Gut,1983,24,193-201Dysfunctionofthecontinentileostomy:clinicalfeatures andbacteriology*DARLENEGKELLY,SFPHILLIPS.KAKELLY,WMWEINSTEIN,ANDMARYJRGILCHRISTFromtheGastroenterologyUnitandDepartmentofLaboratorvMedicine,MayoClinicandMayo Foundation,Rochester,Minnesota,andtheDepartmlentofMedicine,UniversityofCalifornia,LosAngeles, California,USASUMMARYThepathogenesisandtreatmentofdysfunctionofthecontinentileostomywas investigatedin12patients,fiveofwhomhadasymptomaticmalabsorptionandsevenofwhom hadacutecomplaints.Thenumberofanaerobicbacteriainjejunalaspirateswasincreasedin patientswithpouchmalfunction(range103to108/gaspirate),butthemicrobiologyofileal effluentandthemorphologyoftheilealmucosacouldnotbecorrelatedwithdysfunction.Bile acidbreathtestsandlactosetolerancetestswerenot,however,reliableindicatorsofjejunal bacterialovergrowth.Thesymptoms,themalabsorption,andthenumberofjejunalandileal anaerobicbacteriadecreasedinpatientsduringtreatmentwithmetronidazole,implicating overgrowthofanaerobicbacterialflorainthepathogenesisofthesyndrome.Thecontinentileostomy(ilealpouch),devisedby Kock,hasbeenusedasanalternativetocon- ventionalileostomyforselectedpatientswith ulcerativecolitisandfamilialpolyposis.2-5The reservoirfunctionssatisfactorilyinmostpatients, butmalfunctionofthenipplevalvemayoccurinup toathirdofpatientsandleadtoincontinence. Improvedsurgicaltechniquesappear,however,to havedecreasedtheincidenceofvalvular dysfunction;25furthermore,betterselectionof patientsshoulddecreasetheneedfor revisionof prolapsedvalves.6BecauseCrohnsdiseasemay recurafterconstructionofapouch,25webelieve thatthisdiagnosisisacontraindicationtothe operation.25T Morerecentlyothersyndromesofileostomy dysfunctionhavebeenreported.Theseare describedvariablyas:stafnantloopsyndrome,9 enteritis,7pouchitis,“andnon-specific ileitis.5“IThecorrespondingclinicalfeaturesmay includediarrhoea,5l0l2malabsorptionoffatand*SupportedinpartbygrantsfromtheNationalFoundationforlleitisand Colitis.andtheNationalInstitutesofHealth.Bethesda.Maryland(AM69(08.AM2(06(15.AM(16342-Il1.RR585).Apreliminaryreportofthisworkwas presentedattheAmericanGastroenterologicalAssociationannualmeeting. May198(1. Addressforcorrespondence:DrSFPhillips.GastroenterologyUnit.Mayo Clinic.Rochester.MN559(05.USA.Receivedforpublication2(0August1982vitaminB12,912proliferationofanaerobicbacteria inthepouch,9inflammationinthepouch,7 incontinence,“difficultywithintubation,1and bloodydischarge.5Wepreviouslyreported diarrhoeawithsomefeaturesofmalabsorptionin approximatelyone-thirdofasymptomaticpatients withcontinentileostomies.12Here,weextendthese studiestoincludepatientswithsymptomsof ileostomydysfunction;wealsoexaminedthe possiblemechanismsfordysfunctionandthe symptomaticresponsetometronidazole.MethodsPATIENTSWITHPOUCHDYSFUNCTION(Table1) Thesepatientswereselectedonthebasisofdocu- mentedmalabsorptionand/orsymptomsofa malfunctioningpouch.Fivesubjects(nos1-5)with diarrhoeaandmalabsorptionhadbeenidentified earlier.12Theirpouchesweremature(32-51 monthspostoperative,mean40months).On restudy,thesefivestillhadexcessoutputsofvolume (1000g/day)and/orfat(Table1).Sevenpatients (nos6-12)hadsymptomsofdysfunctionofthe pouch(Table1);theseincludedbleedingfromthe pouch,diarrhoea,peristomaldiscomfort,minor leakage,anddifficultieswithintubation.Infive,the onsetofsymptomswasduringthefirstyearafter193group.bmj.com on December 25, 2012 - Published by gut.bmj.comDownloaded from 194Kelly,Phillips,Kelly,Weinstein,andGilchristTable1Clinic(allfaturesofpantient.swithileostomrvdvsflulntioinoSchillingtie.vt$ AfterlleuomnFaecalwit/iintrinsic AgeoperatiotnresectedwveightIieItfiictor Patienti(vr)Sex(montls)(cm)(g/24hi(/,241i(Iinuirinte)SSymptomnsI61)F5122898236Bonepain;otherwiseasymptomatic 239F35141508209Asymptomatic 3*48M367017851012Asymptomaitic 433M3589941532Asymptomiatic 572M506763116Asymptomatic 624F324905518Blcedingfrompouch.RLQpain 7*32F331(-2()1166612Difficultintuhation.pouchpain 818F810)3242Bleedingfrompouch.RLQpaiin 9*19F951052912Nausea.diarrhoea.abdominalcraimps 1021M8314851126Difficultintubation.pouchpain.diarrhoea 11*35F69%.operation(range,onetoninemonths;mean,fiveileostomiesconstructed2()to58months(mean,38 months).Twowerestudied32and33monthsaftermonths)previously. operation.Allpatientsinthestudyhadproctocolectomies performedforchroniculcerativecolitis.Allgave CONTROLPATIENTS(Table2)written,informedconsentfortheprotocolthathad Infivepatients(nos13-17)withcontinentbeenapprovedbytheHumanStudiesCommitteeof ileostomies,wehaddocumentedinapreviousMayoClinic.Thepatientswerehospitalisedinthe study12normalpoucheffluents(weight9%.group.bmj.com on December 25, 2012 - Published by gut.bmj.comDownloaded from Di.stu,(tiottofc(oltinleltileostootin1STUDIESOFII.EOSTOMYEFFILUENT lleostomyeffluentwascollectedfor48hours,and theweightofthespecimenwasrecorded.All specimenswerefrozenimmediatelvuponcollection andthawedonlyforhomogenisationand preparationofaliquots,whichwereprocessed withoutdelay.Thefatcontentofeffluentswas determ