Management of Pouchitis and Inflammatory Pouch Disorders

Publication Date: December 18, 2023
Last Updated: December 19, 2023

Overview and Background

Key Overarching Considerations in the Management of Patients With Pouchitis and Inflammatory Disorders of the Pouch

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  • Normal bowel function after IPAA for UC and typical symptoms of pouchitis: After an initial period of postoperative adjustment, patients can expect to average 4–8 bowel movements per day and 1–2 bowel movements per night. A variety of clinical symptoms have been described in patients with pouchitis; typical symptoms are increased stool frequency, urgency, abdominal pain or cramping, or pelvic discomfort. Clinical symptoms of pouchitis do not necessarily correlate with findings on endoscopy or histology.
  • Endoscopic evaluation in patients with pouch disorders: Pouchoscopy should be performed in patients experiencing frequent recurrent episodes of pouchitis (suspected chronic antibiotic-dependent pouchitis), in patients with inadequate response to antibiotics before considering other therapies (suspected chronic antibiotic-refractory pouchitis), in patients experiencing atypical symptoms of pouchitis, and when the diagnosis of Crohn’s-like disease of the pouch is being considered. Routine pouchoscopy to confirm pouch inflammation in patients experiencing typical symptoms of pouchitis, before initiation of antibiotics, or in patients who experience infrequent episodes of pouchitis that respond to typical management, may not be required, although it may provide additional information on disease severity in this setting.
  • Treatment goals and targets in patients with pouch disorders: The overall goal of treating patients with pouchitis is resolution of symptoms. Endoscopic and/or histologic resolution of inflammation was not considered a critical treatment goal at this time due to lack of data on the additional benefits of achieving these goals. By extension, asymptomatic patients who have endoscopic evidence of inflammation of the pouch may not routinely warrant treatment.
  • Alternative etiologies for patients with pouch disorders: In patients with atypical symptoms of pouchitis or with inadequate response to conventional therapy or recurrent symptoms of pouchitis, alternative etiologies of symptoms should be considered. These include Clostridioides difficile infection of the pouch; mechanical obstructions, such as strictures at the ileo-anal anastomosis or the pouch inlet or stoma takedown site (approximately 20–40 cm proximal to pouch inlet), and nonrelaxing pelvic floor dysfunction.

Prevention of Pouchitis

In patients with UC who undergo IPAA, the AGA makes no recommendation in favor of, or against, the use of probiotics for primary prevention of pouchitis. ( Evidence Gap , No recommendation )
Comment: There is a need for better evidence from clinical trials to inform the use of probiotics as a primary prevention strategy for pouchitis, especially given the potential cost and burden of long-term use with limited data on potential benefits.
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Overview

Title

Management of Pouchitis and Inflammatory Pouch Disorders

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