Patients with acute severe ulcerative colitis are more likely to develop pouchitis followed a total proctocolectomy with ileal pouch-anal anastomosis than patients who do not have acute severe ulcerative colitis.¹

A team, led by Maia Kayal, MD, MS, Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, calculated the likelihood of developing pouchitis for patients with acute severe ulcerative colitis following total proctocolectomy with ileal pouch-anal anastomosis.

How Common is it?

Up to 80% of patients develop pouchitis following a total proctocolectomy with ileal pouch-anal anastomosis. In the past this has been associated with microbial and host-related immunological factors.

“We hypothesized that a more robust immune response at the time of colectomy, manifested by acute severe ulcerative colitis (ASUC), may be associated with subsequent acute pouchitis,” the authors wrote.

The Study

In the retrospective cohort study, the investigators examined all patients with ulcerative colitis or indeterminate colitis complicated by medically refractory disease or dysplasia who underwent total proctocolectomy with ileal pouch-anal anastomosis at Mount Sinai Hospital between 2008-2017.

Each participant had at least 1 subsequent pouchoscopy.

The investigators defined acute pouchitis in accordance with the Pouchitis Disease Activity Index and assessed unadjusted relationships between hypothesized risk factors and acute pouchitis using Cox regression.

There were 416 patients that met the inclusion criteria, 39.7% (n = 165) of which underwent urgent colectomy, 46.7% (n = 77) were admitted with acute severe ulcerative colitis.

Results

The results show 54.8% (n = 228) developed acute pouchitis in a median of 1.3 years after the final surgical stage.

Acute severe ulcerative colitis (hazard ratio [HR], 1.50; 95% confidence interval [CI], 1.04-2.17) and a greater number of biologics precoloectomy (HR, 1.57; 95% CI, 1.06-2.31) were linked to an increased probability of acute pouchitis. On the other hand, older age at colectomy (HR, 0.98; 95% CI, 0.97-0.99) were associated with a decreased probability of acute pouchitis.

Finally, time to pouchitis was significantly less in patients admitted with acute severe ulcerative colitis compared to patients not (P= .002)

“A severe [ulcerative colitis] disease phenotype at the time of colectomy was associated with an increased probability of acute pouchitis,” the authors wrote.

Comparing Two Drugs

Recent research has indicated that cyclosporine fared better in the long-term than infliximab in patients with acute severe ulcerative colitis.

In the retrospective analysis, the investigators examined 121 patients admitted to a single gastroenterology center between 2010-2020 with acute severe ulcerative colitis, defined by the Truelove & Witts criteria. This included 119 patients who initially received intravenous corticosteroids and 2 patients who underwent an emergency colectomy on the first day.

The results show 55% (n = 66) of the patient population responded to intravenous corticosteroids and 45% (n = 53) failed to respond to steroid therapy. In addition, 37% (n = 45) of patients received second-line rescue therapy, 29 with cyclosporine, 16 with infliximab.

There was no significant difference between the 2 drugs in short-term efficacy.

During admission, colectomies were performed in 10.3% of the cyclosporine group, compared to 12.5% of the infliximab group (P = 0.826).

For the long-term efficacy analysis, the investigators found the difference was not statistically significant (10.3% vs. 31.2%, P = 0.079).

References:

Maia Kayal, MD MS, Hannah Posner, BS, Hadar Meringer Milwidsky, MD, Michael Plietz, MD, Sergey Khaitov, MD, Patricia Sylla, MD, Alexander Greenstein, MD MPH, Marla C Dubinsky, MD, Saurabh Mehandru, MD, Jean Frederic Colombel, MD, Acute Severe Ulcerative Colitis Is Associated With an Increased Risk of Acute Pouchitis, Inflammatory Bowel Diseases, 2023;, izad039, https://doi.org/10.1093/ibd/izad039