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For the surgical treatment of ulcerative colitis (UC) and familial adenomatous polyposis (FAP), proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the favored alternative to proctocolectomy with permanent ileostomy since it preserves intestinal continuity and sphincter function and removes the entire colorectal mucosa. This procedure consists of total abdominal colectomy, stripping of the rectal mucosa with preservation of the anal sphincter, and the construction of an ileal pouch that is anastomosed to the anus.

The most frequently observed long-term complication of IPAA is acute and/or chronic inflammation of the ileal reservoir, called pouchitis. This is not a well-defined entity, and much uncertainty remains regarding its true prevalence, etiology, and natural history. However, the condition continues to overshadow the overall good functional results of this sphincter-saving operation.


Patients who undergo ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) have a higher incidence of pouchitis compared to those who undergo the procedure for FAP [1,2]. In patients who undergo IPAA for UC, the reported prevalence of pouchitis varies widely from less than 7 percent [1,3-8] to as high as 44 percent [9]. The large variations that have been reported reflect differences in diagnostic criteria and follow-up and are responsible for much of the confusion surrounding pouchitis. As an example, in one series of 149 patients, the incidence of mild pouchitis (diagnosed by symptoms and endoscopy) was 21, 26, and 39 percent at 6, 12, and 48 months; the respective values for severe pouchitis were 9, 11, and 14 percent [9].


The etiology of pouchitis remains uncertain although preoperative and postoperative factors may contribute.

Preoperative — Factors associated with acute pouchitis include use of steroids before colectomy, and a history of extensive colitis [10,11]. Extraintestinal manifestations of colitis and primary sclerosing cholangitis are associated with an increased risk of chronic pouchitis [1,10,12], while smoking appears to protect against the development of acute and chronic pouchitis [1,10].


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Literature review current through: Jun 2014. | This topic last updated: Apr 4, 2013.
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  1. Lohmuller JL, Pemberton JH, Dozois RR, et al. Pouchitis and extraintestinal manifestations of inflammatory bowel disease after ileal pouch-anal anastomosis. Ann Surg 1990; 211:622.
  2. Mahadevan U, Sandborn WJ. Diagnosis and management of pouchitis. Gastroenterology 2003; 124:1636.
  3. Mignon M, Stettler C, Phillips SF. Pouchitis--a poorly understood entity. Dis Colon Rectum 1995; 38:100.
  4. Sandborn WJ. Pouchitis following ileal pouch-anal anastomosis: definition, pathogenesis, and treatment. Gastroenterology 1994; 107:1856.
  5. Romanos J, Samarasekera DN, Stebbing JF, et al. Outcome of 200 restorative proctocolectomy operations: the John Radcliffe Hospital experience. Br J Surg 1997; 84:814.
  6. Ståhlberg D, Gullberg K, Liljeqvist L, et al. Pouchitis following pelvic pouch operation for ulcerative colitis. Incidence, cumulative risk, and risk factors. Dis Colon Rectum 1996; 39:1012.
  7. Keränen U, Luukkonen P, Järvinen H. Functional results after restorative proctocolectomy complicated by pouchitis. Dis Colon Rectum 1997; 40:764.
  8. Dozois RR, Goldberg SM, Rothenberger DA, et al. Restorative proctocolectomy with ileal reservoir. Int J Colorectal Dis 1986; 1:2.
  9. Fonkalsrud EW. Endorectal ileoanal anastomosis with isoperistaltic ileal reservoir after colectomy and mucosal proctectomy. Ann Surg 1984; 199:151.
  10. Merrett MN, Mortensen N, Kettlewell M, Jewell DO. Smoking may prevent pouchitis in patients with restorative proctocolectomy for ulcerative colitis. Gut 1996; 38:362.
  11. de Silva HJ, de Angelis CP, Soper N, et al. Clinical and functional outcome after restorative proctocolectomy. Br J Surg 1991; 78:1039.
  12. Penna C, Dozois R, Tremaine W, et al. Pouchitis after ileal pouch-anal anastomosis for ulcerative colitis occurs with increased frequency in patients with associated primary sclerosing cholangitis. Gut 1996; 38:234.
  13. Sehgal R, Berg A, Hegarty JP, et al. NOD2/CARD15 mutations correlate with severe pouchitis after ileal pouch-anal anastomosis. Dis Colon Rectum 2010; 53:1487.
  14. Nasmyth DG, Johnston D, Godwin PG, et al. Factors influencing bowel function after ileal pouch-anal anastomosis. Br J Surg 1986; 73:469.
  15. Nasmyth DG, Godwin PG, Dixon MF, et al. Ileal ecology after pouch-anal anastomosis or ileostomy. A study of mucosal morphology, fecal bacteriology, fecal volatile fatty acids, and their interrelationship. Gastroenterology 1989; 96:817.
  16. Sagar PM, Holdsworth PJ, Godwin PG, et al. Comparison of triplicated (S) and quadruplicated (W) pelvic ileal reservoirs. Studies on manovolumetry, fecal bacteriology, fecal volatile fatty acids, mucosal morphology, and functional results. Gastroenterology 1992; 102:520.
  17. Sandborn WJ, Tremaine WJ, Batts KP, et al. Fecal bile acids, short-chain fatty acids, and bacteria after ileal pouch-anal anastomosis do not differ in patients with pouchitis. Dig Dis Sci 1995; 40:1474.
  18. de Silva HJ, Jones M, Prince C, et al. Lymphocyte and macrophage subpopulations in pelvic ileal pouches. Gut 1991; 32:1160.
  19. Nasmyth DG, Johnston D, Williams NS, et al. Changes in the absorption of bile acids after total colectomy in patients with an ileostomy or pouch-anal anastomosis. Dis Colon Rectum 1989; 32:230.
  20. Santavirta J, Mattila J, Kokki M, et al. Absorption of bile acids after ileoanal anastomosis. Ann Chir Gynaecol 1990; 79:134.
  21. Chaussade S, Denizot Y, Valleur P, et al. Presence of PAF-acether in stool of patients with pouch ileoanal anastomosis and pouchitis. Gastroenterology 1991; 100:1509.
  22. Levin KE, Pemberton JH, Phillips SF, et al. Role of oxygen free radicals in the etiology of pouchitis. Dis Colon Rectum 1992; 35:452.
  23. Fleshner PR, Vasiliauskas EA, Kam LY, et al. High level perinuclear antineutrophil cytoplasmic antibody (pANCA) in ulcerative colitis patients before colectomy predicts the development of chronic pouchitis after ileal pouch-anal anastomosis. Gut 2001; 49:671.
  24. Moskowitz RL, Shepherd NA, Nicholls RJ. An assessment of inflammation in the reservoir after restorative proctocolectomy with ileoanal ileal reservoir. Int J Colorectal Dis 1986; 1:167.
  25. de Silva HJ, Millard PR, Soper N, et al. Effects of the faecal stream and stasis on the ileal pouch mucosa. Gut 1991; 32:1166.
  26. Goldberg PA, Kamm MA, Nicholls RJ, et al. Contribution of gastrointestinal transit and pouch characteristics in determining pouch function. Gut 1997; 40:790.
  27. Coffey JC, Rowan F, Burke J, et al. Pathogenesis of and unifying hypothesis for idiopathic pouchitis. Am J Gastroenterol 2009; 104:1013.
  28. Scarpa M, Grillo A, Faggian D, et al. Relationship between mucosa-associated microbiota and inflammatory parameters in the ileal pouch after restorative proctocolectomy for ulcerative colitis. Surgery 2011; 150:56.
  29. Singh S, Sharma PK, Loftus EV Jr, Pardi DS. Meta-analysis: serological markers and the risk of acute and chronic pouchitis. Aliment Pharmacol Ther 2013; 37:867.
  30. McLaughlin SD, Clark SK, Bell AJ, et al. An open study of antibiotics for the treatment of pre-pouch ileitis following restorative proctocolectomy with ileal pouch-anal anastomosis. Aliment Pharmacol Ther 2009; 29:69.
  31. Shen B, Sanmiguel C, Bennett AE, et al. Irritable pouch syndrome is characterized by visceral hypersensitivity. Inflamm Bowel Dis 2011; 17:994.
  32. Shen B, Achkar JP, Lashner BA, et al. Endoscopic and histologic evaluation together with symptom assessment are required to diagnose pouchitis. Gastroenterology 2001; 121:261.
  33. Parsi MA, Shen B, Achkar JP, et al. Fecal lactoferrin for diagnosis of symptomatic patients with ileal pouch-anal anastomosis. Gastroenterology 2004; 126:1280.
  34. Casadesus D, Tani T, Wakai T, et al. Possible role of human cytomegalovirus in pouchitis after proctocolectomy with ileal pouch-anal anastomosis in patients with ulcerative colitis. World J Gastroenterol 2007; 13:1085.
  35. Muñoz-Juarez M, Pemberton JH, Sandborn WJ, et al. Misdiagnosis of specific cytomegalovirus infection of the ileoanal pouch as refractory idiopathic chronic pouchitis: report of two cases. Dis Colon Rectum 1999; 42:117.
  36. Moonka D, Furth EE, MacDermott RP, Lichtenstein GR. Pouchitis associated with primary cytomegalovirus infection. Am J Gastroenterol 1998; 93:264.
  37. Shepherd NA, Healey CJ, Warren BF, et al. Distribution of mucosal pathology and an assessment of colonic phenotypic change in the pelvic ileal reservoir. Gut 1993; 34:101.
  38. de Silva HJ, Millard PR, Kettlewell M, et al. Mucosal characteristics of pelvic ileal pouches. Gut 1991; 32:61.
  39. Navaneethan U, Shen B. Pros and cons of antibiotic therapy for pouchitis. Expert Rev Gastroenterol Hepatol 2009; 3:547.
  40. Madden MV, McIntyre AS, Nicholls RJ. Double-blind crossover trial of metronidazole versus placebo in chronic unremitting pouchitis. Dig Dis Sci 1994; 39:1193.
  41. Shen B, Achkar JP, Lashner BA, et al. A randomized clinical trial of ciprofloxacin and metronidazole to treat acute pouchitis. Inflamm Bowel Dis 2001; 7:301.
  42. Gosselink MP, Schouten WR, van Lieshout LM, et al. Eradication of pathogenic bacteria and restoration of normal pouch flora: comparison of metronidazole and ciprofloxacin in the treatment of pouchitis. Dis Colon Rectum 2004; 47:1519.
  43. Isaacs KL, Sandler RS, Abreu M, et al. Rifaximin for the treatment of active pouchitis: a randomized, double-blind, placebo-controlled pilot study. Inflamm Bowel Dis 2007; 13:1250.
  44. Shen B, Remzi FH, Lopez AR, Queener E. Rifaximin for maintenance therapy in antibiotic-dependent pouchitis. BMC Gastroenterol 2008; 8:26.
  45. Gionchetti P, Rizzello F, Venturi A, et al. Antibiotic combination therapy in patients with chronic, treatment-resistant pouchitis. Aliment Pharmacol Ther 1999; 13:713.
  46. Abdelrazeq AS, Kelly SM, Lund JN, Leveson SH. Rifaximin-ciprofloxacin combination therapy is effective in chronic active refractory pouchitis. Colorectal Dis 2005; 7:182.
  47. Mimura T, Rizzello F, Helwig U, et al. Four-week open-label trial of metronidazole and ciprofloxacin for the treatment of recurrent or refractory pouchitis. Aliment Pharmacol Ther 2002; 16:909.
  48. Tremaine WJ, Sandborn WJ, Wolff BG, et al. Bismuth carbomer foam enemas for active chronic pouchitis: a randomized, double-blind, placebo-controlled trial. Aliment Pharmacol Ther 1997; 11:1041.
  49. Shen B, Fazio VW, Remzi FH, et al. Combined ciprofloxacin and tinidazole therapy in the treatment of chronic refractory pouchitis. Dis Colon Rectum 2007; 50:498.
  50. McLaughlin SD, Clark SK, Shafi S, et al. Fecal coliform testing to identify effective antibiotic therapies for patients with antibiotic-resistant pouchitis. Clin Gastroenterol Hepatol 2009; 7:545.
  51. Gionchetti P, Rizzello F, Poggioli G, et al. Oral budesonide in the treatment of chronic refractory pouchitis. Aliment Pharmacol Ther 2007; 25:1231.
  52. Belluzzi A, Campieri M, Miglioli M, et al. Evaluation of flogistic pattern in "pouchitis" before and after the treatment with budesonide suppositories (abstract). Gastroenterology 1992; 102:A593.
  53. Sambuelli A, Boerr L, Negreira S, et al. Budesonide enema in pouchitis--a double-blind, double-dummy, controlled trial. Aliment Pharmacol Ther 2002; 16:27.
  54. Komanduri S, Gillevet PM, Sikaroodi M, et al. Dysbiosis in pouchitis: evidence of unique microfloral patterns in pouch inflammation. Clin Gastroenterol Hepatol 2007; 5:352.
  55. Gionchetti P, Rizzello F, Venturi A, et al. Oral bacteriotherapy as maintenance treatment in patients with chronic pouchitis: a double-blind, placebo-controlled trial. Gastroenterology 2000; 119:305.
  56. Mimura T, Rizzello F, Helwig U, et al. Once daily high dose probiotic therapy (VSL#3) for maintaining remission in recurrent or refractory pouchitis. Gut 2004; 53:108.
  57. Miglioli M, Barbara L, Di Febo G, et al. Topical administration of 5-aminosalicylic acid: a therapeutic proposal for the treatment of pouchitis. N Engl J Med 1989; 26:320.
  58. Ferrante M, D'Haens G, Dewit O, et al. Efficacy of infliximab in refractory pouchitis and Crohn's disease-related complications of the pouch: a Belgian case series. Inflamm Bowel Dis 2010; 16:243.
  59. Gadacz TR, McFadden DW, Gabrielson EW, et al. Adenocarcinoma of the ileostomy: the latent risk of cancer after colectomy for ulcerative colitis and familial polyposis. Surgery 1990; 107:698.
  60. Smart PJ, Sastry S, Wells S. Primary mucinous adenocarcinoma developing in an ileostomy stoma. Gut 1988; 29:1607.
  61. de Silva HJ, Gatter KC, Millard PR, et al. Crypt cell proliferation and HLA-DR expression in pelvic ileal pouches. J Clin Pathol 1990; 43:824.
  62. Thompson-Fawcett MW, Marcus V, Redston M, et al. Risk of dysplasia in long-term ileal pouches and pouches with chronic pouchitis. Gastroenterology 2001; 121:275.
  63. Löfberg R, Liljeqvist L, Lindquist K, et al. Dysplasia and DNA aneuploidy in a pelvic pouch. Report of a case. Dis Colon Rectum 1991; 34:280.
  64. Veress B, Reinholt FP, Lindquist K, Liljeqvist L. Different types of mucosal adaptation in the ileal reservoir after restorative proctocolectomy. A two-year follow-up study. APMIS 1990; 98:786.
  65. Shepherd NA. Pouchitis and neoplasia in the pelvic ileal reservoir. Gastroenterology 1995; 109:1381.