Laura Raffals, MD, on Disorders of the Pouch

Dr Raffals explains the various types of disorders that patients who have undergone ileal pouch anal anastamosis surgery may present with and how gastroenterologists can ensure these patients receive the care they need. She presented on this topic at the virtual Interdisciplinary Autoimmune Summit 2021 held April 15-18.

Laura Raffals, MD, is an associate professor and gastroenterologist at the Mayo Clinic in Rochester, Minnesota.

TRANSCRIPT:

Dr. Laura Raffals:  Hi, I'm Laura Raffals. I'm a gastroenterologist at the Mayo Clinic in Rochester, Minnesota. Today, I am reaching out to summarize my talk that I gave on pouch disorders at the Interdisciplinary Autoimmune Summit.

For those of you who were not able to attend the summit, I wanted to give a few key points or takeaway messages that I shared during my presentation.

As many of you know, patients who have a J-pouch or an ileal pouch-anal anastomosis often have this procedure done because they have a history of ulcerative colitis and either we're unable to get their disease under control with medical therapies or experienced a neoplastic event such as dysplasia requiring that their colon be removed.

Fortunately, we're able to have an ileal pouch-anal anastomosis, which allows them to have fecal continence and go to the bathroom fairly normally, as we do with our healthy colons.

It is important, as we counsel our patients who are undergoing this surgery, to understand that what is normal with a healthy colon is not necessarily normal with a healthy pouch. That's the first key takeaway point that I shared in my talk.

That is, what is life like with an ileal pouch or a J-pouch? That is to set the expectations of what that normal life is. Quality of life is quite good with the J-pouch. The patients who have a J-pouch tend to have bowel movements 4 to 6 times a day, small volume bowel movements, without urgency.

Again, our patients shouldn't expect that they'll have one to two bowel movements a day as a healthy individual without a J-pouch might. Four to 6, maybe even 8 bowel movements a day, and that includes waking up maybe once throughout the night to have bowel movements, too.

There are different things we can do to help with the consistency of their stool and with their frequency of their bowel movements to improve their quality of life and their pouch function. That was the first takeaway that I wanted to share with those who were able to attend my talk.

It's also important, as a gastroenterologist or any provider who's taking care of these patients, to understand the general anatomy of a J-pouch.

If you're performing endoscopy, it's important that you understand what you're looking at and what you need to be looking for when you're doing endoscopy and to get good photo documentation of the pouch.

Looking at the body of the pouch, the tip of the J, the pouch inlet, and the prepouch ileum, or the afferent limb, and getting well above the pouch inlet. Going deep into the prepouch ileum and documenting all those areas of the pouch.

If you do that consistently, you'll start to notice patterns amongst all of your patients. That will allow you to start to pick up on pathology in patients and start to understand different things that might be going on with your patients. That would be the second point that I was trying to highlight in my talk.

Next is patients will present with symptoms related to their pouch dysfunction, and while the most common problem our patients experience is pouchitis, that certainly is not the only problem that they experience. It's important to take a close history, a detailed history, from our patients.

That history often will provide clues to let us recognize what testing we need to do to try to uncover what's going on for our patients. We have a lot of diagnostic tools at our disposal. Tapping into different radiologic tests, different, of course, endoscopy that we could do, still studies that we can do.

Depending on what the patient is experiencing, will help guide us what testing we need to do next. Once we have considered our patient's symptoms, we can start thinking in terms of the different types of complications, whether we're considering the patient is having inflammatory complications from their disease.

That's going to be pouchitis, chronic inflammatory conditions of the pouch — that's just Crohn's-like complications of the pouch. Sometimes, our patients may experience surgical complications of the pouch or mechanical issues of the pouch. That would be our leaks or even chronic leaks along the anastomosis of the pouch, sometimes twisting of the pouch.

Another category of complications are functional disorders of the pouch. Patients who have irritable pouch disorders or maybe even evacuation disorders of the pouch. All those are some examples of the different categories of complications of the pouch that we might see.

Again, trying to pick our diagnostic test based on the symptoms our patients present with so that we can understand why our patients have the symptoms that they have. We must think more broadly than just narrowly of the pathology of pouchitis. There's a lot more our patients can experience beyond just pouchitis.

Finally, we spent a few moments talking about our therapeutic approach. That's largely driven by what we find through our diagnostic testing. We spent most of our time talking about, how do we treat the inflammatory complications of disease? F

For idiopathic pouchitis, our standard of care still is giving courses of antibiotics to treat our patients with idiopathic pouchitis. Most commonly, we use ciprofloxacin or metronidazole. A simple 2-week course is often effective.

In patients who need a second course of antibiotics, we can do that. Within 3 months, if patients require another course of antibiotics, sometimes it could be helpful to do a tapering off of that antibiotic after a 2-week course to try to help them recover from that pouchitis. That's how we treat simple acute idiopathic pouchitis.

Sometimes, our patients will experience either more chronic antibiotic-dependent pouchitis or antibiotic-refractory pouchitis. That's when things get a bit more complex.

For those patients who are antibiotic-dependent, historically, we've always just treated chronically with antibiotics and trying to minimize the dose or even rotating antibiotics for these patients.

There have been some thought-provoking studies recently, particularly one that was published just this past year in gastroenterology by a great group out of Israel. It showed us that patients who are chronically on antibiotics are developing some antibiotic resistance in their microbial communities so that those communities are less inflammatory in nature.

They are certainly less inflammatory, but the fact that there are antibiotic-resistant genes within that microbiome should alert us to the fact that this could potentially cause problems down the road for our patients. We need to be aware of the potential of developing antibiotic resistance in our patients, many of whom are young.

I challenge the audience to start thinking, "Should we be considering antibiotic-sparing strategies in our patients with antibiotic-dependent pouchitis, similar to how we think about steroid-sparing strategies?"

In our patients who have antibiotic-refractory disease, then it's obviously clear that we need to look to other strategies for treating these patients.

That's when we start looking at our other treatment options that we use for all of our patients with inflammatory bowel disease or immunomodulator therapies such as biologics. There are some case series that show us examples of treatments we can use for those.

At the end of the day, pouchitis and different pouch disorders is a group of disorders that is honestly not super well-studied, so there's room for great improvement and bringing greater therapies to these patients.

If we listen to our patients, take great history, powerful diagnostic approaches, we can target our therapies to help these patients feel better, and give them good quality of life, and help them live a great life with their pouch. Thank you for your time and for your attention today.