Pouchitis

Abstract

Proctocolectomy with an ileal pouch anal anastomosis is the procedure of choice for most patients with ulcerative colitis who require surgery. Idiopathic pouchitis is a non-specific inflammation of the ileal pouch and the most common complication after pelvic pouch for ulcerative colitis. The etiology and pathogenesis of pouchitis are still unclear. The clinical course and medical therapy are different for the acute and chronic forms of pouchitis. Symptoms of pouchitis are non-specific and can commonly occur in other inflammatory, infectious, and functional pouch disorders. Because of the variety of factors that can cause pouch symptoms, the diagnosis of pouchitis should be based on the presence of symptoms together with endoscopic and histological evidence of inflammation of the pouch. Chronic pouchitis is a frequent cause of considerable morbidity, pouch dysfunction and poor quality of life, and a condition that is difficult to manage. It includes antibiotic-dependent and antibiotic-refractory pouchitis. Intensive therapy, including antitumor necrosis factor antibodies and steroids, may be necessary for antibiotic-refractory pouchitis, and pouch failure may occur despite such intensive treatment. Identifying factors predictive of chronic pouchitis may improve outcomes by modifying contributing factors and enhancing patient selection. Reported risk factors for the development of pouchitis include backwash ileitis, extensive disease, refractory indication, pancolitis, primary sclerosing cholangitis, being a non-smoker, pANCA- and ACCA-positive serology, and non-steroidal anti-inflammatory drug use. Patients at high risk to develop pouchitis need to be considered for an array of medical options prior to surgery in order to control inflammation and possibly avoid post-surgical pouchitis. Most of the knowledge is bases on patient with a pelvic pouch but can probably be transferred to patients with a Kock pouch as well.