DDSEP® 8 Quick Quiz

April 2016 Quiz 2

Publish date: March 30, 2016

A 63-year-old female with longstanding ulcerative colitis was found to have dysplasia on colonoscopy approximately a year ago. She subsequently underwent a total abdominal colectomy with an ileal pouch anal anastomosis in a two-stage procedure. She is having problems with nighttime incontinence and with what she considers an excessive number of bowel movements, compared with what she was having the first several months after surgery. You perform an endoscopic exam of the pouch.

You recommend the following therapy at this time.

A. No drug therapy – her complaints and endoscopy are most consistent with pelvic floor dyssynergia and you refer her for manometry and biofeedback.

B. Start an antispasmodic for “irritable pouch.”

C. Start antibiotics for presumed pouchitis.

D. Start steroid foam for initial treatment of cuffitis.

E. Initiate budesonide and 6-mercaptopurine for treatment of Crohn’s disease of the pouch.

Q2: ANSWER: D

Critique

This series of endoscopic findings shows changes consistent with inflammation of the cuff.

Up to 20%-30% of patients with ulcerative colitis ultimately require colectomy due to medically refractory colitis or to the development of dysplasia. A total abdominal protocolectomy with ileal pouch anal anastomosis has become the surgical procedure of choice for most ulcerative colitis patients who require surgery.

There are both early and late complications of this type of surgery. Late complications include anastomotic stricture, pouchitis, abscesses, inflammation of the cuff or cuffitis, and functional difficulties such as irritable pouch syndrome, anal pain, and pouch stasis. Patients may also present with inflammation of the pouch and the prepouch ileum that is consistent with Crohn’s disease. Endoscopy can help to narrow down the differential diagnosis of these pouch complications.

In this series of photos the prepouch ileum has no inflammation. The pouch also has no ulcerations or evidence of pouchitis or Crohn’s disease. The cuff is inflamed consistent with a diagnosis of cuffitis. If the inflammation becomes difficult to manage, immunosuppressive therapy may be required but at this point it is reasonable to start with topical therapy to the inflamed area.

Reference

  1. Li, Y. Shen, B. Evaluating pouch problems. Gastroenterology Clinics North Am. 2012;41:355-78.
  2. Shen, G. Diagnosis and management of post-operative ileal pouch disorders. Clin Colon Rectal Surg. 2010;23:259-68.

Next Article:

Statins inversely linked to colorectal cancer in patients with IBD