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Psychological Factors in Irritable Pouch Syndrome and Other Pouch Disorders

Makkar, Rohit MD*; Graff, Lesley A. PhD; Bharadwaj, Shishira MD*; Lopez, Rocio MS, MPH*; Shen, Bo MD*

doi: 10.1097/MIB.0000000000000552
Original Clinical Articles

Background: Restorative proctocolectomy with ileal pouch–anal anastomosis is the surgical treatment of choice for patients with medically refractory ulcerative colitis. Postsurgery, functional and inflammatory complications of the ileal pouch often occur. Our previous study demonstrated that irritable pouch syndrome (IPS) is associated with the use of antidepressants or anxiolytics, suggesting an influence of psychological factors on patients' symptoms. The aim of this study was to identify the specific psychological factors and coping strategies in patients with functional (IPS) and inflammatory (pouchitis, cuffitis, Crohn's disease of the pouch) pouch disorders.

Methods: Consecutive patients with functional pouch disorders (IPS), inflammatory pouch conditions, and asymptomatic ileal pouch–anal anastomosis patients were surveyed using validated measures of quality of life (the Cleveland Global Quality of Life [CGQL] and Irritable Bowel Syndrome–Quality of Life [IBS-QOL]), daily functional impairment (WSAS), coping mechanisms (brief COPE) and anxiety/depression (DASS-21).

Results: Of 243 patients surveyed, 157 (64.6%) completed the surveys, of whom 137 (56.4%) met inclusion criteria and were included in the analysis. Sixty-one percent of respondents had pouch inflammation (pouchitis, N = 35; cuffitis, N = 14; and Crohn's disease of the pouch, N = 35), 20% had IPS (N = 27) and 19% (N = 26) had asymptomatic normal pouches. The age of participants ranged from 20 to 79 years with the mean ages of patients with normal pouches, IPS and inflammatory pouch conditions being 51.7 ± 12.5, 47.1 ± 15.0, 47.2 ± 15.1 years, respectively. Patients with IPS were more likely to be taking antidepressants, anxiolytics, or narcotics than the other groups (P < 0.04). Patients with IPS or inflammatory pouches had significantly poorer quality of life (CGQL, P < 0.001; IBS-QOL, P < 0.003) than those with asymptomatic pouches, with differences particularly in the areas of food avoidance, activity interference, and sexual difficulties. Those with IPS (median = 11; interquartile range [IQR]: 3–19) or inflammatory pouch conditions (median = 7; IQR: 3–18) had a greater impairment in the domains of daily functioning related to the pouch condition than those with normal pouches (median = 1.5; IQR: 0–6; P = 0.003). The mean depression symptom scores were significantly higher in the IPS group than in the normal pouch group (11.7 ± 9.7 versus 4.4 ± 6.2; P = 0.012).

Conclusions: IPS patients were more likely to have depressive symptoms and had a greater amount of impairment in daily functioning related to their pouch condition. Additionally, patients with functional pouch disorders are more likely to be concurrently treated with antidepressants, anxiolytic or narcotic agents than those with inflammatory pouches or normal pouches.

Article first published online 21 September 2015.Supplemental Digital Content is Available in the Text.

*Center for Inflammatory Bowel Diseases, Digestive Disease Institute, The Cleveland Clinic Foundation, Cleveland, Ohio; and

Department of Clinical Health Psychology, University of Manitoba, Winnipeg, Manitoba, Canada.

Reprints: Bo Shen, MD, Digestive Disease Institute, A31, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195 (e-mail:

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

The study was supported by an research grant from the American College of Gastroenterology (to R. M.). B. Shen is supported by the Ed and Joey Story Endowed Chair. B. Shen is a consultant for Jassen and Abbvie. The remaining authors have no conflicts of interest to disclose.

Received June 08, 2015

Accepted June 17, 2015

© Crohn's & Colitis Foundation of America, Inc.
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