Search Results (29)

Background/Objectives: Indeterminate colitis (IC) is an erroneous diagnosis for predominantly colonic inflammatory bowel disease (IBD) when there is a non-definitive foundation of the benchmark for ulcerative colitis (UC) and Crohn’s colitis (CC) after a combined state-of-the-art classification system of clinical, endoscopic, radiologic, and histologic tools are used. This confounds an effective surgical regimen; specifically pouch surgery, “the restorative proctocolectomy with ileal pouch–anal anastomosis (PRC-IPAA)”. Transforming the distinction between UC and CC in otherwise IC into authentic UC and CC requires priority attention when considering a patient’s candidacy for RPC-IPAA. RPC-IPAA is the accepted standard curative surgical procedure in the treatment for UC (and Familial Adenomatous Polyposis (FAP)). Further, inapproximate/incorrect diagnosis and treatment can sustain potential long-term morbidity from inaccurate and unnecessary surgery and cost. Methods: In trying to resolve these diagnostic ambiguities, the current study advances our understanding by showing the expression of human alpha defensin 5 (DEFA5 alias HD5) restricted in the colon crypt mucosal lining areas, and by identifying the cells of the small intestine (ileum) “colonic ileal metaplasia” in CC that may serve as a biomarker to portray/ascertain authentic CC and UC among IC cohorts, with a positive predictive value (PPV) of 96 percent. Results: Hence, the imprecise diagnosis of IC largely would be circumvented. This new diagnostic tool offers instant tangible benefits over existing diagnostic pathways. The journey toward its widespread clinical use is now subject to logistical and regulatory defiance, which all emerging molecular diagnostic technologies inevitably encounter. Conclusions: The aim of this communication is to provide a summary of the currently available diagnostic advances relating to surgical management for IC in clinical settings, and the related challenges. Further, I briefly discuss aspects of its pathophysiology, surveillance, and diagnostic assay development. Full article

Background: Crohn’s disease (CD) is an inflammatory bowel disease (IBD) that is prevalent worldwide. It can affect any segment of the gastrointestinal tract, from the mouth to the anus. When CD affects the anus, perianal fistulizing disease develops. The management of perianal CD is challenging and may require morbid surgery when there is no response to medical therapy. The emergence of novel biologic therapies, namely tumor necrosis alpha (TNF-α) inhibitors, has proven to provide long-term relief and prevent disease-related complications. Perianal CD is, however, refractory or recurrent in up to 80% of patients. One of the reported options to manage perianal CD is hyperbaric oxygen therapy (HBOT), which aims at increasing tissue oxygen saturation in an attempt to promote repair and reverse local inflammation. Data on this approach is scant. Methods: A retrospective review was performed to identify patients with CD at the Mayo Clinic in Rochester who underwent HBOT for perianal disease between 2014 and 2023. Demographic and clinical data were reviewed, including the history of the disease, concomitant medical and surgical therapy and the need for fecal diversion. The HBOT regimen, including the number of sessions and clinical response, were reviewed. Results: Six patients aged from 19 to 60 years underwent HBOT for perianal CD. Two patients had a history of total proctocolectomy with ileal-anal pouch anastomosis (IPAA). All patients except one were on immunosuppressive medication including biologic agents. Four patients had fecal diversion with an ileostomy or colostomy. Patients received between 10 and 40 sessions of HBOT. Four patients reported symptomatic improvement. On physical examination and/or imaging assessment, improvement was noted in one patient. Progression of the perianal disease was noted in all other patients, with all except one requiring an operation in the following year. Conclusions: HBOT may provide symptomatic relief in some patients with refractory perianal CD, but data on its long-term efficacy remains limited. Full article

Background/Objectives: Anti-tumour necrosis factor (anti-TNF) medications were historically commonly prescribed as the first-line biologic treatment for chronic inflammatory pouch conditions. However, their use in these conditions is mainly based on retrospective studies of relatively small numbers of patients with short follow up periods. We aimed to describe the long-term outcomes of first-line anti-TNF therapy in a large, multi-centre, multi-national patient cohort with chronic inflammatory pouch conditions. Methods: This was an observational, retrospective, multi-centre, multi-national study. We included patients with chronic inflammatory pouch conditions initially treated with anti-TNF drugs infliximab (IFX) or adalimumab (ADA), who had a follow up of at least 1 year. The primary outcome was anti-TNF treatment persistence, defined as continuation of anti-TNF throughout the study period. The secondary outcome was pouch failure, defined by the need for a defunctioning ileostomy or pouch excision. Results: We recruited 98 patients with chronic inflammatory pouch conditions initially treated with anti-TNF medications—63 (64.3%) treated with IFX and 35 (35.7%) treated with ADA. Average follow up length was 94.2 months (±54.5). At the end of the study period only 22/98 (22.4%) patients were still on anti-TNF treatment. In those in whom the first-line anti-TNF was discontinued, the median time to discontinuation was 12.2 months (range 5.1–26.9 months). The most common cause for anti-TNF discontinuation was lack of efficacy despite adequate serum drug levels and absence of anti-drug antibody formation (30 patients, 30.6%). Loss of response due to anti-drug antibody formation was the cause for discontinuation in 18 patients (18.4%), while 12 patients (12.2%) stopped treatment because of adverse events or safety concerns. Out of the 76 patients discontinuing anti-TNF treatment, 34 (34.7% of the cohort) developed pouch failure, and 42 (42.8% of the cohort) are currently treated with a different medical therapy. Conclusions: First-line anti-TNF therapy for chronic pouch inflammatory conditions is associated with low long-term persistence rates. This is due to a combination of lack of efficacy and adverse events. A significant percentage of patients initially treated with anti-TNF therapy develop pouch failure. Full article

Background/Objectives: Ischemic colitis, typically caused by thrombosis or reduced blood flow in the inferior mesenteric artery, is the most common ischemic lesion at the colorectal level. This case contributes to existing knowledge by highlighting the rare co-occurrence of a thrombosed aortic aneurysm and ischemic colitis, pointing to a direct vascular etiology rather than a multifactorial or idiopathic cause. Methods: A thorough electronic search was conducted on PubMed to identify risk factors and etiological determinants of ischemic colitis. Results: We present the case of a 70-year-old male with diffuse abdominal pain and multiple cardiac comorbidities. A CT scan revealed aeroenteritis, aerocolia, fusiform aneurysmal dilation of the abdominal aorta (18 cm long, 7.3 cm in diameter, from below the renal arteries to the bifurcation), parietal thrombosis, a circulating lumen of 2.7 cm, and inferior mesenteric artery thrombosis. Intraoperatively, necrosis was found in the upper rectum, sigmoid colon, descending colon, and the middle third of the left transverse colon, with clear demarcation between healthy and necrotic tissue. A subtotal proctocolectomy with transverse colostomy was performed. Conclusions: This case highlights ischemic colitis as a vascular disorder, urging broader differential diagnosis when common causes are unclear. Timely imaging, a multidisciplinary approach, and attention to vascular risks are key to identifying rare causes like aneurysmal thrombosis. While thrombosed abdominal aortic aneurysms can cause mesenteric ischemia, their link to ischemic and ulcerative colitis is unique, emphasizing the importance of accurate risk assessment in treatment planning. Full article

Despite a combination of medical and surgical treatments, many patients with perianal Crohn’s disease (CD) continue to experience refractory disease, requiring proctectomy or proctocolectomy, with the creation of a permanent stoma. Although proctectomy is seen as an ultimate treatment aimed at effectively relieving debilitating symptoms and enhancing quality of life, many patients may still face long-term and chronic complications. This narrative review aims to provide an overview of the main complications that patients undergoing proctectomy for CD may experience throughout their lives. Relevant publications addressing complications of proctectomy for refractory perianal CD were searched in the Medline/PubMed, Embase, Cochrane, and LILACS databases. The main long-term complications that patients encounter are related to impaired perineal wound healing, stoma-related issues, sexual and urinary dysfunction, small bowel obstructions, and CD recurrence. These complications negatively affect the quality of life and frequently necessitate further treatment. Patients should receive preoperative counselling regarding the implications of these particular issues, and regular follow-up must be guaranteed to identify any problems early, allowing for prompt treatment. Full article

Backwash ileitis (BWI) refers to inflammation in the distal ileum in patients with extensive ulcerative colitis (UC) that is thought to be caused by a “reflux” or “backwash” of colonic contents. In the absence of well-defined diagnostic criteria for BWI, more recently, the term UC-associated ileitis was proposed in favor of the backwash theory, which questions the existence of backwash ileitis as a distinct disease-specific subset of patients. Moreover, distinguishing UC-associated BWI from terminal ileitis of Crohn’s disease or other conditions could be a diagnostic challenge and significantly affect treatment management. Therefore, clinical, endoscopic, histologic, and imagistic diagnostic features may aid in making this distinction. This literature review related to BWI outlines the hypothesis that the ileum may also become involved in UC as a primary manifestation of UC based on recent findings. This study also highlights the possibility that associated ileitis in UC patients may represent a potential risk factor for neoplasia, a positive association with primary sclerosing cholangitis, and a higher risk for the subsequent development of pouchitis after restorative proctocolectomy. It synthesizes recent key findings and highlights areas for further research. Full article

In today’s world, with its continuing advancements in genetics, the identification of Lynch syndrome (LS) increasingly relies on sophisticated genetic testing techniques. Most guidelines recommend a tailored surveillance program, as well as personalized prophylactic and therapeutic approaches, according to the type of dMMR gene mutation. Carriers of path_MLH1 and path_MSH2 genes have a higher risk of developing colorectal cancer (CRC), despite intensive colonoscopic surveillance. Conversely, carriers of path_MSH6 and path_PMS2 genes have a lower risk of developing CRC, which may be due to their lower penetrance and later age of onset. Thus, carriers of path_MLH1 or path_MSH2 would theoretically derive greater benefits from total colectomy, compared to low-risk carriers (path_MSH6 and path_PMS2), in which colonoscopic surveillance might achieve an efficient prophylaxis. Furthermore, regarding the risk of endometrial/ovarian cancer development, there is a global agreement to offer both hysterectomy and bilateral salpingo-oophorectomy to path_MLH1, path_MSH2 and path_MSH6 carriers after the age of 40. In patients with CRC, preoperative knowledge of the diagnosis of LS is of tremendous importance, due to the high risk of metachronous CRC. However, this risk depends on the type of dMMR gene mutation. For carriers of the high-risk variants (MLH1, MSH2 and EPCAM) who have already developed colon cancer, it is strongly recommended a subtotal or total colectomy is performed, while partial colectomy followed by endoscopic surveillance is an appropriate management approach to treat colon cancer in carriers of the low-risk variants (MSH6 and PMS2). On the other hand, extended surgery for index rectal cancer (such as total proctocolectomy) is less effective than extended surgery for index colon cancer from the point of view of metachronous CRC risk reduction, and is associated with a decreased quality of life. Full article

Acute severe ulcerative colitis (ASUC) often requires surgical intervention, such as proctocolectomy with ileal pouch–anal anastomosis (IPAA). While IPAA improves patient outcomes, it can be associated with pouchitis, a common and debilitating complication characterized by inflammation of the pouch. The development of pouchitis is closely linked to dysbiosis—an imbalance in the gut microbiota. Understanding the role of the microbiota in pouch health has spurred interest in probiotics as a therapeutic strategy. Probiotics represent a promising avenue in the management of pouchitis, offering a natural and targeted approach to improving outcomes for UC patients. This review explores the role of probiotics in the management of UC patients, with a specific focus on preventing and treating pouchitis. We compare the microbiota of healthy pouches to those with pouchitis, highlighting key microbial shifts linked to disease onset and discussing the growing evidence for probiotics as a prevention and therapeutic approach. Future directions should prioritize advancing research to optimize probiotic therapies and establish personalized approaches based on individual microbiome profiles, highlighting their significant potential as a promising treatment strategy for pouchitis. Full article

In managing ulcerative colitis (UC), anti-tumour necrosis factor (TNF) agents are among the primary choices. Evidence suggests anti-TNF does not significantly increase malignancy risk (apart from lymphoma and melanoma), though uncertainties persist due to inconsistent long-term data. Kaposi’s sarcoma (KS), induced by human herpesvirus type-8 (HHV-8), is a multifocal neoplasm linked to immunosuppressive therapies, primarily affecting the skin and gastrointestinal tract. KS cases during anti-TNF therapy for UC are anecdotal. We report a rare occurrence of KS in the setting of the long-term use of the standard maintenance dose of infliximab (initiated in 2010) in a 56-year-old male patient with UC diagnosed in 2001. The patient underwent restorative proctocolectomy with ileal J-pouch-anal anastomosis in 2002 and subsequently developed chronic antibiotic-dependent pouchitis. Given the secondary loss of response to infliximab, a switch to vedolizumab was performed. In April 2024, the patient reported the presence of a skin lesion on the right leg. Following surgery, a rhomboid-shaped skin area was removed, encompassing the irregular, greyish KS lesion. The histopathological analysis confirmed the diagnosis of patch-like KS. We continued vedolizumab due to its gut-selective profile. The patient is in clinical remission and under dermatological follow-up with no lesion recurrence. Full article

Background/Objectives: Restorative proctocolectomy with ileo-anal pouch anastomosis (IPAA) remains the preferred surgical treatment for ulcerative colitis (UC). However, complications like pouchitis can occur. This study aimed to describe patients who underwent IPAA for inflammatory bowel disease (IBD) at Padua Hospital from 2005 to 2023 and identify risk factors for pouchitis. Secondary objectives included evaluating the effectiveness of biological therapy in chronic antibiotic-refractory pouchitis (CARP), Crohn’s disease of the pouch (CDP), and Crohn’s-like inflammation of the pouch (CDLPI), and assessing risk factors for pouch failure. Methods: This retrospective, observational study included 109 patients whose data were collected from medical records. Univariate logistic regression was used to analyze associations between preoperative and postoperative factors and outcomes such as acute pouchitis and pouch failure. The effectiveness of biological therapy was assessed by measuring changes in the Pouchitis Disease Activity Index (PDAI) and the Modified Pouchitis Disease Activity Index (mPDAI) over a 12-month treatment period. Results: Univariate logistic regression revealed significant associations between preoperative extraintestinal manifestations (OR 3.569, 95% CI 1.240–10.720), previous diagnosis of Crohn’s disease (OR 10.675, 95% CI 1.265–90.089), and transmural inflammation at cross-sectional imaging before surgery (OR 3.453, 95% CI 1.193–9.991) with an acute pouchitis risk. Pouch failure was significantly associated with a previous diagnosis of Crohn’s disease (OR 9.500, 95% CI 1.821–49.571) and post-surgical fistulas (OR 41.597, 95% CI 4.022–430.172). Biological therapy led to a significant reduction in the PDAI score in patients with CARP, decreasing from a median of 10 to 4 (p = 0.006). Similarly, in patients with CDP or CDLPI, the mPDAI score was significantly reduced from a median of 9 to 1 (p = 0.034), with remission achieved in 5/6 (83.3%) of these patients. Conclusions: This study provides valuable insights into the management of IPAA patients and highlights the importance of early identification and treatment of risk factors for pouchitis and failure. Biological therapy demonstrated significant effectiveness in reducing disease activity in patients with CARP, CDP, and CDLPI, suggesting its role as a crucial component in managing these complications. Full article

Chronic pouchitis occurs in about 50% of patients undergoing a restorative proctocolectomy for ulcerative colitis. This affection represents a significant therapeutic challenge, particularly for symptomatic patients who do not respond to antibiotic treatments and biologic therapies. Several dietary approaches, including low FODMAP diets and the Mediterranean diet, have shown promising results in improving symptoms and disease burden. The rationale for dietary intervention lies in the reduction in inflammation and modulation of gut microbiota. However, conflicting results and methodological heterogeneity jeopardize the transition of these approaches from the field of research to clinical practice. Together with a nutritional approach, innovative methods of microbiota modulation, including probiotics and fecal microbiota transplantation, are emerging as safe and effective strategies in managing chronic pouchitis. This narrative review analyzes recent advancements in nutritional therapies and microbiota modulation as innovative and complementary approaches for managing chronic pouchitis. After examining microbiota modulation strategies, specifically the effectiveness of probiotics, prebiotics, and fecal microbiota transplantation in restoring microbial diversity and their potential role in alleviating symptoms, the review assesses the available clinical evidence concerning dietary interventions and their impact on gut microbiota. A comprehensive understanding of interventions aimed at modulating the microbiota is crucial for enhancing the effectiveness of conventional therapies. Such strategies may lead to significant improvements in patients’ quality of life and their perception of the disease. However, the variability in microbiota composition, the use of restrictive diets, and the lack of standardized methods for evaluating these interventions remain significant challenges. Future research is essential to improve our understanding of the underlying mechanisms and optimize clinical application. Full article

(1) Background: Familial adenomatous polyposis (FAP) is a hereditary condition characterized by the development of numerous adenomas in the large intestine, often necessitating colectomy due to an elevated risk of colorectal cancer. Despite surgical intervention, adenomas frequently recur, underscoring the importance of ongoing surveillance. This study evaluates the outcomes of a 12-year endoscopic follow-up after colectomy and gastrointestinal reconstruction for FAP. (2) Methods: A retrospective analysis was conducted on 41 FAP patients who underwent at least one postoperative endoscopic examination. Assessments of the pouch or rectum were performed every 12–18 months following ileorectal anastomosis and every 18–24 months after ileal pouch–anal anastomosis. Follow-up biopsies were assessed using the adopted Spigelman classification. (3) Results: Postoperative pathology revealed invasive colorectal cancer in three patients. Abdominoperineal resection was performed in two cases due to secondary invasive carcinoma, and one T1 tumor was radically removed with ESD. One patient underwent radical pouch excision following a nodal pelvic recurrence of rectal cancer. Over a 12-year observation period, the mean Spigelman score increased by 2 points, and the proportion of patients with low-grade polypoid lesions decreased. The quantity or size of polyps increased in 24 patients, decreased in 8 patients, and remained stable in 9 patients. In four patients, granular, laterally spreading tumors were discovered in the rectal stump. (4) Conclusions: Regular endoscopic surveillance in FAP patients facilitates early identification of neoplastic and inflammatory changes. The downstaging potential highlights the effectiveness of early interventions. While the Spigelman classification assessed polyps well, it did not predict cancer occurrence. A notable number of patients had invasive cancer at the time of surgery, underscoring the importance of early surgical qualification, which is particularly crucial for identifying upstaging or secondary cancer. Full article

Despite the decreased rates in inflammatory bowel disease (IBD) colectomies due to high advances in therapeutic options, a significant number of patients still require proctocolectomy with ileal pouch-anal anastomosis (IPPA) for ulcerative colitis (UC). Pouchitis is the most common complication in these patients, where up to 60% develop one episode of pouchitis in the first two years after UC surgery with IPAA with severe negative impact on their quality of life. Acute cases usually respond well to antibiotics, but 15% of patients will still develop a refractory disease that requires the initiation of advanced immunosuppressive therapies. For chronic idiopathic pouchitis, current recommendations suggest using the same therapeutic options as for IBD in terms of biologics and small molecules. However, the available data are limited regarding the effectiveness of different biologics or small molecules for the management of this condition, and all evidences arise from case series and small studies. Vedolizumab is the only biologic agent that has received approval for the treatment of adult patients with moderately to severely active chronic refractory pouchitis. Despite the fact that IBD treatment is rapidly evolving with the development of novel molecules, the presence of pouchitis represents an exclusion criterion in these trials. Recommendations for the approach of these conditions range from low to very low certainty of evidence, resulting from small randomized controlled trials and case series studies. The current review focuses on the therapeutic management of idiopathic pouchitis. Full article

Many patients undergo small bowel and colon surgery for reasons related to malignancy, inflammatory bowel disease (IBD), mesenteric ischemia, and other benign conditions, including post-operative adhesions, hernias, trauma, volvulus, or diverticula. Some patients arrive in the operating theatre severely malnourished due to an underlying disease, while others develop complications (e.g., anastomotic leaks, abscesses, or strictures) that induce a systemic inflammatory response that can increase their energy and protein requirements. Finally, anatomical and functional changes resulting from surgery can affect either nutritional status due to malabsorption or nutritional support (NS) pathways. The dietitian providing NS to these patients needs to understand the pathophysiology underlying these sequelae and collaborate with other professionals, including surgeons, internists, nurses, and pharmacists. The aim of this review is to provide an overview of the nutritional and metabolic consequences of different types of lower gastrointestinal surgery and the role of the dietitian in providing comprehensive patient care. This article reviews the effects of small bowel resection on macronutrient and micronutrient absorption, the effects of colectomies (e.g., ileocolectomy, low anterior resection, abdominoperineal resection, and proctocolectomy) that require special dietary considerations, nutritional considerations specific to ostomized patients, and clinical practice guidelines for caregivers of patients who have undergone a surgery for local and systemic complications of IBD. Finally, we highlight the valuable contribution of the dietitian in the challenging management of short bowel syndrome and intestinal failure. Full article

There is no clear evidence on the prevalence and clinical presentation of appendiceal mucinous neoplasm (AMN) among patients with inflammatory bowel disease (IBD), so a systematic review was performed to investigate the diagnosis, management and treatment of AMN in these patients. PubMed, Medline, Scopus and the Cochrane Library were searched for articles published up to September 2023. Twenty-three studies reporting data about 34 AMN patients were included. UC patients had a median age of 52 years and a median length of disease of 10 years; CD patients had a median age of 40.5 years and a median length of disease of 5 years. A pre-operative diagnosis was achieved in 44% of patients. Most patients were symptomatic (82.6%) and showed moderate–severe disease activity (61%). Surgical procedures were performed: laparoscopic appendectomy, ileocecal resection, right hemicolectomy and colectomy/proctocolectomy. Of the patients, 73.5% were diagnosed with low-grade mucinous neoplasm (LAMN) and nine with adenocarcinoma. Synchronous colorectal dysplasia/carcinoma was present in 23.5% of patients. IBD patients with long-standing disease should be routinely screened, not only for colorectal cancer but also for AMN, during gastro-enterologic follow-up. Laparoscopic appendectomy of unruptured LAMN as well as right hemicolectomy of non-metastatic adenocarcinoma are safe procedures in IBD patients. Full article