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• W3136647127 abstract "Approximately 10%–15% of patients with ulcerative colitis require surgery because of medically refractory disease or dysplasia, the most common of which is the total proctocolectomy with ileal pouch-anal anastomosis.1Fumery M. Singh S. Dulai P.S. et al.Natural history of adult ulcerative colitis in population-based cohorts: a systematic review.Clin Gastroenterol Hepatol. 2018; 16: 343-356Abstract Full Text Full Text PDF PubMed Scopus (133) Google Scholar Since 1980, the J-pouch has revolutionized the lives of thousands of patients, providing restoration of intestinal continuity and avoidance of a permanent end ileostomy. Unfortunately, pouchitis is common after surgery with cumulative incidence rates of 50% at 2 years.2Barnes E.L. Herfarth H.H. Kappelman M.D. et al.Incidence, risk factors, and outcomes of pouchitis and pouch-related complications in patients with ulcerative colitis.Clin Gastroenterol Hepatol. 2020 2020/06/26; https://doi.org/10.1016/j.cgh.2020.06.035Abstract Full Text Full Text PDF Scopus (6) Google Scholar,3Kayal M. Plietz M. Rizvi A. et al.Inflammatory pouch conditions are common after ileal pouch anal anastomosis in ulcerative colitis patients.Inflamm Bowel Dis. 2020; 26: 1079-1086Crossref PubMed Scopus (12) Google Scholar There are no currently approved medications for pouchitis, and drug development has been hampered in part because of the lack of validated instruments that reliably measure pouchitis disease activity and response to therapy. It has been more than 40 years since the inception of the J-pouch and yet there is still no consensus on the clinical or endoscopic features of pouchitis. The most commonly used pouchitis classification measures are the Pouchitis Disease Activity Index (PDAI) and the Heidelberg Pouchitis Activity Score (PAS). Developed in 1994, the PDAI defines pouchitis by a composite of clinical, endoscopic, and histologic scores. The clinical components of the PDAI include stool frequency, rectal bleeding, fecal urgency, and fever scored as a continuum of severity relative to each patient’s baseline. The endoscopic features include edema, granularity, friability, loss of vascular pattern, mucoid exudate, and ulceration, and the histologic features include polymorphonuclear leukocyte infiltration and ulceration.4Sandborn W.J. Tremaine W.J. Batts K.P. et al.Pouchitis after ileal pouch-anal anastomosis: a Pouchitis Disease Activity Index.Mayo Clin Proc. 1994; 69: 409-415Abstract Full Text Full Text PDF PubMed Scopus (564) Google Scholar Developed in 2001, the PAS differs slightly from the PDAI with its inclusion of histologic chronic inflammation and exclusion of fever.4Sandborn W.J. Tremaine W.J. Batts K.P. et al.Pouchitis after ileal pouch-anal anastomosis: a Pouchitis Disease Activity Index.Mayo Clin Proc. 1994; 69: 409-415Abstract Full Text Full Text PDF PubMed Scopus (564) Google Scholar,5Heuschen U.A. Autschbach F. Allemeyer E.H. et al.Long-term follow-up after ileoanal pouch procedure: algorithm for diagnosis, classification, and management of pouchitis.Dis Colon Rectum. 2001; 44: 487-499Crossref PubMed Scopus (124) Google Scholar The PDAI and PAS have become the standards for pouch disease activity assessment, yet neither is fully validated and both have significant limitations. Their clinical components correlate poorly with endoscopic and histologic features, raising concern they do not accurately identify patients with pouchitis. In addition, the endoscopic features in each index are not standardized descriptors of disease activity and with the exception of ulcerations, have been shown to have only moderate reliability.6Samaan M.A. Shen B. Mosli M.H. et al.Reliability among central readers in the evaluation of endoscopic disease activity in pouchitis.Gastrointest Endosc. 2018; 88: 360-369Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar Finally, neither offers a validated definition for remission or response, nor provides insight into the long-term implications of endoscopic or histologic findings.6Samaan M.A. Shen B. Mosli M.H. et al.Reliability among central readers in the evaluation of endoscopic disease activity in pouchitis.Gastrointest Endosc. 2018; 88: 360-369Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar, 7Heuschen U.A. Allemeyer E.H. Hinz U. et al.Diagnosing pouchitis: comparative validation of two scoring systems in routine follow-up.Dis Colon Rectum. 2002; 45: 776-786Crossref PubMed Scopus (68) Google Scholar, 8Ben-Bassat O. Tyler A.D. Xu W. et al.Ileal pouch symptoms do not correlate with inflammation of the pouch.Clin Gastroenterol Hepatol. 2014; 12: 831-837Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar In this issue of Clinical Gastroenterology and Hepatology, Akiyama et al9Akiyama S. Ollech J. Rai V. et al.Endoscopic phenotype of the J pouch in patients with inflammatory bowel disease: new classification for pouch outcomes.Clin Gastroenterol Hepatol. 2021; Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar propose an impressive new classification for pouchitis based purely on endoscopic phenotype. In this retrospective cohort, the investigators reviewed 1359 pouchoscopies from 426 patients who underwent total proctocolectomy with ileal pouch-anal anastomosis at the University of Chicago between June 1997 and December 2019. The mean follow-up for all patients was 10.9 years. Each pouchoscopy was individually reviewed and endoscopic findings of inflammation were reported as erythema/edema, erosions/friability, ulceration, stenosis, granularity, and loss of vascular pattern in each anatomic segment. Findings were synthesized in the Chicago Classification of Pouchitis as: (1) normal, (2) afferent limb involvement, (3) inlet involvement, (4) diffuse, (5) focal inflammation of the pouch body, (6) cuffitis, and (7) fistula greater than 6 months after final surgical stage. Clinical factors associated with each phenotype were assessed by logistic regression. The 20-year pouch survival rate for all patients was 81.1%. Afferent limb involvement was significantly associated with body mass index ≥25 and handsewn anastomosis, inlet involvement with male gender, diffuse inflammation with extensive colitis and preoperative anti–tumor necrosis factor use, cuffitis with stapled anastomosis and preoperative Clostridoides difficile infection, and fistulae with preoperative Crohn’s disease. Most patients (35.9%) had at least 1 phenotype and 23.2% had 2 phenotypes, 21.9% 3 phenotypes, and 19.0% more than 3 phenotypes. The most common combination of phenotypes was afferent limb and inlet involvement, and patients with more than 3 phenotypes were at significantly increased risk of pouch excision. Diffuse inflammation, cuffitis, and inlet stenosis were significantly associated with pouch excision, and diffuse inflammation was independently associated with pouch excision in multivariable models (hazard ratio, 2.69; 95% confidence interval, 1.34–5.41). The Chicago Classification of Pouchitis is a significant step toward the refinement of pouchitis assessment. The association of endoscopic pouch phenotype with prognosis delivers the long-term clinical implications that are currently lacking in the PDAI and PAS. Clinical application of the Chicago Classification of Pouchitis may allow for post–ileal pouch-anal anastomosis prognostication and the identification of patients who warrant close surveillance. The introduction of a pouchitis classification based purely on endoscopic phenotype, however, raises important questions to be addressed in future studies. First, what are the anatomic pouch segments that need to be assessed? Akiyama et al9Akiyama S. Ollech J. Rai V. et al.Endoscopic phenotype of the J pouch in patients with inflammatory bowel disease: new classification for pouch outcomes.Clin Gastroenterol Hepatol. 2021; Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar delineated the segments of the pouch as the afferent limb, inlet, pouch body, and cuff, yet excluded other important landmarks that should be evaluated, such as the tip of the “J,” the efferent limb, and outlet.10Shen B. Pouchitis: what every gastroenterologist needs to know.Clin Gastroenterol Hepatol. 2013; 11: 1538-1549Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar,11Quinn K.P. Lightner A.L. Faubion W.A. et al.A comprehensive approach to pouch disorders.Inflamm Bowel Dis. 2019; 25: 460-471Crossref PubMed Scopus (13) Google Scholar Second, should the cuff be included in pouchitis classification? The cuff is residual rectum intentionally spared intraoperatively to construct the stapled anastomosis. Symptoms of cuffitis may overlap with those of pouchitis, and cuffitis has been shown to be associated with pouch failure.3Kayal M. Plietz M. Rizvi A. et al.Inflammatory pouch conditions are common after ileal pouch anal anastomosis in ulcerative colitis patients.Inflamm Bowel Dis. 2020; 26: 1079-1086Crossref PubMed Scopus (12) Google Scholar Yet, the treatment of cuffitis is distinct from that of pouchitis and more closely resembles the treatment of proctitis. In light of this, perhaps measures of disease activity of the pouch and cuff should be distinct but simultaneously reported. Third, what are the elementary endoscopic lesions that should be included in pouchitis classification? Akiyama et al9Akiyama S. Ollech J. Rai V. et al.Endoscopic phenotype of the J pouch in patients with inflammatory bowel disease: new classification for pouch outcomes.Clin Gastroenterol Hepatol. 2021; Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar characterized inflammation according to the endoscopic criteria of the PDAI and PAS; however, with the exception of ulcerations, reliability among these measures is only moderate and their long-term implications are not known.6Samaan M.A. Shen B. Mosli M.H. et al.Reliability among central readers in the evaluation of endoscopic disease activity in pouchitis.Gastrointest Endosc. 2018; 88: 360-369Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar,12Kayal M. Plietz M. Radcliffe M. et al.Endoscopic activity in asymptomatic patients with an ileal pouch is associated with an increased risk of pouchitis.Aliment Pharmacol Ther. 2019; 50: 1189-1194Crossref PubMed Scopus (14) Google Scholar Given the theorized similarity between pouchitis and Crohn’s disease, the use of Crohn’s disease endoscopic index of severity features, such as ulcer size, percent of ulcerated surface, and percent of affected surface, may be more appropriate. Fourth, how should endoscopic response and remission in the pouch be defined? Different thresholds have been used for each and there are no standardized definitions with long-term clinical implications. Endoscopic response has been defined loosely as a greater than 2-point or 50% decrease in the PDAI endoscopic subscore but also as a general decrease in the severity of ulcers and erosions.3Kayal M. Plietz M. Rizvi A. et al.Inflammatory pouch conditions are common after ileal pouch anal anastomosis in ulcerative colitis patients.Inflamm Bowel Dis. 2020; 26: 1079-1086Crossref PubMed Scopus (12) Google Scholar,13Weaver K.N. Gregory M. Syal G. et al.Ustekinumab is effective for the treatment of Crohn's disease of the pouch in a multicenter cohort.Inflamm Bowel Dis. 2019; 25: 767-774Crossref PubMed Scopus (33) Google Scholar Endoscopic remission likewise has been defined with wide variation, described at times as complete normalization of the PDAI endoscopic subscore and others as absence of previously identified mucosal breaks.13Weaver K.N. Gregory M. Syal G. et al.Ustekinumab is effective for the treatment of Crohn's disease of the pouch in a multicenter cohort.Inflamm Bowel Dis. 2019; 25: 767-774Crossref PubMed Scopus (33) Google Scholar,14Ollech J.E. Rubin D.T. Glick L. et al.Ustekinumab is effective for the treatment of chronic antibiotic-refractory pouchitis.Dig Dis Sci. 2019; 64: 3596-3601Crossref PubMed Scopus (22) Google Scholar Clear threshold values of endoscopic response and remission that can be used in clinical trials and clinical practice, and are predictive of favorable outcomes, are needed. It is long past time for the development of an objective, reliable, and clinically relevant endoscopic classification for pouchitis and cuffitis. Consensus processes using robust methodology to establish clinical, endoscopic, and histologic criteria for pouchitis are ongoing and novel instruments for disease activity assessment are forthcoming. Still, there is significant uncertainty regarding the clinical relevance of these criteria and prospective studies are needed to validate these instruments. The Chicago Classification of Pouchitis is a welcome step toward standardized endoscopic assessment of pouchitis, yet much work remains." @default.
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• W3136647127 date "2022-02-01" @default.
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• W3136647127 title "The Chicago Classification of Pouchitis: An Important Step Toward a Needed Consensus" @default.
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