Mistakes in ... Booklet 2020 - 21

ueg education

Key
history
questions

Symptoms

Investigations

Exclude
diﬀerential
diagnosis

Mistakes in... 2020

* Has the pouch ever worked well?
* What is the timing of increased pouch symptoms in relation to surgery?
* How many previous symptomatic episodes have you had (single versus
recurrent versus ongoing)?
* How have your symptoms previously responded to antibiotics?
* What is your past history of gastrointestinal infections and what
is your travel history?
* What, if any, systemic symptoms do you have?
* What, if any, extraintestinal symptoms do you have (skin, eye, joints)?
* Do you experience diﬀicult evacuation?
* What medications do you take (including NSAIDs)?

Increased frequency, pain,
cramping, incontinence,
bleeding

Consider empirical antibiotics
dependent on time to obtain
appropriate investigations

* Bloods (FBC, biochemistry, inﬂammatory
markers, haematinics, coeliac serology,
thyroid function)
* Stool cultures (exclude infections and
Clostridiodes diﬀicile)
* Faecal calprotectin
* Pouchoscopy
* MRI pelvis (to exclude pelvic sepsis)
* MRE (to exclude upstream small intestine
for strictures/signs of Crohn's disease)

Diagnose primary
idiopathic pouchitis
Exclude diﬀerential
diagnosis

Inflammatory
* Cuﬀitis (may coexist with pouchitis)
* Crohn's disease
Mechanical
* Inflow or outflow obstruction (e.g. anastomotic stenosis)
* Small reservoir
Functional
* Evacuation disorder
* Weak sphincter
Sepsis
* Leak/pelvic sepsis
Other
* Pancreatic insuﬀiciency
* Bacterial overgrowth
* Coeliac disease
* Thyroid dysfunction
* Cancer of the pouch

Figure 1 | Evidence-based algorithm for the diagnosis of primary idiopathic pouchitis. Adapted with permission
from Segal JP, et al. Aliment Pharmacol Ther 2017; 45: 581-592 © (2016) John Wiley & Sons Ltd.

Mistake 7 Failing to reassess patients
regularly when they are taking long-term
antibiotic treatment
Chronic primary idiopathic pouchitis develops
in approximately 10-15% of patients with acute
pouchitis and it can be 'responsive' or 'refractory'
to antibiotic therapy.3,4 Some of these patients
require long-term antibiotics to maintain
symptomatic relief.34 The two antibiotics most
commonly used to treat primary idiopathic
pouchitis are ciprofloxacin and metronidazole.
Patients should be counselled on the specific

adverse effects of these medications,
which include tendinopathy in the case of
ciprofloxacin35 and peripheral neuropathy in
the case of metronidazole (see figure 1).36 In
particular, patients should be made aware of
the risks of long-term antibiotic use and other
therapeutic options considered.
The long-term use of antibiotics can be
associated with the development of antibioticresistant organisms.34 There have been case
series suggesting that C. difficile infection occurs
in patients who have a pouch and are taking
antibiotics and that they should be used

cautiously, especially in the elderly.37 We
advise regular reassessment of patients on
long-term antibiotics, including QoL assessment,
endoscopic and radiological investigations and
consideration of alternative medications where
appropriate. As already described, more
than a third of patients considered to have
antibiotic-dependent pouchitis were found to
have evidence of pelvic sepsis on MRI7 and hence
this should be excluded before a diagnosis of
chronic antibiotic-dependent primary
idiopathic pouchitis is made.

Mistake 8 Commencing biologics without
fully reassessing the diagnosis and patient
needs
If antibiotics fail to control chronic pouchitis,
biological therapies can be considered; however,
sepsis must be excluded before embarking on
this. Limited evidence-based on small case
series and not randomised controlled trials-
indicate that, overall, anti-TNF therapies are
associated with a 45-58% response rate.38
Anti-TNF agents were the first to show some
benefit for patients with refractory pouchitis,
with emerging data that ustekinumab39
and vedolizumab40 may also be effective.
Non-biologic alternatives, such as alicaforsen
(an antisense oligonucleotide), may be an option
but formal results from a phase 3 trial have not
yet been published.41
Importantly, if a patient requires biologic
therapies, their symptom burden is usually quite
severe and hence ongoing objective assessment
of drug effectiveness and exploration of quality
of life are essential. We recommend that patients
are counselled thoroughly prior to starting
biologics and, where possible, they have a joint
consultation with an experienced pouch surgeon
to discuss alternatives (pouch diversion or
excision). Chronic pelvic sepsis must be excluded
using cross-sectional imaging. Clear timelines
must be discussed with the patient when
planning a strategy of care, so that if biologic
drugs do not achieve the predetermined goals
set with the patient, alternative options are
sought.

Mistake 9 Failing to optimise diet and fluid
intake
As for all forms of IBD, validated, robust and
consistent data on which to base dietary advice
for patients with pouchitis are lacking. There is
evidence that fruit consumption can reduce the
incidence of primary idiopathic pouchitis42 and
a reduction of foods rich in antioxidants can
predispose to pouchitis.43
In terms of vitamin deficiencies, it has
been highlighted that of patients who have
undergone restorative proctocolectomy, 10.6%
have a vitamin D deficiency and 5% have either
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Mistakes in ... Booklet 2020

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