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Clin Colon Rectal Surg 2022; 35(06): 475-486
DOI: 10.1055/s-0042-1758139
Review Article

Crohn's of the Pouch: Now What?

Tara M. Connelly
1   Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
,
Eddy Lincango
1   Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
,
Stefan D. Holubar
1   Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
› Author Affiliations Funding Crohn's and Colitis Foundation, American Society of Colon & Rectal Surgeons. All other authors have no financial disclosures.
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Abstract

Total proctocolectomy and ileal pouch anal anastomosis (IPAA) is the gold standard surgical treatment for the majority (∼90%) of ulcerative colitis (UC) patients. In cases of carefully selected Crohn's colitis patients without small bowel or perianal involvement an “intentional IPAA” may be a viable option for disease resection and restoration of intestinal continuity. More commonly, Crohn's is incidentally found either in the resection specimen or, more commonly, when inflammatory complications subsequently arise after pouch construction for UC or indeterminate colitis. These incidental Crohn's pouches may be diagnosed early or late period post-IPAA.

Crohn's may manifest within the pouch, in the proximal small bowel, and/or distally in the rectal cuff or anus. Like intestinal Crohn's, Crohn's disease of the pouch may be of an inflammatory, fibrostenosing, or fistulizing phenotype. Treatment depends on the phenotype and includes medical treatment, most commonly in the form of tumor necrosis factor inhibitor medications; however, the newer small molecules offer a potential treatment for these patients. Surgery first entails treating the sequelae of Crohn's and is typically staged. In up to 60% of Crohn's pouches, particularly in fistulizing disease and/or recalcitrant perianal disease, the pouch fails and must be defunctioned or excised. In patients with Crohn's pouches in situ long term, outcomes including quality of life are comparable to patients who underwent IPAA for UC.

Keywords

Crohn's colitis - ileal pouch anal anastomosis - inflammatory bowel disease - pouch revision

Abbreviations

ASCA – anti-Saccharomyces cerevisiae antibodies


CD – Crohn's disease


EIM – extra intestinal manifestation(s)


FDA – Food and Drug Administration


IBD – inflammatory bowel disease


IC – indeterminate colitis


Ig – immunoglobulin


IPAA - ileal pouch-anal anastomosis


IRA – ileorectal anastomosis


JAK – Janus kinase


OR – odds ratio


pANCA – anti-neutrophil cytoplasm antibodies


TNFi – tumor necrosis factor inhibitor


TPC – total proctocolectomy


SNP – single nucleotide polymorphism


UC – ulcerative colitis


Disclosures

S.D.H.: consulting fees: Shionogi, Takeda.




Publication History

Article published online:
08 November 2022

© 2022. Thieme. All rights reserved.

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