Mistakes in ... Booklet 2020 - 20

ueg education

reporting template introduced is a systematic tool
that prompts examination of the anal/perineal
region, rectal cuff, anastomosis, lower and upper
pouch body, pouch inlet and pre-pouch ileum, but
it is not widely used.
Other problems with pouchoscopy include
poor intra- and inter-rater reliability between
pouchitis scoring systems,11 with some of the
PDAI descriptors considered inappropriate for
assessing endoscopic disease activity in
pouchitis. This suggests that we need better
validated scoring systems for assessment of
pouch inflammation.11
We suggest that endoscopic examination of a
pouch is performed by experienced endoscopists
and that a systematic template should be used to
encourage examination (and biopsy) of all pouch
regions and recording of findings. Photographic
evidence of the pouchoscopy can also help

Mistake 4 Failing to appreciate the impact of
symptoms on quality of life
There is a large variation in how different patients
perceive their pouch symptoms and how their
symptoms impact on their overall quality of life
(QoL). There can also be a disconnect between
symptom burden and the severity of inflammation
noted in the pouch. Indeed, some patients with
very minimal objective inflammation noted
endoscopically and histologically can have pouch
function that severely impacts on their quality of
life, whereas other patients can report minimal
symptoms but have severe inflammation noted.
It is essential to be conscious of this variability
and discrepancy, so that investigation and
management is tailored to the individual patient.
In patients who have a high symptom burden
but little inflammation, other causes of their
symptoms should be explored along with all
supportive options available, including
psychological support.
The clinical scoring systems do not take into
account QoL indicators that may be significant to
a patient, which means it is vital to consider
a patient's quality of life when assessing
symptomatology. We recommend that a broad
range of domains (including effect on personal
life, work, sexuality and overall quality of life)
are taken into account. To aid such assessment,
a multidisciplinary team of pouch and stoma
nurses, psychologists, clinicians and patient-topatient support can be valuable when helping
patients with pouch-related issues.
Specifically, it is important to assess the
mental health of a patient who has poor pouch
function and offer them psychological support.
There has been evidence to show that adjuncts
such as biofeedback may be beneficial.12 Irritable
pouch syndrome (analogous to irritable bowel
syndrome) is diagnosed when no other pathology
is present to explain symptoms, and may

Mistakes in... 2020

respond to medications such as tricyclic

Mistake 5 Not recognising the presence
of cuffitis
When forming a pouch, there is an anastomosis
between the ileal pouch and the anorectum.
In some situations, this area-refered to as the
cuff-can become inflamed, resulting in 'cuffitis'.
Essentially this is residual ulcerative proctitis.
The symptoms of cuffitis are characterised by the
frequent passage of stool with small quantities of
blood,13 urgency and pain and it can, therefore, be
mistaken for pouchitis.
A digital examination should be performed to
manually feel the cuff. A long retained rectal cuff
(longer than 2cm) is more prone to inflammation.
Endoscopic evaluation is required to directly
visualise the cuff, with biopsy samples taken
for histological assessment to confirm the
diagnosis.13-15 The incidence of inflammation
of the retained anorectum has not been
extensively studied; some studies report a 9%
The treatment for cuffitis differs from that
for pouchitis and so distinguishing the two
is key. Although cuffitis is a poorly studied
condition, there is evidence that mesalamine
suppositories14 may provide some benefit, with
steroid suppositories as a second-line therapy.17
Essentially the management of cuffitis is the
same as treating ulcerative proctitis.

Mistake 6 Labelling the diagnosis as Crohn's
disease when the features may be due to
another aetiology
Prior to pouch formation a thorough pre-surgical
assessment must be considered to rule out
Crohn's disease, to include small-bowel studies,
histological samples reviewed for the presence
of granuloma and the absence of a history of
perianal disease. A preoperative diagnosis of
Crohn's disease of the pouch is a relative
contraindication to pouch surgery18 because of the
high rate of complications and pouch
failure.19-21 Indeed, it has been estimated that
pouch excision rates are 45-55% in patients
who have a preoperative diagnosis of Crohn's
disease21,22 and that the pouch retention rate
5 and 10 years after formation is 58% and 50%,
respectively.23 Despite this, some small studies
have shown that in the absence of perianal or
small-bowel disease, restorative proctocolectomy
can be performed with similar outcomes to those
who have a pouch for ulcerative colitis.24,25 Indeed,
the European Crohn's and Colitis Organisation
(ECCO) suggest that restorative proctocolectomy
can be offered to patients who have Crohn's
disease without perianal disease or small-bowel
involvement,26 but we suggest that patients are
very carefully counselled about the potential

poor outcomes and such surgery is done highly
There are essentially two scenarios that
lead to a diagnosis of 'Crohn's disease of the
pouch'. The first arises when there has been a
preoperative diagnosis of Crohn's disease, and
the second is the development of Crohn's-like
features after the formation of a pouch in a
patient who has ulcerative colitis.
In one long-term study, 2-8% of patients
who originally underwent restorative
proctocolectomy for presumed ulcerative colitis
had their original diagnosis changed to Crohn's
disease.21 We believe it is important to diagnose
Crohn's disease of the pouch accurately to help
with prognostication and offer appropriate
treatment. The criteria utilised to diagnose
Crohn's disease are varied. Some studies have
defined Crohn's disease of the pouch as
including: inflammation of the pouch that is
resistant to antibiotic treatment, stricturing of the
afferent limb, stricturing of the small bowel, or
fistulating disease.27-30 Furthermore, the presence
of pre-pouch ileitis is controversial-some
studies suggest this may be an endoscopic
feature of Crohn's disease,31,32 but this has been
disputed by others.33
It is likely that Crohn's disease of the
pouch is an overused diagnosis, with one study
highlighting that histological confirmation of
Crohn's disease was found in only 20% of patients
who underwent pouch excision for Crohn's
disease of the pouch.33 It is also important to
appreciate that strictures and fistulas that may
mimic Crohn's disease can be caused by
other factors such as sepsis, anastomotic
complications (e.g. leak and/or stricture) or
ischaemia. We therefore suggest that Crohn's
disease of the pouch should only be diagnosed
by conclusive histology (i.e. granulomas
supporting Crohn's disease) and/or the presence
of characteristic skip lesions in the small bowel.
The timing of when the Crohn's-like problems of
the pouch occur can often aid diagnosis-fistulas
especially around the anastomosis that occur
within a year of pouch formation are likely to
be related to the surgery itself, whereas
complications beyond this point could represent
de novo Crohn's disease, but this still requires
thorough investigation.
We also believe that it can be unhelpful and
confusing for patients to hear that their diagnosis
has changed from ulcerative colitis to Crohn's
disease and suggest it is more useful to
explain that they have active inflammatory
bowel disease. It is more beneficial for the
patient to be clear on the strategies of care for
managing their problem, whether it be a
fistula, stricture or inflammation, using the
appropriate combination of surgical/endoscopic
and medical therapies, than to become
bogged down in semantics regarding


Mistakes in ... Booklet 2020

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