Pouchitis, you’ve heard about it. But what is it exactly?
I have been wanting to write a post about pouchitis for quite some time now. I wrote a general overview of complications that can arise after ileal-pouch anal anastomosis (you can read about that here). While many patients (up to 40%) will develop pouchitis within the first year after surgery, I lived with my j-pouch for 7 years almost to the day before I gained first-hand experience. I knew the symptoms, but as it first presented itself with symptoms similar to a normal, irritated j-pouch, it kind of snuck up on me. So, I researched the subject and now I’m sharing what I learned.
Pouchitis Is…
Researchers in Italy (IRCCS) describe pouchitis as “a non-specific inflammation of the [j-pouch].” Doctor Bo Shen, a leading gastroenterologist who specializes in pouch disorders and has written extensively on the subject. He states that, “Pouchitis is actually a spectrum of diseases that vary in etiology, pathogenesis, phenotype, and clinical course.” In other words, pouchitis varies in the way that it presents itself and how it is treated. In fact, pouchitis is complex and there are various classifications of the illness.
First, there’s acute pouchitis, which is your basic, typical pouchitis that is knocked out with a two week regimen of antibiotics. Then there’s chronic pouchitis; this can be more difficult to treat. Chronic pouchitis can also be grouped into three different sub-categories. For the sake of simplicity and brevity, I will focus mostly on acute pouchitis. Look out for future blog posts on chronic pouchitis.
Causes and Risk Factors
No one really knows what causes pouchitis. But researchers have been able to pinpoint a few risk factors. Men apparently experience more bouts with pouchitis than women. People who are overweight are also at higher risk. In addition, j-pouch patients with ulcerative colitis, or UC are at higher risk for developing pouchitis than those with familial adenomatous polyposis, or FAP. Some researchers have found that anywhere from 5-50% of UC patients experience pouchitis compared to 0-11% of FAP patients. Other risk factors include autoimmune disorders, extra intestinal manifestations of inflammatory bowel disease, and genetic disorders.
Symptoms
Pouchitis presents itself in a variety of ways, and like with any other illness or disease, patients may experience any of the following combinations of symptoms.
- frequency in bowel movements
- watery stools
- bloody stools
- abdominal cramping
- urgency in bowel movements
- tenesmus (the need to pass stool even after a bowel movement)
- fever
- joint pain
- nighttime bowel movements/leakage
How is Pouchitis Diagnosed?
My doctor diagnosed my pouchitis based off of my own personal symptoms alone. After a two week round of antibiotics I was good as new. However, a doctor may also diagnose pouchitis with imaging tests such as a CT scan or an MRI. Your doctor may also run lab tests run or even perform a biopsy of the inside of your pouch.
Treatments
For the majority of patients, the first episode of pouchitis will be treated with oral antibiotics such as metronidazole, ciprofloxacin and tinidazole. While acute pouchitis responds well to this therapy, chronic pouchitis may become a problem. Because of this, more aggressive treatment is necessary. Studies show that between 20-30% of patients do not respond to antibiotics. In these more difficult cases, patients are placed on antibiotics for an extended amount of time. In addition, some patients will undergo a sort of j-pouch “physical therapy” and/or topical anti-inflammatory medicines.
For particularly difficult cases, doctors recommend biologics or immunomodulators. When all else fails (that is, when the pouch is determined to be beyond help), pouch removal is the order of the day. It should be noted, however, that j-pouch failure is extremely rare and up to 94% of j-pouch patients report a better quality of life.
Prevention
Unfortunately we cannot prevent pouchitis from occurring 100%. Reports show that those who have had pouchitis before are at a greater risk (5-19%) for a relapse. However, there are some steps we can take to help reduce our chances. Doctor Shen recommends a low-carbohydrate and/or low-fiber diet. He also believes that elemental diets may help relieve symptoms of chronic pouchitis. Many patients use probiotics successfully in preventing pouchitis from becoming a problem. According to a study by Sigma-Tau Pharmaceuticals, the use of VSL#3 (pharmaceutical-grade probiotics) reduced risks of developing pouchitis from 40% to 10%.
Conclusion
I hope that this post has been helpful in helping you understand more about pouchitis. In my next post, I’ll be detailing my own personal experience with pouchitis. In subsequent posts, I’ll be giving you my personal tips on life with a j-pouch that have made my life a whole lot more manageable. Take care and keep fighting!
Sources
Nyp.org. 2021. Dr. Bo Shen: Leading the Way in IBD and Pouch Disorders – Advances in Gastroenterology and GI Surgery | NewYork-Presbyterian. [online] Available at: <https://www.nyp.org/newsletters/prof-adv/gastro/dr-bo-shen-ibd-and-pouch-disorders> [Accessed 10 November 2021].
Frysh, P., 2021. Pouchitis After J-Pouch Surgery. [online] WebMD. Available at: <https://www.webmd.com/ibd-crohns-disease/ulcerative-colitis/what-is-pouchitis> [Accessed 10 November 2021].
Gionchetti, P., Calabrese, C., Laureti, S., Poggioli, G. and Rizzello, F., 2021. Pouchitis: Clinical Features, Diagnosis, and Treatment. International Journal of General Medicine, Volume 14, pp.3871-3879.
Shen, B., 2013. Pouchitis: What Every Gastroenterologist Needs to Know. Clinical Gastroenterology and Hepatology, 11(12), pp.1538-1549.
Schieffer, K., Williams, E., Yochum, G. and Koltun, W., 2016. Review article: the pathogenesis of pouchitis. Alimentary Pharmacology & Therapeutics, 44(8), pp.817-835.
Rabbenou, W., & Chang, S. (2021). Medical treatment of pouchitis: a guide for the clinician. Therapeutic Advances in Gastroenterology, 14, 17562848211023376. https://doi.org/10.1177/17562848211023376
