Cases reported "pouchitis"

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1/21. Misdiagnosis of specific cytomegalovirus infection of the ileoanal pouch as refractory idiopathic chronic pouchitis: report of two cases.

    PURPOSE: Chronic nonspecific reservoir ileitis (pouchitis) occurs in 5 to 10 percent of patients who undergo ileal pouch-anal anastomosis for ulcerative colitis. Specific infection of the ileal pouch-anal anastomosis with cytomegalovirus has not been reported. AIM: We report two patients with specific cytomegalovirus infection of the ileal pouch-anal anastomosis, initially misdiagnosed as idiopathic chronic pouchitis. CASE SERIES: Patient 1 had ileal pouch-anal anastomosis for ulcerative colitis. Three years later she had diarrhea, fever, pelvic pain, and pouch inflammation at endoscopy consistent with pouchitis. She had no response to medical therapy. Repeat endoscopy showed persistent inflammation and biopsies showed cytomegalovirus. She had symptomatic improvement after treatment with intravenous ganciclovir, 10 mg/kg/day for ten days (stopped for rash). Repeat pouch biopsies were negative for cytomegalovirus. Patient 2 had ileal pouch-anal anastomosis for ulcerative colitis. Nine years later she had resection of obstructing stricture at previous loop ileostomy site. She underwent reoperation with ileostomy and pouch defunctionalization for peritonitis. Four weeks later she had fever and bloody discharge from the diverted pouch. Pouch endoscopy with biopsy showed inflammation consistent with pouchitis. She had no response to medical therapy. Re-examination of pouch biopsies with a specific monoclonal immunofluorescent stain showed cytomegalovirus. She had symptomatic improvement after treatment with intravenous ganciclovir, 10 mg/kg/day for 21 days. Repeat pouch biopsies were negative for cytomegalovirus. CONCLUSIONS: Specific cytomegalovirus infection of the ileal pouch-anal anastomosis may be misdiagnosed as idiopathic refractory chronic pouchitis. cytomegalovirus must be excluded before immune modifier therapy or pouch excision in these patients. ( info)

2/21. Pouch-sacral fistula three years after restorative proctocolectomy for ulcerative colitis.

    fistula formation after restorative proctocolectomy poses a challenge to the surgeon and sometimes can lead to the excision of the pouch. A 21-year-old female patient developed an ileal J-pouch-sacral fistula with abscess and osteomyelitis of the sacrum, more than three years after the pouch construction for ulcerative colitis. Two months prior to this event, the patient had a single and transient episode of pouchitis. The role of pouchitis in the aetiopathogenesis of the fistula is unclear. To our knowledge, the late development of such a fistula has not been reported previously. ( info)

3/21. Complications after ileal pouch-anal anastomosis.

    Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is currently the procedure of choice for ulcerative colitis patients who require colectomy. Despite its wide acceptance, a variety of long-term complications of the procedure exist that can be severe and even lead to pouch excision. pouchitis occurs in up to one half of patients after IPAA, but is usually well controlled with medical therapy. A small percentage of patients develop chronic persistent pouchitis, which often requires long-term medical therapy and may result in pouch failure. Fistulas and strictures can also complicate the pouch procedure. In general, patients with Crohn's disease are not usually offered IPAA, because recurrence of disease, fistulas, abscesses, and strictures may lead to a higher incidence of pouch failure. Some ulcerative colitis patients develop complications after IPAA and are subsequently diagnosed with Crohn's disease. These patients may develop refractory fistulas, strictures, and extraintestinal manifestations of inflammatory bowel disease. Neoplastic transformation of the pelvic pouch has also been reported, particularly in patients with chronic pouchitis. Thorough follow-up and endoscopic surveillance with biopsies of the ileal pouch are therefore recommended. ( info)

4/21. arthritis related to ileal pouchitis following total proctocolectomy for ulcerative colitis.

    OBJECTIVE: To draw attention to arthritis that developed in patients who underwent total proctocolectomy with ileal pouch construction for ulcerative colitis (UC). methods: The course of 4 patients who developed arthritis for the first time after ileal-anal pouch anastomosis is described. In addition, the relationship to the chronic inflammation of the pouch-pouchitis-is discussed. RESULTS: The clinical manifestations were very similar to seronegative arthritis affecting mainly the joints of the lower extremities. It was accompanied by enthesopathy (2 patients) and by sacroiliitis (2 patients). All had active pouchitis. The abnormal laboratory test results were nonspecific, indicating chronic inflammation. All 4 patients tested negative for human leukocyte antigen (HLA) B27, and none had other concomitant extraintestinal manifestations. steroids rapidly improved both the arthritis and pouchitis; however, disease-modifying antirheumatic drugs were required to maintain remission with minimal daily steroids. Flares of the arthritis were always associated with active pouchitis, but the opposite was not necessarily true. CONCLUSIONS: arthritis related to ileal pouchitis after total colectomy for UC has many similarities to the arthritis associated with inflammatory bowel disease and should be added to the list of enteropathic arthropathies. ( info)

5/21. pouchitis-associated iritis (uveitis) following total proctocolectomy and ileal pouch-to-anal anastomosis in ulcerative colitis.

    A 26-year-old woman with ulcerative colitis treated with a proctocolectomy and ileal pouch-to-anal anastomosis developed an erosive and ulcerative pouchitis. Although no ophthalmological manifestations were present before the staged surgical procedures, iritis developed after appearance of the pouchitis. Both conditions subsequently resolved with oral corticosteroids and metronidazole. ( info)

6/21. adenocarcinoma in the ileal pouch: late risk of cancer after restorative proctocolectomy.

    Restorative proctocolectomy and ileal pouch-anal anastomosis is the surgical treatment of choice for patients with ulcerative colitis. As a long-term complication of this procedure, chronic pouchitis impairs the outcome in a number of patients. Aneuploidia and dysplasia have been observed after long-lasting inflammation of ileal mucosa. The question arises whether chronic inflammation of ileal mucosa predisposes to malignant transformation similar to the situation in the chronically inflamed colon. Cancer of the ileal mucosa has been reported in patients with Brooke's ileostomy and in patients with Kock pouch but not as yet in those with an ileoanal pouch. We report a patient with carcinoma in an ileoanal pouch originating from terminal ileal mucosa who had been suffering from pancolitis with long-term backwash ileitis before, and from chronic pouchitis after, restorative proctocolectomy. This case demonstrates the importance of regular follow-up with pouchoscopy and random biopsies in all patients with long-standing inflammation of the ileal mucosa. ( info)

7/21. Endoscopic and histologic evaluation together with symptom assessment are required to diagnose pouchitis.

    BACKGROUND & AIMS: pouchitis often is diagnosed based on symptoms alone. In this study, we evaluate whether symptoms correlate with endoscopic and histologic findings in patients with ulcerative colitis and an ileal pouch-anal anastomosis. methods: Symptoms, endoscopy, and histology were assessed in 46 patients using pouchitis disease Activity Index (PDAI). patients were classified as either having pouchitis (PDAI score > or =7; N = 22) or as not having pouchitis (PDAI score <7; N = 24). RESULTS: patients with pouchitis had significantly higher mean total PDAI scores, symptom scores, endoscopy scores, and histology scores. There was a similar magnitude of contribution of each component score to the total PDAI for the pouchitis group. Of note, 25% of patients with symptoms suggestive of pouchitis did not meet the PDAI diagnostic criteria for pouchitis. In both groups, the correlation coefficients between symptom, endoscopy, and histology scores were near zero (range, -0.26 to 0.20; P > 0.05). CONCLUSIONS: The symptom, endoscopy, and histology scores each contribute to the PDAI and appear to be independent of each other. Symptoms alone do not reliably diagnose pouchitis. ( info)

8/21. adenocarcinoma arising from along the rectal stump after double-stapled ileorectal J-pouch in a patient with ulcerative colitis: the need to perform a distal anastomosis. Report of a case.

    patients treated with restorative proctocolectomy for ulcerative colitis occasionally develop neoplasia from the rectal mucosal remnants. We report a case of a 65-year-old male who developed an adenocarcinoma from the rectal stump after a double-stapled ileorectal J-pouch for ulcerative colitis. We emphasize the need to perform the anastomosis either at the level of the dentate line or just cephalad to the anal transitional zone. Furthermore, when high-grade dysplasia at the rectum is evident, either an ileal pouch-anal anastomosis with mucosectomy or completion proctectomy with an end Brooke ileostomy should be offered. This is the second report in the literature of a carcinoma arising after use of the double-stapled ileal pouch-anal anastomotic technique. ( info)

9/21. clostridium difficile infection--an unusual cause of refractory pouchitis: report of a case.

    PURPOSE: Ileal pouch-anal anastomosis is the surgical procedure of choice for selected patients with severe ulcerative colitis. pouchitis is a common complication of this procedure, with most cases responding to treatment with metronidazole, possibly with the addition of 5-aminosalicylic acid drugs and steroids. can frequently colonize the colon after treatment with broad-spectrum antibiotics, giving rise to diarrhea or colitis. The aim of this report was to describe the first case of -associated diarrhea manifest as pouchitis. methods: The management of refractory pouchitis in a 35-year-old female with toxin in the stool is described followed by a literature review of small-intestinal infection. RESULTS: Assays for toxin on stool sent during an episode considered to be caused by idiopathic chronic pouchitis were positive, and treatment with oral vancomycin was initiated. The patient responded with a reduction in bowel frequency to twice daily, a successful discontinuation of her antidiarrheal medication, and a rapid increase in weight. A subsequent stool assay was negative for the toxin. CONCLUSIONS: infection can complicate pouchitis in patients with an ileal pouch-anal anastomosis and should be considered in patients who fail to respond to standard treatment, including metronidazole. In cases of refractory pouchitis, superadded infection with should be excluded before initiation of potent anti-inflammatory drugs. ( info)

10/21. Treatment of pouchitis with dehydroepiandrosterone (DHEA) - a case report.

    BACKGROUND: dehydroepiandrosterone (DHEA) inhibits activation of nuclear factor kappa B (NF-kappaB), which is known to be activated in inflammatory lesions of ulcerative colitis, via PPARalpha. In a pilot trial DHEA was effective for the treatment of active ulcerative colitis. pouchitis is a common complication after proctocolectomy for ulcerative colitis and still a therapeutical challenge. CASE: DHEA 200 mg/d was tested in chronic active pouchitis in a 35-year-old female patient. DHEA was given for eight weeks, and follow up for further eight weeks was performed. The number of stools dropped from 15-18/d to 8/d, the addition of mucus, which was observed initially, was absent during treatment. The consistence of stools improved from liquid/soft to soft/solid. abdominal pain resolved and endoscopical signs of inflammation improved. Eight weeks after termination of treatment with DHEA, the patient again suffered from 12 to 18 soft to liquid stools per day and mild abdominal pain. CONCLUSION: Therapeutic effects of DHEA in pouchitis should be evaluated systematically. ( info)
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