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10/15/2020 1 www.gi.org/researchawards Read the Grant Flyer , FAQs, or visit the webpage for the RFAs. Grant System Opens: September 8, 2020 Deadline: December 4, 2020 SEVEN different award types; INCREASED Junior Faculty FUNDING; NEW MidCareer Bridge Funding; Med Resident and Student Awards Welcome to the Virtual Grand Rounds Waiting Room – The educational activity will begin promptly at 12 Noon Eastern. The Premier GI Clinical Meeting & Postgraduate Course OnDemand Access Open NowLive Sessions are Just 1 week away! Visit acgmeetings.gi.org Register Now! 1 2 American College of Gastroenterology

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Page 1: Pouch virtual grand rounds Bo Shen 10 15 20 FINAL...Pouch Vaginal Fistula: Differential Diagnosis At the anastomosis (surgical trauma) At the anal canal (Crohn’s disease) At the

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www.gi.org/research‐awards

Read the Grant Flyer, FAQs, or visit the webpage for the RFAs.  

Grant System Opens: September 8, 2020

Deadline: December 4, 2020 

SEVEN different award types; INCREASED Junior Faculty FUNDING; NEW Mid‐Career Bridge Funding; Med Resident and Student Awards

Welcome to the Virtual Grand Rounds Waiting Room – The educational activity will begin promptly at 12 Noon Eastern.  

The Premier GI Clinical Meeting & Postgraduate Course

On‐Demand Access Open Now‐ Live Sessions are Just 1 week away!

Visit acgmeetings.gi.org Register Now! 

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American College of Gastroenterology

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Participating in the Webinar

All attendees will be muted and will remain in Listen Only Mode.

Type your questions here so that the moderator can see them. Not all questions will be answered but we will get to as many as possible.

How to Receive CME and MOC Points

LIVE VIRTUAL GRAND ROUNDS WEBINAR

ACG will send a link to a CME & MOC evaluation to all attendees on the live webinar.

ABIM Board Certified physicians need to complete their MOC activities by December 31, 2020 in order for the MOC points to count toward any MOC requirements that are due by the end of the year. No MOC credit may be awarded after March 1, 2021 for this activity.

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American College of Gastroenterology

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MOC QUESTION

If you plan to claim MOC Points for this activity, you will be asked to: Please list specific changes you will make in your

practice as a result of the information you received from this activity.

Include specific strategies or changes that you plan to implement.THESE ANSWERS WILL BE REVIEWED.

ACG Virtual Grand RoundsJoin us for upcoming Virtual Grand Rounds!

Visit gi.org/ACGVGR to Register 

Week 31: Special Considerations When Discussing Diet Elimination for EoENirmala Gonsalves, MDOctober 22, 2020 at Noon EDT

Week 32: Managing Medical‐Legal Risk in Colonoscopy: Rules for SuccessDouglas K. Rex, MD, MACGNovember 5, 2020 at Noon EDT

NOTE: there will be no Virtual Grand Rounds on October 29 due to ACG 2020

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American College of Gastroenterology

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The Premier GI Clinical Meeting & Postgraduate Course

On‐Demand Access Open Now‐ Live Sessions are Just 1 week away!

Visit acgmeetings.gi.org Register Now! 

Disclosures: 

Bo Shen, MD Consultant for Janssen, AbbVie, and Takeda; Speaker for AbbVie and Takeda

David T. Rubin, MD, FACG Advisory Committee/Board Member: CCFA, Janssen

Consultant: AbbVie Pharmaceuticals, Abgenomics, Allergan, Biomica, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Check-cap,Dizal Pharmaceuticals, Galen Pharma/Atlantica, Genentech, Gilead Sciences, Ichnos Sciences S.A. (formerly Glenmark PharmaceuticalGSK, Janssen, Lilly, Narrow River Mgmt., Pfizer, Prometheus, Reistone, Shire, Takeda, Techlab, Inc.

Employee: Cornerstones Health Inc. (non-profit medical education company), GoDuRn LLC (non-profit medical education company)

Grant/Research Support: AbbVie Pharmaceuticals, Genentech, Janssen, Prometheus Laboratories, Shire, Takeda

Co-Founder: Cornerstones Health Inc. (non-profit medical education company), GoDuRn LLC (non-profit medical education company)

Royalties: Slack Publications

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Pouch or True “Ouch”?Avoid Common Mistakes in the Diagnosis and

Management of Ileal Pouch Disorders

Bo Shen, MDThe Edelman and Jarislowsky Professor of Surgical Sciences

Professor of Medicine and Surgical SciencesDirector of Interventional IBD Center/IBD SectionVice Chair for Innovation in Medicine and Surgery

Columbia University Irving Medical CenterNew York, NY

Indications for Total Colectomy in UC

Shen B (Ed). Pouchitis and Ileal Pouch Disorders Elsevier 2019

Refractory UC Colitis-associated Neoplasia Poor tolerance of medications

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Ileal Pouch-Anal Anastomosis

Shen B (Ed). Pouchitis and Ileal Pouch Disorders Elsevier 2019

J pouch+stapled anastomosis S pouch+handsewn anastomosis

Tip of the “J”

2-cm cuff

2-cm efferent limb

Anal transition zone

Dentate line

Cuff(cancer)

Tip of the “J”

Pouch inlet

Afferent limbJ Pouch

Shen B (Ed). Pouchitis and Ileal Pouch Disorders Elsevier 2019

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Stoma Takedown Site

End-to-end anastomosis(risk of stricture)

Side-to-side anastomosis(risk of staple-line leak)

Shen B (Ed). Pouchitis and Ileal Pouch Disorders Elsevier 2019

Disorders of the Ileal Pouch

FunctionalSurgical/Mechanical

Inflammatory/Infectious

Anastomotic leak Pelvic sepsis Sinus Fistula Strictures Efferent limb syn. Afferent limb syn. Prolapse Pouch folding Twist/volvulus Infecundity Sexual dysfunction Portal vein thrombi Foreign body

Pouchitis Cuffitis Crohn’s dis. Small bowel

bacterial overgrowth

Inflammatory polyps

Irritable pouch syn. Anismus Poor compliance Pseudo-obstruction Megapouch Hypersensitive

suture lines “Pouchalgia fugax”

Neoplastic

Pouch neoplasia Lymphoma Squamous

cell cancer

Systemic/Metabolic

Anemia Bone loss Vit D/B12 def. Renal stone Celiac dis. High PTH

Modified from Shen B, et al. Am J Gastroenterol 2005;100;93-101

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Presenting Symptoms

DiarrheaCrampsUrgency

Incontinence

DyscheziaIncomplete Evacuation

Bloating

FeverNight SweatsTailbone PainLeukocytosis

PouchitisCuffitis

Crohn’s DiseaseIrritable Pouch Syndrome

Pathogen-associated Pouch Inflammation

AbscessSinus/Fistula

StrictureFloppy Pouch Complex

Pouch TwistAnismus

Pouchoscopy Anopouch ManometryBarium Defecography

Pouchoscopy

Pelvic MRIPouchoscopy

Shen B. ACG Virtual Grand Rounds 2020

Gastrograffin Enema for Leaks

Shen B. CUMC 2020

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Stoma Takedown Site

UlcerStricture (end-to-end > side-to-side anastomosis) Fistula (side-to-side anastomosis) “Pseudopouch”:dilated side-to-side anastomosis

EtiologySurgicalCrohn’s disease?

Shen B. ACG Virtual Grand Rounds 2020

BA

C

Stoma Takedown Site

D

Stricture Fistula

Shen B. ACG Virtual Grand Rounds 2020

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“Pseudopouch” at the Stoma Takedown Site

Shen B. ACG Virtual Grand Rounds 2020

Stoma Takedown Site

UlcerStricture Fistula “Pseudopouch”

1st-Line treatmentObserveEndosc.balloon dilation/stricturotomyEndoscopic clippingSurgical conversion to end-to-end

Shen B. ACG Virtual Grand Rounds 2020

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American College of Gastroenterology

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Afferent Limb

Ulcer and inflammationStricture

EtiologyCrohn’s diseaseBackwash enteritis (primary

sclerosing cholangitis)Pre-pouch enteritis Ischemia

Shen B. ACG Virtual Grand Rounds 2020

BA

C D

Afferent Limb

Shen B. ACG Virtual Grand Rounds 2020

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Afferent Limb

Ulcer and inflammationStricture

EtiologyCrohn’s diseaseBackwash enteritisPre-pouch enteritis Ischemia

1st-Line treatmentEndo balloon dilation/stricturotomy

Anti-TNF/UstekinumabBudesonideBudesonideHyperbaric oxygen

Shen B. ACG Virtual Grand Rounds 2020

Inlet

UlcerStricture

EtiologyCrohn’s diseaseSurgical ischemia

Shen B. ACG Virtual Grand Rounds 2020

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B

Owl’s eye

Inlet: Normal and VariationA

C D

Shen B. ACG Virtual Grand Rounds 2020

BA

D

Stricture

InletAfferent Limb

Syndrome

Stricture ProlapseFistulaShen B. ACG Virtual Grand Rounds 2020

C

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Inlet

UlcerStricture

1st-Line treatmentObserveEndo balloon/dilation/stricturotomy

Shen B. ACG Virtual Grand Rounds 2020

Tip of the “J”

Ulcer Fistula

EtiologySurgical ischemia

Shen B. ACG Virtual Grand Rounds 2020

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C

BA

D

Tip of the “J”

Shen B. ACG Virtual Grand Rounds 2020

Tip of the “J”

Ulcer Fistula

1st-Line treatmentObserveEndoscopic clipping

Shen B. ACG Virtual Grand Rounds 2020

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Pouch Body

Pouchitis Floppy pouch complex Prolapse Vertical twist Horizontal twist- “Paperclip” pouch

Shen B. ACG Virtual Grand Rounds 2020

Spectrum of Pouchitis

PouchitisPouchitis

Disease course: Acute Chronic

Pattern: Episodic Relapsing Chronic

Response to antx: Responsive Dependent Refractory

Etiology: Primary Secondary

Etiopathogenesis: Microbiome Immune-mediated Ischemia

Shen B. ACG Virtual Grand Rounds 2020

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Classic Pouchitis

Shen B. Curr Opinion Gastroenterol 2016;32:49-54

Immune-mediated Pouchitis

Shen B. Curr Opinion Gastroenterol 2016;32:49-54

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Primary Sclerosing Cholangitis-associated Pouchitis/Enteritis

Neo-Terminal Ileum Pouch Inlet Pouch

Shen B. ACG Virtual Grand Rounds 2020

Ischemic Pouchitis

Shen B. Curr Opinion Gastroenterol 2016;32:49-54

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Weight Gain and Evolution of Pouchitis

2012 2013 2014 2015 2016

Shen B (Ed). Pouchitis and Ileal Pouch Disorders. Elsevier 2019

Evolving Thoughts on Pouchitis

Bacterial Autoimmune Ischemia Outlet obstruction/Fecal Stasis

Shen B. ACG Virtual Grand Rounds 2020

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Pouchitis

Floppy pouch complexTwisted pouch

? Laparoscopic? Robotic? Effective medical therapy

Observed Trend in Pouch Disorders

2002 2020

Stricture, leak, fistula

Shen B. ACG Virtual Grand Rounds 2020

Fecal Stasis and Dyssynergic Defecation

Shen B. ACG Virtual Grand Rounds 2020

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1st line 2nd line 3rd line

Microbiota-associated Antibiotics(ciproflaxcin, metronidzole,tinidazole, amoxicillin)

Mesalamines;Topically active steroids

Anti-TNF;Anti-integrin;Anti-IL12/23

Immune-mediated BudesonideMesalamines; Oral vancomycin (PSC-enteritis/pouchitis)

Vedolizumab; Immunomodulators

Ustekinumab;Anti-TNFs

Ischemia associated Vedolizumab Hyperbaric oxygen Pouch redo; bariatric surgery?

Structural/functional outlet obstruction-fecal stasis

Endoscopic therapy;Biofeedback

Biofeedback;Endoscopic therapy

Surgery

Treatment of Pouchitis

Shen B. ACG Virtual Grand Rounds 2020

Pouch Prolapse

Shen B (Ed). Pouchitis and Ileal Pouch Disorders. Elsevier 2019

Anterior wall cuffitis

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Pouch Prolapse and Banding Therapy

Shen B. ACG Virtual Grand Rounds 2020

Vertical Twist

Shen B, et al. Clin Gastroenterol Hepatol 2008;6:145-58Shen B, et al. Clin Gastroenterol Hepatol 2008;6:145-58

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Horizontal Twist- ”Paperclip”

Shen B. ACG Virtual Grand Rounds 2020

Anastomosis

StricturePresacral sinusPouch-vagina fistula

EtiologySurgical ischemia

Shen B. ACG Virtual Grand Rounds 2020

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Male: 20 mm balloonFemale: 18 mm balloon

Anastomotic Stricture: Dilation and Stricturotomy

Shen B. ACG Virtual Grand Rounds 2020

Presacral Sinus: Sinusotomy

Lan N, Hull TL, Shen B. Gastrointest Endosc 2019;89:144-56

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Endoscopic Sinusotomy:

Lan N, Hull TL, Shen B. Gastrointest Endosc 2019;89:144-56

Pouch Vaginal Fistula: Differential Diagnosis

At the anastomosis(surgical trauma)

At the anal canal(Crohn’s disease)

At the dentate line(crytoglandular)

Li Y, Wu B, Shen B. Curr Gastroenterol Rep 2012;14:406-13

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Cuffitis and Anal Transition Zone

Classic cuffitis Long cuffitis Ischemic cuffitisCrohn’s diseaseProlapse

remnant ulcerative colitis

Shen B. ACG Virtual Grand Rounds 2020

BA

DC

Cuff and Anal Transition Zone

Anal transition zone

Shen B. ACG Virtual Grand Rounds 2020

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Cuffitis

Ischemia?

Classic cuffitisLong cuffitis

Shen B. ACG Virtual Grand Rounds 2020

Crohn’s Disease and Prolapse in the Cuff

Crohn’s disease

ProlapseShen B. ACG Virtual Grand Rounds 2020

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Cuffitis and Anal Transition Zone

Classic cuffitis Long cuffitis Ischemic cuffitisCrohn’s diseaseProlapse

1st-Line treatmentTopic mesalamine/steroidsAnti-TNFsHyperbaric oxygen?Anti-TNFEndoscopic banding

Shen B. ACG Virtual Grand Rounds 2020

Neoplasia in the CuffA B

Shen B. ACG Virtual Grand Rounds 2020

Majority in the cuff or anal transitional zoneMucosectomy not entirely protectiveYearly surveillance in those with precolectomy colorectal neoplasia

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Stoma takedown site, inlet, tip of the “J”, and anastomosis Common “normal” postsurgical changes: ulcers and stricture Common locations for surgical strictures and acute/chronic leaks

Pouchitis-endoscopic distribution pattern Microbiota vs. Autoimmune vs. Ischemia Fecal stasis-mechanical/functional outlet obstruction

Chronic pouchitis: Vedolizumab Crohn’s disease of the pouch: Anti-TNF > Ustekinumab Cuffitis:

Classic vs. Crohn’s disease vs. prolapse

“Floppy pouch complex” (prolapse, afferent limb syndrome, twist) Endoscopic therapy for stricture, prolapse, & sinus Surveillance pouchoscopy: esp. those with precolectomy colorectal neoplasia

Summary

Shen B. ACG Virtual Grand Rounds 2020

Questions?

Bo Shen, MD

David T. Rubin, MD, FACG

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