P208 Prevalence of chronic peri-pouch sepsis in patients treated as primary idiopathic pouchitis
V. A. van der Ploeg1, Y. Maeda*1, O. D. Faiz1, A.L. Hart2, S. K. Clark1
1St Mark’s Hospital, Department of Surgery, Harrow, United Kingdom, 2St Mark’s Hospital, Department of Gastroenterology, Harrow, United Kingdom
Antibiotic-dependent/refractory primary idiopathic pouchitis (ADRP) is a significant clinical challenge. Ileo-anal pouch inflammation can also be caused by chronic peri-pouch sepsis (CPPS). Both may partially respond to empirical treatment with antibiotics. However, if a persistent pre-sacral collection is present, different treatment such as drainage may be more appropriate, and immunosuppressants and biologics should be avoided. This study aimed to identify the prevalence of CPPS in patients thought to have ADRP. The secondary aims were to identify any specific features on pouchoscopy suggesting CPPS and to evaluate outcomes of treatment for CPPS.
Records of patients who had been managed as ADRP over a period of 9 years were reviewed retrospectively. Only those with endoscopic evidence of inflammation and who had MRI were included. Pouchoscopy findings and outcomes of treatment for CPPS were evaluated.
In total, 68 patients were treated as ADRP between March 2006 and June 2015 (43 male [63%]). MRI pelvis showed a pre-sacral collection in 26 patients (38%). Median age at pouch formation was 33.5 years (range 16–64), and median time between pouch formation and first MRI pelvis was 6 years (range 0–32). No significant differences were found in gender, age at pouch formation, or time between pouch formation and first MRI pelvis between patients with and without a pre-sacral collection. Pouchoscopy identified ulcerative inflammation in the lower pouch in 13% of patients with a pre-sacral collection and in 26% without (p = 0.43).
Examination under anaesthesia was performed in 13 patients (50%) with a pre-sacral collection. In 5 (19%), a collection was identified and drained; symptoms improved in only 1 of these (4%). The collection was not drained in the other patients (because it was too small and was not thought to be contributing to inflammation). They remained on antibiotics (69%) or had their pouch defunctioned or excised (27%).
In patients thought to have ADRP, 38% had a pre-sacral collection on MRI. There was no specific feature on pouchoscopy suggestive of CPPS. The possibility of CPPS should be considered early in patients with recurrent or refractory pouchitis and MRI pelvis performed. This might lead to earlier detection of the collection and prompt appropriate treatment. However, prognosis is poor if a CPPS is present.