Perspectives in clinical gastroenterology and hepatology
Pouchitis: What Every Gastroenterologist Needs to Know

https://doi.org/10.1016/j.cgh.2013.03.033Get rights and content

Pouchitis is the most common complication among patients with ulcerative colitis who have undergone restorative proctocolectomy with ileal pouch–anal anastomosis. Pouchitis is actually a spectrum of diseases that vary in etiology, pathogenesis, phenotype, and clinical course. Although initial acute episodes typically respond to antibiotic therapy, patients can become dependent on antibiotics or develop refractory disease. Many factors contribute to the course of refractory pouchitis, such as the use of nonsteroidal anti-inflammatory drugs, infection with Clostridium difficile, pouch ischemia, or concurrent immune-mediated disorders. Identification of these secondary factors can help direct therapy.

Section snippets

Etiology and Pathogenesis

Mounting evidence suggests that gut microbiota play a key role in the initiation and disease progression of pouchitis. The contribution of gut microbiota to the pathogenesis of pouchitis may be 2-fold: the alteration in commensal bacteria (ie, dysbiosis)9, 10, 11, 12 and the emergence of pathogenic bacteria, fungi, or viruses (such as Clostridium difficile13). The role of bacterial diversity or dysbiosis in the pathogenesis of pouchitis is not entirely clear, as it is in the field of

Risk Factors

In addition to gut microbiota and mucosal immunity, genetic, vascular, and luminal factors (such as nonsteroidal anti-inflammatory drugs [NSAIDs]) are likely to contribute to the initiation, exacerbation, and progression of pouchitis. Pouchitis almost exclusively occurs in patients with restorative proctocolectomy with underlying IBD and rarely in those with FAP, suggesting the contribution of genetic and/systemic factors to its pathogenesis. Immunogenetic studies showed that genetic

References (131)

  • S. Ulisse et al.

    Expression of cytokines, inducible nitric oxide synthase, matrix metalloproteinases in pouchitis: effects of probiotic treatment

    Am J Gastroenterol

    (2001)
  • M.J. Carter et al.

    The interleukin 1 receptor antagonist gene allele 2 as a predictor of pouchitis following colectomy and IPAA in ulcerative colitis

    Gastroenterology

    (2001)
  • J.P. Achkar et al.

    Differentiating risk factors for acute and chronic pouchitis

    Clin Gastroenterol Hepatol

    (2005)
  • B. Shen et al.

    Risk factors for diseases of ileal pouch-anal anastomosis after restorative proctocolectomy for ulcerative colitis

    Clin Gastroenterol Hepatol

    (2006)
  • U. Navaneethan et al.

    Elevated serum IgG4 is associated with chronic antibiotic-refractory pouchitis

    J Gastrointest Surg

    (2011)
  • U. Navaneethan et al.

    Prevalence and clinical implications of positive serum anti-microsomal antibodies in symptomatic patients with ileal pouches

    J Gastrointest Surg

    (2011)
  • P. Fleshner et al.

    A prospective multivariate analysis of clinical factors associated with pouchitis after ileal pouch-anal anastomosis

    Clin Gastroenterol Hepatol

    (2007)
  • B. Shen et al.

    Endoscopic and histologic evaluation together with symptom assessment are required to diagnose pouchitis

    Gastroenterology

    (2001)
  • W.J. Sandborn et al.

    Pouchitis after ileal pouch-anal anastomosis: a Pouchitis Disease Activity Index

    Mayo Clin Proc

    (1994)
  • U. Navaneethan et al.

    Tissue infiltration of IgG4+ plasma cells in symptomatic patients with ileal pouch-anal anastomosis

    J Crohns Colitis

    (2011)
  • R. Khanna et al.

    Low levels of vitamin D are common in patients with ileal pouches irrespective of pouch inflammation

    J Crohns Colitis

    (2013)
  • S.D. McLaughlin et al.

    Fecal coliform testing to identify effective antibiotic therapies for patients with antibiotic-resistant pouchitis

    Clin Gastroenterol Hepatol

    (2009)
  • M.A. Parsi et al.

    Fecal lactoferrin for diagnosis of symptomatic patients with ileal pouch-anal anastomosis

    Gastroenterology

    (2004)
  • S.D. McLaughlin et al.

    Exclusive elemental diet impacts on the gastrointestinal microbiota and improves symptoms in patients with chronic pouchitis

    J Crohns Colitis

    (2013)
  • P. Rutgeerts et al.

    Infliximab for induction and maintenance therapy for ulcerative colitis

    N Engl J Med

    (2005)
  • L.E. Targownik et al.

    The epidemiology of colectomy in ulcerative colitis: results from a population-based cohort

    Am J Gastroenterol

    (2012)
  • C. Penna et al.

    Pouchitis after ileal pouch–anal anastomosis for ulcerative colitis occurs with increased frequency in patients with associated primary sclerosing cholangitis

    Gut

    (1996)
  • V.W. Fazio et al.

    Ileal pouch–anal anastomosis complications and function in 1005 patients

    Ann Surg

    (1995)
  • M. Ferrante et al.

    Outcome after proctocolectomy with ileal pouch–anal anastomosis for ulcerative colitis

    Inflamm Bowel Dis

    (2008)
  • H. Tulchinsky et al.

    Long-term failure after restorative proctocolectomy for ulcerative colitis

    Ann Surg

    (2003)
  • M. Duffy et al.

    Sulfate-reducing bacteria colonize pouches formed for ulcerative colitis but not for familial adenomatous polyposis

    Dis Colon Rectum

    (2002)
  • H. Sokol et al.

    Analysis of bacterial bowel communities of IBD patients: what has it revealed?

    Inflamm Bowel Dis

    (2008)
  • M. Lim et al.

    Dysbiosis and pouchitis

    Br J Surg

    (2006)
  • S.D. McLaughlin et al.

    The bacteriology of pouchitis: a molecular phylogenetic analysis using 16S rRNA gene cloning and sequencing

    Ann Surg

    (2010)
  • G.W. Tannock et al.

    Comprehensive analysis of the bacterial content of stool from patients with chronic pouchitis, normal pouches, or familial adenomatous polyposis pouches

    Inflamm Bowel Dis

    (2012)
  • Y. Li et al.

    Risk factors and outcome of PCR-detected Clostridium difficile infection in ileal pouch patients

    Inflamm Bowel Dis

    (2013)
  • B. Shen et al.

    Fulminant Clostridium difficile-associated pouchitis with a fatal outcome

    Nat Rev Gastroenterol Hepatol

    (2009)
  • B. Shen

    Campylobacter infection in patients with ileal pouches

    Am J Gastroenterol

    (2010)
  • S. Ingram et al.

    Are inflammatory bowel disease (IBD) and pouchitis a reactive enteropathy to group D streptococci (enterococci)?

    Inflamm Bowel Dis

    (2009)
  • M.P. Gosselink et al.

    Eradication of pathogenic bacteria and restoration of normal pouch flora: comparison of metronidazole and ciprofloxacin in the treatment of pouchitis

    Dis Colon Rectum

    (2004)
  • M. Muñoz-Juarez et al.

    Misdiagnosis of specific cytomegalovirus infection of the ileoanal pouch as a refractory idiopathic chronic pouchitis: report of two cases

    Dis Colon Rectum

    (1999)
  • A.J. Kroesen et al.

    Increased bacterial permeation in long-lasting ileoanal pouches

    Inflamm Bowel Dis

    (2006)
  • H.J. de Silva et al.

    Lymphocyte and macrophage subpopulations in pelvic ileal pouches

    Gut

    (1991)
  • I. Hirata et al.

    Immunohistological characterization of intraepithelial and lamina propria lymphocytes in control ileum and colon and in inflammatory bowel disease

    Dig Dis Sci

    (1986)
  • A. Stallmach et al.

    Increased state of activation of CD4 positive T cells and elevated interferon gamma production in pouchitis

    Gut

    (1998)
  • P.D. Thomas et al.

    Altered expression of the lymphocyte activation markers CD30 and CD27 in patients with pouchitis

    Scand J Gastroenterol

    (2001)
  • P.A. Goldberg et al.

    Leukocyte typing, cytokine expression and epithelial turn over in the ileal pouch in patients with ulcerative colitis and familial adenomatous polyposis

    Gut

    (1996)
  • N.A. Shepherd et al.

    Distribution of mucosal pathology and an assessment of colonic phenotype change in the pelvic ileal reservoir

    Gut

    (1993)
  • J.C. Coffey et al.

    Pathogenesis of and unifying hypothesis for idiopathic pouchitis

    Am J Gastroenterol

    (2009)
  • M.N. Merrett et al.

    Intestinal permeability in the ileal pouch

    Gut

    (1996)

    • Cited by (122)

    • A specific phenotype of pouchitis was associated with worst prognosis in patients with ulcerative colitis according to Chicago classification

      2023, Digestive and Liver Disease

    • Increasing Incidence of Pouchitis Between 1996 and 2018: A Population-Based Danish Cohort Study

      2023, Clinical Gastroenterology and Hepatology

    • Ileal Pouch Anal Anastomosis (IPAA) for colitis; development of Crohn's and Pouchitis

      2022, American Journal of Surgery
      Citation Excerpt :

      While considering the discrepancies between described rates of Crohn's disease in older and newer studies, one must take in to account the challenge that is diagnosing Crohn's disease in this patient population. The high incidence of pouchitis (up to 48%),3,24 especially chronic and antibiotic refractory pouchitis (9–15%)21 can create a diagnostic dilemma. Indeed, a portion of patients who eventually receive a Crohn's diagnosis will have previously been diagnosed with chronic or antibiotic refractory pouchitis.

    • Primary Sclerosing Cholangitis–Associated Pouchitis: A Distinct Clinical Phenotype

      2022, Clinical Gastroenterology and Hepatology

    • Endoscopic Assessment of Inflammatory Bowel Disease Activity in Clinical Trials

      2022, Clinical Gastroenterology and Hepatology
      Citation Excerpt :

      Restorative proctocolectomy with ileal pouch-anal anastomosis is the surgery of choice to restore intestinal continuity. Ileal pouch-anal anastomosis is curative, avoids permanent ostomy, may improve quality of life, and reduces the risk of colorectal neoplasia.40 Nevertheless, up to 50% of patients will develop at least 1 episode of pouchitis within 10 years,41 which is characterized by urgency, increased stool frequency, and bleeding.

    • The Chicago Classification of Pouchitis: An Important Step Toward a Needed Consensus

      2022, Clinical Gastroenterology and Hepatology
    View all citing articles on Scopus

    Conflicts of interest The author discloses the following: Bo Shen has received honoraria from Aptalis, Abbott, and Prometheus Lab.

    View full text
    Copyright © 2013 AGA Institute. Published by Elsevier Ltd. All rights reserved.