Gaurav Syal1, Miles P Sparrow2, Fernando Velayos3, Adam S Cheifetz4, Shane Devlin5, Peter M Irving6, Gilaad G Kaplan5, Laura E Raffals7, Thomas Ullman8, Krisztina B Gecse9, Phillip R Fleshner10, Amy L Lightner11, Corey A Siegel12, Gil Y Melmed13. 1. Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, 8730 Alden Drive, E225, Los Angeles, CA, 90048, USA. gaurav.syal@cshs.org. 2. The BRIDGe Group, The Alfred Hospital, Melbourne, VIC, Australia. 3. The BRIDGe Group, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA. 4. The BRIDGe Group, Beth Israel Deaconess Medical Center, Boston, MA, USA. 5. The BRIDGe Group, University of Calgary, Calgary, AB, Canada. 6. The BRIDGe Group, Guy's and St. Thomas' Hospitals, London, UK. 7. The BRIDGe Group, Mayo Clinic, Rochester, MN, USA. 8. Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA. 9. Amsterdam University Medical Center, Amsterdam, Netherlands. 10. Cedars Sinai Medical Center, Los Angeles, CA, USA. 11. Cleveland Clinic, Cleveland, OH, USA. 12. The BRIDGe Group, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA. 13. The BRIDGe Group, Cedars Sinai Medical Center, Los Angeles, CA, USA.
Abstract
BACKGROUND AND AIMS: The treatment of chronic pouchitis remains a challenge due to the paucity of high-quality studies. We aimed to provide guidance for clinicians on the appropriateness of medical and surgical treatments in chronic pouchitis. METHODS: Appropriateness of medical and surgical treatments in patients with chronic pouchitis was considered in 16 scenarios incorporating presence/absence of four variables: pouchitis symptoms, response to antibiotics, significant prepouch ileitis, and Crohn's disease (CD)-like complications (i.e., stricture or fistula). Appropriateness of permanent ileostomy in patients refractory to medical treatments was considered in eight additional scenarios. Using the RAND/UCLA appropriateness method, international IBD expert panelists rated appropriateness of treatments in each scenario on a 1-9 scale. RESULTS: Chronic antibiotic therapy was rated appropriate only in asymptomatic antibiotic-dependent patients with no CD-like complications and inappropriate in all other scenarios. Ileal-release budesonide was rated appropriate in 6/16 scenarios including patients with significant prepouch ileitis but no CD-like complications. Probiotics were considered either inappropriate (14/16) or uncertain (2/16). Biologic therapy was considered appropriate in most scenarios (14/16) and uncertain in situations where significant prepouch ileitis or CD-like complications were absent (2/16). In patients who are refractory to all medications, permanent ileostomy was considered appropriate in all scenarios (7/8) except in asymptomatic patients with no CD-like complications. CONCLUSIONS: In the presence of significant prepouch ileitis or CD-like complications, chronic antibiotics and probiotics are inappropriate. Biologics are appropriate in all patients except in asymptomatic patients with no evidence of complications. Permanent ileostomy is appropriate in most medically refractory patients.
BACKGROUND AND AIMS: The treatment of chronic pouchitis remains a challenge due to the paucity of high-quality studies. We aimed to provide guidance for clinicians on the appropriateness of medical and surgical treatments in chronic pouchitis. METHODS: Appropriateness of medical and surgical treatments in patients with chronic pouchitis was considered in 16 scenarios incorporating presence/absence of four variables: pouchitis symptoms, response to antibiotics, significant prepouch ileitis, and Crohn's disease (CD)-like complications (i.e., stricture or fistula). Appropriateness of permanent ileostomy in patients refractory to medical treatments was considered in eight additional scenarios. Using the RAND/UCLA appropriateness method, international IBD expert panelists rated appropriateness of treatments in each scenario on a 1-9 scale. RESULTS: Chronic antibiotic therapy was rated appropriate only in asymptomatic antibiotic-dependent patients with no CD-like complications and inappropriate in all other scenarios. Ileal-release budesonide was rated appropriate in 6/16 scenarios including patients with significant prepouch ileitis but no CD-like complications. Probiotics were considered either inappropriate (14/16) or uncertain (2/16). Biologic therapy was considered appropriate in most scenarios (14/16) and uncertain in situations where significant prepouch ileitis or CD-like complications were absent (2/16). In patients who are refractory to all medications, permanent ileostomy was considered appropriate in all scenarios (7/8) except in asymptomatic patients with no CD-like complications. CONCLUSIONS: In the presence of significant prepouch ileitis or CD-like complications, chronic antibiotics and probiotics are inappropriate. Biologics are appropriate in all patients except in asymptomatic patients with no evidence of complications. Permanent ileostomy is appropriate in most medically refractory patients.
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