Inflammatory pouch disease: The spectrum of pouchitis

Table 1 Classification of “pouchitis” according to the etiology

Idiopathic pouchitis

Secondary pouchitis

Infectious

Bacterial pathogens

Clostridium difficile, Campylobacter jejuni, Salmonella typhi, Escherichia coli, Klebsiella, Pseudomonas, others

Fungi: Candida

Viruses: CMV

Ischemic

NSAID-associated

Collagenous

Autoimmune-associated

Crohn’s disease-associated

Other diagnoses

Cuffitis

Irritable pouch syndrome

NSAID: Non-steroidal anti-inflammatory drug.

Table 2 The variety of idiopathic pouchitis classifications

Activity

Active

Inactive

Presentation

Acute < 4 wk duration

Chronic > 4 wk duration

Clinical pattern

Single episode

Infrequent < 4 episodes a year

Relapsing > 4 episodes a year

Continuous

Response to treatment

Responsive

Refractory

Response to antibiotics

Antibiotic-responsive:

Infrequent episodes (< 4 episodes per year) responding to a 2-wk course of a single antibiotic

Antibiotic-dependent

Frequent episodes or persistent episodes of pouchitis requiring long-term, continuous therapy for maintaining remission

Chronic antibiotic-refractory

Not responding to a 4-wk course of metronidazole or ciprofloxacin, requiring prolonged therapy of ≥ 4 wk consisting of 2 or more antibiotics, oral or topical 5-ASA, corticosteroids, AZA/6-MP, or biologics

Table 3 The pouchitis disease activity index

Criteria	Score
Clinical
Stool frequency
Usual postoperative stool frequency	0
1-2 stool⁄d > postoperative usual	1
3 or more stool⁄d > postoperative usual	2
Rectal bleeding
None or rare	0
Present daily	1
Fecal urgency or abdominal cramps
None	0
Occasional	1
Usual	2
Fever (temperature > 37.8 °C)
Absent	0
Present	1
Endoscopic findings
Edema	1
Granularity	1
Friability	1
Loss of vascular pattern	1
Mucous exudates	1
Ulceration	1
Histological findings - acute histological inflammation
Polymorphonuclear leucocyte infiltration
Mild	1
Moderate without crypt abscess	2
Severe with crypt abscess	3
Ulceration per low-power field (mean)
< 25%/25%-50%/> 50%	1/2/3
Total pouchitis disease activity index (max 18) pouchitis ≥ 7

Table 4 The pouchitis activity score

Criteria	Score
Clinical
Stool frequency/24 h: < 8/8-10/10-13/> 13	0/2/4/6
Urgency: absent/present	0/3
Rectal bleeding: absent/present	0/3
Endoscopic findings
Edema: absent/present	0/1
Granularity: absent/present	0/1
Friability: absent/mild/severe	0/1/2
Erythema: absent/mild/severe	0/2/3
Mucosal flattening: absent/present	0/2
Ulcerations/erosions: absent/mild/severe	0/2/3
Histological findings
Acute histological inflammation
Polymorphonuclear leucocyte infiltration	0/1/2/3
absent/discrete and patchy/moderate ± crypt abscesses or cryptitis/
extensive ± crypt abscesses or cryptitis
Ulcerations/erosions	0/1/2/3
absent/mild and superficial/moderate/extensive
Chronic histological inflammation
Polymorphonuclear leucocyte infiltration	0/1/2/3
absent/mild and patchy/moderate/extensive
Villous atrophy	0/1/2/3
absent/minimal/partial/subtotal-total
Total pouchitis activity score (max 36)
Pouchitis ≥ 13