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Ileoanal Pouch Frequent Evacuation

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Proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the most popular surgical option when colonic resection is necessary for the treatment of ulcerative colitis (UC) and familial adenomatous polyposis. However, after IPAA, patients will always defecate more frequently than do healthy people. Thus, after proctocolectomy, whether surgical continuity is restored with a terminal ileostomy or with a pouch, daily fecal volumes will be 500 to 700 mL (Metcalf and Phillips, 1986). In health, fecal volumes do not often exceed 200 mL. Moreover, the reservoir of an ileoanal pouch is smaller than that of a normal rectum. IPAA patients complaining of frequent bowel movements must recognize their symptoms in this context; they will never have only one or two solid stools daily! Although patients who complain of frequent defecation after IPAA may have no identifiable pathology, they can, nevertheless, be helped to accept a new lifestyle by being taught to understand the postoperative physiology (Dean and Dozois, 1997; Levitt and Kuan, 1998). Moreover, simple antidiarrheal therapy may significantly improve their lifestyle.

The majority of patients with normally functioning IPAAs should evacuate between four and eight times per day, and once or twice at night. After the initial postoperative phase, IPAA patients should not have extreme fecal urgency and should be able to distinguish between the urges of flatus and feces. Approximately 10 to 20% of IPAA patients experience minor leakage of stool, especially at night, when they may need to wear a pad (Meagher et al, 1998). However, they should be continent during the day. Passage of stools should be painless, should not be accompanied by the need to strain, and should feel complete. In taking the history, the features of "diarrhea" need to be defined precisely; increased fecal frequency needs to be distinguished from urgency, fecal leakage, or gross incontinence.

Importance of an Adequate History

The key to helping IPAA patients who complain of excessive bowel movements is to make an accurate diagnosis. Disorders of the pouch outlet (the anal sphincter segment), the pouch itself, or of the ileum proximal to the pouch may be the cause of an increased stool frequency. In many patients, a careful history will provide the astute clinician with a short list of diagnostic possibilities. The most important element of the history is to determine precisely what it is about pouch function that is unsatisfactory to the patient. A typical complaint might be of having to "go all the time." The physician must then determine exactly what the patient means. Is the patient having true watery diarrhea, or is the main complaint urgency or leakage? Is an inability to completely empty the pouch with consequent leakage of retained stool the real problem? Careful evaluation of the patient's complaints, in conjunction with knowledge of the likely causes of symptoms, should point to the correct diagnosis. In practice, it is advantageous to divide the clinical picture into those patients who are distressed soon after surgery from those who present later.

Excessive or Uncontrolled Bowel Movements with Newly Formed Pouches General Approach

Problems occurring soon after the operation (0 to 6 months) present more often to surgeons, but gastroenterologists need also to be aware of these issues (Table 90-1). It is helpful to

consider the time of onset of increased bowel frequency in relation to the age of the pouch. The first few weeks after closure of the temporary ileostomy and restoration of the fecal stream to the pouch are often marked by frequent loose stools, to which the pouch and the patient must be helped to adapt. The sensation of a full ileal pouch may be qualitatively different from that of a full rectum, and patients must learn to recognize those sensations that indicate that they need to empty the pouch.

Thus, some patients, if they have not received adequate preoperative counseling, have unrealistic expectations about the functional outcomes after "curative" IPAA surgery. They need to be educated; they will always have a high fecal volume, and their stools will never be fully formed. Moreover, it is important to reassure patients that a healthy pouch and anal sphincter will gradually adapt postoperatively and, consequently, bowel function should be expected to improve. In addition to reassurance and education, simple measures can significantly help patients with a new IPAA to learn to compensate. For example, fiber supplements, such as methyl-cellulose or psyllium, of 1 g in a large glass of water once or twice per day, will increase the consistency of stools. Loperamide 2 to 4 mg taken 30 minutes before meals will reduce postprandial urgency. Although many IPAA patients find that certain foodstuffs increase stool, it is not particularly helpful to counsel individual patients on the consumption of specific items of food. One patient's experience is likely to differ so much from another's. Rather, patients should experiment, be moderate, and be guided by their own experience in choosing a lifestyle that minimizes any negative impacts of the pouch. It is important not to promote compulsivity in dietary or other habits.

Although many patients complaining of excessive bowel frequency, diarrhea or leakage soon after IPAA will ultimately be found not to have a structural/organic basis, one must not overlook the possibility of a postoperative complication. Small bowel obstruction occurs in the first weeks after pouch formation in 6 to 20% of patients. Though pain is the expected symptom of obstruction, increased fecal volumes can be the major complaint.