Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, 8730 Alden Drive, E225, Los Angeles, CA, 90048, USA.
The BRIDGe Group, The Alfred Hospital, Melbourne, VIC, Australia.
Dig Dis Sci. 2022 Oct;67(10):4687-4694. doi: 10.1007/s10620-021-07362-y. Epub 2022 Jan 10.
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.
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.
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.
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.
由于高质量研究的缺乏，慢性袋炎的治疗仍然是一个挑战。我们旨在为临床医生提供关于慢性袋炎的医学和手术治疗的适当性的指导。
在 16 种情况下考虑了慢性袋炎患者的医学和手术治疗的适当性，这些情况包括存在/不存在四个变量：袋炎症状、对抗生素的反应、显著的预袋回肠炎和克罗恩病（CD）样并发症（即狭窄或瘘管）。在另外 8 种情况下考虑了对药物治疗无反应的患者永久性回肠造口术的适当性。使用 RAND/UCLA 适当性方法，国际 IBD 专家小组成员根据 1-9 分制对每种情况下的治疗适当性进行评分。
慢性抗生素治疗仅在无症状的抗生素依赖患者且无 CD 样并发症的情况下被评为适当，而在所有其他情况下均为不适当。在有显著预袋回肠炎但无 CD 样并发症的 6/16 种情况下，给予回肠释放布地奈德的治疗被评为适当。益生菌被认为是不适当的（14/16）或不确定的（2/16）。生物治疗在大多数情况下被认为是适当的（14/16），在不存在显著预袋回肠炎或 CD 样并发症的情况下被认为是不确定的（2/16）。对于所有药物治疗无反应的患者，除了无症状且无 CD 样并发症的患者外，永久性回肠造口术被认为是适当的（7/8）。
在存在显著的预袋回肠炎或 CD 样并发症的情况下，慢性抗生素和益生菌是不适当的。生物制剂在所有患者中都是适当的，除了无症状且无并发症证据的患者外。在大多数药物难治性患者中，永久性回肠造口术是适当的。
