<clinical_study>
  <!-- This xml conforms to an XML Schema at:
    https://clinicaltrials.gov/ct2/html/images/info/public.xsd -->
  <required_header>
    <download_date>ClinicalTrials.gov processed this data on September 20, 2023</download_date>
    <link_text>Link to the current ClinicalTrials.gov record.</link_text>
    <url>https://clinicaltrials.gov/ct2/show/NCT02201186</url>
  </required_header>
  <id_info>
    <org_study_id>H13-02740</org_study_id>
    <nct_id>NCT02201186</nct_id>
  </id_info>
  <brief_title>To Determine the Effect of Honey Enema in the Treatment of Patients With Acute Pouchitis</brief_title>
  <official_title>To Determine the Effect of Honey Enema in the Treatment of Patients With Acute Pouchitis (Pilot Study)</official_title>
  <sponsors>
    <lead_sponsor>
      <agency>Dr. Carl J Brown</agency>
      <agency_class>Other</agency_class>
    </lead_sponsor>
    <collaborator>
      <agency>Canadian Association of General Surgeons</agency>
      <agency_class>Other</agency_class>
    </collaborator>
  </sponsors>
  <source>St. Paul's Hospital, Canada</source>
  <oversight_info>
    <has_dmc>No</has_dmc>
  </oversight_info>
  <brief_summary>
    <textblock>
      Patients with a bowel condition called ulcerative colitis have bowel surgery in which a&#xD;
      portion of their bowel is removed and the reconnected at the small bowel to the anus.&#xD;
      Sometimes, after the surgery, this connection part, the pouch, would be inflamed in a&#xD;
      condition called Acute Pouchitis. Physicians usually treat them by prescribing antibiotics;&#xD;
      however, some patients do not respond and need additional surgery. In this study, we will&#xD;
      test an alternative treatment for this complication by performing manuka honey enemas twice a&#xD;
      day for 30 days. This is a pilot study and ten patients will undergo enema treatment.&#xD;
    </textblock>
  </brief_summary>
  <detailed_description>
    <textblock>
      Pouchitis is the most common long-term complication of ileal pouch-anal anastomosis (IPAA) in&#xD;
      ulcerative colitis (UC). Pouchitis is defined as a clinical syndrome of watery, frequent, at&#xD;
      times bloody stool accompanied by urgency, incontinence, abdominal cramps, malaise, and&#xD;
      fever. The PDAI (Pouchitis Disease Activity Index) provides a standardized definition of&#xD;
      pouchitis based on clinical, endoscopic, and histological markers. Pouchitis is defined as a&#xD;
      score ≥ 7 and remission as a score &lt; 7. Recently, the modified Pouchitis Disease Activity&#xD;
      Index has been used to omit biopsy and histology from the standard PDAI. Omission of&#xD;
      endoscopic biopsy and histology from the PDAI simplifies pouchitis diagnostic criteria,&#xD;
      reduces the cost of diagnosis, and avoids delay associated with determining histology score,&#xD;
      while providing equivalent sensitivity and specificity. Patients with acute pouchitis are&#xD;
      managed routinely by antibiotics such as Ciprofloxacin and Metronidazole. This treatment has&#xD;
      some side effects, is expensive, and fails to respond in some patients. Some patients who are&#xD;
      unresponsive to antibiotic therapy will need to have a pouchectomy and ileostomy done.&#xD;
&#xD;
      On the other hand, multiple studies have shown that honey, especially manuka honey has&#xD;
      anti-inflammatory, anti-bacterial, wound healing, and anti-ulcerous effects. Phenolic&#xD;
      compounds in honey, such as flavonoids, have been reported to exhibit a wide range of&#xD;
      biological activities, including antibacterial, antiviral, anti-inflammatory, antioxidant,&#xD;
      antitumor, anti-allergic, and vasodilatory actions. This honey can clear infection, remove&#xD;
      malodour, reduce inflammation and pain, cause edema and exudation to subside, and increase&#xD;
      the rate of healing by stimulation of angiogenesis, granulation and epithelialization.&#xD;
&#xD;
      Due to problems associated with antibiotic therapy, such as side effects, cost and failure of&#xD;
      some patients to respond, we are looking to find an alternative method for treating acute&#xD;
      pouchitis. This study is designed to determine the effect of manuka honey on symptoms, signs&#xD;
      and pathology of acute pouchitis patients. We will select patients with any of the signs and&#xD;
      symptoms of pouchitis, such as abdominal pain, fever, frequency or urgency of defecation.&#xD;
      Proctoscopy will be done before and after honey enema and the modified PDAI scores will be&#xD;
      determined. The manuka honey enema will be administered twice a day, for one month. Then, the&#xD;
      modified PDAI scores before and after completion of honey enema treatment of these patients,&#xD;
      will be compared.&#xD;
&#xD;
      We know that bacterial overgrowth, ischemia, faecal stasis, recurrence of ulcerative colitis&#xD;
      in the pouch, or possibly a novel third form of inflammatory bowel disease, are possible&#xD;
      etiologies of pouchitis. We also know that manuka honey has anti-inflammatory and&#xD;
      anti-bacterial properties. Some studies demonstrate that honey is effective in the treatment&#xD;
      of induced colitis in animal models. However, there is no current literature on the effect of&#xD;
      honey on colitis or pouchitis in humans. Based on the aforementioned properties of honey, and&#xD;
      considering the probable etiologies of pouchitis, we expect that these patients will respond&#xD;
      to this method of treatment.&#xD;
&#xD;
      Some research has been done on the effect of honey in the treatment of colitis in animal&#xD;
      models, but there have been no clinical studies that have assessed this treatment in&#xD;
      pouchitis, or even colitis, in humans. Considering the etiologies of pouchitis, such as&#xD;
      inflammation and bacterial overgrowth, and considering the main effects of honey, such as&#xD;
      anti-bacterial and anti-inflammatory efficacy, honey enema may be useful in the treatment of&#xD;
      pouchitis. Our study is trying to determine the effect of manuka honey enema in the treatment&#xD;
      of acute pouchitis. We will try to determine whether the honey enema helps to decrease&#xD;
      inflammation and infection in the pouch, and thereby provide us with a safe alternative&#xD;
      method for the treatment of pouchitis.&#xD;
&#xD;
      In this pilot study, we will select patients who have any of the signs and symptoms of acute&#xD;
      pouchitis, such as abdominal pain, fever, frequency, or urgency of defecation. Proctoscopy&#xD;
      will be performed on these patients. Ten patients with modified PDAI score ≥ 7 will receive&#xD;
      honey enemas twice a day for one month. We chose a twice daily enema regimen, because&#xD;
      patients with inflammatory bowel disease usually receive their enemas twice a day. We expect&#xD;
      one month to be enough time, because the duration of antibiotic therapy for patients with&#xD;
      acute pouchitis is about one month. Then, the PDAI score of these patients, before and after&#xD;
      honey enema will be compared.&#xD;
    </textblock>
  </detailed_description>
  <overall_status>Completed</overall_status>
  <start_date>October 2014</start_date>
  <completion_date type="Actual">November 2015</completion_date>
  <primary_completion_date type="Actual">November 2015</primary_completion_date>
  <phase>Phase 2</phase>
  <study_type>Interventional</study_type>
  <has_expanded_access>No</has_expanded_access>
  <study_design_info>
    <allocation>N/A</allocation>
    <intervention_model>Single Group Assignment</intervention_model>
    <primary_purpose>Treatment</primary_purpose>
    <masking>None (Open Label)</masking>
  </study_design_info>
  <primary_outcome>
    <measure>PDAI score</measure>
    <time_frame>within 2 weeks after the 30-day treatment</time_frame>
    <description>PDAI score is a criterion for defining pouchitis. A PDAI score will be calculated from a proctoscopy assessment before treatment. Within two weeks after the treatment, another proctoscopy will be performed to determine the post-treatment PDAI score to see if there is a decrease in PDAI score for the study patients.</description>
  </primary_outcome>
  <secondary_outcome>
    <measure>Composite complications</measure>
    <time_frame>throughout the 30-day honey enema treatment and within two weeks of the treatment completion date</time_frame>
    <description>includes stool frequency (no different, 1-2 stools/day &gt; postoperative usual, 3 or more stools/day &gt; postoperative usual), rectal bleeding (none or rare or present daily), fecal urgency or abdominal cramps (none, occasional or usual), presence of fever (temperature &gt;37.8° C), abdominal pain (no, occasional or usual) and readmission to hospital for any reason.</description>
  </secondary_outcome>
  <number_of_arms>1</number_of_arms>
  <enrollment type="Actual">10</enrollment>
  <condition>Pouchitis</condition>
  <arm_group>
    <arm_group_label>manuka honey enema treatment</arm_group_label>
    <arm_group_type>Experimental</arm_group_type>
    <description>Study patients diagnosed with acute pouchitis after bowel surgery for ulcerative colitis will perform manuka honey enemas twice a day for 30 days.</description>
  </arm_group>
  <intervention>
    <intervention_type>Other</intervention_type>
    <intervention_name>Manuka honey enema</intervention_name>
    <description>Study patients diagnosed with acute pouchitis will perform manuka honey enemas twice a day for 30 days.</description>
    <arm_group_label>manuka honey enema treatment</arm_group_label>
  </intervention>
  <eligibility>
    <criteria>
      <textblock>
        Inclusion Criteria:&#xD;
&#xD;
          -  have given written informed consent&#xD;
&#xD;
          -  have been diagnosed with ulcerative colitis&#xD;
&#xD;
          -  have had total colectomy and ileal pouch anal anastomosis before&#xD;
&#xD;
          -  have presented with signs and symptoms of pouchitis within the last two months of&#xD;
             signing the informed consent&#xD;
&#xD;
          -  PDAI of greater than or equal to 7&#xD;
&#xD;
        Exclusion Criteria:&#xD;
&#xD;
          -  patients who are unable to perform enema by themselves&#xD;
&#xD;
          -  patients with an allergy to honey&#xD;
      </textblock>
    </criteria>
    <gender>All</gender>
    <minimum_age>19 Years</minimum_age>
    <maximum_age>65 Years</maximum_age>
    <healthy_volunteers>No</healthy_volunteers>
  </eligibility>
  <overall_official>
    <last_name>Carl Brown</last_name>
    <role>Principal Investigator</role>
    <affiliation>Saint Paul's Hospital</affiliation>
  </overall_official>
  <location>
    <facility>
      <name>Saint Paul's Hospital</name>
      <address>
        <city>Vancouver</city>
        <state>British Columbia</state>
        <zip>V6Z 1Y6</zip>
        <country>Canada</country>
      </address>
    </facility>
  </location>
  <location_countries>
    <country>Canada</country>
  </location_countries>
  <reference>
    <citation>Sandborn WJ, Tremaine WJ, Batts KP, Pemberton JH, Phillips SF. Pouchitis after ileal pouch-anal anastomosis: a Pouchitis Disease Activity Index. Mayo Clin Proc. 1994 May;69(5):409-15. doi: 10.1016/s0025-6196(12)61634-6.</citation>
    <PMID>8170189</PMID>
  </reference>
  <reference>
    <citation>Shen B, Achkar JP, Connor JT, Ormsby AH, Remzi FH, Bevins CL, Brzezinski A, Bambrick ML, Fazio VW, Lashner BA. Modified pouchitis disease activity index: a simplified approach to the diagnosis of pouchitis. Dis Colon Rectum. 2003 Jun;46(6):748-53. doi: 10.1007/s10350-004-6652-8.</citation>
    <PMID>12794576</PMID>
  </reference>
  <reference>
    <citation>Kafadar I, Moustafa F, Yalcin K, Klc BA. A rare adverse effect of metronidazole: nervous system symptoms. Pediatr Emerg Care. 2013 Jun;29(6):751-2. doi: 10.1097/PEC.0b013e318294f389.</citation>
    <PMID>23736071</PMID>
  </reference>
  <reference>
    <citation>Makhdoom A, Khan MS, Lagahari MA, Rahopoto MQ, Tahir SM, Siddiqui KA. Management of diabetic foot by natural honey. J Ayub Med Coll Abbottabad. 2009 Jan-Mar;21(1):103-5.</citation>
    <PMID>20364754</PMID>
  </reference>
  <reference>
    <citation>Kilicoglu B, Gencay C, Kismet K, Serin Kilicoglu S, Erguder I, Erel S, Sunay AE, Erdemli E, Durak I, Akkus MA. The ultrastructural research of liver in experimental obstructive jaundice and effect of honey. Am J Surg. 2008 Feb;195(2):249-56. doi: 10.1016/j.amjsurg.2007.04.011.</citation>
    <PMID>18083132</PMID>
  </reference>
  <reference>
    <citation>Cernak M, Majtanova N, Cernak A, Majtan J. Honey prophylaxis reduces the risk of endophthalmitis during perioperative period of eye surgery. Phytother Res. 2012 Apr;26(4):613-6. doi: 10.1002/ptr.3606. Epub 2011 Oct 6.</citation>
    <PMID>22508360</PMID>
  </reference>
  <reference>
    <citation>Hussein SZ, Mohd Yusoff K, Makpol S, Mohd Yusof YA. Gelam Honey Inhibits the Production of Proinflammatory, Mediators NO, PGE(2), TNF-alpha, and IL-6 in Carrageenan-Induced Acute Paw Edema in Rats. Evid Based Complement Alternat Med. 2012;2012:109636. doi: 10.1155/2012/109636. Epub 2012 Jul 1.</citation>
    <PMID>22919407</PMID>
  </reference>
  <reference>
    <citation>Medhi B, Prakash A, Avti PK, Saikia UN, Pandhi P, Khanduja KL. Effect of Manuka honey and sulfasalazine in combination to promote antioxidant defense system in experimentally induced ulcerative colitis model in rats. Indian J Exp Biol. 2008 Aug;46(8):583-90.</citation>
    <PMID>18814487</PMID>
  </reference>
  <reference>
    <citation>Viuda-Martos M, Ruiz-Navajas Y, Fernandez-Lopez J, Perez-Alvarez JA. Functional properties of honey, propolis, and royal jelly. J Food Sci. 2008 Nov;73(9):R117-24. doi: 10.1111/j.1750-3841.2008.00966.x.</citation>
    <PMID>19021816</PMID>
  </reference>
  <verification_date>April 2017</verification_date>
  <study_first_submitted>July 19, 2014</study_first_submitted>
  <study_first_submitted_qc>July 23, 2014</study_first_submitted_qc>
  <study_first_posted type="Estimate">July 25, 2014</study_first_posted>
  <last_update_submitted>April 24, 2017</last_update_submitted>
  <last_update_submitted_qc>April 24, 2017</last_update_submitted_qc>
  <last_update_posted type="Actual">April 26, 2017</last_update_posted>
  <responsible_party>
    <responsible_party_type>Sponsor-Investigator</responsible_party_type>
    <investigator_affiliation>St. Paul's Hospital, Canada</investigator_affiliation>
    <investigator_full_name>Dr. Carl J Brown</investigator_full_name>
    <investigator_title>Head, Division of General Surgery, clinical assistant professor of surgery at University of British Columbia</investigator_title>
  </responsible_party>
  <keyword>honey enema for pouchitis</keyword>
  <condition_browse>
    <!-- CAUTION:  The following MeSH terms are assigned with an imperfect algorithm            -->
    <mesh_term>Pouchitis</mesh_term>
  </condition_browse>
  <!-- Results have not yet been posted for this study                                          -->
</clinical_study>


download date: ClinicalTrials.gov processed this data on September 20, 2023
link text: Link to the current ClinicalTrials.gov record.
url: https://clinicaltrials.gov/ct2/show/NCT02201186
org study id: H13-02740
nct id: NCT02201186
lead sponsor: 
collaborator: 
has dmc: No
Patients with a bowel condition called ulcerative colitis have bowel surgery in which a
      portion of their bowel is removed and the reconnected at the small bowel to the anus.
      Sometimes, after the surgery, this connection part, the pouch, would be inflamed in a
      condition called Acute Pouchitis. Physicians usually treat them by prescribing antibiotics;
      however, some patients do not respond and need additional surgery. In this study, we will
      test an alternative treatment for this complication by performing manuka honey enemas twice a
      day for 30 days. This is a pilot study and ten patients will undergo enema treatment.
Pouchitis is the most common long-term complication of ileal pouch-anal anastomosis (IPAA) in
      ulcerative colitis (UC). Pouchitis is defined as a clinical syndrome of watery, frequent, at
      times bloody stool accompanied by urgency, incontinence, abdominal cramps, malaise, and
      fever. The PDAI (Pouchitis Disease Activity Index) provides a standardized definition of
      pouchitis based on clinical, endoscopic, and histological markers. Pouchitis is defined as a
      score ≥ 7 and remission as a score < 7. Recently, the modified Pouchitis Disease Activity
      Index has been used to omit biopsy and histology from the standard PDAI. Omission of
      endoscopic biopsy and histology from the PDAI simplifies pouchitis diagnostic criteria,
      reduces the cost of diagnosis, and avoids delay associated with determining histology score,
      while providing equivalent sensitivity and specificity. Patients with acute pouchitis are
      managed routinely by antibiotics such as Ciprofloxacin and Metronidazole. This treatment has
      some side effects, is expensive, and fails to respond in some patients. Some patients who are
      unresponsive to antibiotic therapy will need to have a pouchectomy and ileostomy done.

      On the other hand, multiple studies have shown that honey, especially manuka honey has
      anti-inflammatory, anti-bacterial, wound healing, and anti-ulcerous effects. Phenolic
      compounds in honey, such as flavonoids, have been reported to exhibit a wide range of
      biological activities, including antibacterial, antiviral, anti-inflammatory, antioxidant,
      antitumor, anti-allergic, and vasodilatory actions. This honey can clear infection, remove
      malodour, reduce inflammation and pain, cause edema and exudation to subside, and increase
      the rate of healing by stimulation of angiogenesis, granulation and epithelialization.

      Due to problems associated with antibiotic therapy, such as side effects, cost and failure of
      some patients to respond, we are looking to find an alternative method for treating acute
      pouchitis. This study is designed to determine the effect of manuka honey on symptoms, signs
      and pathology of acute pouchitis patients. We will select patients with any of the signs and
      symptoms of pouchitis, such as abdominal pain, fever, frequency or urgency of defecation.
      Proctoscopy will be done before and after honey enema and the modified PDAI scores will be
      determined. The manuka honey enema will be administered twice a day, for one month. Then, the
      modified PDAI scores before and after completion of honey enema treatment of these patients,
      will be compared.

      We know that bacterial overgrowth, ischemia, faecal stasis, recurrence of ulcerative colitis
      in the pouch, or possibly a novel third form of inflammatory bowel disease, are possible
      etiologies of pouchitis. We also know that manuka honey has anti-inflammatory and
      anti-bacterial properties. Some studies demonstrate that honey is effective in the treatment
      of induced colitis in animal models. However, there is no current literature on the effect of
      honey on colitis or pouchitis in humans. Based on the aforementioned properties of honey, and
      considering the probable etiologies of pouchitis, we expect that these patients will respond
      to this method of treatment.

      Some research has been done on the effect of honey in the treatment of colitis in animal
      models, but there have been no clinical studies that have assessed this treatment in
      pouchitis, or even colitis, in humans. Considering the etiologies of pouchitis, such as
      inflammation and bacterial overgrowth, and considering the main effects of honey, such as
      anti-bacterial and anti-inflammatory efficacy, honey enema may be useful in the treatment of
      pouchitis. Our study is trying to determine the effect of manuka honey enema in the treatment
      of acute pouchitis. We will try to determine whether the honey enema helps to decrease
      inflammation and infection in the pouch, and thereby provide us with a safe alternative
      method for the treatment of pouchitis.

      In this pilot study, we will select patients who have any of the signs and symptoms of acute
      pouchitis, such as abdominal pain, fever, frequency, or urgency of defecation. Proctoscopy
      will be performed on these patients. Ten patients with modified PDAI score ≥ 7 will receive
      honey enemas twice a day for one month. We chose a twice daily enema regimen, because
      patients with inflammatory bowel disease usually receive their enemas twice a day. We expect
      one month to be enough time, because the duration of antibiotic therapy for patients with
      acute pouchitis is about one month. Then, the PDAI score of these patients, before and after
      honey enema will be compared.
allocation: N/A
intervention model: Single Group Assignment
primary purpose: Treatment
masking: None (Open Label)
measure: PDAI score
time frame: within 2 weeks after the 30-day treatment
description: PDAI score is a criterion for defining pouchitis. A PDAI score will be calculated from a proctoscopy assessment before treatment. Within two weeks after the treatment, another proctoscopy will be performed to determine the post-treatment PDAI score to see if there is a decrease in PDAI score for the study patients.
measure: Composite complications
time frame: throughout the 30-day honey enema treatment and within two weeks of the treatment completion date
description: includes stool frequency (no different, 1-2 stools/day > postoperative usual, 3 or more stools/day > postoperative usual), rectal bleeding (none or rare or present daily), fecal urgency or abdominal cramps (none, occasional or usual), presence of fever (temperature >37.8° C), abdominal pain (no, occasional or usual) and readmission to hospital for any reason.
arm group label: manuka honey enema treatment
arm group type: Experimental
description: Study patients diagnosed with acute pouchitis after bowel surgery for ulcerative colitis will perform manuka honey enemas twice a day for 30 days.
intervention type: Other
intervention name: Manuka honey enema
description: Study patients diagnosed with acute pouchitis will perform manuka honey enemas twice a day for 30 days.
arm group label: manuka honey enema treatment
criteria: 
gender: All
minimum age: 19 Years
maximum age: 65 Years
healthy volunteers: No
last name: Carl Brown
role: Principal Investigator
affiliation: Saint Paul's Hospital
facility: 
country: Canada
citation: Sandborn WJ, Tremaine WJ, Batts KP, Pemberton JH, Phillips SF. Pouchitis after ileal pouch-anal anastomosis: a Pouchitis Disease Activity Index. Mayo Clin Proc. 1994 May;69(5):409-15. doi: 10.1016/s0025-6196(12)61634-6.
PMID: 8170189
citation: Shen B, Achkar JP, Connor JT, Ormsby AH, Remzi FH, Bevins CL, Brzezinski A, Bambrick ML, Fazio VW, Lashner BA. Modified pouchitis disease activity index: a simplified approach to the diagnosis of pouchitis. Dis Colon Rectum. 2003 Jun;46(6):748-53. doi: 10.1007/s10350-004-6652-8.
PMID: 12794576
citation: Kafadar I, Moustafa F, Yalcin K, Klc BA. A rare adverse effect of metronidazole: nervous system symptoms. Pediatr Emerg Care. 2013 Jun;29(6):751-2. doi: 10.1097/PEC.0b013e318294f389.
PMID: 23736071
citation: Makhdoom A, Khan MS, Lagahari MA, Rahopoto MQ, Tahir SM, Siddiqui KA. Management of diabetic foot by natural honey. J Ayub Med Coll Abbottabad. 2009 Jan-Mar;21(1):103-5.
PMID: 20364754
citation: Kilicoglu B, Gencay C, Kismet K, Serin Kilicoglu S, Erguder I, Erel S, Sunay AE, Erdemli E, Durak I, Akkus MA. The ultrastructural research of liver in experimental obstructive jaundice and effect of honey. Am J Surg. 2008 Feb;195(2):249-56. doi: 10.1016/j.amjsurg.2007.04.011.
PMID: 18083132
citation: Cernak M, Majtanova N, Cernak A, Majtan J. Honey prophylaxis reduces the risk of endophthalmitis during perioperative period of eye surgery. Phytother Res. 2012 Apr;26(4):613-6. doi: 10.1002/ptr.3606. Epub 2011 Oct 6.
PMID: 22508360
citation: Hussein SZ, Mohd Yusoff K, Makpol S, Mohd Yusof YA. Gelam Honey Inhibits the Production of Proinflammatory, Mediators NO, PGE(2), TNF-alpha, and IL-6 in Carrageenan-Induced Acute Paw Edema in Rats. Evid Based Complement Alternat Med. 2012;2012:109636. doi: 10.1155/2012/109636. Epub 2012 Jul 1.
PMID: 22919407
citation: Medhi B, Prakash A, Avti PK, Saikia UN, Pandhi P, Khanduja KL. Effect of Manuka honey and sulfasalazine in combination to promote antioxidant defense system in experimentally induced ulcerative colitis model in rats. Indian J Exp Biol. 2008 Aug;46(8):583-90.
PMID: 18814487
citation: Viuda-Martos M, Ruiz-Navajas Y, Fernandez-Lopez J, Perez-Alvarez JA. Functional properties of honey, propolis, and royal jelly. J Food Sci. 2008 Nov;73(9):R117-24. doi: 10.1111/j.1750-3841.2008.00966.x.
PMID: 19021816
responsible party type: Sponsor-Investigator
investigator affiliation: St. Paul's Hospital, Canada
investigator full name: Dr. Carl J Brown
investigator title: Head, Division of General Surgery, clinical assistant professor of surgery at University of British Columbia
mesh term: Pouchitis