Functional Disorders of the Functional Disorders of the Ileal Pouch Ileal Pouch Bo Shen, MD Bo Shen, MD The Cleveland Clinic Foundation The Cleveland Clinic Foundation Cleveland, OH Cleveland, OH December 4, 2009 December 4, 2009 Imaging Quiz § IUD § IUD § Bladder stones § Bladder stones § Jewelry smuggler § Jewelry smuggler § Atherosclerotic plaques § Atherosclerotic plaques § ? § ? 1
Anatomy of Pelvic Pouches Anatomy of Pelvic Pouches “J” “S” “W” Afferent limb Afferent limb (neo-TI) (neo-TI) Inlet Inlet Tip of “J” Tip of “J” Efferent Efferent limb limb Outlet/cuff Outlet/cuff Efferent Efferent limb limb J, S, K Pouches vs. Ileostomy J, S, K Pouches vs. Ileostomy Brooke Ileostomy Brooke Ileostomy Kock Pouch Kock Pouch Pelvic J Pouch Pelvic J Pouch 2
Ileal Pouch Disorders and Associated Complications Ileal Pouch Disorders and Associated Complications Surgical/ Inflammatory/ Functional Dysplastic/ Systemic/ Mechanical Infectious Neoplastic Metabolic - Irritable - Irritable - Pouch/ATZ - Pouch/ATZ -Anemia -Anemia -Anastomotic leaks -Anastomotic leaks - Pouchitis - Pouchitis pouch syn. pouch syn. dysplasia dysplasia - Bone loss - Bone loss - Pelvic sepsis - Pelvic sepsis - Cuffitis - Cuffitis - Anismus - Anismus or cancer or cancer - B12 - B12 - Pouch sinuses - Pouch sinuses - Crohn’s dis. - Crohn’s dis. - Pouch inertia - Pouch inertia - Lymphoma - Lymphoma deficiency deficiency - Pouch fistulae - Pouch fistulae - Small - Small - Pseudo- - Pseudo- - Squamous - Squamous - Celiac dis? - Celiac dis? - Strictures - Strictures bowel bacterial bowel bacterial obstruction obstruction cell cancer cell cancer -Afferent limb syn. -Afferent limb syn. overgrowth overgrowth - Levator ani syn. - Levator ani syn. - Efferent limb syn. - Efferent limb syn. -Inflammatory -Inflammatory - “Pouchalgia” - “Pouchalgia” - Infecundity - Infecundity polyps polyps - Sexual - Sexual dysfunction dysfunction - Portal vein thrombi - Portal vein thrombi - Pouch prolapse - Pouch prolapse - Foreign bodies - Foreign bodies Practice Model in Pouch at Cleveland Clinic Practice Model in Pouch at Cleveland Clinic Pouch Pouch Pouchitis Pouchitis Database Database Database Database N 3500 1000 Established 1983 2002 Maintenance RNs MD Population All CCF CCF, non-CCF 3
Evolution of Pouchitis Clinic Anismus 0.2% Surg Refractory Pouchitis Cuffitis complication Nl pouch 10% 10% 7% 9% Active Pouchitis 21% Cuffitis Cuffitis 10% 13% IPS 18% Surg Complication 6% Pouchitis Functional Disease 50% IPS 0% Crohn's 43% IPS disease 20% Nl Pouch 18% 11% Active pouchitis 20% Crohn's Disease Refractory 21% pouchitis 13% N = 931 N = 931 N = 61 N = 61 N = 558 N = 558 IBD Pouches IBD Pouches 2002 2002 2007 2007 2009 2009 Disease Classification § Irritable pouch syndrome § Irritable pouch syndrome § GI-pouch inertia/pseudo-obstruction § GI-pouch inertia/pseudo-obstruction § Anismus § Anismus § Pouch prolapse § Pouch prolapse § Pouch-associated pain syndrome § Pouch-associated pain syndrome § “Pouchalgia fugax” § “Pouchalgia fugax” § Levator ani syndrome § Levator ani syndrome § Phantom pain § Phantom pain 4
Functional Pouch Disorders: Spectrum of Pathophysiological Processes HYPOMOTILITY/HY HYPOMOTILITY/HY HYPERMOTILITY HYPERMOTILITY PERSENSIVITY PERSENSIVITY (GI/pouch inertia, (GI/pouch inertia, MIXED MIXED (irritable pouch (irritable pouch Pseudo- Pseudo- syndrome) syndrome) obstruction) obstruction) Small bowel Small bowel Poucholgia Poucholgia Anismus bacterial bacterial Phantom Phantom growth growth Levator ani Levator ani pain pain syndrome syndrome Diagnostic Tools § Pouchoscopy § Pouchoscopy § Sugar breath test for small bowel bacterial § Sugar breath test for small bowel bacterial overgrowth? overgrowth? § Ano-pouch manometry § Ano-pouch manometry § KUB, small bowel series or CT enterography § KUB, small bowel series or CT enterography § Gastrograffin enemas § Gastrograffin enemas § Barium defecography § Barium defecography § MRI defecography § MRI defecography § Barostat? § Barostat? 5
Ano-pouch Manometry Upper Upper balloon balloon § Pouch volume § Pouch volume § Reflex § Reflex Lower Lower § Balloon expulsion § Balloon expulsion balloon balloon § Synergistic contraction § Synergistic contraction § Sphincter tune § Sphincter tune Upper Upper balloon balloon Lower Lower balloon balloon Pouch-pelvic Dyssynergia-Anismus Strain Strain Squeeze Squeeze 6
Barostat Barostat Anterior Pouchocele- Anterior Pouchocele- Gastrograffin Enema Gastrograffin Enema 7
Barium Defecography Barium Defecography Pouch Prolapse -MRI Defecography 8
Distal Pouch Prolapse Diagnostic Algorithm Diagnostic Algorithm Predominant Symptoms Predominant Symptoms Diarrhea Diarrhea Dyschezia Dyschezia Nausea Nausea Pain Pain Urgency Urgency Incomplete Incomplete Vomiting Vomiting Cramp Cramp Evacuation Evacuation Bloating Bloating Gastrograffin enema Gastrograffin enema KUB/SBS KUB/SBS Endoscopy probing Endoscopy probing Pouch endoscopy Pouch endoscopy MRI/Ba defecography MRI/Ba defecography CT enterography CT enterography Differential nerve block Differential nerve block Labs Labs Manometry Manometry Gastrograffin enema Gastrograffin enema Pouchitis Pouchitis Afferent Limb Syn. Afferent Limb Syn. SBBO SBBO Neuroma Neuroma Cuffitis Cuffitis Efferent Limb Syn. Efferent Limb Syn. Pouch Strictures Pouch Strictures Adhesions Adhesions Crohn’s dz Crohn’s dz Irritable Pouch Syn. Irritable Pouch Syn. GI Inertia GI Inertia Poucholgia Poucholgia Infectious Infectious Anismus Anismus Phantom Phantom Irritable Pouch Syn. Irritable Pouch Syn. Pouch Inertia Pouch Inertia 9
Management Algorithm Management Algorithm Predominant Symptoms Predominant Symptoms Diarrhea Diarrhea Dyschezia Dyschezia Nausea Nausea Pain Pain Urgency Urgency Incomplete Incomplete Vomiting Vomiting Cramp Cramp Evacuation Evacuation Bloating Bloating Anismus Anismus Poucholgia Poucholgia Irritable Pouch Syn. Irritable Pouch Syn. GI Inertia GI Inertia Pouch Inertia Pouch Inertia Phantom Phantom Medical Medical Biofeedback Biofeedback Miralax/Lactulose Miralax/Lactulose Albuterol Inhaler Albuterol Inhaler Therapy Therapy Surgery Surgery Surgery Surgery Neurotin/Lyrica Neurotin/Lyrica B & O suppository B & O suppository Nerve abalation Nerve abalation Irritable Pouch Syndrome 10
Irritable Pouch Syndrome Afferent-limb Pouch Rectal Cuff Pouch Mucosal Biopsy Differential Diagnosis- Those with Normal Pouch Endoscopy/Biopsy § Celiac disease § Celiac disease § Small bowel bacterial overgrowth § Small bowel bacterial overgrowth § Fructose intolerance § Fructose intolerance § Infectious diarrhea (Giardia, crypto) § Infectious diarrhea (Giardia, crypto) § Clostridium -associated pouchitis § Clostridium -associated pouchitis 11
Logistic Regression Model for Risk Factors N Variable OR (95% CI) P -value Colectomy for dysplasia 3.89 (1.69, 8.98) 0.001 NSAID use 3.24 (1.71, 6.13) 0.0003 Never smoked 5.09 (1.01, 25.69) 0.049 Pouchitis 61 Ex-smoker 0.44 (0.11, 1.80) 0.25 Arthralgia 1.01 (0.53, 1.92) 0.97 Non-use of anti-anxiety agents 5.19 (1.45, 18.59) 0.01 Duration of IPAA 1.20 (1.12, 1.30) < 0.0001 NSAID use 0.47 (0.21, 1.06) 0.068 Crohn’s Pouch 39 Current smoking 4.77 (1.39, 16.25) 0.01 Ex-smoker 0.67 (0.16, 2.80) 0.58 Cuffitis 41 Young Age 1.16 (1.01, 1.33) 0.04 Arthralgia 4.13 (1.91, 8.94) 0.0003 Irritable pouch 50 Anti-depressant use 4.17 (1.95, 8.92) 0.0002 syndrome Anti-anxiety agent use 3.21 (1.34, 7.47) 0.007 Shen B, et sl. CGH 2006 Comparison of Cleveland Global QOL Scores P < 0.05 1 Cleveland Global QOL (Scale 0-1.0) 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 Normal Cuffitis Pouchitis Irritable Irritable Pouch N = 7 N = 11 Pouch Bowel N = 14 Syndrome Syndrome N = 13 N = 10 Shen B, et al. DCR 2006 12
Comparison of IBS-QOL Scores P < 0.05 160 140 IBS-QOL (Scale 34-170) 120 100 80 60 40 20 0 Normal Cuffitis Pouchitis Irritable Irritable Pouch N = 7 N = 11 Pouch Bowel N = 14 Syndrome Syndrome N = 13 N = 10 Shen B, et al. DCR 2006 Pouch Tone Pouch Tone P > 0.05 P > 0.05 200 150 ml 100 50 0 30 min 30 min 10 min 10 min 10 min 10 min 30 min 30 min preprandial preprandial Preprandial Preprandial Postprandial Postprandial Postprandial Postprandial Normal Pouch Normal Pouch Irritable Pouch Syndrome Irritable Pouch Syndrome N = 11 N = 11 N = 8 N = 8 Shen B, Sanmagel C, Parsi M, et al DDW 2004 13
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