Prevention and Medical Treatment of Pouchitis In Ulcerative Colitis

Author(s): Cigdem Benlice, Bo Shen, Scott R. Steele*

Journal Name: Current Drug Targets

Volume 20 , Issue 13 , 2019

  Journal Home
Translate in Chinese
Become EABM
Become Reviewer
Call for Editor

Graphical Abstract:


Approximately 50% of patients who have undergone IPAA surgery for Ulcerative Colitis (UC) develop at least 1 episode of pouchitis. Patients with pouchitis have a wide range of symptoms, endoscopic and histologic features, disease course, and prognosis. To date, there are no universally accepted diagnostic criteria in terms of endoscopy and histology; though, semi-objective assessments to diagnose pouchitis in patients with ileal pouch- anal anastomosis (IPAA) have been proposed using composite scores such as the Pouchitis Triad, Heidelberg Pouchitis Activity Score and Pouchitis Disease Activity Index (PDAI). In a systematic review that included four randomized trials evaluating five agents for the treatment of acute pouchitis, ciprofloxacin was more effective at inducing remission as compared with metronidazole. Rifaximin was not more effective than placebo, while budesonide enemas and metronidazole were similarly effective for inducing remission of acute pouchitis. Patients with pouchitis relapsing more than three times per year are advised maintenance therapy, and guidelines recommend ciprofloxacin or the probiotic VSL#3. In patients with antibiotic-refractory pouchitis, secondary factors associated with an antibiotic-refractory course should be sought and treated. In this review, we will discuss the prevention and management of pouchitis in Ulcerative Colitis patients.

Keywords: Pouchitis, prevention, probiotics, antibiotics, remission, medical therapy.

Wu H, Shen B. Pouchitis and pouch dysfunction. Med Clin North Am 2010; 94(1): 75-92.
[] [PMID: 19944799]
Fazio VW, Ziv Y, Church JM, et al. Ileal pouch-anal anastomoses complications and function in 1005 patients. Ann Surg 1995; 222(2): 120-7.
[] [PMID: 7639579]
Baixauli J, Delaney CP, Wu JS, Remzi FH, Lavery IC, Fazio VW. Functional outcome and quality of life after repeat ileal pouch-anal anastomosis for complications of ileoanal surgery. Dis Colon Rectum 2004; 47(1): 2-11.
[] [PMID: 14719144]
Lichtenstein GR, Cohen R, Yamashita B, Diamond RH. Quality of life after proctocolectomy with ileoanal anastomosis for patients with ulcerative colitis. J Clin Gastroenterol 2006; 40(8): 669-77.
[] [PMID: 16940876]
Lohmuller JL, Pemberton JH, Dozois RR, Ilstrup D, van Heerden J. Pouchitis and extraintestinal manifestations of inflammatory bowel disease after ileal pouch-anal anastomosis. Ann Surg 1990; 211(5): 622-7.
[PMID: 2339922]
Achkar JP, Shen B. Medical management of postoperative complications of inflammatory bowel disease: pouchitis and Crohn’s disease recurrence. Curr Gastroenterol Rep 2001; 3(6): 484-90.
[] [PMID: 11696286]
Shen B, Lashner BA. Diagnosis and treatment of pouchitis. Gastroenterol Hepatol (N Y) 2008; 4(5): 355-61.
[] [PMID: 21904509]
Shen B. Acute and chronic pouchitis--pathogenesis, diagnosis and treatment. Nat Rev Gastroenterol Hepatol 2012; 9(6): 323-33.
[] [PMID: 22508158]
Ståhlberg D, Gullberg K, Liljeqvist L, Hellers G, Löfberg R. Pouchitis following pelvic pouch operation for ulcerative colitis. Incidence, cumulative risk, and risk factors. Dis Colon Rectum 1996; 39(9): 1012-8.
[] [PMID: 8797652]
Zezos P, Saibil F. Inflammatory pouch disease: The spectrum of pouchitis. World J Gastroenterol 2015; 21(29): 8739-52.
[] [PMID: 26269664]
Suzuki H, Ogawa H, Shibata C, et al. The long-term clinical course of pouchitis after total proctocolectomy and IPAA for ulcerative colitis. Dis Colon Rectum 2012; 55(3): 330-6.
[] [PMID: 22469801]
Svaninger G, Nordgren S, Öresland T, Hultén L. Incidence and characteristics of pouchitis in the Kock continent ileostomy and the pelvic pouch. Scand J Gastroenterol 1993; 28(8): 695-700.
[] [PMID: 8210985]
Meagher AP, Farouk R, Dozois RR, Kelly KA, Pemberton JH. J ileal pouch-anal anastomosis for chronic ulcerative colitis: complications and long-term outcome in 1310 patients. Br J Surg 1998; 85(6): 800-3.
[] [PMID: 9667712]
Komanduri S, Gillevet PM, Sikaroodi M, Mutlu E, Keshavarzian A. Dysbiosis in pouchitis: evidence of unique microfloral patterns in pouch inflammation. Clin Gastroenterol Hepatol 2007; 5(3): 352-60.
[] [PMID: 17368235]
Seril DN, Yao Q, Shen B. The association between autoimmunity and pouchitis. Inflamm Bowel Dis 2014; 20(2): 378-88.
[] [PMID: 24374879]
Sehgal R, Berg A, Hegarty JP, et al. NOD2/CARD15 mutations correlate with severe pouchitis after ileal pouch-anal anastomosis. Dis Colon Rectum 2010; 53(11): 1487-94.
[] [PMID: 20940596]
Carter MJ, Di Giovine FS, Cox A, et al. The interleukin 1 receptor antagonist gene allele 2 as a predictor of pouchitis following colectomy and IPAA in ulcerative colitis. Gastroenterology 2001; 121(4): 805-11.
[] [PMID: 11606494]
Merrett MN, Soper N, Mortensen N, Jewell DP. Intestinal permeability in the ileal pouch. Gut 1996; 39(2): 226-30.
[] [PMID: 8991861]
Coffey JC, Rowan F, Burke J, Dochery NG, Kirwan WO, O’Connell PR. Pathogenesis of and unifying hypothesis for idiopathic pouchitis. Am J Gastroenterol 2009; 104(4): 1013-23.
[] [PMID: 19259080]
Ohland CL, Macnaughton WK, Ait-Belgnaoui A, et al. Probiotic bacteria and intestinal epithelial barrier function. Am J Physiol Gastrointest Liver Physiol 2010; 298(6): G807-19.
[] [PMID: 20299599]
Batista D, Raffals L. Role of intestinal bacteria in the pathogenesis of pouchitis. Inflamm Bowel Dis 2014; 20(8): 1481-6.
[] [PMID: 25046009]
Matsuoka K, Kanai T. The gut microbiota and inflammatory bowel disease. Semin Immunopathol 2015; 37(1): 47-55.
[] [PMID: 25420450]
Cario E, Podolsky DK. Differential alteration in intestinal epithelial cell expression of toll-like receptor 3 (TLR3) and TLR4 in inflammatory bowel disease. Infect Immun 2000; 68(12): 7010-7.
[] [PMID: 11083826]
Sandborn WJ, Tremaine WJ, Batts KP, Pemberton JH, Phillips SF. Pouchitis after ileal pouch-anal anastomosis: a Pouchitis Disease Activity Index. Mayo Clin Proc 1994; 69(5): 409-15.
[] [PMID: 8170189]
Shen B, Achkar JP, Connor JT, et al. Modified pouchitis disease activity index: a simplified approach to the diagnosis of pouchitis. Dis Colon Rectum 2003; 46(6): 748-53.
[] [PMID: 12794576]
Heuschen UA, Autschbach F, Allemeyer EH, et al. Long-term follow-up after ileoanal pouch procedure: algorithm for diagnosis, classification, and management of pouchitis. Dis Colon Rectum 2001; 44(4): 487-99.
[] [PMID: 11330575]
Pardi DS, D’Haens G, Shen B, Campbell S, Gionchetti P. Clinical guidelines for the management of pouchitis. Inflamm Bowel Dis 2009; 15(9): 1424-31.
[] [PMID: 19685489]
Pronio A, Montesani C, Butteroni C, et al. Probiotic administration in patients with ileal pouch-anal anastomosis for ulcerative colitis is associated with expansion of mucosal regulatory cells. Inflamm Bowel Dis 2008; 14(5): 662-8.
[] [PMID: 18240282]
Gionchetti P, Rizzello F, Morselli C, et al. High-dose probiotics for the treatment of active pouchitis. Dis Colon Rectum 2007; 50(12): 2075-82.
[] [PMID: 17934776]
Gionchetti P, Rizzello F, Helwig U, et al. Prophylaxis of pouchitis onset with probiotic therapy: a double-blind, placebo-controlled trial. Gastroenterology 2003; 124(5): 1202-9.
[] [PMID: 12730861]
Yasueda A, Mizushima T, Nezu R, et al. The effect of Clostridium butyricum MIYAIRI on the prevention of pouchitis and alteration of the microbiota profile in patients with ulcerative colitis. Surg Today 2016; 46(8): 939-49.
[] [PMID: 26510664]
Poritz LS, Sehgal R, Berg AS, Laufenberg L, Choi C, Williams ED. Chronic use of PPI and H2 antagonists decreases the risk of pouchitis after IPAA for ulcerative colitis. J Gastrointest Surg 2013; 17(6): 1027-31.
[] [PMID: 23532599]
Kuisma J, Mentula S, Jarvinen H, Kahri A, Saxelin M, Farkkila M. Effect of Lactobacillus rhamnosus GG on ileal pouch inflammation and microbial flora. Aliment Pharmacol Ther 2003; 17(4): 509-15.
[] [PMID: 12622759]
Tomasz B, Zoran S, Jarosław W, et al. Long-term use of probiotics Lactobacillus and Bifidobacterium has a prophylactic effect on the occurrence and severity of pouchitis: a randomized prospective study. BioMed Res Int 2014; 2014208064.
[] [PMID: 24579075]
Gosselink MP, Schouten WR, van Lieshout LMC, Hop WCJ, Laman JD, Ruseler-van Embden JGH. Delay of the first onset of pouchitis by oral intake of the probiotic strain Lactobacillus rhamnosus GG. Dis Colon Rectum 2004; 47(6): 876-84.
[] [PMID: 15108026]
Shen B. Diagnosis and treatment of patients with pouchitis. Drugs 2003; 63(5): 453-61.
Pardi DS, Sandborn WJ. Systematic review: the management of pouchitis. Aliment Pharmacol Ther 2006; 23(8): 1087-96.
[] [PMID: 16611268]
Sagar PM, Taylor BA, Godwin P, et al. Acute pouchitis and deficiencies of fuel. Dis Colon Rectum 1995; 38(5): 488-93.
[] [PMID: 7736879]
Madden MV, McIntyre AS, Nicholls RJ. Double-blind crossover trial of metronidazole versus placebo in chronic unremitting pouchitis. Dig Dis Sci 1994; 39(6): 1193-6.
[] [PMID: 8200250]
Simchuk EJ, Thirlby RC. Risk factors and true incidence of pouchitis in patients after ileal pouch-anal anastomoses 2000; 24(7): 851-6.
Hurst RD, Molinari M, Philip Chung T, Rubin M, Michelassi F. Prospective study of the incidence, timing, and treatment of pouchitis in 104 consecutive patients after restorative proctocolectomy. Arch Surg 1996; 131(5): 497-500.
Shen B, Achkar JP, Lashner BA, et al. A randomized clinical trial of ciprofloxacin and metronidazole to treat acute pouchitis. Inflamm Bowel Dis 2001; 7(4): 301-5.
[] [PMID: 11720319]
Nygaard K, Bergan T, Bjørneklett A, Høverstad T, Lassen J, Aase S. Topical metronidazole treatment in pouchitis. Scand J Gastroenterol 1994; 29(5): 462-7.
[] [PMID: 8036463]
Wall GC, Schirmer LL, Anliker LE, Tigges AE. Pharmacotherapy for acute pouchitis. Ann Pharmacother 2011; 45(9): 1127-37.
[] [PMID: 21775695]
Sambuelli A, Boerr L, Negreira S, et al. Budesonide enema in pouchitis--a double-blind, double-dummy, controlled trial. Aliment Pharmacol Ther 2002; 16(1): 27-34.
[] [PMID: 11856075]
Abdelrazeq AS, Kelly SM, Lund JN, Leveson SH. Rifaximin-ciprofloxacin combination therapy is effective in chronic active refractory pouchitis. In: Color Dis. 2005.
Gionchetti P, Rizzello F, Venturi A, et al. Antibiotic combination therapy in patients with chronic, treatment-resistant pouchitis. Aliment Pharmacol Ther 1999; 13(6): 713-8.
[] [PMID: 10383499]
Mimura T, Rizzello F, Helwig U, et al. Four-week open-label trial of metronidazole and ciprofloxacin for the treatment of recurrent or refractory pouchitis. Aliment Pharmacol Ther 2002; 16(5): 909-17.
[] [PMID: 11966499]
Shen B, Fazio VW, Remzi FH, et al. Combined ciprofloxacin and tinidazole therapy in the treatment of chronic refractory pouchitis. Dis Colon Rectum 2007; 50(4): 498-508.
[] [PMID: 17279300]
Barreiro-de Acosta M, García-Bosch O, Souto R, et al. Efficacy of infliximab rescue therapy in patients with chronic refractory pouchitis: a multicenter study. Inflamm Bowel Dis 2012; 18(5): 812-7.
[] [PMID: 21826765]
Greuter T, Biedermann L, Rogler G, Sauter B, Seibold F. Alicaforsen, an antisense inhibitor of ICAM-1, as treatment for chronic refractory pouchitis after proctocolectomy: A case series.In: United Eur Gastroenterol J. 2016; 4: pp. (1)97-104.
Hosten. Alicaforsen: An Emerging Therapeutic Agent for Ulcerative Colitis and Refractory Pouchitis. Gastroenterol Res 2014.
Miner P, Wedel M, Bane B, Bradley J. An enema formulation of alicaforsen, an antisense inhibitor of intercellular adhesion molecule-1, in the treatment of chronic, unremitting pouchitis. Aliment Pharmacol Ther 2004; 19(3): 281-6.
[] [PMID: 14984374]
Gionchetti P, Rizzello F, Venturi A, et al. Oral bacteriotherapy as maintenance treatment in patients with chronic pouchitis: a double-blind, placebo-controlled trial. Gastroenterology 2000; 119(2): 305-9.
[] [PMID: 10930365]
Turroni S, Vitali B, Candela M, et al. Antibiotics and probiotics in chronic pouchitis: a comparative proteomic approach. World J Gastroenterol 2010; 16(1): 30-41.
[] [PMID: 20039446]
Shen B, Brzezinski A, Fazio VW, et al. Maintenance therapy with a probiotic in antibiotic-dependent pouchitis: experience in clinical practice. Aliment Pharmacol Ther 2005; 22(8): 721-8.
[] [PMID: 16197493]

Rights & PermissionsPrintExport Cite as

Article Details

Year: 2019
Published on: 23 July, 2019
Page: [1399 - 1408]
Pages: 10
DOI: 10.2174/1389450120666190723130137
Price: $65

Article Metrics

PDF: 59
HTML: 11
PRC: 2