Q) Which of the following is Not a risk factor for pouchitis post IPAA in ULcerative colitis
A) Smoking B ) NSAIDs use post op C) Elderly patients D) UC with extra intestinal manifestation
Ans a
Pouchitis is the complication of Ileal Pouch Anal Anastomosis (IPAA) for Ulcerative colitis. The incidence of pochitis for the same proedure for familial Adenomatous polyposis is less than 10% but for ulcerative colitis can go as high as 50%.
Risk factors for development of pouchitis are
Previous extra intestinal manifestations of IBD especially arthritis
ANCA positive cases of UC
NOD2insC positive patients
Smoking prevents the development of puchitis after IPAA in ulcerative colitis.
5. Other reported factors that may associate with pouchitis include extent of UC, thrombocytosis,and PPI use with NSAId
In radiation proctitis, surgery is typically indicated for complications that are severe or unmanageable through conservative measures. The options can be considered as follows:
A) Pain Abdomen: While abdominal pain can be a symptom associated with radiation proctitis, it is not an indication for surgery on its own. Pain management and other conservative treatments can be employed first.
B) Rectal stricture: This can cause significant obstruction and may require surgical intervention to restore normal bowel function.
C) Haemorrhage: Severe bleeding due to radiation proctitis may necessitate surgical intervention if it is not controlled by endoscopic or conservative measures.
D) Vesical Fistula: The formation of a fistula between the bladder and rectum (vesical fistula) is a serious complication that often requires surgical repair.
Acute Radiation proctitis - Occurs within 6 mths of starting the treatment
Chronic - After 6 mths, Most patients develop symptoms at a median of 8 to 12 months after completion of radiotherapy
Modified Radiation Therapy Oncology Group rectal toxicity scale
Grade 1
Mild and self-limiting
Minimal, infrequent bleeding or clear mucus discharge, rectal discomfort not requiring analgesics, loose stools not requiring medications
Grade 2
Managed conservatively, lifestyle (performance status) not affected
Intermittent rectal bleeding not requiring regular use of pads, erythema of rectal lining on proctoscopy, diarrhea requiring medications
Grade 3
Severe, alters patient lifestyle
Rectal bleeding requiring regular use of pads and minor surgical intervention, rectal pain requiring narcotics, rectal ulceration
Use of newer conformal radiation therapy techniques.
Amifostine is a prodrug that is metabolized to a thiol metabolite that is thought to scavenge reactive oxygen species
Placebo-controlled phase III trials have detected no benefit from either topical or oral sucralfate.
Treatment of radiation proctitis
Medical
Butyrates
ASA
Sucralfate
Metronidazole
Short chain FA
Topical formalin
Hyperbaric o2
Endoscopic
dilatation
Heater and bipolar cautrey
ND YAG
APC
RFA
Surgery
Diverting ostomies for severe stricture - Better for incontinence, stricture and limited benefit for bleed
Reconstruction with Flaps - rectourethral or rectovaginal fistula with a pedunculated gracilis or a Martius flap to facilitate healing by introducing well-vascularized healthy tissue,
Proctectomy complicated fistulous disease, especially when accompanied by significant pain and incontinence, or in cases of severe and intractable bleeding
