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Bo Shen, MD, FACG Managing Ileal Pouch-anal Anastomosis Patients with IBD BBoo SShheenn,, MMDD TThhee EEdd aanndd JJooeeyy SSttoorryy EEnnddoowweedd CChhaaiirr PPrrooffeessssoorr ooff MMeeddiicciinnee TThhee CClleevveellaanndd CClliinniicc FFoouunnddaattiioonn CClleevveellaanndd,, OOhhiioo Indications for Colectomy in UC ACG/LGS Regional Postgraduate Course - New Orleans, LA 1 Copyright 2014 American College of Gastroenterology Bo Shen, MD, FACG J, K Pouches vs. Ileostomy Brooke Ileostomy Kock Pouch Pelvic J Pouch Anatomy of Pelvic Pouches “J” “S” “W” Afferent limb (neo-TI) Inlet TTiip off ““JJ”” Efferent limb Outlet/cuff/ anal transitional Efferent zone limb ACG/LGS Regional Postgraduate Course - New Orleans, LA 2 Copyright 2014 American College of Gastroenterology Bo Shen, MD, FACG Disorders of the Ileal Pouch Surgical/ Inflammatory/ Functional Neoplastic Systemic/ Mechanical Infectious Metabolic • Anastomotic leak  Pouchitis  Irritable pouch  Pouch/ATZ  Anemia • Pelvic sepsis  Cuffitis syn. Neoplasia  Bone loss • Sinus  Crohn’s dis. Anismus  Lymphom  VitD/B12 • Fistula  Smallbowel  Poor a def. • Strictures bacterial compliance  Squamous  Renal stone • Afferent limb syn. overgrowth  Pseudo- cell cancer  Celiac dis. • Efferent limb syn.  Inflammatory obstruction/me  High PTH •• IInnffeeccuunnddiittyy ppoollyyppss ggappouch • Sexualdysfunction  Hypersensitive • Portal vein thrombi suture lines • Prolapse  “Pouchalgia • Twist/volvulus fugax” • Foreign body Updated from Shen B, et al. AJG 2005;100;93-101 ’ Owl s Eyes and Pouch Dysfunction ACG/LGS Regional Postgraduate Course - New Orleans, LA 3 Copyright 2014 American College of Gastroenterology Bo Shen, MD, FACG S pouch (no owls’ eyes) Afferent Limb Syndrome Shen B, Remzi FH, Fazio VW. CGH2008;6:145-58 ACG/LGS Regional Postgraduate Course - New Orleans, LA 4 Copyright 2014 American College of Gastroenterology Bo Shen, MD, FACG Efferent Limb Syndrome 7 cm SShheenn BB,, RReemmzzii FFHH,, FFaazziioo VVWW.. CCGGHH22000088;;66::114455--5588 2 cm Twisted Pouch ACG/LGS Regional Postgraduate Course - New Orleans, LA 5 Copyright 2014 American College of Gastroenterology Bo Shen, MD, FACG Kock Pouch Pathogenetic Model of Pouchitis Why not in FAP Pouches? Therapeutic Abnormal Immune Target Response Genetic Susceptibility Therapeutic Mechanical factors •Alteration commensal Target (e.g. ischemia) bacteria (dysbiosis) ••PPaatthhooggeennss Therapeutic Target Luminal factors (e.g.NSAIDs) NavaneethanU & Shen B. AJG2010;105:51-64 ACG/LGS Regional Postgraduate Course - New Orleans, LA 6 Copyright 2014 American College of Gastroenterology Bo Shen, MD, FACG Natural History of Pouchitis Ischemia Surgery-associated RReeffrraaccttoorryy PPoouucchhiittiiss anatomic comp RReellaappssiinngg PPoouucchhiittiiss Disease Activity EEppiissooddiicc PPoouucchhiittiiss NNll ppoouucchh oorr FFAAPP ppoouucchh MMoonntthhss Metronidazole Cipro Rifaximin Tinidazole Antifungals FMT?… Endoscopic Clues for Etiology of Pouchitis? Hemorrhagic NSAID C. Diff Ischemia Fever-CMV Chronic Pouchitis ACG/LGS Regional Postgraduate Course - New Orleans, LA 7 Copyright 2014 American College of Gastroenterology Bo Shen, MD, FACG Risk Factors for Pouchitis • Extensive UC • Backwash ileitis • Primary sclerosing cholangitis • PP-AANNCCAA • IL-1ra, NOD2 polymorphisms • NOD2 gene polymorphisms • Precolectomy thrombocytosis Fazio VW, et al. Ann Surg1995 • Non-smoker Schmidt CM, et al. Ann Surg1998 LLoohhmmuulllleerrJJLL, eett aall. AAnnnn SSuurrgg11999900 • NSAIDs Fleshner P, et al. Gut2003 AchkarJP, et al. CGH2005 • Arthralgia Shen B, et al AJG2005 Meier CB, et al. IBDJ2005 • Male patients Shen B, et al, CGH 2006 Fleshner P, et al. CGH 2007 KoltunW, et al. DCR 2011 Tyler A, et al. Gut 2012 Wu XR, et al. ACG 2014 Management Algorithm in Our Pouch Center Symptomatic Pouch Patients Exclusion of Mechanical Compplications Inflammatory Disorders Cuffitis Pouchitis Crohn’s Disease MMiiccrroobbee-rreellaatteedd IImmmmuunnee-mmeeddiiaatteedd IIsscchheemmiiaa-rreellaatteedd ACG/LGS Regional Postgraduate Course - New Orleans, LA 8 Copyright 2014 American College of Gastroenterology Bo Shen, MD, FACG Management Algorithm in Our Pouch Center Symptomatic Pouch Patients Exclusion of Mechanical Compplications Inflammatory Disorders Cuffitis Pouchitis Crohn’s Disease MMiiccrroobbee-rreellaatteedd IImmmmuunnee-mmeeddiiaatteedd IIsscchheemmiiaa-rreellaatteedd Management Algorithm in Our Pouch Center Symptomatic Pouch Patients Exclusion of Mechanical Compplications Inflammatory Disorders Cuffitis Pouchitis Crohn’s Disease MMiiccrroobbee-rreellaatteedd IImmmmuunnee-mmeeddiiaatteedd IIsscchheemmiiaa-rreellaatteedd Dysbiosis Pathogens ACG/LGS Regional Postgraduate Course - New Orleans, LA 9 Copyright 2014 American College of Gastroenterology Bo Shen, MD, FACG Management Algorithm in Our Pouch Center Symptomatic Pouch Patients Exclusion of Mechanical Compplications Inflammatory Disorders Cuffitis Pouchitis Crohn’s Disease MMiiccrroobbee-rreellaatteedd IImmmmuunnee-mmeeddiiaatteedd IIsscchheemmiiaa-rreellaatteedd Dysbiosis Pathogens Dysbiosis-associated Pouchitis • Diarrhea • Urgency/seepage • Abdominal pain/cramp • NO – Fever, chills – Bleeding – Leukocytosis ACG/LGS Regional Postgraduate Course - New Orleans, LA 10 Copyright 2014 American College of Gastroenterology

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Managing Ileal Pouch-anal Anastomosis Patients with IBD PDF

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Publication Year:	2014
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Language:	English
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