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Current Management of Pouchitis

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Current Treatment Options in Gastroenterology Aims and scope Submit manuscript

Abstract

Purpose of review

Pouchitis is common after restorative proctocolectomy and ileal pouch-anal anastomosis in patients with underlying ulcerative colitis. A majority of patients with acute antibiotic-responsive pouchitis develop chronic antibiotic-dependent pouchitis or antibiotic-refractory pouchitis. Contributing factors for chronic pouchitis include Clostridium difficile infection, the use of non-steroidal anti-inflammatory drugs, concurrent autoimmune disorders, surgical ischemia, and fecal stasis from structural or functional pouch outlet obstruction. Chronic antibiotic-refractory pouchitis is considered one of “difficult-to-treat” inflammatory bowel diseases (IBD).

Recent findings

While acute pouchitis often responds to oral antibiotic therapy, chronic pouchitis usually requires induction and maintenance therapy. Biological agents, particularly vedolizumab, may be used for the treatment of chronic pouchitis. The role of small molecule agents in the treatment of chronic pouchitis warrants further investigation. Fecal microbiota transplant, though effective in the eradication of Clostridium difficile of the pouch, has a limited therapeutic role in the management of chronic pouchitis. Hyperbaric oxygen therapy showed promising effects on chronic pouchitis.

Summary

Pouchitis represents a disease spectrum ranging from acute antibiotic-responsive to chronic antibiotic-refractory phenotypes. The treatment of chronic antibiotic-refractory pouchitis is similar to that of IBD, with confounding factors from surgery-associated ischemia and concurrent autoimmune disorders, particularly primary sclerosing cholangitis.

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Data Availability

All figures and tables are original and have never published before.

Abbreviations

CADP:

Chronic antibiotic-dependent pouchitis

CARP:

Chronic antibiotic-refractory pouchitis

CD:

Crohn’s disease

CDI:

Clostridium difficile Infection

CDP:

Crohn’s disease of the pouch

CT:

Computed tomography

FAP:

Familial adenomatous polyposis

FDA:

The Food and Drug Administration

FODMAP:

Fermentable oligosaccharides, disaccharides, monosaccharides, and polyols

FMT:

Fecal microbiota transplant

HOBT:

Hyperbaric oxygen therapy

IBD:

Inflammatory bowel disease

IPAA:

Ileal pouch-anal anastomosis

IQR:

Interquartile range

NSAID:

Non-steroidal anti-inflammatory drugs

PDAI:

The Pouchitis Disease Activity Index

RCT:

Randomized controlled trial

TNF:

Tumor necrosis factor

UC:

Ulcerative colitis

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Acknowledgements

Dr. Bo Shen is supported by the Edelman-Jarislowsky Professorship in Surgical Sciences. The author is grateful to Mr. and Mrs. Donaghy, Mr. and Mrs. Story, Mr. and Mrs. Kerr, Mr. and Mrs. Hyman, and Mr. and Mrs. Quint for their general support.

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  1. Center for Inflammatory Bowel Disease, Columbia University Irving Medical Center/NewYork Presbyterian Hospital, 161 Ft Washington Ave., Herbert Irving Pavilion-Suite 843, New York, NY, 10032, USA

    Bo Shen MD

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Shen, B. Current Management of Pouchitis. Curr Treat Options Gastro 21, 395–410 (2023). https://doi.org/10.1007/s11938-023-00438-w

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