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PRE-POUCH ILEITIS AFTER COLECTOMY IN PEDIATRIC ULCERATIVE COLITIS
C Slatter1, S Girgis2, H Huynh1, W El-Matary1
1Division of Pediatric Gastroenterology, Hepatology and Nutrition, Stollery Children’s Hospital, and 2Department of Pathology, University Hospital, University of Alberta, Edmonton, Alberta
Colectomy and ileal pouch anal anastomosis (IPAA) is a potentially curative option for patients with ulcerative colitis. A rare, post-operative complication is terminal ileitis, which arises when the ileum is reanastomosted into a non-physiologic environment. Terminal ileitis is well described in adults, but has been poorly documented in pediatric patients.
AIM: To describe our experience of children with ulcerative colitis who developed terminal ileitis following colectomy and IPAA.
METHODS AND RESULTS: A search of our pediatric inflammatory bowel disease database of patients we are currently following revealed two boys (initially presenting at ages 4 and 9) diagnosed with ulcerative colitis on the basis of clinical presentation, investigations including endoscopy and colonoscopy and biopsies. As they were resistant to medical therapy, including steroids, 5-ASA preparations (oral and rectal), azathioprine, tacrolimus and various antibiotics, they each underwent colectomy with IPAA. Pathological examination of the surgical specimens confirmed the diagnosis of ulcerative colitis.
One year later, both children had recurrence of symptoms, including watery, bloody diarrhea and weight loss. Several endoscopies and biopsies showed acute on chronic mucosal inflammation, ulceration, friability and granularity in the pouch and up to 50cm into the terminal ileum. Biopsies revealed mixed inflammatory infiltrate rich in eosinophils, plasma cells and neutrophils. No granulomas were seen. Stomach and duodenal biopsies were normal. Both children were diagnosed with pouchitis and terminal ileitis. At present, their symptoms are well controlled using 5-ASA preparations in one child and azathioprine in the other.
CONCLUSION: Development of terminal ileitis after colectomy and IPAA can occur in children with ulcerative colitis. Although every effort should be made to exclude Crohn’s disease as a cause of the terminal ileitis, this unique and poorly defined condition should not be considered to be against the diagnosis of ulcerative colitis. More research is needed to develop a better understanding of the aetiopathogenesis of this uncommon condition.