Managing Pouch Inflammation

Podcast Transcript

Dr. Scott Steele: Butts and Guts: a Cleveland Clinic podcast exploring your digestive and surgical health from end to end.

Dr. Scott Steele: Hi again everybody, and welcome to another episode of Butts and Guts. I'm your host, Scott Steele, the Chair of Colorectal Surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. Super excited today to always have a new guest on and we have Dr. Taha Qazi, a Gastroenterologist and Associate Staff here at the Cleveland Clinic and within our own DDSI Institute. Sunny, welcome to Butts and Guts.

Dr. Taha Qazi: Thank you for that introduction, Dr. Steele. I really, really appreciate it.

Dr. Scott Steele: So, we are going to talk a little bit today about pouch inflammation, but before we go into that, as all the listeners of our podcast now we want to find out a little bit first more about you. So, tell us a little bit about yourself. Where are you from, where'd you train, and how did it come to the point that you're here at the Cleveland Clinic?

Dr. Taha Qazi: I'm originally from Fort Wayne, Indiana, but I did my early undergraduate and career at University of Michigan. After that, I did my medical schooling at Indiana University and then I did my early residency and fellowship in Boston, both at Boston University. And then I did an additional year as an advanced IBD fellow at Boston University, as well. I was in the Brigham and Women's Hospital at Harvard for my GI fellowship where I really got into inflammatory bowel disease as my main career interest. A lot of it was based on a sort of personal experience with my family members and also other people that I'm very close to friends with. But, in general, just a lot of good mentorships that I had while I was there. And then as I started working on inflammatory bowel disease, seeing patients get better and improve, I really felt a love for the management of this condition, and I really came to really enjoy it.

So when I was looking for places to train and looking for places to sort of make that next step in terms of my employment, I knew I wanted that same sort of mentorship, but I also knew that I wanted to take the next step as I came to understanding a good aspect of the disease and I think in many ways we're so much siloed in some of our medical fields. But one of the amazing things about being at the Cleveland Clinic is having a colleague like yourself or all our surgical colleagues sitting right next to us, and I think one of the things that Dr. Regueiro when he first approached me about this institution was in many ways our surgical colleagues make us better gastroenterologists. We make our surgical colleagues better surgeons, and I think that's really been the case since I've been here. And I think I've loved working here as a result and it's been a fantastic experience.

In doing so, I started working with patients with pouch and pouch disease mainly as they came into my clinic, but also, once again, through personal experience. And many of our patients do end up getting ileo-anal pouches as a result of the disease, not only from IBD standpoint but for a variety of conditions. So, managing their conditions, managing diseases was something that really struck me.

Dr. Scott Steele: Well, we are super excited to have you here and I know this is an audio podcast, but Dr. Qazi is wearing, unfortunately, the Michigan colors. And as a Badger. I'm going to try to look away from him as I talk to him. So, before we dive in a little bit about pouchitis and pouch inflammation, we've had some topics on this in the past, if our listeners want to go back, but tell us a little about what is a pouch?

Dr. Taha Qazi: Yeah. So, it's amazing because, as a gastroenterologist, when I first started researching this condition, researching these ideas, you start reading the surgical landmarks that happened, like Dr. Park's pouch, and also the greats that have been at the Cleveland Clinic, like Dr. Fazio. An ileo-anal pouch is basically an internal intestinal reservoir where a part of the small bowel called the ileum is folding in and out itself sewn or stapled to the anus or rectum, which allows a patient to basically have voluntary control of their bowel movements but also not have an ostomy. So, it's a means for a patient to maintain the function of the anus and the anal sphincter mechanism, but also allows them to go to the bathroom through the natural orifice that they have.

Dr. Scott Steele: So, pouch inflammation, pouchitis. What is that?

Dr. Taha Qazi: Yeah, you know, it's interesting. I think they call it so many things. It's basically the inflammation of this reservoir inside the body. And in many ways, it can be due to a variety of conditions. Sometimes we divide it into being secondary to a particular cause. So, for example, secondary pouchitis is often related to medications like ibuprofen or NSAIDs, for example. In certain situations, it can be related to radiation, it can be related to dysfunction of the pouch itself. But most commonly idiopathic pouchitis or primary pouchitis is, we're not really quite sure why this happens, but it tends to happen in a good number of our patients as we sort of treat this condition following your surgical intervention.

Dr. Scott Steele: So, I'll jump in right on that last statement you're about to make. And truth or myth: up to 40 percent of patients who receive a pouch will have pouchitis at least once over the course of their lifetime.

Dr. Taha Qazi: Yeah, so the older studies, the ones that we're sort of looking at through Dr. Fazio's work here, suggested that the incidence of pouch within the seven years of follow-up was about 40 percent. So at least a one bout of pouchitis within the first seven year for followship is actually seen.

Most patients tend to develop pouchitis within the first two years of their pouch surgery, about half as they say. Some patients do never develop pouchitis or develop pouchitis much later in their course of life. What we have found though, recently looking at database studies from different countries is that the incidence of pouchitis compared to the early years - 1990 to 2000 - compared to 2008 to 2018 is rising. So, initially you're correct that many of our patients, 40 percent, develop pouchitis, but recently it looks like the numbers have gone up 55 percent as we're sort of seeing these days.

Dr. Scott Steele: So, we've talked a lot about what it is, but what is a patient experience?

Dr. Taha Qazi: The common symptoms of pouchitis usually involve an increase in frequency, often bowel discomfort with going to the bathroom, occasionally associated with incontinence, maybe some increased urgency. Rarely will patients have symptoms of fevers, abdominal cramping. Those are the common hallmark symptoms such so diarrhea, abdominal pain, cramping, urgency. Very rarely, patients will have rectal bleeding, for example, or even difficulty evacuating, and those are usually warning signs for us to take a better look at what's going on and potentially even perineal complications, which once again, is a warning sign that we get to take a really different look at the pouch itself.

Dr. Scott Steele: There's a lot of different kinds of rules of thumb that we use out there for many different medical conditions. But, if I'm a patient listening to this and I have a pouch and I think, "okay, well I'm in that 40 or 55 percent" or whatever number you want to throw out. So, does it just happen to be once, or is this something that I can expect a bunch of times. What's the process going forward for these people?

Dr. Taha Qazi: So, most patients who have developed a bout of pouchitis will have a recurrence. Very few of them, from the major studies, develop chronic recurrent pouch inflammation, which requires longstanding therapy with antibiotics or other agents. And when we talk about pouchitis, we often talk about a continuum disease and we use antibiotics which are the mainstay of treatment as a means to sort of divide pouchitis into patients who respond, patients who don't respond, and patients who are dependent on antibiotics as a means to manage your disease.

Dr. Scott Steele: So, we'll kind of just delve in a little bit deeper down that rabbit hole. So, just give me a broad overview of what are the kind of types of treatments that are available for patients who are? And before you get to that, how do you diagnose pouchitis?

Dr. Taha Qazi: Yeah, so I mean typical symptoms are the most common things. Sometimes the patient will call me with these typical symptoms. But oftentimes, the best way, or the ideal way, to diagnose pouchitis is through an endoscopic evaluation.

Sometimes we can't get to that. There are, unfortunately, not good biomarkers that we can use for the assessment of pouchitis, but we're getting better at understanding a little bit better handle on that. So oftentimes, it's usually an endoscopic evaluation in a patient with typical symptoms. And in patients who respond to antibiotics, oftentimes we can say that this is probably just an acute bout of pouchitis that responded. That's usually how most diagnosis works in terms of pouchitis.

In terms of management, I would say the antibiotics tend to be the mainstay of therapy, and there are a variety of antibiotics that have been studied. So, the most common ones being ciprofloxacin and metronidazole. But agents, for example, like amoxicillin, clavulanate, rifaximin, vancomycin have all been studied, and a lot of our patients respond really well to a two-week course of antibiotics. Some require longer courses or combination antibiotic therapy, but they respond really well, and most of them only require one or two courses over the course of a year oftentimes.

Dr. Scott Steele: You talked about this earlier and you talked a little bit about patients who have already had a bout of pouchitis and sought treatment. But is there a kind of - and I know this is really, really broad and there's a lot of variability depending on so many different factors - but can you tell us a little bit about some general rule of thumb? I mean, is it always antibiotics, or do you like to maybe try somebody on different type treatment, or how do you go about thinking that through?

Dr. Taha Qazi: So, yeah. So, in many patients there are strategies that we've used. And there have been studies, for example, in patients who have developed acute pouchitis and have had recurrences to use a probiotic formulation after a course of antibiotics. The common one that we tend to use often is a De Simone Formulation, often labeled as VSL #3 or Visbiome oftentimes as a product. And that tends to occasionally prevent the recurrence of pouchitis in a lot of our patients.

Diet therapy and pouches is sort of really expanding and we found, for example, some recent studies suggesting that a Mediterranean diet, along with the diet rich in fruits and vegetables tends to sort of decrease not only inflammation in the pouch but also recurrent bouts of pouchitis. So, there are things that are dietary strategies that we can use. There are obviously probiotic formulations that we can use, and oftentimes we require more anti-inflammatory benefit as well so in those situations we use agents like topical Interco studies which have been studied or budesonide, and even the agent vedolizumab, which has been used for the management of pouchitis and with good effect actually.

Dr. Scott Steele: So, you mentioned a little bit before about patients that have pouchitis. We have a lot of practitioners that listen to our podcast, as well. So, if it's not pouchitis, what else could this potentially be? Could it just be something you ate, or is it anything else going on?

Dr. Taha Qazi: The differential is always quite hard in a patient who's had surgical management of their disease. So, when I look at somebody with pouchitis, I often try to categorize if their pouch inflammation is or not. And that's usually my sort of dividing point. And if there is not pouch inflammation, there's a variety of things that can cause pouch dysfunction. Sometimes, it can be something as simple as outlet problems. So, the inability to defecate appropriately due to pelvic floor issues or the mechanical aspects of the pouch itself. My colleague, Dr. Stefan Holubar here is really looking at how the pouch functions and actually is looking into the pouch twisting occasionally in the context of issues as the pouch grows.

So, there's a variety of things that can happen as it relates to the pouch, but oftentimes the decision point really involves getting some blood testing, getting some stool testing occasionally, but also looking at an endoscopic evaluation and really getting a good history from our patients. Are they having difficulty going to the bathroom? Is it really just like them sitting more often or not? Is it fewer bowel movements rather than too many bowel movements? So, I really think there's a lot that can be offered in any sort of thing.

Dr. Scott Steele: So, any advancements on the horizon in terms of treating pouch inflammation?

Dr. Taha Qazi: Yeah, so as I mentioned, I think as we move forward, we're doing a lot of good work here looking at the management of pouch inflammation using biologic therapies. We're part of a large consortium called the PROP-RD Study, looking at biologics in the management of chronic pouch inflammation and chronic pouch refractory pouch diseases.

As I mentioned earlier in this talk, there really is no good biomarker for the management or the assessment of the pouch. And in many ways, we're trying to evaluate other additional biomarkers, for example, the use in breath, urine, and stool as a means to sort of assess the pouch so we can create a non-invasive means to assess for pouch inflammation. We don't have to sort of do these pouchoscopy evaluations as often. So, I tend to use those as a sort of major strategy, and obviously a lot of diet research that we're looking at into here as well and then there's a lot of data coming out about newer medications for the management of chronic pouch inflammation, especially our newer medications that are coming out for inflammatory bowel disease.

Dr. Scott Steele: So now it's time for our quick hitters. It's a chance to get to know you just a little bit better. So, what's your favorite food?

Dr. Taha Qazi: I love sushi. I found some really good restaurants on the West Side. I'm a big fan of seafood in general. But I love sushi.

Dr. Scott Steele: And what's your favorite sport to watch and to play?

Dr. Taha Qazi: To watch, I would say is soccer or football. And to play basketball. But I do also love college football and I love rowing. So, one of the things that I miss most actually is rowing on the Cuyahoga, and I have a rower at my home. And my wife and I actually found each other as a part of the rowing team at the University of Michigan.

Dr. Scott Steele: Oh, fantastic. I hope that Michigan loses to Wisconsin. And what is your favorite trip that you have been on in the past?

Dr. Taha Qazi: I recently took my kids to hike. I have two young boys and now have a really younger baby boy as well. But I took them on a hike with me to Cuyahoga National Park. That's the most recent trip that's really coming to me, but I really had a great time with them, and we camped, and it was the first time that I actually camped with my two sons. So, it was awesome.

Dr. Scott Steele: That leads right to my next question. Tell me something you like about living here in Northeast Ohio.

Dr. Taha Qazi: It really is a pleasure to work at a place like the Cleveland Clinic, but northeast Ohio has diversity. It has great sports. I just bought season tickets to the Cavs. So, I'm really excited about some of these new basketball games. Tough for the Browns. And I tend to go see my team in Arbor occasionally as well so it's always a good time.

Dr. Scott Steele: A final take home message for our listeners regarding pouch inflammation or pouchitis.

Dr. Taha Qazi: So, I think that if I could leave with one thing is that pouchitis is common, but we do have good treatment modalities for the management of it, and most of our patients do respond to our initial treatment strategies. In many ways, there are future strategies that are coming out to manage chronic pouch inflammation, and I look forward to working with our patients and trying to manage the disease as we move forward with the new horizon of disease assessment.

Dr. Scott Steele: That's excellent. So, to schedule an appointment or to learn more about pouch inflammation treatment options here at the Cleveland Clinic, please call the Digestive Disease and Surgery Institute at 216-444-7000. That's 216-444-7000. You can also visit our website at clevelandclinic.org/digestive. That's clevelandclinic.org/digestive. Dr. Qazi, thanks so much for joining us on Butts and Guts.

Dr. Taha Qazi: Thank you.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts and Guts.