| Long Term Concerns with the Pelvic Pouch |
Overview
Patients with ulcerative colitis and familial adenomatous polyposis who were treated surgically used to undergo a total proctocolectomy, with total and permanent ileostomy. A prolectomy is a surgical procedure in which the anus, rectum, and colon are removed. An ileostomy is created for the removal of digestive-tract wastes. The procedure is a common treatment for severe, intractable ulcerative colitis.
An ileostomy is an opening in the abdominal wall through which digested food passes. An ileostomy may be performed when a diseased or injured colon cannot be treated successfully with medicine, such as with Crohn's disease or ulcerative colitis. The end of the ileum (the lowest portion of the small intestine) is brought through the abdominal wall to form a stoma, usually on the lower right side of the abdomen. Digested food, which passes through the stoma, is collected in a device called a pouch or an appliance.
However, in the late 1970s, when the pelvic pouch procedure was introduced, the surgical approach to these diseases was revolutionized.
A pelvic pouch (or ileoanal pouch) procedure involves removing most of the rectum and all of the colon, leaving only the anal sphincters and the wall of the rectum at, and adjacent to, the sphincter muscles. An internal pouch is made out of the lowest portion of the small intestine (ileum). This pouch then is stapled or stitched (an anastomosis) to the remaining rectal wall just inside the sphincters. This internal pouch holds some stool, extracts some water and signals the muscles when it's time to evacuate.
The Gold Standard
The pelvic pouch now has become the "gold standard" in surgical treatment. Although this operation avoids a permanent stoma and usually improves the quality of life, it does not restore bowel function to "normal." Patients can expect to have at least six stools per day and they are pasty to watery in consistency. As with any bowel operation, patients experience many changes, both short-and long-term. I will discuss the potential long-term problems that patients with a pelvic pouch may have.
Skin Care
Patients can expect to have at least six bowel movements daily. The stool consistency is loose to pasty and can vary from one stool to the next. Anal irritation can occur and can be accompanied by itching, pain, seepage or bleeding. Attentive skin care is essential. This does not mean vigorous wiping, because that may make the situation worse. Patients should not wipe profusely in an attempt to more thoroughly clean the area, thinking that it will improve the problem.
When wiping, you should try not to use dry toilet paper, when possible. Try using wet facial tissue or baby wipes and then patting the area dry to prevent irritation. Zinc oxide-based protective creams will protect the skin from small bits of stool or mucous which may leak out of the anus. Desitin (TM) is one such product, but there are many more which your doctor or enterostomal therapy nurse (these nurses also have extra training in specialized skin care besides stoma training) may be able to prescribe. Keeping a dry cotton ball by the anus to pat away moisture may help to keep the area dry. Other medicated treatment may be needed if there are signs of a fungal irritation, similar to diaper rash.
Diarrhea
The function of the pelvic pouch will change over the first year, and improve as it stretches and becomes larger after the ileostomy closure. However, there are still some people who have up to 20 bowel motions daily. Dietary changes may help these people decrease the number of bowel motions. Foods found to help decrease the water content of the stool may help slow the number down. These foods include: applesauce, bananas, rice, creamy peanut.butter, potatoes, cheese, marshmallows, pretzels, toast, yogurt and tapioca pudding. Bulking agents such as Metamucil (TM), Citracel (TM), Fibercon (TM), or Konsyl (TM) also help thicken the stool. These products are ingested with little fluid to allow the extra fluid in the gastrointestinal tract to be absorbed. They can be taken up to three times daily.
Medications such as Lomotil or Imodium sometimes are prescribed by a doctor to slow down stools. They should not be used without your doctor's approval. If these drugs do not work, there are more powerful medications that also can be tried, but only with your doctor's approval. Limiting the intake of fried and fatty foods and milk or milk products may decrease diarrhea. Reaction to foods varies with each individual, and other foods may be found to increase the amount of stool produced or change the consistency. Rarely problems with excessive frequency of stools leads to removal of the pelvic pouch and a permanent ileostomy.
Night-time Defecation
The interruption of sleep to defecate can be exhausting. Most people eat the largest meal for supper and typically, with busy work schedules, this meal is consumed late in the day. This causes increased stools in the night. To decrease the problem of night~time defecation, limiting what you eat four to six hours before bedtime is recommended. This also means avoiding large quantities of liquids (especially carbonated beverages) and evening snacks. Eating your largest meal at lunchtime is encouraged. Also, taking agents such as Lomotil or Imodium before the evening meal and/or at bedtime may be advised.
Protecting the anal skin at night is important because during deep sleep, there can be small amounts of stool or mucous which may escape when the sphincter muscles are relaxed. This can lead to skin irritation that we discussed earlier.
Pouchitis
Pouchitis is an inflammatory condition of the pouch. The cause is unknown but it occurs more frequently in patients who have had a pouch for inflammatory bowel disease versus those who had a pouch for familial polyposis. Patients are at a risk of pouchitis over their entire lives as long as they have a functioning pelvic pouch. For some patients pouchitis is an isolated event, but others can experience multiple episodes or even continuous "chronic pouchitis".
The symptoms are similar to a mini-attack of colitis. Patients report increased bowel motions, pelvic pain, abdominal cramps, malaise, fevers or blood in their stools. However, it is not unusual for patients with a pelvic pouch to notice blood on the toilet paper with normal function of the pouch and not have pouchitis. The most common treatment is flagyl (metronidazole) 750-1500 milligrams daily for seven to 14 days. This is effective 85 percent to 90 percent of the time. Improvement usually is seen in 48 hours. For those with continued symptoms or intolerance of flagyl, other medications are used. These include Cipro, Bactrim, amoxicillin\clavulinic acid, and tetracycline. For resistant or frequently recurring cases, a combination of drugs or long term drugs are used.
Bowel Obstruction/Emptying Concerns
To construct the pelvic pouch, the small bowel is stretched on the blood vessel, which provides blood to the pouch in order to reach the anus. This stretching may predispose you to bowel obstructions from scar tissue, twisting, or kinking. This may occur throughout your entire life. It may require an operation to unkink the bowel or divide scar tissue. Another reason which may lead to problems with pouch emptying is a narrowing or stricture at the pouch anal joint (anastomosis). This is diagnosed by an exam of the anal area and may cause symptoms of a progressive need to strain more and more to move your bowels. Usually, dilatation solves the problem and rarely an operation is needed to correct the problem.
Risk of Cancer
Lifelong follow-up with your doctor, with biopsies and inspection of the pouch, are mandatory. There are two different ways of connecting the pouch to the anal area. The first method involves stapling the pouch to the anal area. If the stapling method is used, there is a small rim of "transitional" tissue that may contain colon cells which is left behind. These colon cells could develop precancerous changes known as dysplasia. Biopsies of the area are essential, at least on a yearly basis, to check for this condition. If dysplasia is found, it does not mean the pouch will need to be removed; however the transition zone tissue may need to be removed.
The other way of connecting the pouch to the anal area involves stripping the anal lining away, including the transition zone (termed mucosectomy) and sewing the pouch to the anal muscles. This procedure has the risk of not removing every cell of transition zone tissue, which may predispose problems in the future. The risk of developing dysplasia is very low. However, I can not stress enough the importance of a yearly exam and pelvic pouch biopsy to discover problems early, so the remedy is easy and not life threatening.
Sexuality Concerns
Sexuality concerns after a pelvic pouch are due to the dissection in the pelvis to remove the last portion of the large intestine (called the rectum). These problems may include urinary emptying problems, impotence, and retrograde ejaculation (the sperm going into the bladder instead of out the end of the penis) Women may experience painful intercourse or vaginal dryness during intercourse. Some women may experience increased fertility due to removal of the inflamed colon.
Unfortunately, others may have decreased fertility from adhesions or scar tissue which develops after the removal of the rectum. Additionally, with pregnancy, the method of delivery remains controversial (C-section versus a vaginal delivery), because any injury to the anal sphincter (control) muscles may lead to the inability to control the stool. Some physicians recommend C-section. However, some women have gone through a vaginal delivery without any detectable sphincter problems. However it is important to inform your obstetrician of your condition so he/she can perform a C-section if any problems arise during the vaginal delivery -- the size of the baby is too large or your pelvis is too small to deliver vaginally without straining the sphincter muscles. It is unknown in women with and without pelvic pouches what happens to their bowel control as their anal sphincter muscles age and normal weakening sets in, leaving room to question which birth method is recommended until more information is known.
Conclusion
In conclusion, multiple issues can affect patients after pelvic pouch construction. It is important to develop a lifelong relationship with a doctor knowledgeable in pelvic pouches, to obtain yearly endoscopy and biopsy of the pelvic pouch and treat any other problems which may arise.
by Tracy L. Hull, M.D., Staff Surgeon Department of Colon and Rectal Surgery
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