Elsevier

Mayo Clinic Proceedings

Volume 68, Issue 10, October 1993, Pages 978-981
Mayo Clinic Proceedings

Chronic Pouchitis After Ileal Pouch-Anal Anastomosis: Responses to Butyrate and Glutamine Suppositories in a Pilot Study

https://doi.org/10.1016/S0025-6196(12)62270-8Get rights and content

Nonspecific, idiopathic inflammation of ileal pouch mucosa (“pouchitis”) after ileal pouch-anal anastomosis is a common complication of this surgical approach. The epithelium of the pouch is ileal, but variable degrees of colonic metaplasia are natural sequelae of construction of such a pouch. One hypothesis is that pouchitis is caused by a deficiency of epithelial nutrition. Thus, a lack of butyric acid (the principal metabolic fuel of colonocytes) or of glutamine (the main fuel of enterocytes) may develop. In this study, our aims were to determine the concentration of total short-chain fatty acids in random stool samples obtained from patients with an ileal pouch-anal anastomosis with and without pouchitis and to test the therapeutic effects of butyrate and glutamine suppositories on pouchitis. During the study, all conventional therapy for pouchitis was discontinued. For 21 days, 9 patients participated in a butyrate trial, and 10 patients were treated with glutamine. Total concentrations of fecal short-chain fatty acids were significantly less in patients with pouchitis than in those without pouchitis. During treatment, 6 of the 10 patients who received glutamine had no recurrence of symptoms, but only 3 of the 9 patients who received butyrate responded similarly. Hence, further studies of glutamine in the treatment of pouchitis seem warranted.

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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Current address: University of Chicago Medical School, Chicago, Illinois.

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