Introduction

Definition of pouchitis

Pouchitis is an inflammation inside the J-pouch, also known as the ileal pouch, which is created during a surgery that involves removing an individual’s whole colon and rectum (total proctocolectomy). Pouchitis may occur after the surgery, as the body needs a new way to hold and pass stools, hence, a J-pouch is provided as a surgical solution.¹

During the surgery, the surgeons use the end of the small intestine, called the ileum, to create the shape of a pouch. This is then attached inside the body to the area above the anus. However, complications may arise from this type of surgery, resulting in conditions like Pouchitis. It is fairly common, as it has around a 45% chance of occurring to those who had the surgery. ^1,2

Various factors can increase the risk of developing pouchitis, including:

• Inflammatory bowel disease (IBD) - pouchitis is most likely to happen in people who have underlying IBD, for instance, ulcerative colitis
• Using nonsteroidal anti-inflammatory drugs (NSAIDs)- taking NSAIDs can increase the risk of pouchitis^1,3

Differentiation based on duration and recurrence

Pouchitis is classified based on the duration, clinical factors and medical response to medication. It is divided into acute (less than 4 weeks) or chronic (longer than 4 weeks), depending on how long you have had the symptoms. Pouchitis can also be classified into recurrence, which can be further grouped into:^4,5

• Infrequent - fewer than 3 episodes of pouchitis per year)
• Relapsing course - 1-3 episodes per year
• Continuous course

Additionally, pouchitis can be classified in terms of the response to medication. This can include cases where an ongoing antibiotic therapy is required to keep the disease in remission (antibiotic-dependent) or cases where the condition is not responding to the standard course of antibiotic therapy (antibiotic-refractory).

Common symptoms 

Symptoms that are experienced may be varied from person to person, but most people may experience:^1,4,5

• Diarrhea
• Abdominal pain
• Joint pain
• Cramps
• Fever
• Frequent need for pooping
• Rectal bleeding
• Stool leakage at night
• Trouble controlling stool passage 
• Strong urge to pass stool

What are the complications caused by pouchitis?

Acute pouchitis rarely leads to complications. However, chronic or treatment-resistant cases often lead to complications. These include:^1,5,6,7

• Irregular bowel habits - inflammation in the pouch can make it harder to hold your poop and swelling can make it hard to release it
• Pouch stricture - chronic inflammation that leads to scarring in your pouch, causing the opening to narrow, leading to reduced blood flow to your pouch
• Erosion - chronic inflammation that causes erosions in the lining of the pouch, leading to ulcers 
• Malabsorption and nutrition - damage to the lining of the pouch can affect its ability to absorb the nutrients from the food, which can lead to malnutrition 
• Abscess - pus collects in your pouch, which can lead to severe pain and fever
• Pouch failure - in more severe cases, persistent problems with your pouch can result in it being unusable, which requires a pouch removal and opting for alternative solutions
• Dehydration and electrolyte imbalance 
• Arthritis and joint pain - mainly associated with the body’s response to the inflammation
• Increased risk of IBD relapse

Management of complications

The management of pouchitis depends on the duration of the symptoms that you are experiencing, which is different for acute and chronic pouchitis:^1,6,7

• Acute pouchitis - treated with a 2-week course of antibiotics (ciprofloxacin and metronidazole) 
• Chronic pouchitis - oral immunosuppressive agents and biologic therapy are used (infliximab, vedolizumab)

In rare cases, surgery may be required if your body does not respond to the medication. 

Summary

Pouchitis is a common complication for individuals with a J-pouch. It can be distressing to encounter ongoing bowel problems after having had most of your large bowel removed. Fortunately, for most people, pouchitis is only an occasional issue. However, chronic pouchitis tends to be more difficult to handle and can lead to ongoing complications, which can be trickier to treat. Your doctor can help you find the best treatment for the complications you may experience.