features, disease course, and prognosis. To date, there are no universally accepted diagnostic criteria in terms of endoscopy and histology; though, semi-objective assessments to diagnose pouchitis in patients with ileal pouch- anal anastomosis (IPAA) have been proposed using composite scores such as the Pouchitis Triad, Heidelberg Pouchitis Activity Score and Pouchitis Disease Activity Index (PDAI). In a systematic review that included four randomized trials evaluating five agents for the treatment of acute pouchitis, ciprofloxacin was more effective at inducing remission as compared with metronidazole. Rifaximin was not more effective than placebo, while budesonide enemas and metronidazole were similarly effective for inducing remission of acute pouchitis. Patients with pouchitis relapsing more than three times per year are advised maintenance therapy, and guidelines recommend ciprofloxacin or the probiotic VSL#3. In patients with antibiotic-refractory pouchitis, secondary factors associated with an antibiotic-refractory course should be sought and treated. In this review, we will discuss the prevention and management of pouchitis in Ulcerative Colitis patients.