- Bo Shen, MD
Bo Shen, MD
- The Ed and Joey Endowed Chair, Professor of Medicine
- Director of Center for Inflammatory Bowel Diseases
- The Cleveland Clinic Foundation
Pouchitis is the most frequently observed long-term complication of an ileal pouch-anal anastomosis (IPAA). This topic will review the management of pouchitis. The epidemiology, pathogenesis, clinical manifestations, and diagnosis of pouchitis are discussed in detail, separately. (See "Pouchitis: Epidemiology, clinical manifestations, and diagnosis".)
Pouchitis is an inflammatory condition of the ileal pouch reservoir of an ileal pouch-anal anastomosis (IPAA).
Classification — Pouchitis has been classified as follows :
●Based on the duration of symptoms into acute (<four weeks) versus chronic (≥four weeks).
●Based on response to antibiotics into antibiotic-responsive versus antibiotic-dependent (requiring ongoing antibiotic therapy to keep disease in remission) versus antibiotic-refractory (not responding to standard course of antibiotic therapy).
- Pardi DS, D'Haens G, Shen B, et al. Clinical guidelines for the management of pouchitis. Inflamm Bowel Dis 2009; 15:1424.
- Gosselink MP, Schouten WR, van Lieshout LM, et al. Delay of the first onset of pouchitis by oral intake of the probiotic strain Lactobacillus rhamnosus GG. Dis Colon Rectum 2004; 47:876.
- 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.
- Tomasz B, Zoran S, Jarosław W, et al. Long-term use of probiotics Lactobacillus and Bifidobacterium has a prophylactic effect on the occurrence and severity of pouchitis: a randomized prospective study. Biomed Res Int 2014; 2014:208064.
- Gionchetti P, Rizzello F, Helwig U, et al. Prophylaxis of pouchitis onset with probiotic therapy: a double-blind, placebo-controlled trial. Gastroenterology 2003; 124:1202.
- Pronio A, Montesani C, Butteroni C, et al. Probiotic administration in patients with ileal pouch-anal anastomosis for ulcerative colitis is associated with expansion of mucosal regulatory cells. Inflamm Bowel Dis 2008; 14:662.
- Ha CY, Bauer JJ, Lazarev M, et al. Early institution of tinidazole may prevent pouchitis following ileal pouch anal anastomosis (IPAA) surgery in ulcerative colitis (UC) patients. Gastroenterology 2010; 138 Suppl:S69.
- Poritz LS, Sehgal R, Berg AS, et al. Chronic use of PPI and H2 antagonists decreases the risk of pouchitis after IPAA for ulcerative colitis. J Gastrointest Surg 2013; 17:1027.
- Navaneethan U, Shen B. Pros and cons of antibiotic therapy for pouchitis. Expert Rev Gastroenterol Hepatol 2009; 3:547.
- 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.
- Holubar SD, Cima RR, Sandborn WJ, Pardi DS. Treatment and prevention of pouchitis after ileal pouch-anal anastomosis for chronic ulcerative colitis. Cochrane Database Syst Rev 2010; :CD001176.
- 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.
- Shen B, Pardi DS, Bennett AE, et al. The efficacy and tolerability of AST-120 (spherical carbon adsorbent) in active pouchitis. Am J Gastroenterol 2009; 104:1468.
- Gionchetti P, Rizzello F, Morselli C, et al. High-dose probiotics for the treatment of active pouchitis. Dis Colon Rectum 2007; 50:2075.
- Kuisma J, Mentula S, Jarvinen H, et al. Effect of Lactobacillus rhamnosus GG on ileal pouch inflammation and microbial flora. Aliment Pharmacol Ther 2003; 17:509.
- 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.
- Gionchetti P, Rizzello F, Venturi A, et al. Antibiotic combination therapy in patients with chronic, treatment-resistant pouchitis. Aliment Pharmacol Ther 1999; 13:713.
- Abdelrazeq AS, Kelly SM, Lund JN, Leveson SH. Rifaximin-ciprofloxacin combination therapy is effective in chronic active refractory pouchitis. Colorectal Dis 2005; 7:182.
- 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.
- 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.
- Shen B, Plesec TP, Remer E, et al. Asymmetric endoscopic inflammation of the ileal pouch: a sign of ischemic pouchitis? Inflamm Bowel Dis 2010; 16:836.
- Remzi FH, Fazio VW, Kirat HT, et al. Repeat pouch surgery by the abdominal approach safely salvages failed ileal pelvic pouch. Dis Colon Rectum 2009; 52:198.
- Barreiro-de Acosta M, García-Bosch O, Gordillo J, et al. Efficacy of adalimumab rescue therapy in patients with chronic refractory pouchitis previously treated with infliximab: a case series. Eur J Gastroenterol Hepatol 2012; 24:756.
- Shen B. Campylobacter infection in patients with ileal pouches. Am J Gastroenterol 2010; 105:472.
- Lan N, Patil DT, Shen B. Histoplasma capsulatum infection in refractory Crohn's disease of the pouch on anti-TNF biological therapy. Am J Gastroenterol 2013; 108:281.
- Patel LN, Schairer J, Shen B. Fecal transplantation therapy for Clostridium difficile-associated pouchitis. Int J Colorectal Dis 2014; 29:263.
- McCurdy JD, Loftus EV Jr, Tremaine WJ, et al. Cytomegalovirus infection of the ileoanal pouch: clinical characteristics and outcomes. Inflamm Bowel Dis 2013; 19:2394.
- Uchino M, Ikeuchi H, Matsuoka H, et al. Topical tacrolimus therapy for antibiotic-refractory pouchitis. Dis Colon Rectum 2013; 56:1166.
- Gionchetti P, Rizzello F, Poggioli G, et al. Oral budesonide in the treatment of chronic refractory pouchitis. Aliment Pharmacol Ther 2007; 25:1231.
- 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.
- 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.
- Navaneethan U, Venkatesh PG, Bennett AE, et al. Impact of budesonide on liver function tests and gut inflammation in patients with primary sclerosing cholangitis and ileal pouch anal anastomosis. J Crohns Colitis 2012; 6:536.
- 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.
- Barreiro-de Acosta M, García-Bosch O, Souto R, et al. Efficacy of infliximab rescue therapy in patients with chronic refractory pouchitis: a multicenter study. Inflamm Bowel Dis 2012; 18:812.
- Wu B, Lian L, Li Y, et al. Clinical course of cuffitis in ulcerative colitis patients with restorative proctocolectomy and ileal pouch-anal anastomoses. Inflamm Bowel Dis 2013; 19:404.
- Gionchetti P, Calabrese C, Calafiore A, et al. Oral beclomethasone dipropionate in chronic refractory pouchitis. J Crohns Colitis 2014; 8:649.
- 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.
- 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.
- Shen B, Brzezinski A, Fazio VW, et al. Maintenance therapy with a probiotic in antibiotic-dependent pouchitis: experience in clinical practice. Aliment Pharmacol Ther 2005; 22:721.
- 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.
- McLaughlin SD, Johnson MW, Clark SK, et al. VSL#3 for chronic pouchitis: experience in UK clinical practice. Gastroenterology 2008; 134 Suppl 1:A711.
- Shen B, Remzi FH, Lopez AR, Queener E. Rifaximin for maintenance therapy in antibiotic-dependent pouchitis. BMC Gastroenterol 2008; 8:26.
- Welters CF, Heineman E, Thunnissen FB, et al. Effect of dietary inulin supplementation on inflammation of pouch mucosa in patients with an ileal pouch-anal anastomosis. Dis Colon Rectum 2002; 45:621.
- McLaughlin SD, Culkin A, Cole J, et al. Exclusive elemental diet impacts on the gastrointestinal microbiota and improves symptoms in patients with chronic pouchitis. J Crohns Colitis 2013; 7:460.
- Liu ZX, Kiran RP, Bennett AE, et al. Diagnosis and management of dysplasia and cancer of the ileal pouch in patients with underlying inflammatory bowel disease. Cancer 2011; 117:3081.
- 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.
- Smart PJ, Sastry S, Wells S. Primary mucinous adenocarcinoma developing in an ileostomy stoma. Gut 1988; 29:1607.
- PRIMARY PROPHYLAXIS FOR ACUTE POUCHITIS
- MANAGEMENT OF ACUTE POUCHITIS
- Initial management
- Subsequent management
- MANAGEMENT OF CHRONIC POUCHITIS
- Initial management
- Evaluate and treat secondary causes
- Subsequent management
- Maintenance therapy
- - Probiotics
- - Antibiotics
- - Diet
- SURVEILLANCE FOR POUCH NEOPLASIA
- SUMMARY AND RECOMMENDATIONS