Radiographic Evaluation of Ileal Pouch Disorders: A Systematic Review.

BACKGROUND: Radiographic imaging of the abdomen and pelvis plays an important role in the diagnosis and management of ileal pouch disorders with modalities including CT, MRI, contrasted pouchography, and defecography. OBJECTIVES: To perform a systematic review of the literature and describe applications of cross-sectional imaging, pouchography, defecography, and ultrasonography. DATA SOURCES: PubMed, Google Scholar, and Cochrane database. STUDY SELECTION: Relevant articles on endoscopy in ileal pouches published between January 2003 and June 2023 in English were included on the basis of Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. INTERVENTION: Main abdominal and pelvic imaging modalities and their applications in the diagnosis of ileal pouch disorders were included. MAIN OUTCOME MEASURES: Accuracy in characterization of ileal pouch disorders. RESULTS: CT is the test of choice for the evaluation of acute anastomotic leaks, perforation, and abscess(es). MRI of the pelvis is suitable for the assessment of chronic anastomotic leaks and their associated fistulas and sinus tracts, as well as for the penetrating phenotype of Crohn's disease of the pouch. CT enterography and magnetic resonance enterography are useful in assessing intraluminal, intramural, and extraluminal disease processes of the pouch and prepouch ileum. Water-soluble contrast pouchography is particularly useful for evaluating acute or chronic anastomotic leaks and outlines the shape and configuration of the pouch. Defecography is the key modality to evaluate structural and functional pouch inlet and outlet obstructions. Ultrasonography can be performed to assess the pouch in experienced IBD centers. LIMITATIONS: This is a qualitative, not quantitative, review of mainly case series and case reports. CONCLUSIONS: Abdominopelvic imaging, along with clinical and endoscopic evaluation, is imperative for accurately assessing structural, inflammatory, functional, and neoplastic disorders. See video from symposium .

Can preoperative CT/MR enterography preclude the development of Crohn's disease-like pouch complications in ulcerative colitis patients undergoing J pouch surgery?

AIM: We aimed to determine whether ulcerative colitis patients with preoperative negative computed tomography or magnetic resonance enterography (CTE/MRE) were less likely to develop Crohn's disease-like pouch complications (CDLPC) and establish risk factors and predictors for developing CDLPC. METHODS: This was a single centre retrospective analysis of patients with ulcerative colitis (UC) and inflammatory bowel disease unclassified (IBDU) who underwent total proctocolectomy with ileal J-pouch between January 2010 and December 2020. The study group comprised patients with negative preoperative CTE/MRE and the control group included patients operated without preoperative CTE/MRE. RESULTS: A total of 131 patients were divided into the negative CTE/MRE study group (76 [58%] patients) and control group (55 [42%] patients). There were no significant differences in incidence rates (21% vs. 23.6%, p = 0.83), time to developing CDLPC from ileostomy closure (22.3 vs. 23.8 months; p = 0.81), pouchitis rates (23.6% vs. 27.2%; p = 0.68), or pouch failure rates (5.2 vs. 7.2; p = 0.71). Multivariate Cox regression analysis showed backwash ileitis (HR 4.1; p = 0.03, CI: 1.1-15.1), severe pouchitis (HR 3.4; p = 0.039, CI: 1.0-10.9), and history of perianal disease (HR 3.4; p = 0.017, CI: 1.4-39.6) were independent predictors for CDLPC. CONCLUSIONS: Negative findings on MRE/CTE prior to J-pouch surgery in ulcerative colitis should be interpreted with caution as it is does not reliably exclude or predict development of CDLPC. These patients should be preoperatively counselled concerning the possibility of developing CDLPC regardless of lack of positive findings on preoperative CTE/MRE. Patients with backwash ileitis with a previous history of perianal disease should be informed of the potentially increased risk of developing such complications.

The anatomy and physiology of the ileal pouch and its relevance to pouch dysfunction.

For the last 40 years, the ileal pouch-anal anastomosis has been used in patients with ulcerative colitis, familial adenomatous polyposis, and occasionally severe constipation to reconstruct the gastrointestinal tract after proctocolectomy. Although the procedure has generally been successful in helping patients avoid an ileostomy, it has come with its own set of problems. These include complications of the surgery such as fistulas and bowel obstruction, persistent inflammation of the pouch known as pouchitis, and functional problems related to the lack of expulsive peristalsis in the pouch. It is this last group of problems that is exacerbated by a poor diet, ill-advised anti-diarrheal medications, anal stenosis and pouch twists. As a consequence, patients with pouch problems are frequently referred for radiologic evaluation, with pouchography, defecation studies, and small bowel imaging commonly requested. In this review, the basic anatomy and physiology of the ileal pouch are discussed to provide a logical baseline against which to measure the anatomy of pouches and its relationship to the symptoms of pouch dysfunction.

Disease Monitoring of the Ileoanal Pouch: How to Utilize Biomarkers, Imaging, and Pouchoscopy.

PURPOSE OF REVIEW: Restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis has been associated with multiple short- and long-term complications. In this review, we examine the role of biomarkers, imaging, and pouchoscopy in the assessment of patients after ileal pouch-anal anastomosis, with a particular focus on the emergence of novel biomarkers and techniques for evaluating and risk stratifying patients after this procedure in the hopes of improving outcomes in this specific population. RECENT FINDINGS: There are indications that that the incidence of pouchitis may be increasing in recent decades. Calprotectin and other non-invasive imaging tests such as ultrasound may offer advantages in distinguishing patients with inflammatory conditions of the pouch from other etiologies. In the search for other biomarkers that may identify patients at risk for inflammatory conditions of the pouch, the stool microbiota and metabolomics may play a key role in identifying those patients at greatest risk for complications. Advances in biomarkers, imaging, and standardized pouchoscopy scoring offer immediate improvements in clinical care and will prompt future research efforts.

Defining normal pouch function in patients with ileal pouch-anal anastomosis: a pilot study.

BACKGROUND: Most patients experience good functional outcomes following ileal pouch-anal anastomosis (IPAA) for ulcerative colitis. AIM: We aimed to determine if asymptomatic patients with an IPAA had findings consistent with normal defecation on standard objective anorectal tests. METHODS: Patients 18-65 years old with IPAA and self-reported healthy pouch function were recruited. Patients with chronic pouchitis, Crohn's disease, anastomotic stricture, or indication for IPAA other than ulcerative or indeterminate colitis were excluded. Patients underwent an interview with an abbreviated Rome Questionnaire followed by high-resolution ano-pouch manometry, balloon expulsion test, pouch barostat, and magnetic resonance (MR) defecography. RESULTS: Twenty patients completed all testing. Six patients were excluded from the final analysis due to symptoms suggestive of pouch evacuation disorder on the abbreviated Rome Questionnaire (n = 2), structural abnormality on MR imaging (n = 3), or both (n = 1). Of the remaining 14 patients, mean anal resting pressure during high-resolution manometry was 72 ± 16 mmHg, mean anal squeeze pressure was 247 ± 69 mmHg, and mean pouch-anal gradient during the simulated evacuation was -27 ± 37 mmHg. The meantime to balloon expulsion was 54 seconds. During dynamic MR defecography, the mean descent of ano-pouch junction was 2.6 cm, and mean pouch evacuation was 44.5% and 74.2% pre- and posttoilet phase, respectively. CONCLUSIONS: A substantial proportion of patients with IPAA and self-reported healthy pouch function have anatomic and/or functional abnormalities of the pouch. In asymptomatic IPAA patients with an anatomically normal pouch, we have proposed normal parameters for high-resolution ano-pouch manometry, time to balloon expulsion, pouch barostat, and MR defecography.

Endoscopy after surgery in inflammatory bowel disease: Crohn's disease recurrence and pouch surveillance.

INTRODUCTION: Crohn's disease (CD) and ulcerative colitis (UC) are immune-mediated disorders characterized by a chronic inflammation, with intermittent exacerbations of symptoms and inflammation. In both diseases, medical treatment has made revolutionary steps forward. Nevertheless, surgery is still required in many cases due to inefficacy of multiple medical therapies. It is not clear whether surgery rates in inflammatory bowel diseases (IBD) are currently decreasing despite all improvements. AREAS COVERED: Multidisciplinary management is critical in surgical patients to improve long-term outcomes. Endoscopy plays a crucial role, both before and after surgery, in planning therapeutic strategies and stratifying risk of recurrence. Aim of this review is to provide a deeper insight into the central role of endoscopy in the postoperative management of IBD patients, focusing on recent research advances, future challenges and unresolved questions. EXPERT OPINION: Both UC and CD surgical patients need endoscopy to define the correct therapeutic choice, predict subsequent disease course and adopt the correct surveillance strategy. In the next future, newer endoscopic techniques could be systematically applied in IBD patients after surgery, to assess early postoperative inflammation, response to treatment, or, regarding UC, to provide enhanced pouch surveillance, allowing for early detection of inflammation and dysplasia.

Difference in the frequency of pouchitis between ulcerative colitis and familial adenomatous polyposis: is the explanation in peripouch fat?

AIM: Patients with ulcerative colitis (UC) have an unexplained higher incidence of pouchitis and a greater amount of peripouch fat compared with patients with familial adenomatous polyposis (FAP). The aims of this study were to compare the peripouch fat areas between patients with UC and patients with FAP, and to explore relationship between peripouch fat and pouchitis or chronic antibiotic-refractory pouchitis (CARP). METHOD: Patients with an abdominal CT image from our prospectively maintained Pouch Database were included. Abdominal fat and peripouch fat were measured on CT images at different levels or planes. Comparisons of peripouch fat and CARP were performed before and after propensity score matching. RESULTS: A total of 277 patients with UC and 40 patients with FAP were included. Compared with patients with FAP, patients with UC were found to have a higher incidence of pouchitis (58.5% vs 15.0%, P < 0.001) and CARP (24.5% vs 2.5%, P = 0.002) and a higher total peripouch fat area (P = 0.030) and mesenteric peripouch fat area (P = 0.022) at Level-3. Univariate and multivariate analyses showed that diagnosis (UC vs FAP) and peripouch fat areas at Level-3 and Level-5 were independent risk factors for CARP. With propensity score matching, 38 pairs of patients with UC and FAP were matched successfully. After matching, patients with UC were found to have higher total peripouch fat area and higher mesenteric peripouch fat area at Level-3, and a higher incidence of pouchitis (57.9% vs 13.2%, P < 0.001) and CARP (23.7% vs 2.6%, P = 0.007). CONCLUSION: Our study demonstrates that patients with UC have more peripouch fat than those with FAP, which may explain the difference in the frequency of pouchitis and CARP between these groups of patients.

Reliability among central readers in the evaluation of endoscopic disease activity in pouchitis.

BACKGROUND AND AIMS: Pouchitis is a common adverse event after proctocolectomy with ileal pouch anal anastomosis for ulcerative colitis. Evaluation of pouchitis disease activity and response to treatment requires use of validated indices. We assessed the reliability of items evaluating endoscopic pouchitis disease activity. METHODS: Twelve panelists used a modified RAND appropriateness methodology to rate the appropriateness of items evaluating endoscopic pouchitis disease activity derived from a systematic review and also identified additional potential endoscopic items based on expert opinion. Four central readers then evaluated 50 pouchoscopy videos in triplicate, in random order. Intra- and inter-rater reliability for each item was assessed by calculating and comparing intraclass correlation coefficients (ICCs). A Delphi process identified common sources of disagreement among the readers. RESULTS: Ten existing endoscopic items were identified from the systematic review and an additional 7 exploratory items from the panelists. ICCs for inter-rater reliability were highest for the existing item of pouch ulceration (.72; 95% confidence interval [CI], .60-.82) and for the exploratory item of ulcerated surface in the pouch body (.67; 95% CI, .53-.75). Inter-rater reliability for all other existing and exploratory items was "moderate" (ICC < .60). The item "ulcerated surface in the pouch body" demonstrated the best correlation with a global evaluation of lesion severity (r = .80; 95% CI, .73-.85). CONCLUSION: Substantial reliability was observed only for the endoscopic items of ulceration and ulcerated surface in the pouch body. Future studies should assess responsiveness to treatment in the next stage toward development of an endoscopic pouchitis disease activity index.

Peripouch Fat Area Measured on MRI Image and Its Association With Adverse Pouch Outcomes.

Background: There are no published studies on the impact of peripouch fat on pouch outcomes in inflammatory bowel disease (IBD) patients. Methods: Patients with pelvic MRI-DIXON scans from our prospectively maintained Pouch Database between 2002 and 2016 were evaluated. Peripouch fat area was measured on MRI-DIXON-F images at the middle height level of the pouch (area M) and the highest level of the pouch (area H). Results: Of all 1863 patients in the database, 197 eligible patients were included in this study. The median of area M was 52.4 cm2, so the 197 patients were classified into 2 groups: group 1 (Area-M <52.4 cm2) and group 2 (Area-M ≥52.4 cm2). Compared with group 1, group 2 was found to have thicker perianal fat, more Caucasian and more males. Group 2 also had a higher Area-H, more weight, height, and body mass index, along with greater age at IBD diagnosis, age at pouch construction and pouch age, and a higher frequency of total pouch complication (86.7% versus 66.7%, P = 0.001), chronic pouch complication (68.4% versus 51.5%, P = 0.016), and chronic antibiotic-refractory pouchitis (16.3% versus 7.1%, P = 0.043). Multivariate logistic analysis showed that Area-M was an independent risk factor for chronic antibiotic-refractory pouchitis (odds ratio [OR]: 1.025; 95% confidence interval [CI]: 1.007-1.042, P = 0.005). The 22 patients with 2 or more pelvic MRI-DIXON scans were further classified into 2 groups by the change from the initial to latest MRI-DIXON scans. Patients with Area-M increase ≥10% and Area-M/height increase ≥10% were found to have shorter pouch survivals than those with increase <10%. Conclusions: A new method was established for measuring peripouch fat using pelvic MRI-DIXON-F image. Our study suggests that accumulation of peripouch fat may be associated with poor outcomes in selected IBD patients suspected of inflammatory or mechanical disorders of the pouch. Whether this association is causal warrants further investigation.

The prevalence of chronic peri-pouch sepsis in patients treated for antibiotic-dependent or refractory primary idiopathic pouchitis.

AIM: Chronic peri-pouch sepsis (CPPS) may be mistaken for antibiotic-dependent or refractory primary idiopathic pouchitis (ADRP), but requires different treatment such as drainage. The study aimed to identify the prevalence of CPPS in patients thought to have ADRP. The secondary aims were to identify any specific features on pouchoscopy suggesting CPPS and to determine the results of treatment for CPPS. METHOD: The records of patients who had been treated for ADRP between March 2006 and June 2015 were reviewed retrospectively. Only those with endoscopic evidence of pouch inflammation who had also undergone MRI of the pelvis were included. The findings on pouchoscopy and the outcome of treatment were determined. RESULTS: Sixty-eight patients (43 men, 63%) were identified with apparent ADRP between March 2006 and June 2015. MRI of the pelvis showed CPPS in 26 (38%). In those with CPPS, the inflammation was more often located in the upper pouch alone (15%) compared with patients without CPPS (0%) (P = 0.0184). Examination under anaesthesia was performed in 13 of those with CPPS. In five a collection was identified and drained; symptoms improved in only one (4%). Eighteen patients (69%) remained on antibiotics and seven (27%) had a defunctioning stoma or underwent pouch excision. CONCLUSION: In patients thought to have ADRP, 38% had CPPS on MRI. There was no clinically relevant specific feature on pouchoscopy suggestive of CPPS. The possibility of CPPS should be considered early in patients with apparent ADRP and pelvic MRI performed. This might lead to earlier detection of CPPS and appropriate treatment.

Multidetector-row computed tomography enterographic assessment of the ileal-anal pouch: descriptive radiologic analysis with endoscopic and pathologic correlation.

OBJECTIVE: To describe the multidetector-row computed tomography enterographic (MD-CTE) features of the ileal-anal pouch after ileal pouch anal anastomosis (IPAA) surgery and correlate them with pouch endoscopy and histopathologic findings. METHODS: All MD-CTE examinations performed on patients who underwent IPAA from July 1, 2005 to December 1, 2010 (n = 35; 16 [45.7%] men; mean age, 37.7 years; age range, 22-72 years) were retrospectively evaluated in consensus by 2 radiologists. All studies were evaluated for the presence of multiple imaging features. Two radiographic scores were then calculated: a total radiographic score and a radiographic active inflammation score. In patients who underwent MD-CTE, pouch endoscopy, and biopsy within 30 days (n = 13), both scores were correlated with findings on pouch endoscopy and histopathology. RESULTS: Of the 35 patients, 33 (94%) had at least one MD-CTE finding of active or chronic pouch inflammation and 27 patients (77%) had at least one MD-CTE finding of active pouch inflammation. Of the 13 patients who underwent endoscopy and biopsy, the total radiographic score demonstrated a strong positive correlation with endoscopic score (r = 0.81; P = 0.001) and a moderate positive correlation with histopathologic score (r = 0.56; P = 0.047). The radiographic active inflammation score demonstrated a strong positive correlation with endoscopic score (r = 0.83; P = 0.0004), but only a weak nonsignificant positive correlation with histopathologic score (r = 0.492, P = 0.087). CONCLUSIONS: In patients who had IPAA surgery, findings on MD-CTE correlate positively with findings on pouch endoscopy and histopathology and are sensitive measures for pouch inflammation with high positive predictive value. Thus, MD-CTE can be a useful noninvasive test in the early evaluation of symptomatic patients.

Relapse of Crohn's disease following ileal pouch-anal anastomosis: MDCT and MR features.

OBJECTIVE: The purpose of our study is to use MDCT and MR imaging to describe the normal ileal pouch and to identify features of Crohn's disease (CD) relapse in patients after ileal pouch-anal anastomosis (IPAA). CONCLUSIONS: After total colectomy followed by IPAA, features, optimally evaluated with pelvic MRI, such as fistulas, abscesses, pouch inflammation, and stenoses, indicate CD relapse. Although uncommon, radiologists should be aware that these imaging features strongly favor this diagnosis.

Diagnosis and management of pouchitis and ileoanal pouch dysfunction.

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) has become the surgical treatment of choice for patients with medically refractory ulcerative colitis (UC) or UC with dysplasia and for the majority of patients with familial adenomatous polyposis. However, UC patients with IPAA are susceptible to inflammatory and noninflammatory sequelae, such as pouchitis, Crohn's disease of the pouch, cuffitis, and irritable pouch syndrome, in addition to common surgery-associated complications, which adversely affect the surgical outcome and compromise health-related quality of life. Pouchitis is the most frequent long-term complication of IPAA in patients with UC, with a cumulative prevalence of up to 50%. Pouchitis may be classified based on the etiology into idiopathic and secondary types, and the management is often different. Pouchoscopy is the most important tool for the diagnosis and differential diagnosis in patients with pouch dysfunction. Antibiotic therapy is the mainstay of treatment for active pouchitis. Some patients may develop dependency on antibiotics, requiring long-term maintenance therapy. Although management of antibiotic-dependent or antibiotic-refractory pouchitis has been challenging, secondary etiology for pouchitis should be evaluated and modified, if possible.

Stasis predisposes ileal pouch inflammation in a rat model of ileal pouch-anal anastomosis.

BACKGROUND: While restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) has become the definitive surgical treatment for patients suffering from chronic ulcerative colitis (CUC), pouchitis still remains a major late complication. Fecal stasis has been implicated in the etiology of ileal inflammation; however, the mechanism(s) remain unclear, in part due to the lack of an animal model. Our goal was to surgically mimic the IPAA procedure in a rat to investigate the hypothesis that stasis leads to biochemical changes that predispose the ileal pouch to inflammation. MATERIALS AND METHODS: Thirty-two Sprague-Dawley rats underwent total colectomy with either straight ileorectal (IRA) or IPAA, and 11 nonoperated rats served as controls (Controls). Twenty-one d postoperatively, 48 h serial barium radiographs and 12 h charcoal transit follow-through studies were performed. Following sacrifice, ileal tissue was harvested for the measurement of myeloperoxidase activity (MPO) activity, intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1) mRNA levels, and histology. RESULTS: Serial barium radiographs showed stasis in the ileal pouch compared with IRA animals, and charcoal transit times that were two times longer (P ≤ 0.05) than that in the straight IRA rats. Ileal pouch MPO levels were significantly elevated in the IPAA rats compared with the straight IRA rats. ICAM-1 and VCAM-1 mRNA levels were not associated with neutrophil infiltration. CONCLUSIONS: These studies showed that ileal pouch stasis predisposes biochemical and histological evidence of ileal pouch mucosal inflammation. Studies such as this may provide the rationale for novel, adjunct therapies for the management of pouchitis in patients having undergone IPAA for CUC.

Ileal J-pouch perforation at the blind end: report of a case.

A 34-year-old woman presented with severe abdominal pain 8 years after undergoing ileal J-pouch anal anastomosis for ulcerative colitis (UC). Computed tomography (CT) showed free air and ascites in the abdomen, so she underwent laparotomy. A perforation was found at the ileal J-pouch blind end, which was remarkably enlarged. When we resected the blind end surgically, we observed a 3-mm perforation and some small ulcers. About 2 months after this operation, the patient complained of abdominal pain and an increased frequency of bowel movements. Based on our endoscopic observation of multiple ulcers, we diagnosed pouchitis. We report this case to show that the combination of an enlarged J-pouch blind end and pouchitis can result in perforation. To prevent such complications, we recommend avoiding the formation of a blind end during construction of a J-pouch.

[Aspects of the complications after restorative proctocolectomy in the treatment of ulcerative colitis. Review of the literature and personal experience]. / Aspetti delle complicanze dopo proctocolectomia restaurativa nel trattamento della colite ulcerosa. Revisione della letteratura ed esperienza personale.

PURPOSE: Analysis of complications and causes of failure after stapled restorative proctocolectomy with ileal J pouchanal anastomosis in patients with ulcerative colitis is presented. PATIENTS AND METHODS: The procedure was performed in 28 patients, 19 males (68%) and 9 females (32%); diverting ileostomy was always performed. RESULTS: There was no perioperative mortality. The overall morbidity rate was 31%. Six patients (21%) had pelvic abscess, 2 (7%) pelvic hematoma, 4 patients (14%) presented ileo-anal anastomotic stricture, 1 patient (3.6%) had pouch-vaginal fistula, three patients (11%) presented intestinal obstruction and 7 (25%) pouchitis. Reoperation was necessary in patients with small bowel obstruction and with pouch-vaginal fistula. Septic complications and pouchitis were resolved with medical treatment. Stenosis of the anastomosis required anal dilation. No patient underwent pouch excision for pouch failure. CONCLUSION: The main significant complications of ileal pouch-anal anastomosis for ulcerative colitis were pelvic sepsis, intestinal obstruction and pouchitis. Our results suggest that the use of stapling technique is safer and has fewer early septic complications and sepsis-related pouch removals. Success in ileo-anal construction increases with experience. The selection of patients with exclusion of Crohn disease, a correct surgical timing, a carefully technique, a delayed ileostomy closure and a low pre and postoperative regimen of steroids are important factors of success.