What to Know About Pouchitis

Pouchitis is an inflammation that occurs in some people who have had ileal pouch-anal anastomosis (IPAA) surgery. This surgery is commonly called a J-pouch. The surgery is often used to treat ulcerative colitis or other disorders that affect the colon and/or the rectum.

The J-pouch can become irritated or inflamed, leading to symptoms such as diarrhea (sometimes bloody), an urgent need to go to the bathroom, accidents (incontinence), and pain or discomfort. Pouchitis doesn’t happen to everyone with a J-pouch, but it is common. It can be a chronic problem for some people.

This article will discuss how and why a J-pouch is created, what causes inflammation (pouchitis) in a J-pouch, and how pouch dysfunction might be treated. 

Pouchitis and J-Pouch Surgery

J-pouch surgery is a complex surgery usually done in two or three steps. It is used to treat ulcerative colitis and some other digestive conditions, such as familial adenomatous polyposis (FAP).

The first step of creating a J-pouch is the surgical removal of the large intestine. This procedure is called a colectomy. All or part of the rectum may also be removed. In most cases, an ileostomy will be placed after the colectomy.

Pouchitis

An ileostomy is when the end of the small intestine is brought through the abdomen, which is called a stoma. A bag is worn over the stoma to collect stool as it leaves the body. The ileostomy is needed to allow the newly constructed J-pouch to heal. 

The J-pouch itself is created by folding the last part of the small intestine (the terminal ileum) over on itself. The result is a holding place for stool to take on the role of the removed rectum. It is often formed in the shape of the letter  “J,” but other shapes are sometimes used.

When the surgery is done in two steps, the colectomy, J-pouch creation, and ileostomy are done all in one step. The second step is reversing the ileostomy to allow stool to leave the body through the bottom again. When three steps are used, the first is the colectomy, the second is the J-pouch construction, and the third is the reversal.

Pouchitis

The J-pouch is made from living tissue and can be affected by diseases and conditions. For some people, a type of inflammation called pouchitis can develop in the J-pouch. It is still not entirely understood, but some things are known about why it happens and how to treat it. 

Types of Pouchitis 

Pouchitis was first described in 1986. It was found that people who had this surgery for ulcerative colitis experienced pouchitis more often than other forms, including FAP.

Knowledge of what causes pouchitis and its different forms has expanded over the years. Pouchitis is now considered a spectrum, whose categories include acute, chronic, refractory, or secondary pouchitis.

Types of pouchitis include:

  • Acute pouchitis: This is when the symptoms last less than a month (four weeks). The symptoms usually improve with the standard treatment of antibiotics.
  • Chronic/relapsing pouchitis: When pouchitis returns after antibiotic treatment and continues for more than four weeks, it may be considered relapsing.
  • Antibiotic-responsive pouchitis: This is when there are four or fewer episodes of pouchitis a year that get better after two weeks of antibiotics.
  • Chronic antibiotic-dependent pouchitis: This is when pouchitis comes back three or more times per year and improves with antibiotics but comes back when the antibiotics are stopped.
  • Chronic antibiotic-refractory pouchitis (CARP): This is pouchitis that doesn’t get better even when treated with antibiotics.
  • Secondary pouchitis: In some cases, the cause of pouchitis could actually be Crohn’s disease, a second form of inflammatory bowel disease (IBD). Crohn’s disease of the pouch may also be considered its own type of disease.

Pouchitis Symptoms

The symptoms of pouchitis can include: 

  • Abdominal cramps
  • Bloody stools
  • Fever
  • More frequent stools
  • Urgency

The signs that healthcare providers may look for inside a pouch that could point to pouchitis include inflammation and ulcers (sores). A biopsy of the pouch tissue may show an increase in white blood cells. In a biopsy, a sample of tissue is collected and analyzed in the lab.

What Causes Pouchitis?

It’s not well understood what causes pouchitis, but it is thought to be a group of conditions with multiple causes.

Pouchitis is more common in people who have had the surgery for ulcerative colitis than those who have it done for other conditions, such as FAP. For this reason, one theory is that it could be a continuation of ulcerative colitis.

Dysbiosis, meaning an imbalance in the bacteria that live in the intestine and the pouch (the microbiome), may be another cause. Autoimmune conditions that affect the gastrointestinal system, such as ulcerative colitis, can also be a cause.

There May Be Multiple Factors

For some people, there could be more than one cause that leads to a bout of pouchitis. It is a complicated disorder. People who live with chronic pouchitis may want to consider asking for a referral to see a pelvic pouch specialist.

How Pouchitis Is Diagnosed

Pouchitis is often diagnosed by a healthcare provider when pouch function suddenly worsens, causing diarrhea and other symptoms.

Some healthcare providers may want to look at the pouch with an endoscopic procedure before or after treating for pouchitis. It is similar to colonoscopy but is often called a pouchoscopy by specialists. This is a procedure in which a specialized tool with a light and a camera on the end is inserted into the anus to see inside the pouch.

A pouchoscopy is done in a variety of ways. One procedure requires a full prep to clean out the intestine before placing the patient under anesthesia while the pouchoscopy is performed. Another is a short procedure requiring no sedation that is performed after an enema is used to remove stool from the pouch. Other procedures are available that fall between these two extremes.

A healthcare provider (usually a gastroenterologist or a colorectal surgeon) will give directions and do the procedure.

Some conditions may mimic pouchitis. A healthcare provider may want to rule out these before offering treatment for pouchitis or if treatment doesn’t seem to help: 

  • Adhesions: Scar tissue in or around the pouch
  • Bile salt malabsorption (BAM): Bile salts that are not absorbed properly by the intestines, which can cause diarrhea
  • Crohn’s disease of the pouch: Inflammation or ulceration in the pouch caused by Crohn’s disease
  • Cytomegalovirus or Clostridioides difficile (C. diff): Infections in the digestive tract that cause diarrhea
  • Impaired pouch emptying: Not being able to empty the pouch of stool
  • Inflammation of the rectal cuff or cuffitis: An inflammation of the rectal cuff, which can only occur in people who have a section of their rectum left in place
  • Irritable pouch syndrome: When there are symptoms such as diarrhea, abdominal pain, or pelvic pain, but there is no inflammation found in the pouch
  • Pelvic floor dysfunction: When the pelvic muscles are not working properly to allow a person to empty their pouch of stool
  • Pouch ischemia: A lack of blood flow to the pouch
  • Pouch stenosis: A narrowed section of the pouch
  • Pouch stricture: Scar tissue or inflammation causing a narrowed section in the pouch

Pouchitis Treatment

Treatment for acute pouchitis is usually antibiotics. First-line treatment for acute pouchitis is a two- to four-week course of antibiotics, such as Flagyl (metronidazole) or Cipro (ciprofloxacin).

If symptoms don’t improve after four weeks, antibiotics might be prescribed for longer, such as another 28 days. Adding another antibiotic, such as Xifaxan (rifaximin), might also be tried.

Pouchitis that is chronic or refractory might be treated by rotating different antibiotics. The probiotic known as VSL#3 is and potentially prevent it from happening again. However, it can be prohibitively expensive for some people.

If antibiotics don’t work, there is less evidence and more trial and error. The next step might be with drugs that suppress the immune system. A type of steroid called budesonide might be tried. It has shown good results in some trials.

Biologics might also be tried for chronic pouchitis. Remicade (infliximab), Humira (adalimumab), Entyvio (vedolizumab), and Stelara (ustekinumab) have all been used in trials. As new biologics and other therapies come to market, patients have more options for treatment.

There has been little study on diet and pouchitis. Some healthcare providers may recommend a low-carbohydrate, low-fiber, high-protein diet. However, one 2023 study has found no connection between diet and pouchitis. 

What’s the Outlook for Pouchitis?

In most cases, the outlook is positive, and pouchitis is a short-term condition that is managed with a course of antibiotics. In 80% of cases of acute pouchitis, antibiotic treatment will result in remission (symptoms stopping).

In one study of people with a J-pouch, of the 53% who developed acute pouchitis:

  • 30% went on to have chronic pouchitis
  • 30% developed cuffitis
  • 11% developed a Crohn’s-like condition of the pouch

Chronic pouchitis is associated with a risk of pouch failure. Pouch failure is when the J-pouch needs to be bypassed or removed, and a permanent ileostomy is placed. Having chronic pouchitis may carry a 5% to 10% risk of pouch failure.

Chronic pouchitis unfortunately is linked to a risk of cancer, although this is rare. Studies show some differences in the potential risks. However, the risk does seem to increase with the age of the J-pouch.

The risk at 20 years after surgery is higher than it is five years after surgery. A study of over 3,000 people showed that the risk of cancer at five, 10, 15, and 20 years after surgery is 0.9%, 1.3%, 1.9%, and 4.2%, respectively.

Monitoring Chronic Pouchitis

It’s recommended that people with chronic pouchitis get a pouchoscopy to look at the interior of the pouch every one to two years. Biopsies will be taken to test for changes in the tissue that could indicate a risk of cancer.

Summary

Pouchitis is a common condition after having ileal pouch surgery. Most cases of pouchitis will get better with a two- to four-week course of one or more antibiotics. If pouchitis doesn’t respond, a step-up approach to using different therapies, including biologics, might be tried.

Pouch failure and needing an ileostomy because of pouchitis is uncommon. People who live with a J-pouch should get regular care to ensure that the pouch is healthy and that they are keeping up with the latest information on pouch function, diet, and lifestyle. 

11 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
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Additional Reading

By Amber J. Tresca
Amber J. Tresca is a freelance writer and speaker who covers digestive conditions, including IBD. She was diagnosed with ulcerative colitis at age 16.