Chronic Pouchitis After Ileal Pouch-Anal Anastomosis: Responses to Butyrate and Glutamine Suppositories in a Pilot Study
Section snippets
Study Subjects and Clinical Observations.
The study was approved by the Mayo Clinic Institutional Review Board, and written informed consent was obtained from all the participants.
For analysis of fecal short-chain fatty acids, we recruited 24 patients; all had undergone colectomy for chronic ulcerative colitis, and J pouches had been constructed.3 Among these 24 patients with ileal pouch-anal anastomosis, 13 were healthy (43 ± 5 months after operation), and 11 had pouchitis (39 ± 9 months postoperatively). Random stool samples were
Analysis of Short-Chain Fatty Acids.
Total fecal concentrations of short-chain fatty acids in the patients with pouchitis were significantly lower (P<0.01) than those in asymptomatic control patients (Table 1). Specifically, acetic acid and butyric acid concentrations were significantly decreased, whereas those of propionate were not.
Glutamine Trial.
Of the 11 patients in the glutamine trial, 1 withdrew from the study after 3 days because an anal stricture precluded the easy insertion of suppositories. The 10 other patients were able to retain the
DISCUSSION
In several ways, butyric acid may be relevant to pouchitis after ileal pouch-anal anastomosis. First, butyric acid reportedly prevents villous atrophy in such ileal pouches13 by nourishing and protecting the pouch epithelium. Second, butyric acid may be the primary nutritional source for metaplastic colonocytes that line ileal pouches; indeed, butyric acid is the major source of energy for colonocytes and enhances cell proliferation in colonic crypts.8 Finally, a syndrome of deficiency of
CONCLUSION
The results of this pilot study, with glutamine showing 60% efficacy, were encouraging. On the basis of these results, the use of glutamine in patients with chronic or acute pouchitis should be further analyzed in a larger controlled study. Because glutamine seemed more effective than butyric acid, colonic metaplasia may not have been extensive in the pouches of these patients. In both treatment protocols, however, the dosages may have been insufficient. The amount of butyrate that we used was
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2018, Pouchitis and Ileal Pouch Disorders: A Multidisciplinary Approach for Diagnosis and ManagementTreatment of acute pouchitis
2017, Seminars in Colon and Rectal SurgeryCitation Excerpt :A pilot study of 19 patients comparing butyrate suppositories at a dose of 40 millimoles (mmol) twice daily to glutamine suppositories at a dose of 1 gram (g) twice daily for a 21 day treatment period demonstrated that glutamine suppositories may have some efficacy for remission and warranted further evaluation, though this has not been performed. It was postulated that glutamine plays an important role in the metabolism of enterocytes and thereby helped maintain the mucosal barrier of the pouch by preventing a deficiency in epithelial nutrition.41 In a pilot study, AST-120, an experimental spherical carbon adsorbent, at a dose of 2000 mg 3 times per day for 4 weeks has shown some promising preliminary data for the management of acute pouchitis, but is not commercially available and needs further study (Table 2).42
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2013, Journal of Crohn's and ColitisCitation Excerpt :Ciclosporin enemas were successful for chronic pouchitis in a pilot study59 and oral azathioprine may help if patients relapse become budesonide-dependent. Uncontrolled studies of short-chain fatty acid enemas and suppositories.60–62 Of more interest, infliximab has been tried in patients with chronic, refractory pouchitis.63
Network meta-analysis: efficacy of treatment for acute, chronic, and prevention of pouchitis in ulcerative colitis
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Current address: University of Chicago Medical School, Chicago, Illinois.