📘 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• Chronic antibiotic-dependent pouchitis (CADP): symptoms recur when antibiotics are withdrawn.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.