Is pouchitis a bacterial infection?

Humans tend to forget the many blessings in life even though many are indeed blessings in disguise. To have a healthy body that functions properly can help a person to have a fulfilling life and of course a happier one. However, not everyone might be lucky to have a healthy body all the time. They may need medicine to help with recovery.  Some may have problems with the digestive system that causes them to have surgery such as surgically-constructed pouches. One of the complications that could occur after this surgery is pouchitis.

Pouchitis is inflammation of the surgically-constructed pouch. The need for the pouch is often in patients with ulcerative colitis whose colon and rectum is removed. The construction of the pouch is made from a loop of small intestine and placed in the rectum. Such surgery is known as ileal pouch-anal anastomosis (IPAA) surgery. Pouchitis is the most common complication in patients with IPAA surgery accounting for up to 81%, with 40% of patients presented with pouchitis within the first year of surgery.

There are a number of risk factors that have been associated with development of pouchitis. This means that when a person has any of the risk factors, they are likely to get pouchitis. Risk factors include gene mutations, other health conditions such as rheumatologic disease and extensive ulcerative colitis and history of pre-colectomy anti-tumor necrosis factor uses.

It is not exactly understood how pouchitis happened. However, it is believed due to the changes in the gut microbiota. The construction of the ileal pouch creates a new and altered bowel anatomy. This then leads to faecal matter accumulating in the intestine. Since this is considered as something different by the body, it triggers an abnormal immune response and creates an environment supporting inflammation.

Thus, pouchitis itself can be considered as a bacterial infection. This is because changes in the gut microbiota may have favoured the growth of the bacteria that was once considered normal in the gut. The overgrowth bacteria then cause the symptoms of pouchitis in response to the inflammation process.

A person with pouchitis will have symptoms such as diarrhoea, increased bowel movement, abdominal cramping, faecal urgency (sudden need to empty the bowel), tenesmus (feeling of constantly the need pass stool) and incontinence (unintentional passing of urine). Some may feel unwell and have fever. Patients may have symptoms of iron-deficiency anaemia. Symptoms can last less than 4 weeks and this is known as acute pouchitis. Chronic pouchitis refers to symptoms that last more than 4 weeks. Patients with severe pouchitis occasionally presented with fever, dehydration and malnutrition.

Diagnosis of pouchitis is not made solely depending on the presenting symptoms. This is because symptoms may be caused by other diseases relating to the intestine. The severity of the symptoms does not simply reflect the severity of the inflammation to the pouch. Thus, doctors often combine assessment of symptoms and endoscopic with histologic features is ideal for diagnosing pouchitis. Imaging studies such as contrast pouchography, CT and MRI of the pelvis are typically used to assess within and around the pouch.

People with pouchitis are usually treated with a 2 week course of antibiotics. Most people do get better after taking antibiotics. However, 1 out of 10 people may not find relief from antibiotics. When a patient does not get better after the 2-week antibiotic course or has been sick for longer than 4 weeks, it can be a bit tricky to treat. Other agents apart from antibiotics such as steroid, immunomodulator and biologics agents such as vedolizumab and ustekinumab may be used in chronic pouchitis. Since microbiota changes are thought to be the important factors for development of pouchitis, studies have studied the role of faecal microbiota transplant (FMT) in treating chronic pouchitis. While FMT still not be recommended for medical management of chronic pouchitis, study is still undergoing as it promises to correct the microbiota altered by the ileal pouch.

Apart from medical treatments, patients need to take preventative measures to lessen the risk for developing pouchitis. Here are few common lifestyle modification that needs to be paid attention by patients:

  • Avoid smoking and secondhand smoker
  • Be careful of using pain relief, specifically oral nonsteroidal anti-inflammatory drugs (NSAIDs), though limited topical or oral NSAIDs are considered acceptable for occasional use as needed when other pain relief are ineffective
  • Eat more fruits and vegetables to improve microbial gut
  • Eat small, frequent meals focusing on lean protein, moderate carbohydrate and soluble fibre.
  • Avoid or limit high-fat food such as fried food and fatty meats.

It is worth noting that pouchitis may develop again as data shows more than half of people who initially recover from pouchitis, can have the pouchitis again. Some may need to have repeated courses of antibiotics. Some may even need to stay on long-term treatment even if they have recovered to try and prevent pouchitis from re-develop again.

It can be concluded that pouchitis is the most common complication of IPAA surgery. It can be considered as the latter of bacterial infection. Patients may have a wide range of symptoms with a variety of outcomes. Medical therapy for pouchitis typically starts with antibiotics. Lifestyle modifications may play a role in the development or management of pouchitis. Patients need to understand that both medical treatment and lifestyle changes can greatly help improve the outcome.

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