Pouchitis is an inflammation of the internal pouch lining, referred to as an ileal pouch, which is created during surgery for treating diseases affecting your colon. Pouchitis can cause health issues like abdominal pain and discomfort, and if left untreated, it can lead to more serious complications, such as chronic inflammation, which requires long-term medications or additional surgery. Therefore, preventing pouchitis is crucial for improving your quality of life. This article will help you understand pouchitis and some of the approaches used to prevent and treat this condition.

What is pouchitis?

Patients who have conditions like ulcerative colitis or familial adenomatous polyposis undergo ileal pouch-anal anastomosis (IPAA) surgery. During this surgery, a small internal reservoir known as the ileal pouch is created for the faeces to be collected and removed from your body since the surgery removes the colon and rectum. Even though the surgery can treat your disease,  following surgery, in around 80 % of patients, the ileal pouch gets inflamed as a complication, which is referred to as pouchitis. According to reports, approximately 40% of patients may get pouchitis within a year of their operation.¹

So, what can cause pouchitis? It is believed that changes in the gut microbiota in the ileal pouch cause pouchitis. Following IPAA surgery, the small intestine is repurposed to serve as the large intestine, where it comes into contact with new types of bacteria. These alterations might lead your immune system to misinterpret that you are having an infection and to produce inflammation.²

Symptoms

Common symptoms of pouchitis include:

• Pain and cramping in the lower abdomen
• Increased urgency and frequency of bowel movements
• Having to use the bathroom during the night
• Bowel incontinence 
• Difficulty to poop 
• Blood in faeces
• Fever²

Prevention of pouchitis

There are several strategies that can be employed to effectively prevent pouchitis and maintain optimal pouch health.

Role of probiotics

Your gut contains a diverse community of beneficial bacteria called gut microbiota, which helps overall health, immunity, digestion, etc. However, after surgery, this microbiota can be disrupted, often causing an overgrowth of harmful bacteria, which can trigger inflammation and increase the risk of conditions like pouchitis. Probiotics are beneficial bacteria that can aid in restoring the microbiota of the gut, which is crucial in avoiding pouchitis by lowering intestinal inflammation.²

For example, probiotics such as VSL#3 have been found in several studies to significantly reduce the risk of pouchitis following surgery. Research has found that 40% of individuals who did not take VSL#3 experienced pouchitis compared to just 10% of those who did.

Even though probiotics are generally safe to take occasionally, they might have side effects, including diarrhoea, vomiting, or cramping in the stomach. Moreover, rare instances of serious infections like fungemia, bacteremia, and sepsis also occurred in individuals with compromised immune systems².

Dietary adjustments

• Role of fruit consumption– Eating more fruit has been shown to potentially reduce the occurrence of pouchitis. For instance, a study which involved 172 patients with ulcerative colitis who underwent IPAA surgery found that the group with the lowest fruit consumption had a higher incidence of pouchitis (30.8% vs 3.8%)³
• Low-FODMAP Diet– Reducing the amount of FODMAPs in the diet may help reduce discomfort associated with frequent stools in pouch users. Reducing consumption of high-fat foods like fried foods and fatty meats is also advised⁴
• Mediterranean Diet– Due to its high fibre and antioxidant content, this diet of fruits, vegetables, whole grains, and healthy fats has been associated with reducing inflammation⁵

Restricting NSAID use

It has been found that nonsteroidal anti-inflammatory drugs (NSAIDs) can irritate the gastrointestinal tract and raise the risk of pouchitis. In one study, the symptoms and quality of life of 17 individuals with IPAA who had been using NSAIDs every day for more than six months had significantly improved once they stopped taking the NSAIDs. Therefore, NSAIDs should be used for long-term use under the guidance of a healthcare professional.^1,6

Quitting smoking

According to some research, smoking increases the likelihood of developing pouchitis.^1,7 For example, in a study comparing nonsmokers and smokers, smoking was found to be a potential risk factor for the development of pouchitis. Moreover, since smoking can negatively affect your general health, it is generally advised to avoid smoking.^1,8

Treatment for pouchitis

Various approaches are used to treat pouchitis. These typically include antibiotics, steroids, and advanced treatments that help control your immune system.

Antibiotics

When treating pouchitis, antibiotics are the primary line of treatment. The first course of therapy is often an antibiotic, such as metronidazole or ciprofloxacin. However, ciprofloxacin has fewer adverse effects and is more successful than metronidazole in treating symptoms. Although they are not used commonly as first-line therapy, some additional antibiotics, such as rifaximin, vancomycin and amoxicillin-clavulanic acid, can be useful in maintaining health in certain people who react well to early treatments. However, these are frequently based on case reports and smaller research ¹.

Sulfasalazine

One medication that has demonstrated some promise in the treatment of acute pouchitis is sulfasalazine. A small study conducted in 2010 found that it improved patient conditions and reduced symptoms. Nevertheless, the absence of large-scale research has led to its uncommon recommendation as a first-line therapy.⁹

Treatment of chronic pouchitis

Antibiotics

After having the first episode of pouchitis, around 60% of patients have the chance of experiencing another one, and around 20% develop chronic pouchitis. Treatment usually starts with antibiotics like ciprofloxacin or metronidazole. However, doctors may switch antibiotics if you continue to experience flare-ups even after taking these antibiotics (e.g., ciprofloxacin with rifaximin or tinidazole). In certain cases, long-term antibiotic usage may even be necessary. However, patients need to be aware of potential antibiotic side effects such as nausea, diarrhoea, or stomach discomfort, so antibiotics should be discontinued if these signs appear.¹

Steroids

Your doctor may recommend steroids for managing inflammation if antibiotics are ineffective. For example, a study found that 75% of patients who didn’t respond to antibiotics were able to achieve complete recovery when treated with oral budesonide (a type of steroid) over 8 weeks.¹⁰ Steroids may also be delivered directly into the pouch through a procedure known as enemas. However, long-term steroid use is not recommended due to its potential side effects.¹

Immunomodulators

Drugs that alter the reaction of the immune system are known as immunomodulators. These drugs, like azathioprine or 6-mercaptopurine, are sometimes used when antibiotics and steroids fail. Even though these are not commonly used as a first option, they have been effective in certain patients, especially those with severe pouch inflammation.¹

Anti-TNF inhibitors

If chronic pouchitis doesn’t respond to other treatments, anti-TNF inhibitors like infliximab or adalimumab can be helpful. Research indicates that 38% of individuals treated with adalimumab and 56% of patients treated with infliximab experienced short-term remission.¹¹

Vedolizumab

This drug works by blocking certain gut-specific immune responses and is especially useful for patients who have not responded well to anti-TNF inhibitors. Studies indicate that during a 14-week course of therapy, vedolizumab reduced inflammatory scores and alleviated symptoms in 64% of patients.¹² Moreover, a bigger study with 83 patients revealed that 19% obtained complete remission after at least 3 months, and 71% had a clinical response.¹³

Ustekinumab

This drug acts by targeting another part of the immune system involved in inflammation. For example, according to one study, after six months of ustekinumab therapy, 60% of patients were able to discontinue using antibiotics. Long-term recovery rates of this drug are currently being investigated.¹⁴

Tacrolimus

It is a drug that suppresses the immune system by reducing T-cell activity. It has been investigated for treating chronic pouchitis in small patient groups. Two patients receiving tacrolimus orally experienced remission for at least eight weeks in one study, while 70% of patients receiving tacrolimus enemas saw symptom improvement but no total healing of the pouch lining.^15,16

Tofacitinib

This drug has been approved for ulcerative colitis, but has only been studied in small numbers for pouchitis. It is a medication that blocks inflammation pathways. In one study, a patient who had not responded to prior treatments exhibited improvement in symptoms and endoscopic healing with tofacitinib, whereas in two other cases, patients showed improvement but relapsed when the dose was lowered.^17,18

Alicaforsen enema

Alicaforsen targets molecules in the bowel that cause inflammation. In an early study of 12 patients with chronic pouchitis, nightly alicaforsen enemas over 6 weeks led to remission in 58% of the participants¹⁹. Another study conducted on 13 patients with antibiotic-resistant pouchitis also showed a reduction in symptoms and inflammation when treated for 6 weeks. However, 82% of patients experienced their symptoms returning after an average of 16 weeks. Since target studies did not find significant benefits, it is not currently approved for use.^1,20

Fecal microbiota transplant (FMT) 

In this procedure, stool from a healthy donor is transferred into the bowel of the patient in order to restore a balance of gut bacteria. Small studies have explored FMT as a potential treatment. For instance, in a study, of the 44 patients treated with FMT, 23% went into recovery, and 32% exhibited some improvement. However, some studies have shown little or no improvements. Therefore, FMT is not currently recommended as a standard treatment, as its potential for improving gut microbiota is an ongoing research.^1,21

Summary

Pouchitis is an inflammation of the ileal pouch that occurs as a common consequence of ileal pouch-anal anastomosis surgery. Common symptoms of pouchitis include abdominal pain, increased bowel urgency, and fever.  Prevention for pouchitis includes the use of probiotics in order to restore a healthy gut microbiota and reduce inflammation. It also includes dietary modifications that support pouch health, like increasing fruit consumption and switching to a low-FODMAP or Mediterranean diet. Additionally, it is advised to reduce NSAIDs use to minimise gastrointestinal irritation and the associated risk of inflammation. Antibiotics are usually the first line of treatment. However, if they prove unsuccessful, other treatments include steroids, immunomodulators, and biologics such as anti-TNF inhibitors.