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home - IBD - Surgery - Pouch problems Written by Dr Sebastian Zeki

Knows the criteria for assessing the severity and extent of IBD, in
particular recognition of acute severe colitis. Knows treatment options
including aminosalicylates, corticosteroids, and steroid sparing

Knows differing methods of delivery for therapy.
Selects of appropriate treatment for extent and severity of disease,
including timing of immunomodulator therapy and referral for surgery.

Recognises the urgency of treating acutely sick patients, including
multidisciplinary team early, particularly surgeons. Clearly explains
the clinical situation and treatment options to patient and family.
Involves patient and family in decision making about treatment

Knows the complications of IBD including stricturing, fistulae,
extraintestinal manifestations, colon cancer and special situations
such as pregnancy.

Able to recognise potential complications and take appropriate action
to investigate and alter treatment as necessary including referral for
surgery and involvement of other healthcare professionals

Works with patient to explain complications and options for treatment
Involves the multidisciplinary team especially IBD nurse and surgeon
in management, and tailors treatment to the needs of the patient.
Discusses with colleagues early and appropriately



Understands the indications for surgery in active disease and for
complications including structuring and fistulising disease

Understands different surgical approaches in particular methods of
bowel-preserving surgery in Crohn’s disease and long term options
for surgery in UC

Recognises that early liaison with surgeons is important in high
quality patient management

Has appropriate discussions with surgeons when patients are
admitted with active disease

Involves surgeons early in patients with difficult chronically active
disease or with complications

Is able to explain clearly to patients and relatives the role of the
surgeon and possible surgical approaches to treatment
Shows willingness to liaise appropriately with surgical teams
Explains clearly to patients and relatives the involvement of the
surgical teams and their importance and possible outcomes



Knows the pathogenesis and complications of fistulising Crohn’s
disease including perianal enteroenteric enterocutaneous
colovesical and rectovaginal fistulae

Understands the different treatment modalities available for treatment
of fistulae including antibiotics immune modulators biologics
surgical drainage and the possible combinations that may be

Is aware of the importance of joint medical-surgical management of
complex fistulae and of nutritional support for high output fistulae

Able to detect the possibility of fistulising disease and to perform
appropriate investigations

Can liaise with surgical colleagues to define the most appropriate
management plan

Can make an appropriate of fistulae including deciding a
long term management strategy

Can provide an appropriate explanation of the problem to the patient PS
Involves all relevant health professionals and patient in deciding the
appropriate treatment strategy

Pouch problems

PouchitisInc. freq.with duration- 50% of patients 10 years after IPAAHigher freq. of pouchitis in UC vs others eg FAP (0-10% at 10 years proportion of patients (perhaps 20–30%) will develop pouchitis which may be recurrent or persist- Fertility and delivery in patients with a restorative proctocolectomy 30-70% reduced female fecundity after IPAA probably related to fallopian tube adhesions.Ileo-rectal anastomosis (IRA) may be better option as doesnt reduce fecundity (less pelvic adhesions) with possible IPAA later after family begun. The mode of delivery for patients with restorative proctocolectomy Vaginal delivery has a 2.5% risk of inflicting serious maternal sphincter tears.Sphincter is v important for maintaining continence post IPAA.The highest risk is at the first delivery.Patients should have a C-section. Complicatons of IPAA-pouch problems Endoscopy (‘pouchoscopy’)Ileoanal pouch can have pouch-anal anastomosis stricture, so a gastroscope may be better than a colonoscope for pouchoscopy. Risk factors for pouchitis:Extensive colitis.Extraintestinal manifestations (eg PSC).Being a non-smoker.p-ANCA positive serology.NSAID use.Cuffitis was associated with symptoms of arthralgia and a younger age. Histopathology of pouchitisNeutrophilic infiltration.Crypt abscesses and ulceration.Chronic inflamm-tory infiltrate.Get colonic meta-plasia- pouchitis which usually occurs only after this develops. Symptoms of pouchitis:Inc. stool frequency and liquidity (Post IPAA, BO 4-8 times/ day).Abdominal cramping;Urgency;Tenesmus ;Pelvic discomfort.Rectal bleeding, fever, or EIM may occur-(rectal bleeding is more often related to inflammation of the rectal cuff (“cuffitis”), than to pouchitis). Cuffitis:Cuffitis, especially after double-stapled IPAA can cause pouch dysfunction with symptoms that mimic pouchitis or irritable pouch syndrome (IPS).Unlike IPS (which may coexist) bleeding is a characteristic feature of cuffitis. Endoscopy by an informed endoscopist is diagnostic, but care has to be taken to examine the cuff of columnar epithelium between the dentate line and pouch-anal anastomosis.Mesalazine suppositories may be useful here. 92% of patients have bloody bowel movements and 70% with arthralgia (a characteristic clinical feature of cuffitis) improved on therapy. Pre-pouch ileitis Cuffitis Pouchitis Pouch inlet/ outlet stricture (tx: dilate or revision) Small volumepouchTx: Revision Functional outflow obstructionTx: Medina catheter and biofeedback Investigation: Defaecating prctography Investigation:Pouch biopsiesTx: as per pouchitis Abscess (MRI pelvis) Yes Irrigation training Unsuccessful? Symptoms of evacuatory difficulty +/- frequency Exclude strictures at anal anastomosis and pouch inlet with clinical examinationand flexible sigmoidoscopy Defaecating pouchogram confirms diagnosis? Refer to pouch nurse specialist for medina catheterisation training Investigating and tx of suspected functional outflow obstruction in Restorative proctocolectomy (pouch) patients Complications of pouchitis:AbscessesFistulaeStenosis of the pouch-anal anastomosis Adenocarcinoma of the pouch. Findings include Oedema;Granularity;Friability; Spontaneous or contact bleedingLoss of vascular pattern; Mucous exudates;Haemorrhage; Erosions;Ulceration (Dont take bx from staple line as it is non-specific). Written by Dr Sebastian Zeki This latter complication is exceptional and almost only occurs when there is pre-exiting dysplasia or carcinoma in the original colectomy specimen.

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