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Background: A perforating phenotype is associated with an increased postoperative morbidity in patients with Crohn's disease undergoing ileocolic resection. Sequential conservative treatment attempts applied to patients with unrecognized perforating complications may lead to a delay of surgery and a further increase in morbidity., Methods: In all, 197 patients underwent 231 bowel resections for perforating ileitis between 1992 and 2009. The duration or clinical deterioration was calculated from the onset of clinical exacerbation unresponsive to any medical treatment to the date of surgery., Results: The median duration of clinical deterioration leading to surgery was 5 months. Patients with preoperative exacerbation lasting for >5 months had a higher number of structures involved in the inflammatory mass (3.3 versus 2.8 structures, P = 0.013), and had a higher probability to take immunosuppressive drugs (26% versus 14%, P = 0.042), budesonide (29% versus 14%, P = 0.009), and a multiple-drug combination (31% versus 16%, P = 0.015) at the time of surgery. Patients with symptoms lasting >5 months prior to surgery had a higher incidence of postoperative septic complications (31% versus 13%, P = 0.002), both by univariate and multivariate analysis. There was a significant increase in duration of preoperative clinical deterioration, size of the inflammatory mass, incidence of preoperative weight loss, intake of immunosuppressants and multiple-drug combination, and postoperative morbidity during the last 5 years of the study., Conclusions: Delay of surgery in patients presenting with symptoms attributable to perforating ileitis is associated with an increased postoperative risk., (Copyright © 2010 Crohn's & Colitis Foundation of America, Inc.)

Inflammation of ileal reservoir mucosa ("pouchitis") is a common sequelae in ulcerative colitis (UC) patients who have had a colectomy with ileal pouch anal-anastomosis (IPAA). Although several clinical, genetic, and laboratory parameters have been evaluated, reliable pathologic predictors for the development of pouchitis are lacking. The purpose of this case-control study was to determine whether there are any pathologic features in UC colectomy specimens that may help predict the subsequent development of pouchitis after an IPAA procedure. The study group consisted of 39 UC patients (male/female ratio: 21/18, mean age: 35 years), who had at least 1 episode of pouchitis after an IPAA procedure during the follow-up period (mean: 57 months, range: 12-121 months). There were 26 control patients (male/female ratio: 11/15, mean age: 37 years), all of whom also underwent a total colectomy and IPAA procedure for UC, but did not develop pouchitis during the follow-up period (mean: 78 months, range: 14-223 months). Routinely processed tissues from each colectomy specimen were evaluated for a variety of histologic features, such as extent of colitis, severity of colitis, extent of severe colitis, type and extent of ulceration, presence and severity of appendiceal inflammation, and the presence of active ileitis, and compared between the study and control patients. Pathologic features that were associated with the subsequent development of pouchitis included the presence of severe colitis that extended into the cecum (severe pancolitis), which was present in 7/39 (18%) pouchitis patients, but in none (0%) of the control patients (P = 0.03), early fissuring ulcers [9/39 (23%) pouchitis cases versus 1/26 (4%) controls (P = 0.04)], active inflammation of the appendix [20/32 (63%) pouchitis patients versus 7/19 (31%) controls (P = 0.03)], and appendiceal ulceration [13/32 (41%) pouchitis patients versus none (0%) of the controls (P = 0.002)]. No significant differences in patient gender or age, depth or extent of ulceration, or the presence or absence of "backwash ileitis" were identified between the 2 groups. In conclusion, there are several histologic features in colectomy specimens from UC patients who have undergone an IPAA procedure that may help predict the subsequent development of pouchitis. Of these features, appendiceal ulceration is highly associated with pouchitis.

We report the case of a 50-year-old woman who was admitted to the hospital with an acute abdomen and underwent exploratory laparotomy. Intraoperatively, we suspected Crohn's disease of the ileocecal valve and decided to treat conservatively. However, in the further clinical course the patient became severely sick and developed a necrotizing ileocecal inflammation in combination with multiple perforations, 4-quadrants peritonitis and several other complications. Histopathology revealed an unspecific inflammation of the ileocecal valve. Furthermore, numerous little cellulose sponges were found in the resected intestinal segment. They were obstructing the lumen and were identical with the contents of an appetite suppressing medical device. A connection between the ingestion of this medical device and the penetrating inflammation of the ileocecal valve has to be suspected.

We describe a patient requiring a HeartMate 1000 IP left-ventricular assist device (LVAD) due to cardiogenic shock. After prolonged gastrointestinal bleeding without identifying the source of bleeding technetium scintigraphy pointed to the right lower abdomen. The patient underwent a laparotomy and inflamed ileum was resected. Pathologic examination revealed cytomegalovirus ileitis. This was treated with ganciclovir and acyclovir. The patient is now (14 months later) awaiting heart transplantation since she could not be weaned from LVAD. The diagnostic and management problems are discussed as well as the relevance for future transplantation.

An ileitis developing years or months after ileostomy was recognised and described many years ago but has rarely been mentioned since. We describe nine patients with a non-specific preanastomotic ileitis that developed years after colectomy in patients operated on for ulcerative colitis or carcinoma. The disease developed after various types of reconstruction: ileorectal, ileoanal, with or without pouch. The diseased ileum showed inflammation, erosions, ulcerations, and sometimes strictures. The disease course ranged from asymptomatic to severe pain and diarrhoea. No specific cause could be shown. Granulomas, infectious agents or ischaemic changes were not found. The anastomosis was always patent. Three patients have had numerous episodes of intestinal obstruction presumably because of adhesions. Seven of nine patients were female. The response to steroids, 5-aminosalicylic acid preparations, and methotrexate was poor, three patients responded well to azathioprine. The condition is not rare and the cause remains unknown.

Purpose: This study was undertaken to assess the electron microscopic and microbiologic findings in tissue biopsy samples from patients with pouchitis and to compare them with findings in patients with normal pouches, conventional ileostomies, and normal ileum., Methods: Tissue samples were obtained from 78 patients: 23 patients with normal pouches endoscopically and histologically (Group 1), 12 patients with endoscopic and histologic evidence of inflammation (pouchitis) (Group 2), 14 patients who had either endoscopic or histologic evidence of inflammation but not both (Group 3), 20 patients with conventional ileostomies (Group 4), and 9 patients without ileostomies from whom biopsy samples of normal ileum were obtained (Group 5)., Results: The mean total aerobic facultative counts in the biopsy samples from the pouchitis patients were significantly higher when compared with biopsy samples from Groups 4 and 5 (P < 0.05). There were no significant differences in the mean anaerobic counts among the five groups. Positive cultures were obtained in 90 percent of patients with pouches compared with 69 percent of patients with conventional ileostomies or normal ileum (P < 0.05). Intramural bacteria were observed on electron microscopy in biopsy specimens of 47 percent patients with pouches compared with 14 percent of patients with conventional ileostomies or normal ileum (P < 0.05). However, the proportion of patients with positive cultures or intramural bacteria was not increased in the pouchitis group compared with the normal pouch group., Conclusion: These data suggest that intramural aerobic facultative bacterial counts are elevated in patients with pouchitis and may play a role in the pathogenesis of pouchitis.

A study was performed to investigate whether acute reservoir ileitis (pouchitis) is associated with specific changes in mucosal morphology, crypt cell kinetics and faecal bacteriology in the ileal pouch. Forty-six patients were studied (ileal reservoir, 36; end ileostomy, ten) using clinical grading, sigmoidoscopy and biopsy; 24 patients with a reservoir were restudied after therapy for 1 month with metronidazole 400 mg three times daily. An index of villus atrophy and crypt cell production rate (CCPR) were determined in all biopsy material. Faecal bacteriology was assessed in 12 patients with a pouch before and after metronidazole therapy. The mucosa of patients with pouchitis was associated with a lower villus atrophy index (P = 0.052), a higher CCPR (P = 0.03) and a higher grade of acute inflammation than that in those without pouchitis. There was no difference in faecal bacterial counts between patients with and without pouchitis. A low atrophy index correlated with a high CCPR (P < 0.001), worse functional score (P < 0.001) and more severe pouch mucosal acute inflammation (P < 0.001), but not with faecal bacteriology. Following metronidazole therapy there was resolution of acute pouch inflammation, increased villus atrophy index (P = 0.049), decreased CCPR (P = 0.049) but no differences in faecal bacterial counts apart from Bacteroides species. These data show that metronidazole therapy does not specifically alter the growth of common faecal bacteria in patients with pouchitis, apart from Bacteroides species. However, metronidazole causes resolution of the typical changes in pouch mucosal morphology and crypt cell kinetics associated with pouchitis.

To investigate whether tumour recurrence or histological changes occur in the Kock pouch, periodic endoscopy with biopsy of the pouch was performed in 15 patients 6 to 66 months after radical cystectomy and urinary diversion for invasive bladder cancer. Endoscopy was undertaken 1 to 4 times in each patient (a total of 37 times in all patients). During endoscopy, random biopsies were taken from the pouch wall, and from the afferent and the efferent nipples. The histological changes were graded as: (1) villous atrophy (grade 0 to 3, 0: nearly normal; 1: shortening, villi/crypt of Lieberkuhn [length] between 1.5 and 4.0; 2: moderate flattening, villi/crypt < 1.5; and 3: almost complete disappearance of villi); (2) fibrosis; and (3) chronic inflammation (grade 0 to 3, based on the amount of fibrous tissue and inflammatory cell infiltration in the lamina propria, respectively). There was no dysplasia or malignant tumour in the Kock pouch in any of the 15 patients. The histology of the ileum changed in terms of villous atrophy, fibrosis and chronic inflammation in the lamina propria and thickening of the muscularis mucosa. The same grade of villous atrophy of the pouch wall, the afferent and the efferent nipples was only found in 3 patients. More fibrosis and less chronic inflammation in the lamina propria were found at the efferent nipple than at the afferent nipple or pouch wall in 8 patients and 5 patients, respectively. Thickening of the muscularis mucosa was found in 13 of 15 patients (86.7%). In conclusion, there was no dysplasia or recurrent tumour in the Kock pouch in patients who were followed for up to 66 months. Various grades of histological changes of the ileum in terms of villous atrophy, fibrosis and chronic inflammation of the lamina propria, and thickening of the muscularis mucosa were found in the pouch wall, and in the afferent and efferent nipples. More fibrosis and less chronic inflammation were commonly observed at the efferent nipple than at the afferent nipple or pouch wall. The degree of histological changes varied even among patients followed over the same period after operation. The time to progression of villous atrophy also varied. The histological changes in some patients were dissimilar even at the same site of the Kock pouch.

A case of persistent ileitis following the refashioning of a Kock ileal pouch into a Brooke ileostomy for severe pouchitis is reported. Preserving the terminal ileum by a salvage procedure may not be a safe alternative to pouch excision with the formation of a new end ileostomy in the surgical management of pouchitis refractory to medical treatment.

This study aimed to characterise the mucosal cellular infiltrate in ileal reservoirs with and without pouchitis (reservoir ileitis). Intraepithelial lymphocyte counts were performed in biopsy specimens obtained from ileal pouches and compared with counts in normal ileum and normal colon. T lymphocyte and macrophage subpopulations were characterised immunohistochemically in pouch biopsy specimens using a panel of monoclonal antibodies. Normal ileum was used as a control. Intraepithelial lymphocyte densities (expressed as intraepithelial lymphocyte/100 epithelial cells) in pouches with and without pouchitis were significantly less than in normal ileum, and approached counts found in normal colon. There was no significant increase in counts even in pouchitis. There were no significant differences in the helper/inducer to suppressor/cytotoxic T cell (CD4:CD8) ratios between normal ileum and pouches with or without pouchitis, either in the epithelium or in the lamina propria. The proportions of RFD9+ (epithelioid cells and tingible body macrophages) and 3G8+ (CD16) macrophages were significantly higher in pouchitis compared with pouches without pouchitis or normal ileum. There were no significant differences between the three groups in the proportions of cells positive for the other macrophage markers (CD68, RFD1-dendritic cells, and RFD7-mature macrophages). The significance of low intraepithelial lymphocyte counts in ileal pouches is unknown, but this may be an adaptive response to the new luminal environment. Since an increase in RFD9+ macrophages occurs in inflammatory bowel disease, but does not occur as a non-specific response to an acute infective process, their presence in pouchitis suggests that effector mechanisms similar to those triggering the original ulcerative colitis may be operating in pouchitis.

This study aimed to investigate the effects of the faecal stream and stasis on the mucosa of ileal pouches. Nine patients were followed up. Two pouch biopsy specimens were obtained from each at the time of pouch formation, ileostomy closure, and three, six, and 12 months after operation. None developed pouchitis. Two pouch biopsy specimens each were also obtained from 20 patients (six with pouchitis), whose pouches had been functioning for at least a year and in whom pouch evacuation was assessed by radioisotope labelled artificial stool. Biopsy specimens were assessed for the degree of acute and chronic inflammation, mucin type (high iron diamine-alcian blue stain), a morphometric index of villous atrophy (villous height:total mucosal thickness), and crypt cell proliferation (using the monoclonal antibody Ki67). Mean values from the two biopsy specimens were obtained for each parameter. After three months of pouch function, the scores for acute and chronic inflammation, the degree of sulphomucin, and crypt cell proliferation were significantly higher, and the index of villous atrophy was significantly lower (indicating a greater degree of villous atrophy), than at pouch formation or at ileostomy closure. The values at pouch formation and ileostomy closure were similar. For all parameters, the changes seen at six and 12 months were not significantly different from those at three months. There was no significant correlation between the efficiency of pouch evacuation and any of the mucosal changes. It is concluded that exposure to the faecal stream is necessary for changes to take place in the pouch mucosa, although the amount of stasis, as measured by radioisotopic evacuation studies, seems to be irrelevant. The mucosal changes occur soon after ileostomy closure and then remain stable for at least one year.

The creation of a pelvic ileal reservoir is associated with inflammatory changes in the reservoir mucosa. Chronic inflammation and villous atrophy are seen in most patients with both ulcerative colitis and familial adenomatous polyposis (FAP), the two prime indications for the operation. The mucosa undergoes a form of colonic metaplasia which is demonstrable by morphological, mucin histochemical, immunohistochemical and proliferation methods. Other pathological features such as mucosal ischaemia, mucosal prolapse, granulomas and pyloric metaplasia are seen in the pouch mucosa and these changes contribute to the confusion over definitions of pouchitis. The term pouchitis denotes a chronic relapsing inflammatory condition of the reservoir which occurs in 10-20% of patients and is one of the more severe long-term complications of reservoir construction. Useful definitions of pouchitis should include clinical, endoscopic and histopathological criteria. There are close associations between pouchitis and an original diagnosis of ulcerative colitis. The cause of pouchitis is currently obscure but there is evidence to suggest it may represent a recurrence of colitis in metaplastic mucosa and may provide a useful human model for colitis. The demonstration of markedly increased proliferative activity in association with colonic metaplasia has worrying connotations. However, dysplasia has not yet been described in colitic reservoirs and very few adenomas have been seen in polyposis reservoirs. Nevertheless the clinical and pathological evidence would indicate that long-term surveillance of the reservoir mucosa by endoscopy and mucosal biopsy is warranted.

A 19 year old male patient suffered from ulcerative colitis and was colectomized 5 1/2 years ago. He presented now with an acute illness, characterized by massive discharges from the ileostoma, fever, leucocytosis, meteroism, melaena and a tender abdomen. A severe ulcerative inflammation of the total ileum was found. A "toxic megaileum" developed. At an operation the ileum was opened and drained. The patient recoverd under treatment with prednisolone, salazosulfypyridine, parenteral nutrition and Vivasorb. It is suggested that in this case the severe ileitis was due to the same disease which led to the total colectomy 5 1/2 years ago: ulcerative colitis.

"Pouchitis" is an inflammation of the ileal pouch that has been described as occurring after Kock's procedure--the continent ileal pouch. The case presented herein demonstrates clinical and histological features that resemble ulcerative colitis, implying that this disorder may be a recurrence of the patient's original inflammatory bowel disease and not merely a local and nonspecific process as previously suggested.