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  • Review Article
  • Published:

Pouchitis: pathophysiology and management

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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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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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 21, 463–476 (2024). https://doi.org/10.1038/s41575-024-00920-5

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