The term pouchitis describes a range of conditions causing inflammation to an area of the bowel formed after certain kinds of surgery. This article aims to help you understand the different types of pouchitis, what symptoms to look out for, and how this is managed.

What is pouchitis?

A ‘pouch’ refers to an ileal pouch-anal anastomosis, joining a portion of the small bowel (the ileum) to the anus. This is typically formed after a proctocolectomy (removal of most of the large bowel), a procedure usually undertaken for individuals suffering from severe inflammatory bowel disease.¹ It may also be performed as part of risk-reducing procedures for individuals at high risk of developing bowel cancer, such as those with familial adenomatous polyposis. A common complication associated with the formation of this pouch is swelling (or inflammation) of the tissue in and around the pouch, which is known as pouchitis.² It is a common complication, affecting up to nearly four in five postoperative patients.³

You can find out more general information on pouchitis here.

What increases my chances of developing pouchitis?

There are many reasons that an individual can develop pouchitis. This may sometimes just be due to chance, but there are certain factors that can increase the risk, including:⁴

• Genetics – in particular, mutations in the NOD2 gene make developing pouchitis more likely
• Changes to your natural gut bacteria, including infections with organisms such as Clostridium difficile
• Having an overactive immune system
• Having a case of pouchitis previously
• Using non-steroidal anti-inflammatory drugs regularly, such as ibuprofen
• Having underlying conditions, such as primary sclerosing cholangitis, Crohn’s disease and ulcerative colitis

How is pouchitis diagnosed?

Clinical assessment

A clinician will assess symptoms and perform a physical examination, such as feeling your abdomen and checking your vital signs.

Further investigations

A camera may be inserted to look at the inside of the gut to the level of the pouch. This is known as endoscopy, and allows the clinician to directly visualise the tissue around the pouch. Often, a small sample of tissue will be taken during the endoscopy process, known as a biopsy, which is then looked at under a microscope to confirm the diagnosis.⁵

Pouchitis disease activity index (PDAI)

The PDAI is a scoring system that allows your healthcare provider to assess the severity of your pouchitis. It is a combined score based on clinical findings, signs seen on endoscopy and features seen under the microscope on the biopsy sample.⁶

What treatments are available for pouchitis?

Treatments include:

• Antibiotics, commonly ciprofloxacin and metronidazole, although the choice of medication varies between regions⁷
• Probiotics to improve gut health
• Biologic medications
• Surgical intervention is a last resort when other treatments have failed

What are the different forms of pouchitis?

An important means of understanding pouchitis is to think of how long the problem has been going on for. For about one in three patients, there will only be one short episode, known as acute pouchitis. For the remaining two-thirds, the inflammation will persist, causing a chronic picture of pouchitis.⁸  

Acute pouchitis

This describes short-term inflammation of the pouch, usually only lasting a few weeks.

What causes acute pouchitis?

There often is not a clear cause, although a change to the natural bacteria in your gut may be responsible. It may also be a consequence of a larger-than-expected response from the immune system in the time following surgery.

What are the symptoms of acute pouchitis?

In an acute episode of pouchitis, you may experience the following:⁹

• Changes to stool, including more watery stools, going more frequently and persistent diarrhoea
• Abdominal pain
• Needed to open your bowels urgently
• Incontinence of stool or faecal leaking
• Needing to open your bowels frequently
• The sensation of not fully emptying your bowels (tenesmus)
• Fever
• Bleeding when opening bowels

What are the next steps if I am worried about acute pouchitis?

It is important that you see your clinician for an assessment. In the days following surgery, you may be given a means of contacting the team who operated on you, but if this is not the case, then see your GP or local health centre instead. The usual treatment is a short course of antibiotics, and the symptoms typically start to improve within a few days of this treatment.

Chronic pouchitis

This refers to pouchitis lasting over four weeks or recurring frequently (two or more episodes per year). It can be antibiotic dependent, where the symptoms come back once you have finished a course of antibiotics for an episode of pouchitis, or antibiotic refractory, where the pouchitis does not get better with antibiotics.

What are the symptoms of chronic pouchitis?

The symptoms are very similar to acute pouchitis, with the key difference being that these do not improve with initial treatments or recur once you have finished a round of treatment. Many of these symptoms can progress, causing long-term issues with bowel opening.

What causes chronic pouchitis?

An acute pouchitis that does not get better with treatment will progress to chronic pouchitis with time. The causes can be similar, but a lack of response to treatment may be associated with an overactive immune system or imbalances in your gut bacteria.

What are the next steps if I am concerned about chronic pouchitis?

If you already have a diagnosis of pouchitis, and it is not resolving with simple treatments, you should already be known to your local team, or be actively managed/followed up by your GP. If symptoms persist despite treatment, the diagnosis will usually be confirmed with endoscopy and biopsy.

Your team may then suggest alternative antibiotics to be continued long-term, acting to treat the current pouchitis and prevent any future episodes. Steroids and biologic agents can also help regulate the immune response to prevent recurrence of disease. There is no role for faecal microbiota transplantation.¹⁰  

If other treatments are unsuccessful, a repeat surgery may be offered. 

Clinical forms of pouchitis

Pouchitis can also be classified according to the clinical features. This can be based on its symptoms, associated conditions and the response to treatment. 

Antibiotic-refractory pouchitis

This term describes pouchitis that is not responding to the normal antibiotic treatments your doctor may start. A stool sample can help guide your healthcare provider’s choice of antibiotics, and you will often be required to take a new combination of two or more antibiotics.¹¹ In severe cases, you may need steroid and biologic therapy or even surgical revision of the pouch.

Pouchitis with Crohn’s disease-like features

Also known as Crohn’s disease of the pouch, this is inflammation mimicking Crohn’s disease which develops in the small bowel after surgery. If untreated, this can cause fistulas and abscesses. Treatment involves steroids and biologic medications.¹²

Pouchitis in primary sclerosing cholangitis (PSC)

Individuals with a previous diagnosis of PSC are at higher risk of developing chronic pouchitis. Often, this is resistant to the standard treatments and may require more aggressive treatment strategies, such as strong immunomodulators or surgery.¹³

What else could my symptoms be?

Cuffitis

This is swelling around the small stub of the rectum left behind after surgery.¹⁴ Treatment involves applying creams to the anal area, including steroids and mesalazine.

Irritable pouch syndrome

This is a condition causing similar symptoms to irritable bowel syndrome. There are, however, no concerning blood test results or changes found in tissue samples taken as biopsies.¹⁵ Management of this condition is similar to that of irritable bowel syndrome. 

What is the long-term picture of pouchitis?

Acute pouchitis

If identified and treated promptly, acute pouchitis usually has good long-term outcomes. If treatment is unsuccessful in the initial stages, and inflammation continues for a period of weeks, then this will progress to chronic pouchitis.

Chronic pouchitis

This often requires long-term management strategies, and you may find regular meetings are needed with your healthcare provider to reassess your disease and make any necessary adjustments to your treatment.

Complications

Occasionally, chronic pouchitis may lead to failure of the pouch, which will then require further surgical intervention to resolve.

Are there ways of preventing pouchitis?

Use of probiotics has been shown in small samples to reduce the number of future episodes of pouchitis.¹⁶ Further discussion with your healthcare provider can help you decide which options are best for you. 

Summary

Pouchitis is a common complication following bowel surgery involving the formation of an ileal pouch. There are many ways of classifying this, although the simplest method would be on the basis of time, where short-term episodes are referred to as acute pouchitis, and generally have no long-term effects, and longer-lasting episodes are termed chronic pouchitis. The type of treatment needed is individualised based on the severity and type of pouchitis, and it is important that your treatment is personalised to you to ensure it is managed effectively.