Authors' reply: Dysbiosis and pouchitis (Br J Surg 2006; 93: 1325–1334)

Extract

Sir

We are pleased to see that our review article on ‘Dysbiosis and pouchitis’ achieved the desired aim and stimulated thought and debate amongst our colleagues in London. However, they appear to have missed the point of the algorithm that was constructed ‘to aid management and suggest a structured approach for future research’ as stated, in bold, at the start of the article. Further, we would take issue with a number of points raised by Dr McLaughlin et al.

Pre-pouch ileitis is a recognized but not well worked-out condition as described by Bell et al.¹. Afferent limb inflammation and ulcers are associated with a higher likelihood of Crohn's disease. If biopsies from the area do not confirm Crohn's disease, then treatment should be directed towards the reduction of inflammation. The evidence for use of oral or topical steroids in this group of patients is lacking, but the evidence for use of antibiotics is no better. Dr McLaughlin et al. suggest that topical steroids are an inappropriate treatment. This is at odds with Bell's group (which includes a number of McLaughlin's co-authors) who obtained responses with topical steroids. Topical preparations may not always reach the affected pre-pouch area but that should not preclude an attempt.