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home - IBD - Surgery - Pouchitis Written by Dr Sebastian Zeki
Knowledge

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
therapies.

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

Behaviours
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
options.

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

Skills
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

Behaviours
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

Also...

Knowledge


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

Skills
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
PS
Behaviours
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

Also...

Knowledge


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
required

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

Skills
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

Behaviours
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

Pouchitis

Pouch FailureConsider salvage surgery. Algorithm for the treatment of pouchitis Ciprofloxacin 500mg bd 14 days or Metronidazole 400mg tds 14 days Rapid relapse or no response= Refrac-tory pouchitis (Exclude CDT/CMV) Simple pouchitis Remission Ciprofloxacin 500mg bd 14 days and Metronidazole 400mg tds 28 days No responseConsider alternative diagnosis Rapid relapseThis is defined as >/= 3 episodes per year (Chronic relapsing pouch-tis or chronic pouchitis = >4 weeks symptoms). Consider maintenance therapy Maintenance TreatmentGive ciprofloxacin 500mg or VSL#3 6g od (if mucosa normal at repeat pouchoscopy). Review and consider reducing dose of ciprofloxacin at 3 months) Stool coliform sensitivity testing 28 days appropriate antibiotic (eg. co-amoxiclav, clarithromy-cin, cefixime) Medical treatmentBudesonide enemas are as effective as metronidazole for acute pouchitis in a randomised controlled trial.Ciclosporin enemas are successful for chronic pouchitis.Oral azathioprine may help if patients relapse become budesonide-dependent.Uncontrolled studies of short-chain fatty acid enemas showed little value.Glutamine and butyrate suppositories have been compared for chronic pouchitis.Infliximab may be of benefit.Antidiarrhoeal drugs may reduce the number of daily liquid stools in patients, independent of pouchitis.Benefit been also been reported from alicaforsen enemas (an inhibitor of intercellular adhesion molecule (ICAM)-1) in an open-label trial. 10–15% of patients with acute pouchitis develop chronic pouchitis Recurrent pouchitis and complications Pouchitis recurs in more than 50%.Patients with recurrent pouchitis can broadly be grouped into three categories: infrequent episodes (b1/yr), a relapsing course (1–3 episodes/yr) or a continuous course. Pouchitis may further be termed treatment responsive or refractory, based on response to single-antibiotic therapy. Scoring of pouchitis The Pouchitis Disease Activity Index (PDAI) has been developed to standardize diagnos-tic criteria and assess the severity of pouchi-tis.The PDAI is a composite score that evaluates symptoms, endoscopy and histology. Each component score has a maximum of 6 points.Pouchitis= total PDAI score =7. Remission Alternatives: If ciprofloxacin does not work, then try it in combination with an imidazole antibiotic or rifaximin, or try oral budesonide. Written by Dr Sebastian Zeki Other agents for acute and chronic refractory pouchitis.

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