Mistakes in ... Booklet 2020 - 19

ueg education

Mistakes in... 2020

Mistakes in pouchitis and how to avoid them
Jonathan P Segal, Susan K Clark and Ailsa L Hart
Restorative proctocolectomy can be considered a quality-of-life surgical procedure for
patients who have ulcerative colitis that has not responded to medical therapy, and for
some patients who have familial adenomatous polyposis. The procedure removes the
entire diseased large bowel and utilises the patient's small bowel to create a reservoir
that allows defaecation without the need for a long-term ileostomy. Despite generally
good outcomes, complications can occur. One of the most frequent problems is
primary idiopathic pouchitis, which is characterized by increased stool frequency,
haematochezia, abdominal cramping, urgency, tenesmus, incontinence, fever and
flare-up of extraintestinal manifestations.1 The incidence of acute primary idiopathic
pouchitis following surgery has been reported to be 20% at 1 year, and up to 40% at
5 years.2 Chronic primary idiopathic pouchitis develops in 10-15% of all patients who
undergo restorative proctocolectomy for ulcerative colitis and can be 'responsive' or
'refractory' to antibiotic therapy. Chronic pouchitis is defined as symptoms of pouchitis
that persist beyond 4 weeks or multiple relapses of acute pouchitis within a year.3,4 Here
we discuss mistakes in the assessment and management of primary idiopathic pouchitis
and how best to avoid them. Most of the discussion is evidenced based, but where evidence is lacking the discussion is based on our extensive clinical experience of treating
patients who have pouch dysfunction.
Mistake 1 Assuming all pouch dysfunction
is primary idiopathic pouchitis without
excluding alternative diagnoses
There are no validated scoring systems available
to define pouchitis. The pouch disease activity
index (PDAI)5 is used in the research setting but it
remains unvalidated and its routine use in clinical
practice is rare.
Importantly, there can be a lack of correlation
between symptoms, endoscopic activity
and histological findings, leading to potential
misdiagnosis.6,7 Furthermore, there is a
tendency to label every patient who has pouch
dysfunction as having pouchitis; primary
idiopathic pouchitis is often diagnosed without
endoscopic and histological confirmation, which
can result in other pathologies being missed. In
addition, patients often self-diagnose primary
idiopathic pouchitis based on their symptoms,
without objective markers of inflammation or
endoscopic assessment being used.
It is also important to distinguish between
primary and secondary types of pouchitis.
Primary idiopathic pouchitis is defined as
pouchitis when all secondary causes have been
excluded, whereas secondary pouchitis can
be due to Crohn's disease, infection (e.g. with
Clostridiodes [formerly Clostridium] difficile,

© (2020) Segal, Clark and Hart.
Cite this article as: Segal JP, Clark SK and Hart AL. Mistakes in
pouchitis and how to avoid them. UEG Education 2020; 20: 7-11.
Jonathan Segal is a specialist gastreonterology registrar and
Susan Clark is a consultant colorectal surgeon at St Mark's
Hospital, Harrow, United Kingdom and in the Department of

Campylobacter, Salmonella, Candida or
cytomegalovirus), pelvic sepsis, faecal stasis,
ischaemia or drugs (particularly NSAIDs).8
When patients present with symptoms related
to their pouch it is important to be mindful that
other possible causes (e.g. hyperthyroidism,
coeliac disease or pouch cancer) are excluded.
This is best done by following an algorithm, such
as the one presented in figure 1.9
It is essential to take a robust history, perform
a thorough examination and offer timely
investigations (including pouchoscopy and
radiological examination) before confirming a
diagnosis of primary idiopathic pouchitis. An
important question to ask is "Has the pouch ever
worked well?" If this is not the case, a diagnosis
of anastomotic leak/pelvic sepsis needs
careful consideration. Importantly, it is essential
to establish the baseline pouch function for an
individual patient; the median 24-hour stool
frequency is four to eight, with roughly half of
patients needing to defecate at night.

Mistake 2 Missing pelvic sepsis as a cause of
pouchitis
In one retrospective study, more than a third of
patients considered to have antibiotic-dependent
pouchitis were actually found to have evidence of

Surgery and Cancer, Imperial College London, United Kingdom.
Ailsa Hart is a consultant gastroenterologist at St Mark's Hospital,
Harrow, United Kingdom and in the Faculty of Medicine,
Department of Metabolism, Digestion and Reproduction, Imperial
College London, United Kingdom.
Illustrations: J. Shadwell.

pelvic sepsis on MRI.7 It is therefore imperative to
thoroughly assess a dysfunctional pouch with MRI.
The potential consequences of missing this
diagnosis are inappropriate use of antibiotics,
antibiotic resistance, side effects and worsening
clinical state. Furthermore, by missing pelvic
sepsis and assuming symptoms are primary
idopathic pouchitis, there is the potential
to escalate to biologics, which may cause
immunosuppression and worsening sepsis.
Should pelvic sepsis be found, appropriate
antibiotic therapy should be considered, with a
multidisciplinary discussion to plan management
that may include drainage and diversion.

Mistake 3 Not systematically assessing
and reporting all pouch regions
endoscopically
Thorough endoscopic assessment is vital to
help understand the potential reasons for a
poorly functional pouch. However, no validated
endoscopic reporting systems, key performance
indicators, training or certification are available to
assess competency in pouchoscopy. Furthermore,
there is considerable variation in the quality of
endoscopy reports and efforts have only recently
been made to develop a reporting template
specific to pouchoscopy.10 The standardised

Correspondence to: jonathansegal1@nhs.net
Conflict of interest: The authors declare they have no conflicts of
interest to declare in relation to this article.
Published online: July 9, 2020.

Mistakes in ... Booklet 2020

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