R. J. Nicholls

Review article: faecal transplantation therapy for gastrointestinal disease.

Aliment Pharmacol Ther 2011; 34: 409–415

Review article: restorative proctocolectomy, indications, management of complications and follow-up - a guide for gastroenterologists

Background  Restorative proctocolectomy with ileal pouch‐anal anastomosis is the procedure of choice for the majority of patients with ulcerative colitis who require surgery. Over 2500 patients in the UK have undergone restorative proctocolectomy. It is now increasingly being performed in district general hospitals as well as in specialist inflammatory bowel disease units. Gastroenterologists are increasingly involved in the management of patients following restorative proctocolectomy.

Nationwide linkage analysis in Scotland implicates age as the critical overall determinant of mortality in ulcerative colitis

Aliment Pharmacol Ther 31, 1310–1321

Etiology of pouchitis

Abstract: Restorative proctocolectomy with ileal‐pouch anal anastomosis (RPC) is the operation of choice for ulcerative colitis (UC) patients requiring surgery. It is also used for patients with familial adenomatous polyposis (FAP). Pouchitis accounts for 10% of pouch failures. It is an idiopathic inflammatory condition that may occur in up to 50% of patients after RPC for UC. It is rarely seen in FAP patients after RPC. The etiology of pouchitis remains unclear. An overlap with UC is suggested by the frequency with which pouchitis affects patients with UC compared with FAP patients. There is significant clinical evidence implicating bacteria in the pathogenesis of pouchitis. Studies using culture and molecular methods demonstrate a dysbiosis of the pouch microbiota in pouchitis. Risk factors, genetic associations, and serological markers of pouchitis suggest that the interactions between the host immune responses and the pouch microbiota underlie the etiology of this idiopathic inflammatory condition. Here we present a detailed review of the data focusing on the pouch microbiota and the immune responses that support this hypothesis. We also discuss the contribution of luminal metabolic factors and the epithelial membrane in the etiology of this inflammatory process. The ileoanal pouch offers a unique opportunity to study the inter‐relationships between the gut microbiota and host immune responses from before the onset of disease. For this reason the study of pouchitis could serve as a human model that significantly enhances our understanding of inflammatory bowel diseases in general. (Inflamm Bowel Dis 2012;)

A systematic review and meta-analysis of laparoscopic vs open restorative proctocolectomy.

The benefits of a laparoscopic approach to restorative proctocolectomy (RPC) are controversial. The aim of this meta‐analysis was to compare the outcome following laparoscopic and open RPC, with particular attention to adverse events and long‐term function.

The bacterial pathogenesis and treatment of pouchitis

Restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis is the operation of choice for patients with ulcerative colitis. Pouchitis is the most common cause of pouch dysfunction. Although the pathogenesis of this disease is not well understood, bacteria have been implicated in the disease process. Numerous bacterial studies have been reported over the last 25 years with few unifying findings. In addition, many different treatments for pouchitis have been reported with varying results. Antibiotic treatment remains the most studied and is the mainstay of treatment. In this article we review the aetiology of pouchitis and the evidenced-based treatment options.

An open study of antibiotics for the treatment of pre‐pouch ileitis following restorative proctocolectomy with ileal pouch–anal anastomosis

Background  Pre‐pouch ileitis is a recently described condition which may occur following restorative proctocolectomy. Its aetiology remains unknown and only one study has reported the effect of treatment. We report a series of fourteen patients treated and followed up with repeat pouchoscopy.

Exclusive elemental diet impacts on the gastrointestinal microbiota and improves symptoms in patients with chronic pouchitis.

BACKGROUND Treatment resistant chronic pouchitis causes significant morbidity. Elemental diet is effective treatment for Crohns disease. Since pouchitis shares some similarities to Crohns disease we hypothesised that elemental diet may be an effective treatment. METHOD Seven pouchitis patients (with ulcerative colitis) were studied. All had active pouchitis with a pouch disease activity index (PDAI) ≥7. Exclusion criteria were recent NSAIDs, antibiotics or probiotics. Sufficient elemental diet to achieve energy requirements was provided. Flexible-pouchoscopy was performed, and the Cleveland Global Quality of Life score (CGQoL), Pouch Disease Activity Index (PDAI) and BMI were recorded at baseline and following 28 days of elemental diet. Faecal samples were also collected at these time points and analysed for major bacterial groups using culture independent fluorescence in situ hybridisation. Data were analysed using Wilcoxons signed-rank test. RESULTS Following 28 days of exclusive elemental diet, median stool frequency decreased from 12 to 6 per day (p=0.028), median clinical PDAI decreased from 4 to 1 (p=0.039). There was no significant difference in quality of life scores or PDAI before and following treatment. There was a trend towards an increase in the concentration of Clostridium coccoides-Eubacterium rectale (median 7.9 to 8.5 log₁₀/g, p=0.08) following exclusive elemental diet. CONCLUSION Treatment with four weeks elemental diet appeared to improve the symptoms of chronic pouchitis in some patients but is not an effective strategy for inducing remission. Although a potential symptom modifier, elemental diet cannot be recommended for the routine treatment of active pouchitis.

Restorative proctocolectomy for ulcerative colitis: development and validation of a new scoring system for pouch dysfunction and quality of life

The purpose of this study was to develop and validate a pouch dysfunction score that could identify the aspects of function which have the greatest impact on quality of life as perceived by the patient.

An open study of maintenance antibiotic therapy for chronic antibiotic-dependent pouchitis: efficacy, complications and outcome

Aim  About 5% of restorative proctocolectomy (RPC) patients develop chronic antibiotic‐dependent pouchitis. These require antibiotic maintenance therapy. We report our experience in managing this patient group.