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 . 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 .
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].