📘 Must-read: “Chronic pouchitis: what every gastroenterologist needs to know” – Segal et al, Frontline Gastroenterology
🎥 Don’t miss: FG Expert Webinar on Chronic Pouchitis – Watch now on YouTube
Restorative proctocolectomy with ileal pouch–anal anastomosis (IPAA) often represents a major milestone for patients with ulcerative colitis. But for many, the journey doesn’t end with surgery.
Chronic pouchitis is a persistent and often challenging complication that significantly affects quality of life for a subset of patients. Despite its frequency, approaches to assessment, treatment, and escalation remain inconsistent across clinical practice.
A recent open-access Frontline Gastroenterology review by Segal et al. offers a clear, evidence-based framework to help clinicians navigate this increasingly relevant clinical challenge. Paired with an excellent FG webinar, this is essential material for any clinician managing IBD.
Here’s a summary of the key takeaways—with a clinical focus.
Chronic Pouchitis: Definitions and Risk
While acute pouchitis is common (seen in up to 50% of UC patients with a pouch), chronic pouchitis is a more persistent problem:
- Chronic antibiotic-dependent pouchitis (CADP): symptoms recur when antibiotics are withdrawn.
- Chronic antibiotic-refractory pouchitis (CARP): symptoms persist despite 4+ weeks of antibiotic therapy.
Risk factors include:
- Primary sclerosing cholangitis (PSC) – a strong predictor.
- Extraintestinal manifestations (EIMs) such as arthritis or erythema nodosum.
- Non-smokers and patients with pancolitis or backwash ileitis pre-surgery.
Recognising these features early can guide monitoring and prompt earlier escalation.
Diagnosing It Right: Objective Over Assumption
Symptoms alone aren’t reliable. Stool frequency, urgency, and nocturnal symptoms might suggest pouchitis—but could also be:
- Cuffitis (rectal cuff inflammation)
- Irritable pouch syndrome
- Mechanical complications
Pouchoscopy is crucial to confirm inflammation and exclude differentials.
Use the Pouchitis Disease Activity Index (PDAI)—a combined clinical, endoscopic, and histologic tool (score ≥7 is diagnostic). Histology adds value in distinguishing pouchitis from Crohn’s disease or early neoplasia.
Management: When to Stop Repeating Antibiotics
Antibiotics (First-Line)
- Ciprofloxacin (500 mg BD) and metronidazole (500mg BD) for a 2-week duration are standard first-line agents.
- Ciprofloxacin may be better tolerated and more effective based on limited RCT data.
- Selection should be dependent on previous tolerance or allergy profile
However, if a patient becomes dependent on or refractory to antibiotics, it’s time to escalate.
Escalation: Biologics and Beyond
Anti-TNFs
- Infliximab and adalimumab can be effective in CARP and Crohn’s-like pouchitis.
- Response rates: 50–70% in some retrospective studies.
Vedolizumab
- A gut-selective integrin antagonist with a favourable safety profile.
- Real-world data supports its use in both CADP and CARP, particularly in older or comorbid patients.
Ustekinumab
- Considered for Crohn’s-like features or post-anti-TNF failure.
- Early data promising but still limited.
Other Options
- Budesonide (9 mg daily) may be useful short-term in CARP.
- Thiopurines may support combination therapy, though evidence is limited.
Supporting Therapies
- Probiotics: Demonstrated benefit in maintaining remission post-antibiotic therapy.
- Diet: Low-FODMAP or anti-inflammatory diets may improve symptoms; data still emerging.
- Psychological support: Essential for chronic symptoms and fatigue—often overlooked but valuable.
When to Consider Surgery
Medical therapy may fail. Red flags for surgical referral include:
- Persistent symptoms despite multiple biologics.
- Structural pouch problems (e.g. twist, stricture).
- Profound impact on quality of life.
Surgical options include pouch revision or excision with end ileostomy—decisions best made in a multidisciplinary setting.
Clinical Tips for the Busy Gastroenterologist
✅ Don’t treat on symptoms alone—scope first.
✅ Consider risk factors (PSC, EIMs) when symptoms arise.
✅ Avoid long-term antibiotics—escalate to biologics early if needed.
✅ Vedolizumab offers a safe and effective option in many.
✅ MDT input is essential—particularly for refractory or complex cases.
Watch the Webinar
For expert insights and practical decision-making tips, watch the recent Frontline Gastroenterology webinar on chronic pouchitis, featuring a panel of leading IBD clinicians.
🎥 Watch now: https://www.youtube.com/watch?v=xyN_b1RXZ6w
Final Thoughts
Chronic pouchitis can be a turning point in a patient’s IBD journey—often unexpected and emotionally exhausting. But with a structured, escalation-based approach and the right team, we can improve outcomes and support patients through a difficult path.
👉 Read the full article by Segal et al here for an in-depth review and evidence-based recommendations.