Complications After Ulcerative Colitis: A Man With Acute Pouchitis
Edward L. Barnes, MD, MPH | University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
A 28-year-old man presented to your office after he had undergone a restorative proctocolectomy with ileal pouch-anal anastomosis surgical procedure (IPAA) 7 months prior. In the past week, he has developed increased bowel movement frequency with up to 15 bowel movements per day, as well as urgency and increased nocturnal bowel movements. He reported intermittent abdominal pain and malaise.
You arranged a pouchoscopy, results of which reveal inflammation throughout the pouch body, characterized by erythema, edema, loss of vascularity, granularity, and friability with spontaneous bleeding. There were scattered erosions and shallow ulcerations throughout the mucosa of the pouch body, with biopsies taken at the time of pouchoscopy demonstrating minimally active chronic patchy active pouchitis, negative for dysplasia, with no granulomas identified.
This patient’s presentation is consistent with acute pouchitis, which affects approximately 40% of patients within the first year after an IPAA for ulcerative colitis.1, 2 Pouchitis symptoms are classically described as a combination of increased bowel movement frequency, urgency, and/or abdominal discomfort. With the first episode of pouchitis, it is often important to perform a pouchoscopy to rule out potential other causes of these symptoms, including postoperative complications depending on the timing of symptom onset in relation to stages of an IPAA. This also allows for the evaluation of ischemia, other potential secondary etiologies of pouch inflammation, and cuffitis, which can present with similar symptoms after an IPAA.
References:
1. Barnes EL, Lightner AL, Regueiro M. Perioperative and postoperative management of patients with Crohn's disease and ulcerative colitis. Clin Gastroenterol Hepatol. 2020;18(6):1356-1366. https://doi.org/10.1016/j.cgh.2019.09.040
2. Gionchetti P, Rizzello F, Helwig U, et al. Prophylaxis of pouchitis onset with probiotic therapy: a double-blind, placebo-controlled trial. Gastroenterology. 2003;124(5):1202-9. https://doi.org/10.1016/s0016-5085(03)00171-9
