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Crohn’s disease and Pouches

Crohn’s disease and Pouches. Bruce George. Kangaroo Club 31-5-14. Crohn’s disease and Pouches Why is this a question?. Pre-pouch surgery Crohn’s disease is a contra-indication to pouch surgery What about indeterminate colitis? Is it ever reasonable to make a pouch for known Crohn’s?

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Crohn’s disease and Pouches

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  1. Crohn’s disease and Pouches Bruce George Kangaroo Club 31-5-14

  2. Crohn’s disease and PouchesWhy is this a question? • Pre-pouch surgery • Crohn’s disease is a contra-indication to pouch surgery • What about indeterminate colitis? • Is it ever reasonable to make a pouch for known Crohn’s? • Post pouch surgery • If pouch function is poor/complication, could this be due to Crohn’s • What happens if you develop Crohn’s in a pouch?

  3. They are very different diseases • UC • mucosa only • continuous from top of anal canal upwards

  4. If you don’t want to see pictures of bowels and bottoms: • Look away now!!

  5. Crohn’s disease

  6. The problem • Pouch surgery for Crohn’s disease highly likely to fail • Small bowel and anal disease • Deep inflammation: fistulae, leaks, strictures • But sometimes Crohn’s can mimic UC • Isolated to colon • Similar histology

  7. Pre-pouch work-up • Review pathology available • Review distribution of disease • skip lesions • small bowel pathology • anal pathology • Indeterminate • UC, but minor features of CD • Effects of therapy • patchy • Ordinary anal pathology • piles • tears

  8. Cleveland Clinic • Over 3000 pouches • 204 for Crohn’s • 20 intentional • 97 immediate diagnosis on colon pathology • 87 delayed diagnosis • Outcome • 29% failure rate at 10 years (71% functioning) • Delayed group worse Metton et al 2008

  9. Policy in Oxford • Not to offer pouch surgery for known Crohn’s disease • Minimise surprise finding of Crohn’s disease on proctocolectomy specimen • Review of all available pathology • Colectomy first approach • Slow lane for indeterminate • Increased risks • Delay in case features of Crohn’s develop

  10. Pouches behaving badly • What is normal? • Acute deterioration usually called pouchitis and treated with ciprofloxacin or metronidazole

  11. Pouchitis Histology acute inflammation + chronic inflammation villous atrophy crypt hyperplasia chronic inflammatory infiltrate Symptoms increased stool frequency looseness blood urgency incontinence abdominal pain fever arthralgia Endoscopy oedema granularity contact bleeding loss of vascularity haemorrhage ulceration

  12. Treatment • Cochrane meta-analysis of 11 RCTs • Acute pouchitis (4RCT, 5 agents) Rifaximin and lactobacillus GG not significantly different to placebo Budesonide enemas = metronidazole

  13. Cochrane meta-analysis • Chronic pouchitis (4 RCT, 4 agents) • VSL3 better than placebo in maintaining remission after treatment with antibiotics

  14. It’s probably not that simple • Many other causes of poor pouch function • many of which may respond to antibiotics • many patients fulfilling definition of pouchitis may have poor pouch function due to other causes

  15. Assessment of pouch dysfunction • Identification of • True pouchitis • Other causes of pouch inflammation (secondary) • Pathogens (C diff, cmv) • Adjacent inflammation (sepsis, ischaemia, intussusception) • Drugs (NSAIDS) • Crohn’s disease • Other causes of poor pouch function

  16. History of poor function Always bad Recent deterioration Review histology Review peri-operative course Clinical examination PR Pouchoscopy + biopsy Stool culture Phase 1assessment of poor pouch function

  17. Acute pouchitis ciprofloxacin Pouch-anal anastomotic stricture EUA + gentle dilatation Cuffitis topical steroids or mesalazine Common problems

  18. Inside Flexible pouchoscopy + biopsy pouchogram Outside CT or MR pelvis Below Sphincter physiology and ultrasound Pouchogram EUA, pouch and cuff biopsies Above MRE endoscopy Emptying the pouch Dynamic evacuating “proctography” Phase 2Assessment of persistent poor pouch function

  19. INSIDE THE POUCH • Chronic pouchitis • Irritable pouch • Small volume/non compliant pouch • Cmv/c diff

  20. OUTSIDE THE POUCH • Pelvic abscess/induration • Fistula • Unrelated pathology • Fibroid, desmoid

  21. Below the pouch • Narrowing at anastomosis • Pouch fistula • Sphincter weakness • Cuffitis • Long rectal cuff

  22. ABOVE THE POUCH • Adhesions • Bacterial overgrowth • Crohn’s disease • Pre-pouch ileitis • NSAIDs • coeliac

  23. EMPTYING THE POUCH Internal pouch prolapse Anismus

  24. Treatment • Dependant on identification of cause of poor pouch function • Emerging concept: • Inflammation in/around pouch/fistula. Suspicion but no proof of Crohn’s • Leuven group: • 88% improvement with infliximab/adalimumab

  25. Surgical options for the failing pouch • Indefinite diversion • with pouch excision • with pouch left in-situ • Re-do pouch reconstruction • Kock pouch

  26. and finally...Summary of problems • Weather • 20 mph headwind • Under-estimating the task • Separation of cyclists and cyclists from van • Swanley underpass • Getting lost • Maidstone at 04.15 • Different speeds • Non-chain gang • Food and drink • Strategy when problems occur • Negotiating skills • 22.00, 45 miles from Paris

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