11/21. pouchitis-associated pyoderma gangrenosum following restorative proctocolectomy for ulcerative colitis. A 43-year-old female with ulcerative colitis treated by proctocolectomy and ileal pouch--anal anastomosis developed acute pouchitis. Although no extra-intestinal manifestations were present before the surgical procedure, pyoderma gangrenosum developed concomitantly with the appearance of acute pouchitis. Both conditions completely resolved with oral metronidazole only. This is the first report of acute pouchitis-related pyoderma gangrenosum. This association suggests that pouchitis may represent a recurrent ulcerative colitis-like syndrome within the novel environment of the pouch. ( info) |
12/21. Infliximab therapy in pediatric Crohn's pouchitis. OBJECTIVE: We describe the prolonged clinical benefit of murine chimeric antitumor necrosis factor (TNF)-alpha monoclonal antibody, infliximab, on pediatric patients with Crohn's disease and ileal pouch anal anastomosis (IPAA). methods: A retrospective review of patients originally diagnosed with ulcerative colitis, status post colectomy and IPAA, who developed findings compatible with Crohn's disease was undertaken. Refractory pouchitis developed in all patients as well as protracted symptoms of diarrhea, abdominal pain, joint pain, and incontinence. All patients received infliximab. RESULTS: Four pediatric patients (2 males and 2 females) with mean age of 14.5 years (range 11-18 years) were studied. The development of perianal fistulas in 2 patients, granuloma on biopsy in 1 patient and perianal skin tag in 1 patient, led to a diagnosis change of CD. After failure to respond to antibiotics, aminosalicylates and immunomodulators such as azathioprine and 6-mercaptopurine (6-MP), all patients were treated with infliximab. patients received infliximab infusions at a dose of 5 mg/kg, initially at weeks 0, 2 and 6 and subsequently at 8 weeks intervals in combination with an immunomodulator drug. All patients showed marked improvement clinically, endoscopically, and histologically. CONCLUSION: Infliximab can be used successfully for the treatment of pediatric patients with Crohn's disease and IPAA who are refractory to conventional therapies. ( info) |
13/21. arthritis accompanying ileal pouchitis or undifferentiated HLA B27-related spondyloarthropathy? The case of an HLA B27( ) patient who developed inflammatory arthritis accompanying ileal pouchitis, following total proctocolectomy for familial adenomatous polyposis is presented for the first time in the literature. Based on its clinical presentation and serology, it can be classified either as arthritis accompanying ileal pouchitis, or as an undifferentiated spondyloarthropathy. ( info) |
14/21. Secondary pouchitis in a post-operative patient with ulcerative colitis, successfully treated by salvage surgery. We report a case of secondary pouchitis, defined as a mucosal inflammatory lesion in the ileal reservoir provoked by pouch-related complication following total colectomy and pouch anal anastomosis, which was successfully treated by salvage surgery. A 20-year-old woman with ulcerative colitis developed acute severe bloody diarrhea following proctocolectomy, ileal pouch-anal anastomosis and diverting ileostomy. She was diagnosed as having a secondary pouchitis mainly caused by a peripouch abscess and partly concerned with the abnormal pouch formation. The remnant rectum and ileal pouch were excised and ileal pouch-anal anastomosis and diverting ileostomy were constructed. The postoperative course was uneventful with no sign of pouchitis. Salvage surgery may be indicated to treat secondary pouchitis when caused by surgery-related complications. ( info) |
15/21. Successful treatment of severe pouchitis with rebamipide refractory to antibiotics and corticosteroids: a case report. The antibiotics, metronidazole and ciprofloxacin, are the first-line treatment for pouchitis. patients who do not respond to antibiotics or conventional medications represent a major challenge to therapy. In this report, we have described a successful treatment of severe refractory pouchitis with a novel agent, rebamipide, known to promote epithelial cell regeneration and angiogenesis. A 27-year-old male with ileo-anal pouch surgery presented with worsening anal pain, diarrhea, and abdominal pain. The patient was diagnosed to have pouchitis and was given metronidazole together with betamethasone enema (3.95 mg/dose). However, despite this intensive therapy, the patient did not improve. On endoscopy, ulceration and inflammation were seen in the ileal pouch together with contact bleeding and mucous discharge. The patient was treated with rebamipide enema (150 mg/dose) twice a day for 8 wk without additional drug therapy. Two weeks after the rebamipide therapy, stool frequency started to decrease and fecal hemoglobin became negative at the 4th wk. At the end of the therapy, endoscopy revealed that ulcers in the ileal pouch had healed with no obvious inflammation. The effect of rebamipide enema was dramatic and was maintained throughout the 11-mo follow-up. The patient continued to be in remission. No adverse effects were observed during the treatment or the follow-up period. The sustained response seen in this case with severe and refractory pouchitis indicates that agents, which promote epithelial cell growth, angiogenesis and mucosal tissue regeneration, are potential therapeutic agents for the treatment of refractory colorectal lesions. ( info) |
16/21. Collagenous pouchitis. Collagenous colitis is characterised by watery diarrhoea, normal colonic mucosa on endoscopy, diffuse colitis with surface epithelial injury, and a distinctive thickening of the subepithelial collagen table on histology. Some patients can develop medically refractory collagenous colitis, in which case they may require surgical intervention. This is the first report of collagenous pouchitis in a collagenous colitis patient with proctocolectomy and ileal pouch-anal anastomosis. A patient with medically refractory collagenous colitis who underwent a total proctocolectomy and ileal pouch-anal anastomosis was sequentially evaluated with an endoscopy and histology of the colon, distal small intestine, and ileal pouch. A 58-year-old female had a 10-year history of collagenous colitis before having a total proctocolectomy and ileal pouch-anal anastomosis for medically refractory disease. The histologic features of collagenous colitis were present in all colon and rectum biopsy or resection specimens, but were absent in the distal ileum specimen. The post-operative course was complicated by persistent increase of stool frequency, abdominal cramps, and incontinence. A pouch endoscopy was performed 3 years after ileal pouch-anal anastomosis which showed the histologic features of collagenous colitis in the ileal pouch, collagenous pouchitis, while the pre-pouch neo-terminal ileum had no pathologic changes. After antibiotic therapy, the histologic changes of collagenous pouchitis resolved. This is the first reported case of collagenous pouchitis. Since the abnormal collagen table and its associated features were only present in the pouch and absent in the neo-terminal ileum, and the patient had histologic improvement after antibiotic therapy, it would suggest that faecal stasis and bacterial load may play a role in the pathogenesis. ( info) |
17/21. Diffuse gastroduodenitis and pouchitis associated with ulcerative colitis. We experienced a very rare case of ulcerative colitis (UC) accompanied with analogous lesions in the stomach, duodenum, and ileal J-pouch. Ileal J-pouch anal anastomosis was performed on a 29-year old woman in 1996. Six years later, she was admitted again to our hospital because of epigastralgia, nausea, watery diarrhea and low fever. Based on the results of endoscopic examination, we diagnosed it as pouchitis. Moreover, on hypotonic duodenography, expansion of the duodenal bulb and the descending portion were poor. Kerckring folds disappeared with typical lead-pipe appearance. The pathogenesis of the gastric and duodenal lesion in this patient was similar to that of the colonic lesions of UC. For the gastroduodenal lesions in this patient, symptomatic remission was obtained following administration of crushed mesalazine tablets (1500 mg/d) for 14 d with continuous administration of omeprazole. Firstly we used ciprofloxacin to treat pouchitis. On the fifth day, she got a fever because of catheter infection. In the catheter culture, methicillin-resistant staphylococcus aureus (MRSA) was detected. Therefore we changed ciprofloxacin to vancomycin hydrochloride (vancomycin). vancomycin was very effective, and the stool frequency dramatically improved in three days. Now she continues to take mesalazine, but her condition is stable and there has been no recurrence of pouchitis. ( info) |
18/21. Ileal pouch arthritis: a case report. A patient is described with arthritis of both wrists and tendinitis of one achilles tendon in the presence of severe pouchitis. The rapid disappearance of arthritis and tendinitis after removal of the pouch strongly suggests their relationship. The pathogenesis of arthritis in pouchitis has not been elucidated but may be the same as in ulcerative colitis. Rheumatologists should be aware of the occurrence of arthritis in patients with ulcerative colitis after the construction of an ileo-anal anastomosis with a so-called pouch. ( info) |
19/21. lymphoma of the pouch after ileal pouch-anal anastomosis: report of a case. The most common cause of pouch dysfunction after ileal pouch-anal anastomosis is pouchitis. Although low-grade dysplasia in the mucosa of the pouch has been recently described in the presence of pouchitis, there has been no report of carcinoma arising in the pouch itself. We describe a patient who developed a large-cell lymphoma of the ileal pouch after ileal pouch-anal anastomosis. ( info) |
| We report a patient with a history of ulcerative colitis status after total proctocolectomy with an ileoanal J pouch who presented with marked, refractory pouchitis associated with a primary cytomegalovirus (CMV) infection. The patient had atypical lymphocytosis in the blood and serology consistent with primary CMV infection. Biopsies of the pouch revealed CMV inclusion bodies and yielded positive CMV cultures. The patient improved clinically with resolution of pouchitis after a 10-day course of therapy with gancyclovir and has remained in remission for over 5 yr. This is the first report of pouchitis associated with a primary CMV infection. This case demonstrates that CMV infection is in the differential diagnosis for causes of pouchitis, and it suggests that the pouch, like the colon, is a potential site for a primary CMV infection in an immunocompetent host. ( info) |