Pouch dysfunction, inflammation and failure

After ileoanal pouch surgery, pouch dysfunction can appear and is accompanied by a greater stool frequency, by difficulty in evacuating the pouch, or by abdominal pain, swelling or inflammation, as in the case described in this session. Nonspecific pouch inflammation is the most frequent long-term complication after pouch surgery in ulcerative colitis. The differential diagnosis of pouch inflammation can have three manifestations which, while infrequent, should not be overlooked: solitary pouch ulcer; the "anorectal paradox" which causes leaking and visible infection of the pouch; and pouch failure, defined as the removal of the pouch or the creation of a stoma for permanent discharge. This occurs in 5-10% of cases. The etiology of these symptoms is as yet unknown. A number of theories have been suggested, including intestinal stasis with bacterial overgrowth, mucosal ischemia, Crohn's disease and recurrent ulcerative colitis. In this session, the medical treatment for pouch infection is discussed based on possible pathogenic mechanisms. The theory that acute infection of the pouch may be due to intestinal stasis and bacterial overgrowth has led to the use of antibiotic treatment, which in the absence of controlled trials has become the standard treatment. Metronidazole is the most frequent initial treatment and most patients show a spectacular response in just the first few days of therapy. Other antibiotics have also been suggested such as ciprofloxacin, amoxicillin-clavulanic acid and tetracycline. Different alternative therapies have also been the subject of non-controlled clinical trials, and include corticosteroids, 5-aminosalicylic acid, immunosuppressants or short-chain fatty acid enemas, which have shown a clinical benefit. Recent data are also presented on the administration of probiotics in the treatment of this disease and in the maintenance of remission. The role of biofeedback is also discussed and in certain cases of overt prolapse, the insertion of a transabdominal pouch and pouch reconstruction.