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Pouchitis: pathophysiology and management

Nature Reviews Gastroenterology & Hepatology (2024)Cite this article

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Abstract

Pouchitis is an acute or chronic inflammatory disease of the ileal reservoir. It is common after restorative proctocolectomy with ileal pouch–anal anastomosis, and treatment of chronic antibiotic-refractory pouchitis has proven challenging. Most cases of acute pouchitis evolve into chronic pouchitis. The aetiology of acute pouchitis is likely to be partly related to the gut microbiota, whereas the pathophysiology of chronic pouchitis involves abnormal interactions between genetic disposition, faecal stasis, the gut microbiota, dysregulated host immunity, surgical techniques, ischaemia and mesentery-related factors. Pouchoscopy with biopsy is the most valuable modality for diagnosis, disease monitoring, assessment of treatment response, dysplasia surveillance and delivery of endoscopic therapy. Triggering or risk factors, such as Clostridioides difficile infection and use of non-steroidal anti-inflammatory drugs, should be modified or eradicated. In terms of treatment, acute pouchitis usually responds to oral antibiotics, whereas chronic antibiotic-refractory pouchitis often requires induction and maintenance therapy with integrin, interleukin or tumour necrosis factor inhibitors. Chronic pouchitis with ischaemic features, fistulae or abscesses can be treated with hyperbaric oxygen therapy.

Key points

  • Pouchitis is the most common disorder of ileal pouch–anal anastomosis, and chronic antibiotic-refractory pouchitis has been listed as one of the five difficult-to-treat inflammatory bowel disease conditions.

  • The aetiology and pathogenesis of pouchitis, especially chronic pouchitis, is likely to be multifactorial, involving genetic predisposition, gut microbiota, faecal stasis, disrupted or dysregulated innate and adaptive immunity, mesentery factors, technical factors, tissue ischaemia, and oxidative stress.

  • Accurate diagnosis and classification are important to properly managing and identifying possible aetiopathogenetic factors; known triggering or risk factors should be evaluated and possibly modified.

  • Acute pouchitis usually responds to as-needed oral antibiotic therapy; chronic pouchitis, particularly chronic antibiotic-refractory pouchitis, requires induction and maintenance therapy.

  • Chronic pouchitis can be treated with topical or oral budesonide for induction; chronic antibiotic-refractory pouchitis can be treated with anti-integrin, anti-interleukin or anti-tumour necrosis factor agents for both induction and maintenance; chronic pouchitis with features of ischaemia or fistulas might benefit from hyperbaric oxygen therapy.

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Fig. 1: Multifactorial pathophysiology model of pouchitis.
Fig. 2: Presentation of classic pouchitis.
Fig. 3: Endoscopic patterns of pouch inflammation.
Fig. 4: Proposed algorithm for the diagnosis of pouchitis.

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References

  1. Eriksson, C. et al. Changes in medical management and colectomy rates: a population-based cohort study on the epidemiology and natural history of ulcerative colitis in Örebro, Sweden, 1963-2010. Aliment. Pharmacol. Ther. 46, 748–757 (2017).

    Article  CAS  PubMed  Google Scholar 

  2. Cha, J. M. et al. Long-term prognosis of ulcerative colitis and its temporal changes between 1986 and 2015 in a population-based cohort in the Songpa-Kangdong district of Seoul, Korea. Gut 69, 1432–1440 (2020).

    Article  CAS  PubMed  Google Scholar 

  3. Ley, D. et al. New therapeutic strategies are associated with a significant decrease in colectomy rate in pediatric ulcerative colitis. Am. J. Gastroenterol. 118, 1997–2004 (2023).

    Article  CAS  PubMed  Google Scholar 

  4. Ni, A. et al. Trends in colectomies for colorectal neoplasms in ulcerative colitis: a national inpatient sample database analysis over two decades. J. Gastrointest. Surg. 24, 1721–1728 (2020).

    Article  PubMed  Google Scholar 

  5. Law, C. C. Y. et al. Early biologic treatment decreases risk of surgery in Crohn’s disease but not in ulcerative colitis: systematic review and meta-analysis. Inflamm. Bowel Dis. https://doi.org/10.1093/ibd/izad149 (2023).

    Article  PubMed  Google Scholar 

  6. Worley, G. et al. Restorative surgery after colectomy for ulcerative colitis in England and Sweden: observations from a comparison of nationwide cohorts. Colorectal Dis. 20, 804–812 (2018).

    Article  CAS  PubMed  Google Scholar 

  7. Holubar, S. D. et al. Long-term direct costs before and after proctocolectomy for ulcerative colitis: a population-based study in Olmsted County, Minnesota. Dis. Colon. Rectum 52, 1815–1823 (2009).

    Article  PubMed  PubMed Central  Google Scholar 

  8. Nordenvall, C. et al. Probability, rate and timing of reconstructive surgery following colectomy for inflammatory bowel disease in Sweden: a population-based cohort study. Colorectal Dis. 17, 882–890 (2015).

    Article  CAS  PubMed  Google Scholar 

  9. Shen, B. et al. Diagnosis and classification of ileal pouch disorders: consensus guidelines from the International Ileal Pouch Consortium. Lancet Gastroenterol. Hepatol. 6, 826–849 (2021).

    Article  PubMed  Google Scholar 

  10. Fazio, V. W. et al. Ileal pouch anal anastomosis: analysis of outcome and quality of life in 3707 patients. Ann. Surg. 257, 679–685 (2013).

    Article  PubMed  Google Scholar 

  11. Parigi, T. L. et al. Difficult-to-treat inflammatory bowel disease: results from an international consensus meeting. Lancet Gastroenterol. Hepatol. 8, 853–859 (2023).

    Article  PubMed  Google Scholar 

  12. James, S. D. et al. The MYTHS of de novo Crohn’s disease after restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis. Jpn J. Gastroenterol. Hepatol. 3, 1166 (2020).

    PubMed  PubMed Central  Google Scholar 

  13. Shen, B. 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. 7, 69–95 (2022).

    Article  CAS  PubMed  Google Scholar 

  14. Yamamoto, T., Shimoyama, T., Bamba, T. & Matsumoto, K. Consecutive monitoring of fecal calprotectin and lactoferrin for the early diagnosis and prediction of pouchitis after restorative proctocolectomy for ulcerative colitis. Am. J. Gastroenterol. 110, 881–887 (2015).

    Article  CAS  PubMed  Google Scholar 

  15. Gionchetti, P. et al. Prophylaxis of pouchitis onset with probiotic therapy: a double-blind, placebo-controlled trial. Gastroenterology 124, 1202–1209 (2003).

    Article  PubMed  Google Scholar 

  16. Barnes, E. L., Allin, K. H., Iversen, A. T., Herfarth, H. H. & Jess, T. Increasing incidence of pouchitis between 1996 and 2018: a population-based Danish cohort study. Clin. Gastroenterol. Hepatol. 21, 192–199.e7 (2023).

    Article  PubMed  Google Scholar 

  17. Sriranganathan, D., Kilic, Y., Nabil Quraishi, M. & Segal, J. P. Prevalence of pouchitis in both ulcerative colitis and familial adenomatous polyposis: a systematic review and meta-analysis. Colorectal Dis. 24, 27–39 (2022).

    Article  CAS  PubMed  Google Scholar 

  18. Pedersen, K. E., Jia, X., Holubar, S. D., Steele, S. R. & Lightner, A. L. Ileal pouch-anal anastomosis in the elderly: a systematic review and meta-analysis. Colorectal Dis. 23, 2062–2074 (2021).

    Article  PubMed  Google Scholar 

  19. Dubinsky, V. et al. Predominantly antibiotic-resistant intestinal microbiome persists in patients with pouchitis who respond to antibiotic therapy. Gastroenterology 158, 610–624.e13 (2020).

    Article  CAS  PubMed  Google Scholar 

  20. Kayal, M. et al. Inflammatory pouch conditions are common after ileal pouch anal anastomosis in ulcerative colitis patients. Inflamm. Bowel Dis. 26, 1079–1086 (2020).

    Article  PubMed  Google Scholar 

  21. Tome, J., Raffals, L. E. & Pardi, D. S. Management of acute and chronic pouchitis. Dis. Colon Rectum 65, S69–S76 (2022).

    Article  PubMed  Google Scholar 

  22. Okita, Y. et al. Characteristics of extremely early-onset pouchitis after proctocolectomy with ileal pouch-anal anastomosis. J. Gastrointest. Surg. 17, 533–539 (2013).

    Article  PubMed  Google Scholar 

  23. Esckilsen, S., Kochar, B., Weaver, K. N., Herfarth, H. H. & Barnes, E. L. Very early pouchitis is associated with an increased likelihood of chronic inflammatory conditions of the pouch. Dig. Dis. Sci. 68, 3139–3147 (2023).

    Article  PubMed  Google Scholar 

  24. Hassan, Y., Connell, W. R., Rawal, A. & Wright, E. K. Review of long-term complications and functional outcomes of ileoanal pouch procedures in patients with inflammatory bowel disease. ANZ J. Surg. 93, 1503–1509 (2023).

    Article  PubMed  Google Scholar 

  25. Cowherd, E. et al. The cumulative incidence of pouchitis in pediatric patients with ulcerative colitis. Inflamm. Bowel Dis. 28, 1332–1337 (2022).

    Article  PubMed  PubMed Central  Google Scholar 

  26. Gajendran, M. et al. A comprehensive review and update on ulcerative colitis. Dis. Mon. 65, 100851 (2019).

    Article  PubMed  Google Scholar 

  27. Coppell, K. J. et al. Annual incidence and phenotypic presentation of IBD in Southern New Zealand: an 18-year epidemiological analysis. Inflamm. Intest. Dis. 3, 32–39 (2018).

    Article  PubMed  PubMed Central  Google Scholar 

  28. Akiyama, S. et al. Endoscopic phenotype of the J pouch in patients with inflammatory bowel disease: a new classification for pouch outcomes. Clin. Gastroenterol. Hepatol. 20, 293–302.e9 (2022).

    Article  PubMed  Google Scholar 

  29. Liu, Z. X. et al. Transmural inflammation is not pathognomonic for Crohn’s disease of the pouch. Surg. Endosc. 25, 3509–3517 (2011).

    Article  PubMed  Google Scholar 

  30. Takakura, W. R. et al. Magnitude of preoperative C-reactive protein elevation is associated with de novo Crohn’s disease after ileal pouch-anal anastomosis in patients with severe colitis. Dis. Colon Rectum 65, 399–405 (2022).

    Article  PubMed  Google Scholar 

  31. Yang, Y. et al. A literature review and case report of severe and refractory post-colectomy enteritis. BMC Gastroenterol. 19, 61 (2019).

    Article  PubMed  PubMed Central  Google Scholar 

  32. Emile, S. H., Khan, S. M., Silva-Alvarenga, E., Garoufalia, Z. & Wexner, S. D. A systematic review and meta-analysis of the outcome of ileal pouch-anal anastomosis in patients with ulcerative colitis versus patients with familial adenomatous polyposis. Tech. Coloproctol. 26, 691–705 (2022).

    Article  CAS  PubMed  Google Scholar 

  33. Kistangari, G., Lopez, R. & Shen, B. Frequency and risk factors of Clostridium difficile infection in hospitalized patients with pouchitis: a population-based study. Inflamm. Bowel Dis. 23, 661–671 (2017).

    Article  PubMed  Google Scholar 

  34. Quinn, K. P. et al. Primary sclerosing cholangitis-associated pouchitis: a distinct clinical phenotype. Clin. Gastroenterol. Hepatol. 20, e964–e973 (2022).

    Article  CAS  PubMed  Google Scholar 

  35. Wasmuth, H. H. et al. Primary sclerosing cholangitis and extraintestinal manifestations in patients with ulcerative colitis and ileal pouch-anal anastomosis. J. Gastrointest. Surg. 14, 1099–1104 (2010).

    Article  PubMed  Google Scholar 

  36. Shen, B. et al. Primary sclerosing cholangitis is associated with endoscopic and histologic inflammation of the distal afferent limb in patients with ileal pouch-anal anastomosis. Inflamm. Bowel Dis. 17, 1890–1900 (2011).

    Article  PubMed  Google Scholar 

  37. Nakamura, M. et al. Postoperative joint symptoms: a risk factor for pouchitis in ulcerative colitis patients. Dig. Surg. 23, 60–64 (2006).

    Article  PubMed  Google Scholar 

  38. Hata, K. et al. Meta-analysis of the association of extraintestinal manifestations with the development of pouchitis in patients with ulcerative colitis. BJS Open 3, 436–444 (2019).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  39. Okada, S. et al. A polymorphism in interleukin-1β gene is associated with the development of pouchitis in Japanese patients with ulcerative colitis. Digestion 102, 489–498 (2021).

    Article  CAS  PubMed  Google Scholar 

  40. Achkar, J. P. et al. Differentiating risk factors for acute and chronic pouchitis. Clin. Gastroenterol. Hepatol. 3, 60–66 (2005).

    Article  PubMed  Google Scholar 

  41. Fleshner, P. et al. A prospective multivariate analysis of clinical factors associated with pouchitis after ileal pouch-anal anastomosis. Clin. Gastroenterol. Hepatol. 5, 952–958 (2007).

    Article  PubMed  Google Scholar 

  42. Fadel, M. G. et al. Risks factors associated with the development of Crohn’s disease after ileal pouch-anal anastomosis for ulcerative colitis: a systematic review and meta-analysis. J. Crohns Colitis 17, 1537–1548 (2023).

    Article  PubMed  PubMed Central  Google Scholar 

  43. Gonzalez, A., Gupta, K., Rahman, A. U., Wadhwa, V. & Shen, B. Risk factors associated with hospital readmission and costs for pouchitis. Crohns Colitis 360, otab006 (2021).

    Article  Google Scholar 

  44. Kulkarni, G., Liu, X. & Shen, B. Pouchitis associated with pelvic radiation for prostate cancer. ACG Case Rep. J. 3, e129 (2016).

    Article  PubMed  PubMed Central  Google Scholar 

  45. Seril, D. N. & Shen, B. Clostridium difficile infection in the postcolectomy patient. Inflamm. Bowel Dis. 20, 2450–2469 (2014).

    Article  PubMed  Google Scholar 

  46. Martinez Ugarte, M. L. et al. Clostridium difficile infection after restorative proctocolectomy and ileal pouch anal anastomosis for ulcerative colitis. Colorectal Dis. 18, O154–O157 (2016).

    Article  CAS  PubMed  Google Scholar 

  47. McCurdy, J. D. et al. Cytomegalovirus infection of the ileoanal pouch: clinical characteristics and outcomes. Inflamm. Bowel Dis. 19, 2394–2399 (2013).

    Article  PubMed  Google Scholar 

  48. Wu, X. R., Zhu, H., Kiran, R. P., Remzi, F. H. & Shen, B. Excessive weight gain is associated with an increased risk for pouch failure in patients with restorative proctocolectomy. Inflamm. Bowel Dis. 19, 2173–2181 (2013).

    Article  PubMed  Google Scholar 

  49. Tyler, A. D. et al. The NOD2insC polymorphism is associated with worse outcome following ileal pouch-anal anastomosis for ulcerative colitis. Gut 62, 1433–1439 (2013).

    Article  CAS  PubMed  Google Scholar 

  50. Sehgal, R. et al. NOD2/CARD15 mutations correlate with severe pouchitis after ileal pouch-anal anastomosis. Dis. Colon. Rectum 53, 1487–1494 (2010).

    Article  PubMed  Google Scholar 

  51. Sehgal, R. et al. Genetic risk profiling and gene signature modeling to predict risk of complications after IPAA. Dis. Colon. Rectum 55, 239–248 (2012).

    Article  PubMed  Google Scholar 

  52. Seril, D. N., Yao, Q. & Shen, B. Auto-inflammatory diseases in ileal pouch patients with NOD2/CARD15 mutations. Gastroenterol. Rep. 4, 73–76 (2016).

    Google Scholar 

  53. Carter, M. J. et al. The interleukin 1 receptor antagonist gene allele 2 as a predictor of pouchitis following colectomy and IPAA in ulcerative colitis. Gastroenterology 121, 805–811 (2001).

    Article  CAS  PubMed  Google Scholar 

  54. Lammers, K. M. et al. Combined carriership of TLR9-1237C and CD14-260T alleles enhances the risk of developing chronic relapsing pouchitis. World J. Gastroenterol. 11, 7323–7329 (2005).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  55. Shen, B. et al. A randomized clinical trial of ciprofloxacin and metronidazole to treat acute pouchitis. Inflamm. Bowel Dis. 7, 301–305 (2001).

    Article  CAS  PubMed  Google Scholar 

  56. Li, K. Y. et al. Fecal microbiota in pouchitis and ulcerative colitis. World J. Gastroenterol. 22, 8929–8939 (2016).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  57. Shen, B. Campylobacter infection in patients with ileal pouches. Am. J. Gastroenterol. 105, 472–473 (2010).

    Article  PubMed  Google Scholar 

  58. Cohen, G. S. & Schenck, R. J. Cryptosporidium pouchitis. Clin. Gastroenterol. Hepatol. 15, A27–A28 (2017).

    Article  PubMed  PubMed Central  Google Scholar 

  59. Machiels, K. et al. Specific members of the predominant gut microbiota predict pouchitis following colectomy and IPAA in UC. Gut 66, 79–88 (2017).

    Article  PubMed  Google Scholar 

  60. Palmieri, O. et al. Microbiome analysis of mucosal ileoanal pouch in ulcerative colitis patients revealed impairment of the pouches immunometabolites. Cells 10, 3243 (2021).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  61. Kousgaard, S. J. et al. The microbiota profile in inflamed and non-inflamed ileal pouch-anal anastomosis. Microorganisms 8, 1611 (2020).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  62. Richardson, M. et al. Analysis of 16S rRNA genes reveals reduced Fusobacterial community diversity when translocating from saliva to GI sites. Gut Microbes 12, 1–13 (2020).

    Article  PubMed  Google Scholar 

  63. Gao, X. et al. Identification of gut microbiome and transcriptome changes in ulcerative colitis and pouchitis. Scand. J. Gastroenterol. 57, 942–952 (2022).

    Article  CAS  PubMed  Google Scholar 

  64. Vineis, J. H. et al. Patient-specific bacteroides genome variants in pouchitis. mBio 7, e01713–e01716 (2016).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  65. Reshef, L. et al. Pouch inflammation is associated with a decrease in specific bacterial taxa. Gastroenterology 149, 718–727 (2015).

    Article  PubMed  Google Scholar 

  66. Ha, C. W. Y. et al. Translocation of viable gut microbiota to mesenteric adipose drives formation of creeping fat in humans. Cell 183, 666–683.e17 (2020).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  67. Zhao, L. et al. Microbiota DNA translocation into mesentery lymph nodes is associated with early development of pouchitis after IPAA for ulcerative colitis. Dis. Colon Rectum 66, e1107–e1118 (2023).

    Article  PubMed  Google Scholar 

  68. Kühbacher, T. et al. Bacterial and fungal microbiota in relation to probiotic therapy (VSL#3) in pouchitis. Gut 55, 833–841 (2006).

    Article  PubMed  PubMed Central  Google Scholar 

  69. Karjalainen, E. K. et al. Fecal microbiota transplantation in chronic pouchitis: a randomized, parallel, double-blinded clinical trial. Inflamm. Bowel Dis. 27, 1766–1772 (2021).

    Article  PubMed  PubMed Central  Google Scholar 

  70. Kayal, M., Lambin, T., Pinotti, R., Dubinsky, M. C. & Grinspan, A. A systematic review of fecal microbiota transplant for the management of pouchitis. Crohns Colitis 360, otaa034 (2020).

    Article  Google Scholar 

  71. Shen, B. Acute and chronic pouchitis — pathogenesis, diagnosis and treatment. Nat. Rev. Gastroenterol. Hepatol. 9, 323–333 (2012).

    Article  CAS  PubMed  Google Scholar 

  72. Landy, J. et al. Innate immune factors in the development and maintenance of pouchitis. Inflamm. Bowel Dis. 20, 1942–1949 (2014).

    Article  PubMed  Google Scholar 

  73. Knowles, J. & Church, J. Normal ileal mucus is inadequate for epithelial protection in ileal pouch mucosa. Dis. Colon Rectum https://doi.org/10.1097/DCR.0000000000003163 (2024).

    Article  PubMed  Google Scholar 

  74. Kiehne, K. et al. Defensin expression in chronic pouchitis in patients with ulcerative colitis or familial adenomatous polyposis coli. World J. Gastroenterol. 12, 1056–1062 (2006).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  75. Scarpa, M. et al. Innate immune environment in ileal pouch mucosa: α5 defensin up-regulation as predictor of chronic/relapsing pouchitis. J. Gastrointest. Surg. 16, 188–202 (2012).

    Article  PubMed  Google Scholar 

  76. Leal, R. F. et al. Differential expression of pro-inflammatory cytokines and a pro-apoptotic protein in pelvic ileal pouches for ulcerative colitis and familial adenomatous polyposis. Tech. Coloproctol. 12, 33–38 (2008).

    Article  CAS  PubMed  Google Scholar 

  77. Verstockt, B. et al. Outcome of biological therapies in chronic antibiotic-refractory pouchitis: a retrospective single-centre experience. U. Eur. Gastroenterol. J. 7, 1215–1225 (2019).

    Article  CAS  Google Scholar 

  78. Huguet, M. et al. Systematic review with meta-analysis: anti-TNF therapy in refractory pouchitis and Crohn’s disease-like complications of the pouch after ileal pouch-anal anastomosis following colectomy for ulcerative colitis. Inflamm. Bowel Dis. 24, 261–268 (2018).

    Article  PubMed  Google Scholar 

  79. Uchino, M. et al. Association between serum tumor necrosis factor-alpha level and the efficacy of infliximab for refractory pouchitis after restorative proctocolectomy in patients with ulcerative colitis. J. Anus Rectum Colon. 1, 106–111 (2018).

    Article  PubMed  PubMed Central  Google Scholar 

  80. Morgan, X. C. et al. Associations between host gene expression, the mucosal microbiome, and clinical outcome in the pelvic pouch of patients with inflammatory bowel disease. Genome Biol. 16, 67 (2015).

    Article  PubMed  PubMed Central  Google Scholar 

  81. Inoue, E. et al. Altered expression of microRNAs in patients with pouchitis after restorative proctocolectomy. Surg. Today 47, 1484–1491 (2017).

    Article  CAS  PubMed  Google Scholar 

  82. Boniface, K., Blom, B., Liu, Y. J. & de Waal Malefyt, R. From interleukin-23 to T-helper 17 cells: human T-helper cell differentiation revisited. Immunol. Rev. 226, 132–146 (2008).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  83. Lyakh, L., Trinchieri, G., Provezza, L., Carra, G. & Gerosa, F. Regulation of interleukin-12/interleukin-23 production and the T-helper 17 response in humans. Immunol. Rev. 226, 112–131 (2008).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  84. Rocchi, C. et al. Is ustekinumab effective in refractory Crohn’s disease of the pouch and chronic pouchitis? A systematic review. Dig. Dis. Sci. 67, 1948–1955 (2022).

    Article  PubMed  Google Scholar 

  85. Travis, S. et al. EARNEST Study Group. Vedolizumab for the treatment of chronic pouchitis. N. Engl. J. Med. 388, 1191–1200 (2023).

    Article  CAS  PubMed  Google Scholar 

  86. de Krijger, M. et al. Expression of MAdCAM-1 and gut-homing T cells in inflamed pouch mucosa. J. Crohns Colitis 15, 1491–1499 (2021).

    Article  PubMed  Google Scholar 

  87. Melde, M. et al. α4β7 integrin-dependent adhesion of T cells to MAdCAM-1 is blocked by vedolizumab in patients with chronic refractory pouchitis. Ther. Adv. Gastroenterol. 14, 17562848211054707 (2021).

    Article  CAS  Google Scholar 

  88. Miner, P., Wedel, M., Bane, B. & Bradley, J. An enema formulation of alicaforsen, an antisense inhibitor of intercellular adhesion molecule-1, in the treatment of chronic, unremitting pouchitis. Aliment. Pharmacol. Ther. 19, 281–286 (2004).

    Article  CAS  PubMed  Google Scholar 

  89. Feagan, B., Lindsay, J., Gerhard, R., Moran, G. & Varawalla, N. Alicaforsen enema in chronic pouchitis: results of a phase 3 randomized, double-blind, placebo-controlled trial. Am. J. Gastroenterol. 116, S365 (2021).

    Google Scholar 

  90. Leal, R. F. et al. Activation of signal transducer and activator of transcription-1 (STAT-1) and differential expression of interferon-gamma and anti-inflammatory proteins in pelvic ileal pouches for ulcerative colitis and familial adenomatous polyposis. Clin. Exp. Immunol. 160, 380–385 (2010).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  91. Uzzan, M. et al. & GETAID TOFA-POUCH Study Group. Effectiveness and safety of tofacitinib in patients with chronic pouchitis multirefractory to biologics. Dig. Liver Dis. 55, 1158–1160 (2023).

    Article  CAS  PubMed  Google Scholar 

  92. Akiyama, S. et al. Treatment of chronic inflammatory pouch conditions with tofacitinib: a case series from 2 tertiary IBD centers in the United States. Inflamm. Bowel Dis. 29, 1504–1507 (2023).

    Article  PubMed  PubMed Central  Google Scholar 

  93. Devlin, J. C. et al. Single-cell transcriptional survey of ileal-anal pouch immune cells from ulcerative colitis patients. Gastroenterology 160, 1679–1693 (2021).

    Article  CAS  PubMed  Google Scholar 

  94. Yanai, H. et al. Gene expression alterations in ulcerative colitis patients after restorative proctocolectomy extend to the small bowel proximal to the pouch. Gut 64, 756–764 (2015).

    Article  CAS  PubMed  Google Scholar 

  95. Sherman Horev, H. et al. Increase in processing factors is involved in skewed microRNA expression in patients with ulcerative colitis who develop small intestine inflammation after pouch surgery. Inflamm. Bowel Dis. 24, 1045–1054 (2018).

    Article  PubMed  Google Scholar 

  96. Burns, E. M. et al. Volume analysis of outcome following restorative proctocolectomy. Br. J. Surg. 98, 408–417 (2011).

    Article  CAS  PubMed  Google Scholar 

  97. Wu, X. R. et al. The impact of mesenteric tension on pouch outcome and quality of life in patients undergoing restorative proctocolectomy. Colorectal Dis. 16, 986–994 (2014).

    Article  PubMed  Google Scholar 

  98. Ray, J. J. et al. Association of malnutrition with postoperative outcomes after ileal pouch-anal anastomosis. J. Gastrointest. Surg. 25, 1562–1564 (2021).

    Article  PubMed  Google Scholar 

  99. Syed, A. et al. Association between portal vein thrombosis and pouchitis in patients with ulcerative colitis. Dig. Dis. Sci. 67, 1303–1310 (2022).

    Article  PubMed  Google Scholar 

  100. Kayal, M. et al. Early pouchitis is associated with Crohn’s disease-like pouch inflammation in patients with ulcerative colitis. Inflamm. Bowel Dis. 28, 1821–1825 (2022).

    Article  PubMed  PubMed Central  Google Scholar 

  101. Shen, B. Endoscopic evaluation of the ileal pouch. Dis. Colon Rectum https://doi.org/10.1097/DCR.0000000000003269 (2024).

    Article  PubMed  Google Scholar 

  102. Ma, H. Y., Kim, H. W., Khurana, S., Bentley-Hibbert, S. & Shen, B. Fluoroscopic defecography characterization of floppy pouch complex with clinical and endoscopic correlations. J. Radiol. Clin. Imaging https://doi.org/10.26502/jrci.2809090 (2024).

    Article  Google Scholar 

  103. Mukewar, S., Wu, X., Lopez, R. & Shen, B. Comparison of long-term outcomes of S and J pouches and continent ileostomies in ulcerative colitis patients with restorative proctocolectomy-experience in subspecialty pouch center. J. Crohns Colitis 8, 1227–1236 (2014).

    Article  PubMed  Google Scholar 

  104. Aoki, T. et al. Abdominal fat accumulation, as measured by computed tomography, increases the risk of ischemic colitis: a retrospective case-control study. Dig. Dis. Sci. 60, 2104–2111 (2015).

    Article  PubMed  Google Scholar 

  105. Rowan, C. R., McManus, J., Boland, K. & O’Toole, A. Visceral adiposity and inflammatory bowel disease. Int. J. Colorectal Dis. 36, 2305–2319 (2021).

    Article  PubMed  Google Scholar 

  106. Emile, S. H., Khan, S. M. & Wexner, S. D. A systematic review and meta-analysis of the outcome of ileal pouch anal anastomosis in patients with obesity. Surgery 170, 1629–1636 (2021).

    Article  PubMed  Google Scholar 

  107. Pandrangi, V. et al. Abdominal visceral fat area and chronic pouchitis after ileal pouch-anal anastomosis. Am. Surg. 83, 1029–1032 (2017).

    Article  PubMed  Google Scholar 

  108. Gao, X. H. et al. Greater peripouch fat area on CT image is associated with chronic pouchitis and pouch failure in inflammatory bowel diseases patients. Dig. Dis. Sci. 65, 3660–3671 (2020).

    Article  PubMed  Google Scholar 

  109. Ginocchio, L. A. et al. Structured versus non-structured reporting of pelvic MRI for ileal pouch evaluation: clarity and effectiveness. Abdom. Radiol. 48, 2978–2985 (2023).

    Article  Google Scholar 

  110. Broder, J. C., Tkacz, J. N., Anderson, S. W., Soto, J. A. & Gupta, A. Ileal pouch-anal anastomosis surgery: imaging and intervention for post-operative complications. Radiographics 30, 221–233 (2010).

    Article  PubMed  Google Scholar 

  111. Viscido, A., Kohn, A., Papi, C. & Caprilli, R. Management of refractory fistulizing pouchitis with infliximab. Eur. Rev. Med. Pharmacol. Sci. 8, 239–246 (2004).

    CAS  PubMed  Google Scholar 

  112. Luglio, G. et al. Surgical prevention of anastomotic recurrence by excluding mesentery in Crohn’s disease: the SuPREMe-CD study — a randomized clinical trial. Ann. Surg. 272, 210–217 (2020).

    Article  PubMed  Google Scholar 

  113. Shen, B. et al. Asymmetric endoscopic inflammation of the ileal pouch: a sign of ischemic pouchitis? Inflamm. Bowel Dis. 16, 836–846 (2010).

    Article  PubMed  Google Scholar 

  114. Eltzschig, H. K., Bratton, D. L. & Colgan, S. P. Targeting hypoxia signalling for the treatment of ischaemic and inflammatory diseases. Nat. Rev. Drug Discov. 13, 852–869 (2014).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  115. Vavricka, S. R. et al. High altitude journeys and flights are associated with an increased risk of flares in inflammatory bowel disease patients. J. Crohns Colitis 8, 191–199 (2014).

    Article  PubMed  Google Scholar 

  116. Kienle, P. et al. Association of decreased perfusion of the ileoanal pouch mucosa with early postoperative pouchitis and local septic complications. Arch. Surg. 136, 1124–1130 (2001).

    Article  CAS  PubMed  Google Scholar 

  117. El Muhtaseb, M. S. et al. Free radical activity and lipid soluble anti-oxidant vitamin status in patients with long-term ileal pouch-anal anastomosis. Colorectal Dis. 11, 67–72 (2009).

    Article  CAS  PubMed  Google Scholar 

  118. Shebani, K. O. et al. Role of stasis and oxidative stress in ileal pouch inflammation. J. Surg. Res. 90, 67–75 (2000).

    Article  CAS  PubMed  Google Scholar 

  119. Hasan, B. et al. Hyperbaric oxygen therapy in chronic inflammatory conditions of the pouch. Inflamm. Bowel Dis. 27, 965–970 (2021).

    Article  PubMed  Google Scholar 

  120. Fahad, H., Dulai, P. S., Shen, B. & Kochhar, G. S. Hyperbaric oxygen therapy is effective in the treatment of inflammatory and fistulizing pouch complications. Clin. Gastroenterol. Hepatol. 19, 1288–1291 (2021).

    Article  PubMed  Google Scholar 

  121. Mehta, M., Ahmed, S. & Dryden, G. Refractory pouchitis improves after administration of the green tea polyphenol EGCG: a retrospective review. Int. J. Colorectal Dis. 33, 83–86 (2018).

    Article  PubMed  Google Scholar 

  122. Abbass, M. A. et al. Nonspecific, acute pouchitis in patients with familial adenomatous polyposis: less common than we think. Dis. Colon Rectum 65, 846–850 (2022).

    Article  PubMed  Google Scholar 

  123. Ward, M. A. et al. Insights into the pathogenesis of ulcerative colitis from a murine model of stasis-induced dysbiosis, colonic metaplasia, and genetic susceptibility. Am. J. Physiol. Gastrointest. Liver Physiol. 310, G973–G988 (2016).

    Article  PubMed  PubMed Central  Google Scholar 

  124. Quinn, K. P. et al. Nonrelaxing pelvic floor dysfunction is an underestimated complication of ileal pouch-anal anastomosis. Clin. Gastroenterol. Hepatol. 15, 1242–1247 (2017).

    Article  PubMed  Google Scholar 

  125. Nugent, E. & Church, J. M. When pouches cannot empty: a cohort study of the symptoms this causes, the reasons it’s happening, and the treatments needed. ANZ J. Surg. 92, 3237–3241 (2022).

    Article  PubMed  Google Scholar 

  126. Lan, N. et al. Endoscopic treatment of pouch inlet and afferent limb strictures: stricturotomy vs. balloon dilation. Surg. Endosc. 35, 1722–1733 (2021).

    Article  PubMed  Google Scholar 

  127. Sandborn, W. J., Tremaine, W. J., Batts, K. P., Pemberton, J. H. & Phillips, S. F. Pouchitis after ileal pouch-anal anastomosis: a Pouchitis Disease Activity Index. Mayo Clin. Proc. 69, 409–415 (1994).

    Article  CAS  PubMed  Google Scholar 

  128. Shen, B. et al. Modified pouchitis disease activity index: a simplified approach to the diagnosis of pouchitis. Dis. Colon Rectum 46, 748–753 (2003).

    Article  PubMed  Google Scholar 

  129. Sedano, R. et al. An expert consensus to standardise clinical, endoscopic and histologic items and inclusion and outcome criteria for evaluation of pouchitis disease activity in clinical trials. Aliment. Pharmacol. Ther. 53, 1108–1117 (2021).

    Article  PubMed  Google Scholar 

  130. Shen, B. et al. Comprehensive evaluation of inflammatory and noninflammatory sequelae of ileal pouch-anal anastomoses. Am. J. Gastroenterol. 100, 93–101 (2005).

    Article  PubMed  Google Scholar 

  131. Freeha, K., Gao, X. H., Hull, T. L. & Shen, B. Characterization of risk factors for floppy pouch complex in ulcerative colitis. Int. J. Colorectal Dis. 34, 1061–1067 (2019).

    Article  PubMed  Google Scholar 

  132. Khan, F., Hull, T. L. & Shen, B. Diagnosis and management of floppy pouch complex. Gastroenterol. Rep. 6, 246–256 (2018).

    Article  Google Scholar 

  133. Roussel, B. N. & Shah, S. A. Diagnosis and management of functional pouch disorders: a systematic review. Dis. Colon Rectum 65, S113–S118 (2022).

    Article  PubMed  Google Scholar 

  134. Haveran, L. A. et al. Infliximab and/or azathioprine in the treatment of Crohn’s disease-like complications after IPAA. Dis. Colon Rectum 54, 15–20 (2011).

    Article  PubMed  Google Scholar 

  135. Akiyama, S., Dyer, E. C. & Rubin, D. T. Diagnostic and management considerations for the IPAA with Crohn’s disease-like features. Dis. Colon Rectum 65, S77–S84 (2022).

    Article  PubMed  Google Scholar 

  136. Ardalan, Z. S. et al. Perceived dietary intolerances, habitual intake and diet quality of patients with an ileoanal pouch: associations with pouch phenotype (and behaviour). Clin. Nutr. 42, 2095–2108 (2023).

    Article  CAS  PubMed  Google Scholar 

  137. Ardalan, Z. S., Yao, C. K., Sparrow, M. P. & Gibson, P. R. Review article: the impact of diet on ileoanal pouch function and on the pathogenesis of pouchitis. Aliment. Pharmacol. Ther. 52, 1323–1340 (2020).

    Article  PubMed  Google Scholar 

  138. Godny, L. et al. Fruit consumption is associated with alterations in microbial composition and lower rates of pouchitis. J. Crohns Colitis 13, 1265–1272 (2019).

    Article  CAS  PubMed  Google Scholar 

  139. Godny, L. et al. Adherence to the Mediterranean diet is associated with decreased fecal calprotectin in patients with ulcerative colitis after pouch surgery. Eur. J. Nutr. 59, 3183–3190 (2020).

    Article  CAS  PubMed  Google Scholar 

  140. McLaughlin, S. D. et al. Exclusive elemental diet impacts on the gastrointestinal microbiota and improves symptoms in patients with chronic pouchitis. J. Crohns Colitis 7, 460–466 (2013).

    Article  CAS  PubMed  Google Scholar 

  141. Shen, B. et al. Effect of withdrawal of nonsteroidal anti-inflammatory drug use on ileal pouch disorders. Dig. Dis. Sci. 52, 3321–3328 (2007).

    Article  CAS  PubMed  Google Scholar 

  142. Liu, Z. X. et al. Chronic pouchitis is associated with pouch polyp formation in patients with underlying ulcerative colitis. J. Crohns Colitis 8, 363–369 (2014).

    Article  PubMed  Google Scholar 

  143. Navaneethan, U. 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 6, 536–542 (2012).

    Article  PubMed  Google Scholar 

  144. Shen, B. et al. Endoscopic and histologic evaluation together with symptom assessment are required to diagnose pouchitis. Gastroenterology 121, 261–267 (2001).

    Article  CAS  PubMed  Google Scholar 

  145. Samaan, M. A. et al. Reliability among central readers in the evaluation of endoscopic disease activity in pouchitis. Gastrointest. Endosc. 88, 360–369.e2 (2018).

    Article  PubMed  Google Scholar 

  146. Jairath, V. et al. Travis mucosal healing with vedolizumab in inflammatory bowel disease patients with chronic pouchitis: evidence from EARNEST, a randomized, double-blind, placebo-controlled trial. J. Crohns Colitis 17, i13–i14 (2023).

    Article  Google Scholar 

  147. Ollech, J. E. et al. Fecal calprotectin is increased in pouchitis and progressively increases with more severe endoscopic and histologic disease. Clin. Gastroenterol. Hepatol. 20, 1839–1846.e2 (2022).

    Article  CAS  PubMed  Google Scholar 

  148. Barreiro-de Acosta, M. et al. Recommendations of the Spanish Working Group on Crohn’s Disease and Ulcerative Colitis (GETECCU) on pouchitis in ulcerative colitis. Part 2: treatment. Recomendaciones del Grupo Español de Trabajo en Enfermedad de Crohn y Colitis Ulcerosa (GETECCU) sobre la reservoritis en la colitis ulcerosa. Parte 2: Tratamiento. Gastroenterol. Hepatol. 43, 649–658 (2020).

    Article  PubMed  Google Scholar 

  149. Lamb, C. A. et al. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut 68, s1–s106 (2019).

    Article  PubMed  Google Scholar 

  150. Magro, F. et al. Third European evidence-based consensus on diagnosis and management of ulcerative colitis. Part 1: definitions, diagnosis, extra-intestinal manifestations, pregnancy, cancer surveillance, surgery, and ileo-anal pouch disorders. J. Crohns Colitis 11, 649–670 (2017).

    Article  PubMed  Google Scholar 

  151. Pardi, D. S., D’Haens, G., Shen, B., Campbell, S. & Gionchetti, P. Clinical guidelines for the management of pouchitis. Inflamm. Bowel Dis. 15, 1424–1431 (2009).

    Article  PubMed  Google Scholar 

  152. Barnes, E. L. et al. AGA clinical practice guideline on the management of pouchitis and inflammatory pouch disorders. Gastroenterology 166, 59–85 (2024).

    Article  PubMed  Google Scholar 

  153. Nguyen, N., Zhang, B., Holubar, S. D., Pardi, D. S. & Singh, S. Treatment and prevention of pouchitis after ileal pouch-anal anastomosis for chronic ulcerative colitis. Cochrane Database Syst. Rev. 5, CD001176 (2019).

    PubMed  Google Scholar 

  154. Gionchetti, P. et al. Oral bacteriotherapy as maintenance treatment in patients with chronic pouchitis: a double-blind, placebo-controlled trial. Gastroenterology 119, 305–309 (2000).

    Article  CAS  PubMed  Google Scholar 

  155. Mimura, T. et al. Once daily high dose probiotic therapy (VSL#3) for maintaining remission in recurrent or refractory pouchitis. Gut 53, 108–114 (2004).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  156. Shen, B. et al. Maintenance therapy with a probiotic in antibiotic-dependent pouchitis: experience in clinical practice. Aliment. Pharmacol. Ther. 22, 721–728 (2005).

    Article  CAS  PubMed  Google Scholar 

  157. Yasueda, A. et al. The effect of Clostridium butyricum MIYAIRI on the prevention of pouchitis and alteration of the microbiota profile in patients with ulcerative colitis. Surg. Today 46, 939–949 (2016).

    Article  PubMed  Google Scholar 

  158. Gosselink, M. P. et al. Delay of the first onset of pouchitis by oral intake of the probiotic strain Lactobacillus rhamnosus GG. Dis. Colon Rectum 47, 876–884 (2004).

    Article  PubMed  Google Scholar 

  159. Brown, S. J. et al. Bifidobacterium longum BB-536 and prevention of pouchitis. Gastroenterology 126, S465 (2004).

    Google Scholar 

  160. Ha, C. Y. et al. Early institution of tinidazole may prevent pouchitis following ileal pouch-anal anastomosis (IPAA) surgery in ulcerative colitis (UC) patients. Gastroenterology 138, S69 (2010).

    Article  Google Scholar 

  161. Isaacs, K. L. et al. Rifaximin for the treatment of active pouchitis: a randomized, double-blind, placebo-controlled pilot study. Inflamm. Bowel Dis. 13, 1250–1255 (2007).

    Article  PubMed  Google Scholar 

  162. Shen, B., Remzi, F. H., Lopez, A. R. & Queener, E. Rifaximin for maintenance therapy in antibiotic-dependent pouchitis. BMC Gastroenterol. 8, 26 (2008).

    Article  PubMed  PubMed Central  Google Scholar 

  163. Abdelrazeq, A. S., Kelly, S. M., Lund, J. N. & Leveson, S. H. Rifaximin-ciprofloxacin combination therapy is effective in chronic active refractory pouchitis. Colorectal Dis. 7, 182–186 (2005).

    Article  CAS  PubMed  Google Scholar 

  164. Mimura, T. et al. Four-week open-label trial of metronidazole and ciprofloxacin for the treatment of recurrent or refractory pouchitis. Aliment. Pharmacol. Ther. 16, 909–917 (2002).

    Article  CAS  PubMed  Google Scholar 

  165. Shen, B. et al. Combined ciprofloxacin and tinidazole therapy in the treatment of chronic refractory pouchitis. Dis. Colon Rectum 50, 498–508 (2007).

    Article  PubMed  Google Scholar 

  166. Shen, B. Oral vancomycin in the treatment of primary sclerosing cholangitis-associated pouchitis. Gastroenterol. Rep. 9, 274–275 (2021).

    Article  Google Scholar 

  167. Seril, D. N., Ashburn, J. H., Lian, L. & Shen, B. Risk factors and management of refractory or recurrent Clostridium difficile infection in ileal pouch patients. Inflamm. Bowel Dis. 20, 2226–2233 (2014).

    Article  PubMed  Google Scholar 

  168. Bar, N. et al. Long-term antibiotic treatment in pouchitis-patterns of use and safety. Inflamm. Bowel Dis. 28, 1027–1033 (2022).

    Article  PubMed  Google Scholar 

  169. Fukushima, K., Saito, T., Kohyama, A. & Watanabe, K. Increased quinolone-resistant mutations of gyrA and parC genes after pouchitis treatment with ciprofloxacin. Dig. Surg. 37, 321–330 (2020).

    Article  CAS  PubMed  Google Scholar 

  170. Scaioli, E. et al. Sulfasalazine in prevention of pouchitis after proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis. Dig. Dis. Sci. 62, 1016–1024 (2017).

    Article  CAS  PubMed  Google Scholar 

  171. Balbir-Gurman, A., Schapira, D. & Nahir, M. Arthritis related to ileal pouchitis following total proctocolectomy for ulcerative colitis. Semin. Arthritis Rheum. 30, 242–248 (2001).

    Article  CAS  PubMed  Google Scholar 

  172. Miner, P. B. Jr, Wedel, M. K., Xia, S. & Baker, B. F. Safety and efficacy of two dose formulations of alicaforsen enema compared with mesalazine enema for treatment of mild to moderate left-sided ulcerative colitis: a randomized, double-blind, active-controlled trial. Aliment. Pharmacol. Ther. 23, 1403–1413 (2006).

    Article  CAS  PubMed  Google Scholar 

  173. Gionchetti, P. et al. Oral budesonide in the treatment of chronic refractory pouchitis. Aliment. Pharmacol. Ther. 25, 1231–1236 (2007).

    Article  CAS  PubMed  Google Scholar 

  174. Viazis, N. et al. Long term benefit of one year infliximab administration for the treatment of chronic refractory pouchitis. J. Crohns Colitis 7, e457–e460 (2013).

    Article  PubMed  Google Scholar 

  175. Winter, T. A., Dalton, H. R., Merrett, M. N., Campbell, A. & Jewell, D. P. Cyclosporin A retention enemas in refractory distal ulcerative colitis and ‘pouchitis’. Scand. J. Gastroenterol. 28, 701–704 (1993).

    Article  CAS  PubMed  Google Scholar 

  176. Daniels, Beynon & Carr. The use of cyclosporin retention enemas for pouchitis. Colorectal Dis. 1, 49 (1999).

    Article  CAS  PubMed  Google Scholar 

  177. Uchino, M. et al. Topical tacrolimus therapy for antibiotic-refractory pouchitis. Dis. Colon Rectum 56, 1166–1173 (2013).

    Article  PubMed  Google Scholar 

  178. Barreiro-de Acosta, M. et al. Efficacy of infliximab rescue therapy in patients with chronic refractory pouchitis: a multicenter study. Inflamm. Bowel Dis. 18, 812–817 (2012).

    Article  CAS  PubMed  Google Scholar 

  179. Kjær, M. D., Qvist, N., Nordgaard-Lassen, I., Christensen, L. A. & Kjeldsen, J. Adalimumab in the treatment of chronic pouchitis. A randomized double-blind, placebo-controlled trial. Scand. J. Gastroenterol. 54, 188–193 (2019).

    Article  PubMed  Google Scholar 

  180. Lindh, S., Bengtsson, J. & Kaczynski, J. Is biologic therapy effective for antibiotic-refractory pouchitis? Scand. J. Gastroenterol. 58, 148–150 (2023).

    Article  CAS  PubMed  Google Scholar 

  181. Ribaldone, D. G. et al. Treatment of antibiotic refractory chronic pouchitis with JAK inhibitors and S1P receptor modulators: an ECCO CONFER Multicentre Case Series. J. Crohns Colitis https://doi.org/10.1093/ecco-jcc/jjad194 (2023).

    Article  PubMed  Google Scholar 

  182. Lan, N. & Shen, B. Efficacy and safety of upadacitinib in the treatment of chronic pouchitis, cuffitis, and Crohn’s disease of the pouch. ACG Case Rep. J. 11, e01245 (2024).

    Article  PubMed  PubMed Central  Google Scholar 

  183. Lan, N., Ashburn, J. & Shen, B. Fecal microbiota transplantation for Clostridium difficile infection in patients with ileal pouches. Gastroenterol. Rep. 5, 200–207 (2017).

    Article  Google Scholar 

  184. Nyabanga, C. T., Kulkarni, G. & Shen, B. Hyperbaric oxygen therapy for chronic antibiotic-refractory ischemic pouchitis. Gastroenterol. Rep. 5, 320–321 (2017).

    Google Scholar 

  185. Remzi, F. H. et al. Transabdominal redo ileal pouch surgery for failed restorative proctocolectomy: lessons learned over 500 patients. Ann. Surg. 262, 675–682 (2015).

    Article  PubMed  Google Scholar 

  186. Novello, M., Shen, B. & Stocchi, L. Pouchitis as an indication for ileal pouch surgical revision. Inflamm. Bowel Dis. 25, e25 (2019).

    Article  PubMed  Google Scholar 

  187. Maspero, M. et al. Ileal pouch-anal anastomosis in primary sclerosing cholangitis-inflammatory bowel disease (PSC-IBD): long-term pouch and liver transplant outcomes. Ann. Surg. https://doi.org/10.1097/SLA.0000000000006041 (2023).

    Article  PubMed  Google Scholar 

  188. Freeman, K. et al. Impact of orthotopic liver transplant for primary sclerosing cholangitis on chronic antibiotic refractory pouchitis. Clin. Gastroenterol. Hepatol. 6, 62–68 (2008).

    Article  PubMed  Google Scholar 

  189. Lee, K. E. & Shen, B. Endoscopic therapy for pouch leaks and strictures: a systematic review. Dis. Colon Rectum 65, S92–S104 (2022).

    Article  PubMed  Google Scholar 

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Acknowledgements

The author would like to thank S. Edelman, S. Jarislowsky, E. Story, J. Story, D. Quint, S. Quint, B. Donaghy, L. Donaghy, J. Hyman and R. Hyman for their philanthropy support to the Ileal Pouch Program at Columbia University Irving Medical Center/New York Presbyterian Hospital.

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  1. Center for Inflammatory Bowel Diseases and the Global Center for Integrated Colorectal Surgery and IBD Interventional Endoscopy, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York, NY, USA

    Bo Shen

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B.S. is a former consultant for Abbvie, Takeda and Janssen.

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Review criteria A literature search was performed using PubMed for articles published from January 2001 to August 2023. Additionally, relevant abstracts from professional society meetings were searched. The following keywords were used: “ulcerative colitis”, “ileal pouch”, “pouchitis”, “restorative proctocolectomy”, “antibiotics”, “primary sclerosing cholangitis”, “extraintestinal manifestations”, “bacteria”, “gut microbiota”, “gut microflora”, “ischemia”, “mesentery”, “pathogenesis”, “treatment”. Only relevant, English language articles were included.

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Shen, B. Pouchitis: pathophysiology and management. Nat Rev Gastroenterol Hepatol (2024). https://doi.org/10.1038/s41575-024-00920-5

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