What to Know About Pouchitis

Table of ContentsView AllTable of ContentsPouchitis and J-Pouch SurgeryTypes of PouchitisPouchitis SymptomsWhat Causes Pouchitis?How Pouchitis Is DiagnosedPouchitis TreatmentWhat’s the Outlook for Pouchitis?

Table of ContentsView All

View All

Table of Contents

Pouchitis and J-Pouch Surgery

Types of Pouchitis

Pouchitis Symptoms

What Causes Pouchitis?

How Pouchitis Is Diagnosed

Pouchitis Treatment

What’s the Outlook for Pouchitis?

Pouchitisis an inflammation that occurs in some people who have hadileal pouch-anal anastomosis (IPAA)surgery. This surgery is commonly called a J-pouch. The surgery is often used to treat ulcerative colitis or other disorders that affect the colon and/or the rectum.

The J-pouch can become irritated or inflamed, leading to symptoms such as diarrhea (sometimes bloody), an urgent need to go to the bathroom, accidents (incontinence), and pain or discomfort. Pouchitis doesn’t happen to everyone with a J-pouch, but it is common. It can be a chronic problem for some people.

This article will discuss how and why a J-pouch is created, what causes inflammation (pouchitis) in a J-pouch, and how pouch dysfunction might be treated.

J-pouch surgery is a complex surgery usually done in two or three steps. It is used to treatulcerative colitisand some other digestive conditions, such asfamilial adenomatous polyposis (FAP).

The first step of creating a J-pouch is the surgical removal of thelarge intestine. This procedure is called acolectomy. All or part of the rectum may also be removed. In most cases, an ileostomy will be placed after the colectomy.

Pouchitis

Anileostomyis when the end of the small intestine is brought through the abdomen, which is called a stoma. A bag is worn over the stoma to collect stool as it leaves the body. The ileostomy is needed to allow the newly constructed J-pouch to heal.

When the surgery is done in two steps, the colectomy, J-pouch creation, and ileostomy are done all in one step. The second step is reversing the ileostomy to allow stool to leave the body through the bottom again. When three steps are used, the first is the colectomy, the second is the J-pouch construction, and the third is the reversal.

Pouchitis was first described in 1986. It was found that people who had this surgery for ulcerative colitis experienced pouchitis more often than other forms, including FAP.

Knowledge of what causes pouchitis and its different forms has expanded over the years. Pouchitis is now considered a spectrum, whose categories include acute, chronic, refractory, or secondary pouchitis.

Types of pouchitis include:

The symptoms of pouchitis can include:

The signs that healthcare providers may look for inside a pouch that could point to pouchitis include inflammation andulcers(sores). Abiopsyof the pouch tissue may show an increase in white blood cells.In a biopsy, a sample of tissue is collected and analyzed in the lab.

It’s not well understood what causes pouchitis, but it is thought to be a group of conditions with multiple causes.

Pouchitis is more common in people who have had the surgery for ulcerative colitis than those who have it done for other conditions, such as FAP.For this reason, one theory is that it could be a continuation of ulcerative colitis.

Dysbiosis, meaning an imbalance in the bacteria that live in the intestine and the pouch (themicrobiome), may be another cause. Autoimmune conditions that affect the gastrointestinal system, such as ulcerative colitis, can also be a cause.

There May Be Multiple FactorsFor some people, there could be more than one cause that leads to a bout of pouchitis. It is a complicated disorder. People who live with chronic pouchitis may want to consider asking for a referral to see a pelvic pouch specialist.

There May Be Multiple Factors

For some people, there could be more than one cause that leads to a bout of pouchitis. It is a complicated disorder. People who live with chronic pouchitis may want to consider asking for a referral to see a pelvic pouch specialist.

A pouchoscopy is done in a variety of ways. One procedure requires afull prepto clean out the intestine before placing the patient under anesthesia while the pouchoscopy is performed. Another is a short procedure requiring no sedation that is performed after anenemais used to remove stool from the pouch. Other procedures are available that fall between these two extremes.

A healthcare provider (usually agastroenterologistor acolorectal surgeon) will give directions and do the procedure.

Some conditions may mimic pouchitis. A healthcare provider may want to rule out these before offering treatment for pouchitis or if treatment doesn’t seem to help:

Treatment for acute pouchitis is usually antibiotics. First-line treatment for acute pouchitis is a two- to four-week course of antibiotics, such as Flagyl (metronidazole) or Cipro (ciprofloxacin).

If symptoms don’t improve after four weeks, antibiotics might be prescribed for longer, such as another 28 days. Adding another antibiotic, such as Xifaxan (rifaximin), might also be tried.

If antibiotics don’t work, there is less evidence and more trial and error. The next step might be with drugs that suppress the immune system. A type of steroid calledbudesonidemight be tried. It has shown good results in some trials.

Biologicsmight also be tried for chronic pouchitis.Remicade (infliximab), Humira (adalimumab), Entyvio (vedolizumab), and Stelara (ustekinumab) have all been used in trials.As new biologics and other therapies come to market, patients have more options for treatment.

There has been little study ondietand pouchitis. Some healthcare providers may recommend a low-carbohydrate, low-fiber, high-protein diet.However, one 2023 study has found no connection between diet and pouchitis.

In most cases, the outlook is positive, and pouchitis is a short-term condition that is managed with a course of antibiotics. In 80% of cases of acute pouchitis, antibiotic treatment will result in remission (symptoms stopping).

In one study of people with a J-pouch, of the 53% who developed acute pouchitis:

Chronic pouchitis unfortunately is linked to a risk ofcancer, although this is rare. Studies show some differences in the potential risks. However, the risk does seem to increase with the age of the J-pouch.

The risk at 20 years after surgery is higher than it is five years after surgery. A study of over 3,000 people showed that the risk of cancer at five, 10, 15, and 20 years after surgery is 0.9%, 1.3%, 1.9%, and 4.2%, respectively.

Monitoring Chronic PouchitisIt’s recommended that people with chronic pouchitis get a pouchoscopy to look at the interior of the pouch every one to two years. Biopsies will be taken to test for changes in the tissue that could indicate a risk of cancer.

Monitoring Chronic Pouchitis

It’s recommended that people with chronic pouchitis get a pouchoscopy to look at the interior of the pouch every one to two years. Biopsies will be taken to test for changes in the tissue that could indicate a risk of cancer.

Summary

Pouchitis is a common condition after having ileal pouch surgery. Most cases of pouchitis will get better with a two- to four-week course of one or more antibiotics. If pouchitis doesn’t respond, a step-up approach to using different therapies, including biologics, might be tried.

Pouch failure and needing an ileostomy because of pouchitis is uncommon. People who live with a J-pouch should get regular care to ensure that the pouch is healthy and that they are keeping up with the latest information on pouch function, diet, and lifestyle.

11 SourcesVerywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.Dalal RL, Shen B, Schwartz DA.Management of pouchitis and other common complications of the pouch.Inflamm Bowel Dis. 2018;24:989-996. doi:10.1093/ibd/izy020Donet JA, Rieder F, Charabaty A.#MondayNightIBD: Management of chronic #pouchitis.Crohns Colitis 360. 2020;2:otaa071. doi:10.1093/crocol/otaa071Travis S, Silverberg MS, Danese S, et al.Vedolizumab for the treatment of chronic pouchitis.N Engl J Med. 2023;388:1191-1200. doi:10.1056/NEJMoa2208450Nugent E, Church JM.When pouches cannot empty: a cohort study of the symptoms this causes, the reasons it’s happening, and the treatments needed.ANZ J Surg.2022;92:3237-3241. doi:10.1111/ans.17998Serrero M, Santoni A, Grimaud JC, Desjeux A, Gonzalez JM, Barthet M.Cuffitis: is an endoscopic approach possible?Endosc Int Open. 2020;8:E544-E547. doi:10.1055/a-0996-7975Makkar R, Graff LA, Bharadwaj S, Lopez R, Shen B.Psychological factors in irritable pouch syndrome and other pouch disorders.Inflamm Bowel Dis. 2015;21:2815-2824. doi:10.1097/MIB.0000000000000552Gionchetti P, Calabrese C, Laureti S, Poggioli G, Rizzello F.Pouchitis: clinical features, diagnosis, and treatment.Int J Gen Med. 2021;14:3871-3879. doi:10.2147/IJGM.S306039Lindh S, Bengtsson J, Kaczynski J.Is biologic therapy effective for antibiotic-refractory pouchitis?Scand J Gastroenterol. 2023;58:148-150. doi:10.1080/00365521.2022.2110383Barnes EL, Beniwal-Patel P, Deepak P, et al.Dietary patterns are not associated with disease activity among patients with inflammatory conditions of the pouch in a prospective cohort.Crohns Colitis 360. 2023;5:otad039. doi:10.1093/crocol/otad039Khan F, Shen B.Inflammation and neoplasia of the pouch in inflammatory bowel disease.Curr Gastroenterol Rep. 2019;21:10. doi:10.1007/s11894-019-0679-4Kayal M, Plietz M, Rizvi A, et al.Inflammatory pouch conditions are common after ileal pouch anal anastomosis in ulcerative colitis patients.Inflamm Bowel Dis. 2020;26:1079-1086. doi:10.1093/ibd/izz227Additional ReadingLamb CA, Kennedy NA, Raine T, et al.British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults[published correction appears in Gut. 2021 Apr;70(4):1].Gut. 2019;68(Suppl 3):s1-s106. doi:10.1136/gutjnl-2019-318484.Shen B, Kochhar GS, Rubin DT, et al.Treatment of pouchitis, Crohn’s disease, cuffitis, and other inflammatory disorders of the pouch: consensus guidelines from the International Ileal Pouch Consortium.Lancet Gastroenterol Hepatol.2022;7:69-95. doi:10.1016/S2468-1253(21)00214-4.Uzzan M, Nachury M, Amiot A, et al.Effectiveness and safety of tofacitinib in patients with chronic pouchitis multirefractory to biologics.Dig Liver Dis. 2023;55:1158-1160. doi:10.1016/j.dld.2023.04.028.

11 Sources

Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.Dalal RL, Shen B, Schwartz DA.Management of pouchitis and other common complications of the pouch.Inflamm Bowel Dis. 2018;24:989-996. doi:10.1093/ibd/izy020Donet JA, Rieder F, Charabaty A.#MondayNightIBD: Management of chronic #pouchitis.Crohns Colitis 360. 2020;2:otaa071. doi:10.1093/crocol/otaa071Travis S, Silverberg MS, Danese S, et al.Vedolizumab for the treatment of chronic pouchitis.N Engl J Med. 2023;388:1191-1200. doi:10.1056/NEJMoa2208450Nugent E, Church JM.When pouches cannot empty: a cohort study of the symptoms this causes, the reasons it’s happening, and the treatments needed.ANZ J Surg.2022;92:3237-3241. doi:10.1111/ans.17998Serrero M, Santoni A, Grimaud JC, Desjeux A, Gonzalez JM, Barthet M.Cuffitis: is an endoscopic approach possible?Endosc Int Open. 2020;8:E544-E547. doi:10.1055/a-0996-7975Makkar R, Graff LA, Bharadwaj S, Lopez R, Shen B.Psychological factors in irritable pouch syndrome and other pouch disorders.Inflamm Bowel Dis. 2015;21:2815-2824. doi:10.1097/MIB.0000000000000552Gionchetti P, Calabrese C, Laureti S, Poggioli G, Rizzello F.Pouchitis: clinical features, diagnosis, and treatment.Int J Gen Med. 2021;14:3871-3879. doi:10.2147/IJGM.S306039Lindh S, Bengtsson J, Kaczynski J.Is biologic therapy effective for antibiotic-refractory pouchitis?Scand J Gastroenterol. 2023;58:148-150. doi:10.1080/00365521.2022.2110383Barnes EL, Beniwal-Patel P, Deepak P, et al.Dietary patterns are not associated with disease activity among patients with inflammatory conditions of the pouch in a prospective cohort.Crohns Colitis 360. 2023;5:otad039. doi:10.1093/crocol/otad039Khan F, Shen B.Inflammation and neoplasia of the pouch in inflammatory bowel disease.Curr Gastroenterol Rep. 2019;21:10. doi:10.1007/s11894-019-0679-4Kayal M, Plietz M, Rizvi A, et al.Inflammatory pouch conditions are common after ileal pouch anal anastomosis in ulcerative colitis patients.Inflamm Bowel Dis. 2020;26:1079-1086. doi:10.1093/ibd/izz227Additional ReadingLamb CA, Kennedy NA, Raine T, et al.British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults[published correction appears in Gut. 2021 Apr;70(4):1].Gut. 2019;68(Suppl 3):s1-s106. doi:10.1136/gutjnl-2019-318484.Shen B, Kochhar GS, Rubin DT, et al.Treatment of pouchitis, Crohn’s disease, cuffitis, and other inflammatory disorders of the pouch: consensus guidelines from the International Ileal Pouch Consortium.Lancet Gastroenterol Hepatol.2022;7:69-95. doi:10.1016/S2468-1253(21)00214-4.Uzzan M, Nachury M, Amiot A, et al.Effectiveness and safety of tofacitinib in patients with chronic pouchitis multirefractory to biologics.Dig Liver Dis. 2023;55:1158-1160. doi:10.1016/j.dld.2023.04.028.

Dalal RL, Shen B, Schwartz DA.Management of pouchitis and other common complications of the pouch.Inflamm Bowel Dis. 2018;24:989-996. doi:10.1093/ibd/izy020Donet JA, Rieder F, Charabaty A.#MondayNightIBD: Management of chronic #pouchitis.Crohns Colitis 360. 2020;2:otaa071. doi:10.1093/crocol/otaa071Travis S, Silverberg MS, Danese S, et al.Vedolizumab for the treatment of chronic pouchitis.N Engl J Med. 2023;388:1191-1200. doi:10.1056/NEJMoa2208450Nugent E, Church JM.When pouches cannot empty: a cohort study of the symptoms this causes, the reasons it’s happening, and the treatments needed.ANZ J Surg.2022;92:3237-3241. doi:10.1111/ans.17998Serrero M, Santoni A, Grimaud JC, Desjeux A, Gonzalez JM, Barthet M.Cuffitis: is an endoscopic approach possible?Endosc Int Open. 2020;8:E544-E547. doi:10.1055/a-0996-7975Makkar R, Graff LA, Bharadwaj S, Lopez R, Shen B.Psychological factors in irritable pouch syndrome and other pouch disorders.Inflamm Bowel Dis. 2015;21:2815-2824. doi:10.1097/MIB.0000000000000552Gionchetti P, Calabrese C, Laureti S, Poggioli G, Rizzello F.Pouchitis: clinical features, diagnosis, and treatment.Int J Gen Med. 2021;14:3871-3879. doi:10.2147/IJGM.S306039Lindh S, Bengtsson J, Kaczynski J.Is biologic therapy effective for antibiotic-refractory pouchitis?Scand J Gastroenterol. 2023;58:148-150. doi:10.1080/00365521.2022.2110383Barnes EL, Beniwal-Patel P, Deepak P, et al.Dietary patterns are not associated with disease activity among patients with inflammatory conditions of the pouch in a prospective cohort.Crohns Colitis 360. 2023;5:otad039. doi:10.1093/crocol/otad039Khan F, Shen B.Inflammation and neoplasia of the pouch in inflammatory bowel disease.Curr Gastroenterol Rep. 2019;21:10. doi:10.1007/s11894-019-0679-4Kayal M, Plietz M, Rizvi A, et al.Inflammatory pouch conditions are common after ileal pouch anal anastomosis in ulcerative colitis patients.Inflamm Bowel Dis. 2020;26:1079-1086. doi:10.1093/ibd/izz227

Dalal RL, Shen B, Schwartz DA.Management of pouchitis and other common complications of the pouch.Inflamm Bowel Dis. 2018;24:989-996. doi:10.1093/ibd/izy020

Donet JA, Rieder F, Charabaty A.#MondayNightIBD: Management of chronic #pouchitis.Crohns Colitis 360. 2020;2:otaa071. doi:10.1093/crocol/otaa071

Travis S, Silverberg MS, Danese S, et al.Vedolizumab for the treatment of chronic pouchitis.N Engl J Med. 2023;388:1191-1200. doi:10.1056/NEJMoa2208450

Nugent E, Church JM.When pouches cannot empty: a cohort study of the symptoms this causes, the reasons it’s happening, and the treatments needed.ANZ J Surg.2022;92:3237-3241. doi:10.1111/ans.17998

Serrero M, Santoni A, Grimaud JC, Desjeux A, Gonzalez JM, Barthet M.Cuffitis: is an endoscopic approach possible?Endosc Int Open. 2020;8:E544-E547. doi:10.1055/a-0996-7975

Makkar R, Graff LA, Bharadwaj S, Lopez R, Shen B.Psychological factors in irritable pouch syndrome and other pouch disorders.Inflamm Bowel Dis. 2015;21:2815-2824. doi:10.1097/MIB.0000000000000552

Gionchetti P, Calabrese C, Laureti S, Poggioli G, Rizzello F.Pouchitis: clinical features, diagnosis, and treatment.Int J Gen Med. 2021;14:3871-3879. doi:10.2147/IJGM.S306039

Lindh S, Bengtsson J, Kaczynski J.Is biologic therapy effective for antibiotic-refractory pouchitis?Scand J Gastroenterol. 2023;58:148-150. doi:10.1080/00365521.2022.2110383

Barnes EL, Beniwal-Patel P, Deepak P, et al.Dietary patterns are not associated with disease activity among patients with inflammatory conditions of the pouch in a prospective cohort.Crohns Colitis 360. 2023;5:otad039. doi:10.1093/crocol/otad039

Khan F, Shen B.Inflammation and neoplasia of the pouch in inflammatory bowel disease.Curr Gastroenterol Rep. 2019;21:10. doi:10.1007/s11894-019-0679-4

Kayal M, Plietz M, Rizvi A, et al.Inflammatory pouch conditions are common after ileal pouch anal anastomosis in ulcerative colitis patients.Inflamm Bowel Dis. 2020;26:1079-1086. doi:10.1093/ibd/izz227

Lamb CA, Kennedy NA, Raine T, et al.British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults[published correction appears in Gut. 2021 Apr;70(4):1].Gut. 2019;68(Suppl 3):s1-s106. doi:10.1136/gutjnl-2019-318484.Shen B, Kochhar GS, Rubin DT, et al.Treatment of pouchitis, Crohn’s disease, cuffitis, and other inflammatory disorders of the pouch: consensus guidelines from the International Ileal Pouch Consortium.Lancet Gastroenterol Hepatol.2022;7:69-95. doi:10.1016/S2468-1253(21)00214-4.Uzzan M, Nachury M, Amiot A, et al.Effectiveness and safety of tofacitinib in patients with chronic pouchitis multirefractory to biologics.Dig Liver Dis. 2023;55:1158-1160. doi:10.1016/j.dld.2023.04.028.

Shen B, Kochhar GS, Rubin DT, et al.Treatment of pouchitis, Crohn’s disease, cuffitis, and other inflammatory disorders of the pouch: consensus guidelines from the International Ileal Pouch Consortium.Lancet Gastroenterol Hepatol.2022;7:69-95. doi:10.1016/S2468-1253(21)00214-4.

Uzzan M, Nachury M, Amiot A, et al.Effectiveness and safety of tofacitinib in patients with chronic pouchitis multirefractory to biologics.Dig Liver Dis. 2023;55:1158-1160. doi:10.1016/j.dld.2023.04.028.

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There May Be Multiple Factors#

Monitoring Chronic Pouchitis#

Summary#

There May Be Multiple Factors

Monitoring Chronic Pouchitis

Summary