Management of Acute and Chronic Pouchitis

BACKGROUND: Restorative proctocolectomy with ileal pouch-anal anastomosis is the procedure of choice when colectomy is needed for medically refractory ulcerative colitis. Pouchitis is one of the most common complications among patients who have undergone ileal pouch-anal anastomosis and represents a spectrum of disease varying in both phenotype and clinical course. OBJECTIVE: The aim of this review is to assist clinicians and surgeons in the treatment of both acute and chronic pouchitis, including newer therapies and future directions. DIAGNOSIS AND MANAGEMENT: Diagnosis is made by endoscopy of the pouch with biopsy, since other conditions may produce similar symptoms such as increased stool frequency, abdominal cramps, and urgency. Pouchitis is classified by duration (acute versus chronic), disease pattern (infrequent, relapsing, continuous), and response to antibiotics (responsive, dependent, refractory). The Pouchitis Disease Activity Index may be used to measure disease activity. The management of pouchitis is guided by the disease phenotype. Acute episodes are treated with an initial 2-week course of antibiotics (typically ciprofloxacin or metronidazole), although patients with relapsing or chronic pouchitis may require long-term antibiotic treatment or the cycling of different antibiotics. Certain probiotics may also be used for maintenance therapy in those with chronic symptoms. For patients with chronic antibiotic refractory pouchitis, oral budesonide, immunosuppressive agents (azathioprine), or biologic therapy (infliximab, adalimumab, vedolizumab, ustekinumab) may be required for both induction and maintenance with close monitoring for potential side effects. In rare cases, diverting ileostomy or pouch excision may be required. CONCLUSION: Pouchitis represents a spectrum of disease phenotypes, ranging from acute antibiotic responsive pouchitis to chronic antibiotic refractory pouchitis. The management of pouchitis is primarily directed by the disease phenotype.