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Introduction: Pouchitis is one of the most common long term complications after ileal pouch anal anastomosis (IPAA) for ulcerative colitis (UC). One common theory of pathogenesis is bacterial overgrowth in the pouch. Proton pump inhibitors (PPI) and H2 antagonists (H2) are commonly used in the general population for control of gastric acid. The change in pH of the stomach effluent caused by anti-acid therapies may lead to alteration of the enteric bacteria population in the gastrointestinal tract and is known to be associated with small bowel bacterial overgrowth. We hypothesize that chronic use of PPI or H2 antagonists will alter the incidence of pouchitis after IPAA for UC.

Methods: Patients who had undergone IPAA for UC at least 2 years ago were identified from our familial inflammatory bowel disease registry. They were classified as having no history of pouchitis (no attacks of pouchitis since IPAA 2 or more years ago) or pouchitis (documented episodes of pouchitis in the medical record by biopsy and/or endoscopy and response to antibiotic therapy). Patients were then contacted and questioned about use of PPI, H2, and antacids. PPI and H2 were classified as never used, daily use, or occasional use (1/month-2/week). Antacid use was classified as less or more than once a week. Patients were also questioned about known risk factors for pouchitis including tobacco use, extraintestinal manifestations of IBD, primary sclerosing cholangitis (PSC) and the use of NSAIDS. Data on the use of fiber supplementation, antidiarrheal medications, probiotics, and immunosuppressive medications was also obtained. Two-sided Fisher’s exact test was used to compare groups.

Results: 85 patients were identified that had complete PPI/H2 data available. The data is shown in the table. There was a statistically significant increase in the use of daily PPI/H2 in patients without pouchitis. There was also a statistically significant increase in the use of antacids more than one time per week in patients without pouchitis. There was no association between the use of PPI/H2 and the use of antacids. Occasional use of PPI/H2 did not alter the rate of pouchitis. None of the other variables were statistically significantly different between groups (see table).

Conclusions: 1. Our data suggests that the daily use of PPI or H2 antagonists is associated with a decreased risk of pouchitis and may be protective against pouchitis in patients with IPAA for UC. 2. Occasional use of these agents did not seem to afford the same protection. 3. Regular antacid use provided similar protection as PPI and H2 antagonists. 4. This data suggests that altering the acid content/pH of the GI tract may influence the development of pouchitis, possibly by altering the bacterial flora. Further work to identify the changes in fecal flora is warranted.

	No Pouchitis	Pouchitis	p value
PPI/H2 antagoinist: Never (Y/N)	26/20	28/11	0.178
PPI/H2 antagoinist: Daily (Y/N)	15/31	5/34	0.041
PPI/H2 antagoinist: Occasional (Y/N)	5/41	6/32	0.534
Antacid use (<1/week / >=1/week)	22/12	24/3	0.0381
PSC (Y/N)	5/25	2/24	0.436
Extraintestinal manifestations (Y/N)	14/21	14/13	0.443
Smoking			0.568
Never	25	18
Quit	7	8
Current	3	1
Use of Probiotics (Y/N)	7/37	11/26	0.182
Use of NSAIDS > 1/week (Y/N)	14/21	8/19	0.435
Use of fiber supplementation (Y/N)	7/28	8/19	0.257
Use of anti-diarrheal medication (Y/N)	19/16	14/13	1
Use of immunosuppressive medications (Y/N)	5/30	4/23	1