UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Pouchitis: Management

Author
Bo Shen, MD
Section Editor
Paul Rutgeerts, MD, PhD, FRCP
Deputy Editor
Shilpa Grover, MD, MPH

INTRODUCTION

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".)

DEFINITION

Pouchitis is an inflammatory condition of the ileal pouch reservoir of an ileal pouch-anal anastomosis (IPAA).

Classification — Pouchitis has been classified as follows [1]:

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).

               

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Tue Jul 22 00:00:00 GMT 2014.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Pardi DS, D'Haens G, Shen B, et al. Clinical guidelines for the management of pouchitis. Inflamm Bowel Dis 2009; 15:1424.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. Navaneethan U, Shen B. Pros and cons of antibiotic therapy for pouchitis. Expert Rev Gastroenterol Hepatol 2009; 3:547.
  10. 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.
  11. 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.
  12. 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.
  13. 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.
  14. Gionchetti P, Rizzello F, Morselli C, et al. High-dose probiotics for the treatment of active pouchitis. Dis Colon Rectum 2007; 50:2075.
  15. 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.
  16. 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.
  17. Gionchetti P, Rizzello F, Venturi A, et al. Antibiotic combination therapy in patients with chronic, treatment-resistant pouchitis. Aliment Pharmacol Ther 1999; 13:713.
  18. Abdelrazeq AS, Kelly SM, Lund JN, Leveson SH. Rifaximin-ciprofloxacin combination therapy is effective in chronic active refractory pouchitis. Colorectal Dis 2005; 7:182.
  19. 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.
  20. 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.
  21. 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.
  22. 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.
  23. 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.
  24. Shen B. Campylobacter infection in patients with ileal pouches. Am J Gastroenterol 2010; 105:472.
  25. 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.
  26. Patel LN, Schairer J, Shen B. Fecal transplantation therapy for Clostridium difficile-associated pouchitis. Int J Colorectal Dis 2014; 29:263.
  27. 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.
  28. Uchino M, Ikeuchi H, Matsuoka H, et al. Topical tacrolimus therapy for antibiotic-refractory pouchitis. Dis Colon Rectum 2013; 56:1166.
  29. Gionchetti P, Rizzello F, Poggioli G, et al. Oral budesonide in the treatment of chronic refractory pouchitis. Aliment Pharmacol Ther 2007; 25:1231.
  30. 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.
  31. 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.
  32. 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.
  33. 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.
  34. 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.
  35. 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.
  36. Gionchetti P, Calabrese C, Calafiore A, et al. Oral beclomethasone dipropionate in chronic refractory pouchitis. J Crohns Colitis 2014; 8:649.
  37. 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.
  38. 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.
  39. 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.
  40. 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.
  41. McLaughlin SD, Johnson MW, Clark SK, et al. VSL#3 for chronic pouchitis: experience in UK clinical practice. Gastroenterology 2008; 134 Suppl 1:A711.
  42. Shen B, Remzi FH, Lopez AR, Queener E. Rifaximin for maintenance therapy in antibiotic-dependent pouchitis. BMC Gastroenterol 2008; 8:26.
  43. 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.
  44. 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.
  45. 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.
  46. 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.
  47. Smart PJ, Sastry S, Wells S. Primary mucinous adenocarcinoma developing in an ileostomy stoma. Gut 1988; 29:1607.