Dr Kayal, from the Icahn School of Medicine at Mt Sinai, discusses her presentation from Digestive Disease Week on complications of the pouch among patients who have undergone ileal pouch anal anastamosis.

Maia Kayal, MD, is an assistant professor in the Division of Gastroenterology at the Icahn School of Medicine at Mt Sinai in New York, New York.

TRANSCRIPT:

Hello, my name is Dr. Maia Kayal and I'm an assistant professor at the Icahn School of Medicine in NewYork City. I'm presenting to you today live from DDW 2023. I spent an afternoon yesterday presenting during the IBD Difficult Topic Session where I talked about our approach and our understanding of inflammatory and functional pouch disorders.

Despite our improvements in medical therapy, still about 10 to 15% of patients with ulcerative colitis will require surgery for medically refractory disease or dysplasia. The typical expectations after pouch surgery include 6 to 8 bowel movements per day with thick or cords-like consistency. Unfortunately, many of our patients do develop pouch disorders after surgery, and the symptoms of these disorders include increased stool frequency, urgency, bleeding, pelvic discomfort, or evacuatory disorders where there is incomplete evacuation or chronic passive passage of stool. We know that about 80% of our patients with ulcerative colitis will develop acute pouchitis. And the typical treatment for acute pouchitis is antibiotics because pouchitis seems to be very much a microbially-driven disease.        

Now, about 20% of these patients progress to chronic pouchitis, and this is a wide phenotype that includes antibiotic-dependent disease and antibiotic-refractory disease, and Crohn's disease-like pouch inflammation. And for these patients, you can either consider continuous low-dose antibiotics for those that are chronic antibiotic dependent, or you can consider biologic therapy for patients who have antibiotic refractory disease or Crohn's disease-like pouch inflammation.

There's been no true comparative effectiveness studies for biologic use in patients who have antibiotic refractory disease or Crohn's disease-like pouch inflammation. But we saw the recent presentation of the EARNEST trial in the New England Journal of Medicine in March, which showed and studied the use of vedolizumab for patients with chronic pouchitis. This was shown to be significantly better than placebo for achieving clinical and endoscopic responses. So this is one of the first signals that we have for biologic therapy in patients with chronic pouchitis.        

During my presentation, we also reviewed the much less understood functional pouch disorders. This includes things like dyssynergic defecation, when patients have significant issues with straining and incomplete evacuation. It also includes fecal incontinence, which is characterized by chronic passive stool passage. It also includes irritable pouch syndrome and pouchalgia fugax, which is similar to proctalgia fugax, where patients have recurrent episodes of anal pouch pain that is separated by episodes of no pain.        

We discussed our approach to these patients and for patients who have defecatory disorders such as dyssynergic defecation or fecal incontinence, anal pouch manometry is recommended. But it's important to understand that anal pouch manometry alone is an imperfect assessment of pouch function. Many of these patients should have confirmatory dynamic imaging with either an MR defecography or barium defecography. We spoke a lot about how up to 75% of our patients will have functional pouch disorders, and it's important to make this diagnosis early by doing a thorough history of physical and medication review as many of these symptoms might be iatrogenic.

The final important note that we talked about was that any patient who's presenting with symptoms within the first 12 months of surgery, these symptoms are likely related to surgical complications from their pouch surgery rather than a new diagnosis of inflammatory or functional pouch disorder. So it's important to approach these patients with a multidisciplinary lens, incorporating the use of your nutritionist and your surgeons and your dieticians, including your pharmacist as well, to really approach the patient in a very multidisciplinary way. Thank you.