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  • Review Article
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Acute and chronic pouchitis—pathogenesis, diagnosis and treatment

Nature Reviews Gastroenterology & Hepatology volume 9, pages 323–333 (2012)Cite this article

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Abstract

Restorative proctocolectomy with ileal pouch–anal anastomosis has become the procedure of choice for the majority of patients with ulcerative colitis who require surgical treatment. Pouchitis, the most common long-term complication of the procedure, involves a spectrum of disease processes with heterogeneous risk factors, clinical features, disease courses and prognoses. In addition, clinical symptoms of pouchitis are not specific and often overlap with those of other inflammatory and functional pouch disorders, such as Crohn's disease of the pouch and irritable pouch syndrome. Pouchoscopy and biopsy, along with laboratory and radiographic evaluations, are often required for accurate diagnosis in patients with symptoms indicative of pouchitis. Dysbiosis has been implicated as a triggering factor for pouchitis, and concurrent infection with pathogens, such as Clostridium difficile, might contribute to disease relapse and exacerbation. Antibiotic therapy is the main treatment modality. However, the management of antibiotic-dependent and antibiotic-refractory pouchitis remains challenging. Secondary causes of pouchitis, such as ischaemia, NSAID use, the presence of concurrent primary sclerosing cholangitis and other systemic immune-mediated disorders, should be evaluated and properly managed.

Key Points

  • Pouchitis comprises a spectrum of disease, ranging from antibiotic-responsive forms to antibiotic-refractory entities, which involve various aetiological and pathogenetic pathways and have differing clinical presentations, disease courses and prognoses

  • Relapsing or chronic forms of pouchitis are also emerging

  • Dysbiosis (quantitative and/or qualitative alterations of the pouch microbiota) has a key role in the initiation and progression of pouchitis

  • Concurrent infections (such as Clostridium difficile) and other triggering factors (such as NSAID use) should be identified and treated or eradicated

  • Antibiotics are the mainstay of treatment for pouchitis

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Figure 1: Characterization of pouchitis.
Figure 2: Algorithm for the diagnosis and management of pouchitis.
Figure 3: Endoscopic appearance of pouchitis and pouch disorders.

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  1. Department of Gastroenterology and Hepatology-A31, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, 44915, OH, USA

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The author has acted as a consultant for Gi Health Education Foundation, Optimer and Prometheus Laboratories, and has received honoraria from Abbott, Axcan and UCB.

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Shen, B. Acute and chronic pouchitis—pathogenesis, diagnosis and treatment. Nat Rev Gastroenterol Hepatol 9, 323–333 (2012). https://doi.org/10.1038/nrgastro.2012.58

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