Comprehensive Guide for Managing Pouchitis

The American Gastroenterological Association (AGA) has published the first comprehensive evidence-based guideline on the treatment of pouchitis , the most common complication experienced by people with ulcerative colitis after surgery to remove the colon.

Between 150,000 and 300,000 people with ulcerative colitis in the U.S. live with an internal reservoir or “pouch” surgically created from their small intestine as an alternative way to store and pass stool after their diseased colon is removed. . The pouch can become inflamed, a condition called pouchitis , which affects nearly half of patients within two years of surgery and up to 80% of patients over time.

“As providers, we struggle to obtain insurance approval for medications to treat pouchitis , because it has not been a well-defined or recognized entity. Our intention with this guideline is to help improve access for patients and providers to use these advanced therapies,” said guideline author Siddharth Singh, MD, MS, University of California, San Diego.

The AGA provides the following guidance for physicians caring for patients with ulcerative colitis undergoing proctocolectomy with ileal pouch-anal anastomosis , also known as IPAA or J-pouch.

AGA suggests initial treatment of pouchitis with antibiotics.
Treatment with multi-strain probiotics is suggested after a course of antibiotics to prevent recurrent pouchitis .
AGA suggests cyclical or near-continuous antibiotic therapy to treat pouchitis that responds to antibiotics but recurs frequently and shortly after antibiotics are discontinued.
In patients with recurrent pouchitis unresponsive to antibiotics or Crohn’s-like pouch disease, AGA suggests advanced immunosuppressive medications (i.e., infliximab, vedolizumab, ustekinumab, upadacitinib, etc.).
Pouchitis has a significant impact on patients’ quality of life, so there is interest in finding ways to prevent it from occurring . The AGA guideline suggests against using antibiotics for primary prevention of pouchitis , and the guideline authors did not find enough scientific evidence to recommend for or against the use of probiotics for prevention.

AGA describes four types of inflammatory pouch disorders.

Intermittent pouchitis
This occurs when a patient experiences infrequent episodes of pouchitis symptoms that improve with treatment.
Antibiotic-dependent chronic pouchitis.
This occurs when a patient’s pouchitis responds to antibiotics, but symptoms return quickly after antibiotics are stopped (usually within a few days or weeks).
Chronic pouchitis refractory to antibiotics.
This occurs when patients experience ongoing symptoms of pouchitis that do not improve with antibiotic therapy. Patients often require more advanced treatment, such as steroids or immunosuppressive medications.
Crohn’s-like pouch disease
Patients may have problems such as fistulas (abnormal ducts), strictures (narrowing), and inflammation in the small intestine above the pouch.

Amber Tresca, a patient advocate who has lived with a J-pouch for over 20 years, shares that "it is important for patients to know how to care for their pouch if they develop pouchitis , especially if they do not have access to a pouch and a care provider. " "This guideline can help patients understand that pouchitis is a real condition, that there is treatment for it, and that they do not have to live with symptoms."

Download the full text (in English) of the AGA guide

Comprehensive Guide for Managing Pouchitis

Pouchitis, the most common complication following surgery for ulcerative colitis, is addressed comprehensively in this first-of-its-kind medical guide.