A preliminary study of a sulfide-reducing diet in patients with an ileoanal pouch

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Resection of the large bowel and creation of a new rectum or reservoir by forming a pouch from the small bowel is the surgical treatment of choice for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). The new reservoir is termed ileal pouch anal anastomosis (IPAA) or ileoanal pouch. Quality of life following IPAA creation is generally good. However, a considerable number of patients have persistent pouch-related symptoms of increased frequency, urgency, leakage and incontinence. Furthermore, most patients report food intolerances and the need to alter their diet to mitigate or improve symptoms. Additionally, around 40-50% of UC IPAA and 10-20% of FAP IPAA develop inflammation of the pouch, called pouchitis. Increased exposure of the pouch mucosa to hydrogen sulphide (H2S), reduced exposure to SCFA, particularly butyrate, and excessive delivery of water to the pouch are putatively pathogenic factors in pouch dysfunction. We hypothesised that dietary change that reverses these might lead to improved pouch function and less inflammation and have designed a dietary approach that manipulates carbohydrate and protein fermentation such that H2S production can be minimised and SCFA deficiency can be corrected, the free water content of ileal effluent can be reduced, and substrates that contain sulphur minimised so that reductive pathways to H2S production can be suppressed. An innovative whole food diet strategy called a ‘5-strategies to a SUlphide-REducing’ (5URE) diet was developed.The study would include a baseline period of 1 week whereby a patient’s usual diet is assessed through a food diary. A dietitian educates participants on the components of the SURE diet, which patients then follow for 5 weeks. During this time, they will complete food diaries and receive a phone call three weeks after starting the diet to inquire about adherence and to help answer any questions. Participants are encouraged to contact the research for any query. The total study will include three visits. Questionnaires are be used to assess how the subject is tolerating and accepting the diet, and to document the effects on bowel symptoms and health-related quality of life. Participants are asked to collect a small sample of stool on the day before they start the diet (reflecting their usual diet), and the last day of the SURE diet (to assess the effects of the diet). The results will inform further adjustments to the dietary approach and form the basis from future clinical trials.