Pouchitis

What a J-pouch is

When ulcerative colitis does not respond to medicines, or when there is precancer or cancer, surgeons may remove the colon and rectum (proctocolectomy). To avoid a permanent ileostomy bag, they fold the last part of the small intestine (the ileum) into a reservoir, often J-shaped, and join it to the anus. This operation is called an ileal pouch-anal anastomosis (IPAA). People with a well-functioning pouch typically pass 4 to 8 soft stools a day.

Pouchitis is inflammation of the lining of this pouch. It probably results from changes in the bacteria that colonize the pouch, together with the same immune tendency that caused ulcerative colitis. It is much less common in people who had a pouch for familial adenomatous polyposis, which supports the immune link.

Symptoms

• more frequent bowel movements than your usual baseline
• urgency and difficulty holding stool
• watery or looser stools
• night-time seepage or fecal incontinence
• cramping and lower belly or pelvic discomfort
• blood in the stool
• fever, tiredness and a general feeling of being unwell
• joint pains in some people

Symptoms can resemble the original colitis. Severity ranges from a mild nuisance to feeling very unwell and dehydrated.

Types of pouchitis

Causes and risk factors

• changes in pouch bacteria (dysbiosis)
• original diagnosis of ulcerative colitis rather than FAP
• extensive colitis before surgery
• primary sclerosing cholangitis (a liver condition linked with UC)
• arthritis or other inflammation outside the gut related to IBD
• regular use of NSAIDs such as ibuprofen

How pouchitis is diagnosed

Symptoms alone are not enough, because other pouch problems feel the same.

• Pouchoscopy: a short flexible camera test of the pouch, often done without sedation. It shows redness, swelling, ulcers and bleeding, and biopsies are taken.
• Stool tests: to rule out C. diff and other infections.
• Blood tests: blood count, inflammation markers and, in some cases, testing for cytomegalovirus.
• Fecal calprotectin: a stool marker of inflammation, used to monitor.
• Imaging: MRI of the pelvis or a pouchogram (contrast X-ray) if a fistula, abscess or narrowing is suspected.

Doctors often grade severity with the Pouchitis Disease Activity Index, which combines symptoms, endoscopy and biopsy findings.

Conditions that mimic pouchitis

• Cuffitis: inflammation of the small strip of rectal tissue left at the join. It often causes bleeding and responds to mesalamine or steroid suppositories.
• Crohn's disease of the pouch: ulcers above the pouch, fistulas or strictures. Treated like Crohn's disease.
• Irritable pouch syndrome: symptoms without inflammation, similar to irritable bowel syndrome.
• Strictures, pelvic infection or poor pouch emptying.

Treatment

Acute pouchitis

• Antibiotics: ciprofloxacin or metronidazole for about 14 days is first-line. Ciprofloxacin is often better tolerated. Most people feel better within a few days.

Recurrent and chronic pouchitis

• Repeated or rotating antibiotics, or a combination of two antibiotics for refractory cases.
• Probiotics: a specific high-concentration multi-strain probiotic can help prevent recurrence after remission in some people. Ordinary store-bought probiotics have not been shown to work.
• Biologic drugs: vedolizumab, infliximab, adalimumab and ustekinumab are used for chronic antibiotic-dependent or refractory pouchitis. Vedolizumab has the strongest trial evidence.
• Budesonide or other steroids for short periods.
• Treating mimics: cuffitis, Crohn's-like disease or strictures need their own treatment.

Surgery

In a small minority, persistent pouchitis or other pouch failure leads to removal or bypass of the pouch with a permanent ileostomy.

Self-care that helps

• Avoid NSAIDs such as ibuprofen and naproxen when possible.
• Stay hydrated, especially during flares and in hot weather.
• Some people find that limiting alcohol, caffeine, spicy food and high-sugar drinks reduces frequency.
• Track your usual stool frequency so you notice changes early.

Outlook

Most people with pouchitis keep their pouch and have a good quality of life. Many have one or a few episodes that respond to antibiotics. About 10% to 20% develop chronic pouchitis that needs ongoing treatment. Regular follow-up is also important because people who had colitis-related precancer need periodic pouch surveillance.

Frequently asked questions

What are the first signs of pouchitis?

The first signs are usually a noticeable rise in the number of bowel movements compared with your normal, urgency, looser stools, cramping and leakage at night. Some people also have blood in the stool, fever or a general unwell feeling.

How is pouchitis treated?

Acute pouchitis is usually treated with a 2-week course of ciprofloxacin or metronidazole, and most people improve within days. Repeated or chronic pouchitis may need longer antibiotic courses, a specific high-dose probiotic, biologic drugs such as vedolizumab, or, rarely, surgery.

How common is pouchitis?

It is the most common complication of J-pouch surgery for ulcerative colitis. Up to about half of people have at least one episode within the first several years after surgery. It is far less common in people who had their pouch made for familial adenomatous polyposis.

Can pouchitis be prevented?

Not completely. Avoiding NSAIDs may reduce the risk, and a specific high-concentration probiotic can help prevent recurrences after antibiotics have induced remission. Early treatment of symptoms helps limit the severity of each episode.

Is pouchitis the same as ulcerative colitis coming back?

Not exactly. Ulcerative colitis affects the colon and rectum, which are removed during surgery. Pouchitis is inflammation in the new pouch made from the small intestine. It likely shares the same immune tendency, which is why it mostly occurs in people who had colitis.