Incidence, Risk Factors, and Outcomes of Pouchitis and Pouch-Related Complications in Patients With Ulcerative Colitis

Edward L Barnes, Hans H Herfarth, Michael D Kappelman, Xian Zhang, Amy Lightner, Millie D Long, Robert S Sandler, Edward L Barnes, Hans H Herfarth, Michael D Kappelman, Xian Zhang, Amy Lightner, Millie D Long, Robert S Sandler

Abstract

Background & aims: Acute pouchitis is the most common non-surgical complication after restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC). We used validated case-finding definitions for pouchitis to search administrative claims data and determine the incidence of pouchitis in the first 2 years after IPAA.

Methods: We identified all patients who underwent proctocolectomy with IPAA for UC in the IQVIA Legacy PharMetrics Adjudicated Claims Database, from January 1, 2007 through June 1, 2016. The primary outcome was the development of pouchitis within 2 years after IPAA. Secondary outcomes included isolated acute vs recurrent pouchitis, immunosuppressive therapy, further surgery, and admission to the hospital.

Results: Among 594 patients, the cumulative incidence of pouchitis within 2 years of IPAA was 48% (95% CI, 44%-52%). The cumulative incidence of isolated acute pouchitis was 29% (95% CI, 26%-33%). Compared to patients with isolated acute pouchitis, patients who received a diagnosis of recurrent pouchitis (cumulative incidence, 19%: 95% CI, 16%-22%) demonstrated increased outpatient visits, emergency department visits, and inpatient admissions (all P < .001). Patients who developed pouchitis were more likely to have a history of primary sclerosing cholangitis (adjusted odds ratio [aOR], 3.94; 95% CI, 1.05-14.8) and anti-tumor necrosis factor alpha therapy prior to colectomy (aOR 1.63; 95% CI, 1.09-2.45). Among patients with pouchitis, the cumulative frequency of new immunosuppressive therapy was 40% (95% CI, 35%-46%) and the cumulative incidence of pouch excision was 1.0% (95% CI, 0.4%-3.0%). The cumulative incidence of a new diagnosis of Crohn's disease after IPAA for UC was 9.0% (95% CI, 7.2%-11%).

Conclusions: In a geographically diverse population, 48% of patients with UC developed pouchitis within the first 2 years after IPAA. Patients with pouchitis had greater use of healthcare resources, indicating a significant burden of disease.

Keywords: Antibiotics; Hospitalization; Inflammation; Utilization.

Copyright © 2021 AGA Institute. Published by Elsevier Inc. All rights reserved.

Figures

Figure 1.
Figure 1.
Flow diagram for evaluation of patients after restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis between January 1, 2007 and June 1, 2016
Figure 2.
Figure 2.
Pouchitis free survival after an initial episode of pouchitis comparing patients who developed pouchitis within the first six months of ileal pouch-anal anastomosis for ulcerative colitis to those who developed pouchitis greater than six months after surgery Legend: log-rank p=0.107

References

    1. Shen B Acute and chronic pouchitis--pathogenesis, diagnosis and treatment. Nat Rev Gastroenterol Hepatol 2012;9:323–33.
    1. Barnes EL, Herfarth HH, Sandler RS, et al. Pouch-Related Symptoms and Quality of Life in Patients with Ileal Pouch-Anal Anastomosis. Inflamm Bowel Dis 2017;23:1218–1224.
    1. Lightner AL, Mathis KL, Dozois EJ, et al. Results at Up to 30 Years After Ileal Pouch-Anal Anastomosis for Chronic Ulcerative Colitis. Inflamm Bowel Dis 2017;23:781–790.
    1. Gionchetti P, Rizzello F, Helwig U, et al. Prophylaxis of pouchitis onset with probiotic therapy: a double-blind, placebo-controlled trial. Gastroenterology 2003;124:1202–9.
    1. Fleshner P, Ippoliti A, Dubinsky M, et al. Both preoperative perinuclear antineutrophil cytoplasmic antibody and anti-CBir1 expression in ulcerative colitis patients influence pouchitis development after ileal pouch-anal anastomosis. Clin Gastroenterol Hepatol 2008;6:561–8.
    1. Shen B, Fazio VW, Remzi FH, et al. Risk factors for diseases of ileal pouch-anal anastomosis after restorative proctocolectomy for ulcerative colitis. Clin Gastroenterol Hepatol 2006;4:81–9; quiz 2–3.
    1. Kappelman MD, Rifas-Shiman SL, Kleinman K, et al. The prevalence and geographic distribution of Crohn’s disease and ulcerative colitis in the United States. Clin Gastroenterol Hepatol 2007;5:1424–9.
    1. Long MD, Martin CF, Pipkin CA, et al. Risk of melanoma and nonmelanoma skin cancer among patients with inflammatory bowel disease. Gastroenterology 2012;143:390–399 e1.
    1. Singh S, Heien HC, Sangaralingham LR, et al. Comparative effectiveness and safety of infliximab and adalimumab in patients with ulcerative colitis. Aliment Pharmacol Ther 2016;43:994–1003.
    1. Coward S, Clement F, Benchimol EI, et al. Past and Future Burden of Inflammatory Bowel Diseases Based on Modeling of Population-Based Data. Gastroenterology 2019;156:1345–1353 e4.
    1. Barnes EL, Kochar B, Herfarth HH, et al. Creation of a Case-Finding Definition for Identifying Patients with Acute Pouchitis in Administrative Claims Data. Clin Gastroenterol Hepatol 2020. epublished March 5.
    1. Bernstein CN, Blanchard JF, Rawsthorne P, et al. Epidemiology of Crohn’s disease and ulcerative colitis in a central Canadian province: a population-based study. Am J Epidemiol 1999;149:916–924.
    1. Madiba T, Bartolo D. Pouchitis following restorative proctocolectomy for ulcerative colitis: incidence and therapeutic outcome. J R Coll Surg Edinb 2001;46:334–7.
    1. Fazio VW, Kiran RP, Remzi FH, et al. Ileal pouch anal anastomosis: analysis of outcome and quality of life in 3707 patients. Ann Surg 2013;257:679–85.
    1. Segal JP, Ding NS, Worley G, et al. Systematic review with meta-analysis: the management of chronic refractory pouchitis with an evidence-based treatment algorithm. Aliment Pharmacol Ther 2017;45:581–592.
    1. Kayal M, Plietz M, Rizvi A, et al. Inflammatory Pouch Conditions Are Common After Ileal Pouch Anal Anastomosis in Ulcerative Colitis Patients. Inflamm Bowel Dis 2019. epublished October 6.
    1. Fleshner P, Ippoliti A, Dubinsky M, et al. A prospective multivariate analysis of clinical factors associated with pouchitis after ileal pouch-anal anastomosis. Clin Gastroenterol Hepatol 2007;5:952–8; quiz 887.
    1. Yanai H, Ben-Shachar S, Mlynarsky L, et al. The outcome of ulcerative colitis patients undergoing pouch surgery is determined by pre-surgical factors. Aliment Pharmacol Ther 2017;46:508–515.
    1. Bertucci Zoccali M, Hyman NH, Skowron KB, et al. Exposure to Anti-tumor Necrosis Factor Medications Increases the Incidence of Pouchitis After Restorative Proctocolectomy in Patients With Ulcerative Colitis. Dis Colon Rectum 2019;62:1344–1351.
    1. Barnes EL, Lightner AL, Regueiro M. Peri-operative and Post-operative Management of Patients with Crohn’s Disease and Ulcerative Colitis. Clin Gastroenterol Hepatol 2020;18:1356–1366.
    1. Shen B Pouchitis: what every gastroenterologist needs to know. Clin Gastroenterol Hepatol 2013;11:1538–49.
    1. Bar N, Dubinsky V, Avraham Y, et al. Long Term Use of Ciprofloxacin and Metronidazole for Pouchitis The Low Rate of Adverse Events and the High Association with Antibiotic Resistance. Gastroenterology 2018;154:S–28.
    1. Dubinsky V, Reshef L, Bar N, et al. Predominantly Antibiotic-resistant Intestinal Microbiome Persists in Patients With Pouchitis Who Respond to Antibiotic Therapy. Gastroenterology 2020;158:610–624.e13.
    1. Long MD, Hutfless S, Kappelman MD, et al. Challenges in designing a national surveillance program for inflammatory bowel disease in the United States. Inflamm Bowel Dis 2014;20:398–415.
    1. Weaver KN, Kochar B, Hansen JJ, et al. Chronic Antibiotic Dependent Pouchitis Is Associated With Older Age at the Time of Ileal Pouch Anal Anastomosis (J-pouch) Surgery. Crohns Colitis 360 2019;1:otz029.
    1. Singh S, Sharma PK, Loftus EV Jr., et al. Meta-analysis: serological markers and the risk of acute and chronic pouchitis. Aliment Pharmacol Ther 2013;37:867–75.
    1. Barnes EL, Kochar B, Jessup HR, et al. The Incidence and Definition of Crohn’s Disease of the Pouch: A Systematic Review and Meta-analysis. Inflamm Bowel Dis 2019;25:1474–1480.

Source: PubMed

Sponsorer och medarbetare

Medicinska tillstånd

Läkemedelsinterventioner

3
Prenumerera