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You may be one of those that needs to stay on it for a longer period of time at the lowest dose to maintain pouch healthy. It may mean cycling different antibiotics. Maybe you could try Xifaxin to see if that works. And maybe you don't have to stay on antibiotics for the very long term but maybe you need a longer course of them while adding a very good probiotic.

I'm sorry that it seems to be backtracking.

kathy Wink
Plus, sometimes 10 days just is not long enough. My standing order of Flagyl for my occasional pouchitis is for 10 days, and may repeat another 10 days if needed. If that doesn't do it, then I need to be seen. Once I had to be on it for nearly six weeks. Turned out I was having NSAID induced pouchitis that time and things simmered down once my arthritis was handled with non-NSAID treatment.

Jan Smiler
I had pouchitis right away and eventually figured it out. Cipro was a wonderful thing for me, too. The only antibiotic that really made me feel good. I took it on and off for about three months until I finally went off it for good. Or at least for now. It's been about 5 months. One thing that helps me is taking pysillium fiber several times a day with lots of water. any time I get the gas and feel like the pouchitis is coming back, I load up on the stuff and it has always made it stop. Good luck! Don't get too discouraged. I was always just so thankful that the cipro gave some relief and now it's been 5 months with few problems!
Hi Holly,

I am in much the same boat. In fact I will be calling my doctors' office for another round of cipro today. I was on it for a month last time and the pouchitis came back. I suspect I will be on it for at least another month this time 'round.

The only thing I plan to do different is hit the probiotics really hard once I am off the cipro. I decided to pursue this strategy after reading a journal article a couple of days ago concerning a male patient experiencing recurring pouchitis. They decided to treat it with probiotics (VSL) after a round of antibiotics. The first experience failed. After two months on antibiotics they tried again but increased the dose (two packets twice per day). He has been in remission ever since.

So I'm going to try that approach. Probably throw in a probiotic enema for good measure. Really don't want to be antibiotic dependent if it can be avoided. I will keep you posted.
holly, the same thing happened to me the first time on cipro. after being on it for 10 days and then another 2 weeks like you, i started to taper off instead of doing cold turkey. i went from one pill twice a day to one pill once a day and then 1/2 a pill once a day. this did the trick for me for quite awhile. not sure this works for everyone, but it did for me. and as i decreased the cipro, i increase the probiotic.
I believe that tapering off antibiotics, and simultaneously increasing probiotics as you wean off antibiotics, is a very good strategy. I am currently doing a variation of this as the program of alternating cold turkey "no antibiotic weeks" with weeks of antibiotics did not work. What I did notice through this experiment, however, is that I could go longer before experiencing symptoms if I consumed large amounts of probiotics during the cold turkey no antibiotic weeks. However, just probiotics and no antibiotics as an extended treatment has not worked in my case. I am dependent on some level of antibiotics, and we are in the process of experimenting to see what the bare minimum levels of various rotating antibiotics, in combination with probiotics and Entocort, is needed to achieve maintainence. The current experiment is reducing from 1000 cipro and 1000 mg flagyl to 1000 mg cipro and 500 flagyl. In the past I could not get below the 750/750 threshold so this is the new twist my GI wants to try.

I am doing this until Saturday at which time I fly to Key West, Florida, for a holiday vacation and since I will be out in the sun, I plan to rotate to xifaxin starting Saturday (1100 mg per day). Cipro is a drug that seriously sensitizes your skin to sunlight and you will burn much faster. So that is why I am taking it this week and not during my Florida vacation week.

This is a difficult trial and error process. I have spent 17 years at it and still have not figured it all out.
Last edited by CTBarrister
Thanks for your update ct and Holly. I have included an update on my situation here as I am also attempting to end a round of cipro. This is long if you are interested.

I'm on my way home from Cleveland after seeing Bo Shen and Dr Remzi for a SSO for pouch advancement surgery for chronic cuffitis coupled with chronic pouchitis.

I was told I will need Canasa for life as even with it I still have inflammation even though I am currently asymptomatic. Most of my inflammation is in the ATZ. This obviously concerns me as prior to this surgery I never used suppositories for my UC treatment in 25 years. It was suggested  to discontinue pentasa as it only works in the small bowel. This does not make sense to me either as my small bowel obviously has been giving me issues re pouchitis in my pouch. He did indicate my surgeon did a very nice job on my pouch and it looks great. The biopsies have not come back at this time. It appears there was no visible pouchitis but I have been on cipro for about two weeks and this is the best my pouch has behaved since takedown 18 months ago.


Dr. Shen told me I could use steroid rectal suppositories for life which is something both my Gi and surgeon do not agree with due to compromising the tissue. He indicated if the cuffitis is refractory he often injects steroids into the cuff and my current Gi is trained to do this (under him I might add). The issue with this is the treatment can help anywhere from two weeks to three months. He also indicated 10% of people with chronic cuffitis lose their pouch.

It seems my issue is a stubborn recurrent stricture at the anastomoses site where it cannot be determined if it was due to surgical technique and tension when creating the anastomoses which could be causing ischemia at the anastomoses site or from residual UC. He then contradicted himself by indicating I had no separation etc at the site which would have indicated tension when creating anastomoses. This is giving me most of my issues including most likely fecal status causing pouchitis in my distal pouch.

As far as pouch advancement surgery goes, Remzi indicated all surgeons have their own way of doing it snd he would more than likely not do it without a diverting ostomy, something my original surgeon felt pretty comfortable he would not need to do and could pretty much do the surgery all transanally. Now I am starting to wonder if my surgeon was just going to scrape the cuff and not detach and advance the pouch as his original method and if he did not feel this would work while in there, would then advance the pouch. This is another confusing issue for me as I would rather have the ostomy and be safe for healing than not have and then need another operation to get one if I have infection issues etc when healing. I communicated this to my original surgeon who told me not to worry about the ostomy and if needed we would deal with that after (did not leave me feeling comfortable). Dr. Remzi laid it all on the table for me and basically wanted me to be fully aware
of what to expect with a three month diverting ostomy and possible midline incision and    
hopefully going in on the old ostomy site if possible. HE indicated the pain factor is very high for the surgery and if he did not do an I would most likely be begging him for one after due to the pain factor. e also indicated modestly speaking he does 1-2 of these a week. My original surgeon told me 2% of people end up with chrchronic cuffitis( I think this is understated) and yet he has done several dozen pouch advancement surgeries. Somehow those numbers just do not add up for me. I also believe that my very narrow pelvis has been an issue for me when my anastomisis was created. I know the opening is the size of a straw which is what has caused so many issues for me and it has been dilated at least four times or more.

My surgeon mentored Dr Remzi and Remzi has high regard for him and was going to communicate his findings with him. I don't want my surgeon to play hero. I just want The most conservative approach possible to save my pouch if I do need this surgery. At the moment I am overwhelmed and not feeling like I am in a better position than when I came here and hate feeling like a medical experiment. On top of that they found a blood clot in a back artery and were again concerned about my thickened endometrial stripe where they suggested a biopsy be done again. So with a tumor in my gallbladder they are watching, numerous cysts on my liver, calcifications in both breasts where I need a mammo and ultrasound this week, fibroid tumors and uterine issues, low potassium and continual jpouch issues, I am feeling pretty discouraged right now to say the least.

The plan is to try and get off the cipro snd see what happens. If the pouchitis flares I'm moving to rotating antibiotics and obviously will continue with Canasa as instructed. I guess the good news is my cuff inflammation is now a 2/3 versus an 8/10 out of 10 as it was in October at my last scope and my frequency has slowed wAy down with the cipro and I just feel better. I have no fistulas or sinus tracts, no crohns suspected and my pouch looks good. Now I am keeping my fingers crossed the bottom does not fall out within the next few days and will be communicating with all these guys and will post updates if anyone is interested. I hope you guys are doing ok.
Jeane,

Gee, this sounds rough, and you really must feel like you are circling the drain right now. But still, if you are anything like me, you will appreciate Dr. Remzi's candor, and not sugar coating the possible outcomes. Knowing what may lie ahead may not be pleasant, but at least you can process it, then make some decisions....move forward fully informed.

Regarding the issue of ischemia, I think what he meant was that even though you did not have the cardinal signs of separation of the anastomosis, you could still have had tension on the suture line and resulting ischemia. Like anything else, it is seldom an "all or nothing" scenario, and occur in varying degrees. A blood clot in a feeder artery would be a sign of ischemia, along with your chronic symptoms. Of course, UC in the retained rectal cuff could be the sole cause too, and that is why they are scratching their heads. They don't want to subject you to more surgery if it would not likely result in a better function. But, you are being evaluated and advised by the best and most experienced, so take comfort in that. Still, it must be quite difficult to have all these multiple issues going on simultaneously!

I recommend you take a "spa day" where you pamper yourself indulgently, try to relax, then ponder all this in a few days. Hopefully, then you will be able to have a good handle on all of this. You seem like a strong person...

Jan Smiler
Thank you for your replies and prayers. I keep trying to focus on the positive in my life like a wonderful husband, great kids and devoted family and friends. Seeing how sick some unfortunate people at Cleveland are really puts things in perspective. I just keep on pushing through and refuse to let this keep me from living life. If it becomes too much a burden I will have the pouch removed. I'm going to be 50 this year. I do think my vanity years are pretty much behind me and really need to focus on quality of life now.
jeane.. I second jan's vote that you deserve an immediate spa day.
once things settle down a bit, everything may not quite seem so overwhelming, and you will be able to proceed with confidence whichever direction you take.
And yes, Dr. Remzi is very honest and up front about things. Also, he is very conservative which is probably why he is such a successful surgeon. When he and Dr. Shen decided my pouch was a complete failure, Dr. Remzi would do nothing but divert it. He said I was way too sick to undergo a major operation of a jpouch redo or a jpouch excision at that time. He made me wait minimum of six months before he would touch me again.
fyi.. Dr. shen once told me that the most challenging jpouch creation operations are in small petite women,sounds like you and I both fall in that category.

So for you... off to the spa.. and then just try your best to not put all of your issues in a big bucket and look at the bucket. Just one thing and one day at a time.
and yes.. its all about quality of life.
For some reason I cannot edit my message while on my iPhone.

Holly, I mix my Vsl with yogurt, applesauce or any liquid. Take it two to three hours before or after antibiotic dosage as the meds negate the probiotic effect.

CT... Enjoy your trip!

Jan.... thanks for your input. Always look forward to your take on things and your comments.
Jeane,

Best wishes on that regimen.....I am told the same thing as far as spacing probiotics between antibiotic dosages. Some Docs will tell you the effect of probiotics is totally negated by strong wide spectrum antibiotics like cipro but if you are weaning off a higher dose I don't think it is true. I have also personally noticed delayed pouchitis symptom onset when using probiotics. You may need to stick with a regimen for a while before noticing a pattern.

Anyway I wish you luck with the VSL.

I am looking forward to the Key West trip, I have actually never been there before, but I can mark it down as another island my Pouch has travelled to! I am taking my Dad for his 75th birthday and then we go back to Bradenton for Thanksgiving. We are taking the high speed ferry to Key West.
CT,
You will love Key West. My husband and I went there about 15 years ago (I was much younger). It is a very lively town. Don't expect to sleep much while there. Duval street is fun and you will enjoy the pier!! It is very unassuming when you first enter Duval street and may take you by surprise (honky tonk feel), but once you get into the groove of the town, you will be having a great time! I hope your pouch cooperates!!!
quote:
I hope your pouch cooperates!!!


It better, I am not going to tolerate any misbehavior!!!!!!!!! Wink

I am staying at a hotel located on Truman Street near its intersection with Duval, in the center of town. Very much looking forward to the trip. I timed my rotations so I can be on Xifaxin due to the lack of sun/photosensitivity issues with Xifaxin plus my last rotation with Xifaxin was really, really good, so hopefully more of the same while I am in Key West. I am packing the usual assortment of backup remedies like Pepto Bismol as well.
Subzero,

I have actually done copious research on Yelp and Trip Advisor regarding Key West restaurants and cuisine. There is a distinctive Caribbean flavor to the local cuisine and it is something I am used to having been to many Caribbean destinations. However I actually already handpicked some restaurants for me and my Dad to eat at, because I liked their selection of salads and/or seafood dishes which included broiled seafoods and stone crabs, which are now in season in Southern Florida and which I LOVE. No sauce necessary with stone crabs.

On vacation I eat more than normal usually, but I am careful and will bring Pepto Bismol and the usual supply of imodium and anti-spasmodics in case I run into any issues.

I should note that although I have never been to Key West, I am no stranger to the Sarasota/Bradenton area of the Gulf Coast. My family has owned property down there since the mid 1970s and I have vacationed there annually since the early 1970s. For whatever reason, we never went to Key West. That will change this weekend.
Last edited by CTBarrister
liz-

My parents owned condos on Longboat Key going back to the 1970s, eventually sold those properties, and now live full time on the intercoastal waterway in Bradenton, in a condo that is right on the water and looks out at Anna Maria Key. I am very familiar with Sarasota, St. Armand's and Longboat and Siesta Keys. I once ate breakfast at the Broken Egg on Siesta Key and saw Dick Vitale the college basketball announcer in the restaurant and said hello to him. He has a home in the area.

Key West, however, will be a new experience which I am looking forward to.
HOLLY,I HOPE YOU ARE FEELING BETTER,THANKS TO THE AMAZING ADVICE OF JEANE AND SUEBEAR,I DID NOT WAIT UNTIL 12/05/12 TO SEE MY COLON AND RECTAL SURGEON CALLED HIS OFFICE AND THEY PUT ME ON CIPRO 500MG I TIME DAILY,I BELIEVE THEY WERE CONCERNED THAT ALONG WITH THE LEAKAGE I WAS ALSO EXPERIENCING FEVER OF 100-101.THEY ALSO ADVISED ME TO SEE GI DR BRIAN BOSWORTH OF NEW YORK PRESBYTERIAN,HAS ANYONE HAD EXPERIENCE WITH DR BOSWORTH? THANKS AGAIN TO SUEBEAR AND JEANE YOU ARE THE BEST PAULN
Holly and Jeane -

It sounds like we are all having the same issues! I believe we are all near each other in the takedown date. My date was 4/30. I am on steroidal suppository and a antispasmodic drug, now. I go back to GI and surgeon in two months. My surgeon told me about another surgery to hand stitch the anus (what is left) to the j pouch. To get rid of what is still diseased. Certainly not ready for another surgery. My body either is in pain from the anus or just aches. This cold weather isn't helping me out. I long for the heat and sun! I so, am trying to get healthy but I don't every think I will feel good at any time. Just keep getting use to being in some type of pain. Eeker I hope you both are doing better!

Roberta

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