When Should Chronic Pouchitis Be Treated as Crohn’s Disease?

Maya Kayal, MD and Benjamin L. Cohen MD, MAS

When Should Chronic Pouchitis Be Treated as Crohn's Disease?


Approximately 30% of ulcerative colitis patients will require surgery during their disease course (1). The preferred and most common surgery is the staged total proctocolectomy with ileal pouch-anal anastomosis (IPAA). Despite the benefits of intestinal continuity and improved quality of life, IPAA is associated with multiple complications, the most common of which is pouchitis. Characterized by inflammation of the pouch reservoir, pouchitis has a wide range of clinical manifestations that include urgency, increased frequency, hematochezia and abdominal or pelvic pain. The prevalence of pouchitis increases with time, with cumulative incidence rates of 25% at 1 year, 35% at 3 years and 45% at 5 years (2).

Antibiotics are the mainstay of treatment for acute pouchitis and have been shown to induce remission at rates of approximately 80% after a single course (3). After initial successful treatment, however, approximately 60% of patients will develop at least one recurrence and up to 20% of patients will develop chronic pouchitis. Defined as clinical symptoms that last longer than four weeks, chronic pouchitis is categorized as antibiotic dependent or antibiotic refractory. Patients with chronic antibiotic dependent pouchitis respond well to antibiotics, but experience greater than three relapses per year when antibiotics are withdrawn. In contrast, patients with chronic antibiotic refractory pouchitis have persistent symptoms and objective inflammation on pouchoscopy despite multiple antibiotic courses (4).

It is difficult to distinguish between chronic antibiotic refractory pouchitis and Crohn’s disease of the pouch, particularly because standardized diagnostic criteria for Crohn’s disease of the pouch are lacking. A recent systematic review and meta-analysis of available studies reported a standardized incidence rate of 10.3% (95% confidence interval, 6.1%-15.4%) for development of Crohn’s disease of the pouch (5). Crohn’s disease of the pouch describes a clinical phenotype characterized by inflammation of the pouch or afferent limb resistant to antibiotics, stricturing of the pouch body, afferent limb or proximal small bowel, and/or fistulizing disease involving the perineum or small bowel (6). Timing of these features is critical in differentiating Crohn’s disease from post-operative complications, with incidence of strictures or fistulas more than one year after IPAA highly suggestive of Crohn’s disease (5). Of note, stricture of the pouch-anal anastomosis is not generally considered to be Crohn’s disease of the pouch.  Endoscopic features consistent with Crohn’s disease include mucosal ulcerations of the afferent limb, distinct inflammation patterns in the pouch body and afferent limb, areas of nodularity, inflammatory pseudopolyps, or the presence of fistulous tracts (6). Granulomas noted on mucosal biopsy are specific for Crohn’s disease, however only present in approximately 10% of cases (7). One study has also suggested that pyloric gland metaplasia present in pouch biopsies may be associated with Crohn’s disease of the pouch (8).

The treatment of chronic antibiotic refractory pouchitis and Crohn’s disease of the pouch is similar and consists of steroids and biologics such as infliximab, vedolizumab and ustekinumab (9-13). Despite this, it is important to make the distinction between the two disorders and confirm the diagnosis of Crohn’s disease.  A meta-analysis of available studies has demonstrated that anti-TNF agents have a higher and faster rate of efficacy in patients with Crohn’s disease of the pouch than those with chronic refractory pouchitis (14).  Additionally, patients with Crohn’s disease of the pouch are at significant risk for pouch failure with reported frequencies up to 45% (15). Once the diagnosis is confirmed, appropriate treatment for Crohn’s disease should be instituted early in order to decrease the risk of pouch excision.

  1. Ross H, Steele SR, Varma M, et al. Standards Practice Task Force of the American Society of Colon and Rectal Surgeons. Practice parameters for the surgical treatment of ulcerative colitis. Dis Colon Rectum. 2014;57:5–22.
  2. Ferrante M, Declerck S, De Hertogh G, et al. Outcome after proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis. Inflamm Bowel Dis. 2008;14:20-28.
  3. Shen B. Acute and chronic pouchitis – pathogenesis, diagnosis and treatment. Nat Rev Gastroenterol Hepatol. 2012;9(6):323-33.
  4. Shen B, Remzi FH, Lavery IC, et al. A proposed classification of ileal pouch disorders and associated complications after restorative proctocolectomy. Clin Gastroenterol Hepatol. 2008;6(2):145-58
  5. Barnes, EL, Kochar B, Jessup HR, et al. The Incidence and Definition of Crohn's Disease of the Pouch: A Systematic Review and Meta-analysis. Inflamm Bowel Dis. 2019. doi: 10.1093/ibd/izz005.
  6. Lightner AL, Pemberton JH, Loftus EJ. Crohn’s disease of the ileoanal pouch. Inflamm Bowel Dis. 2016;22(6):1502-8.
  7. Shen B, Fazio VW, Remzi FH, et al. Clinical features and quality of life in patients with different phenotypes of Crohn’s disease of the ileal pouch. Dis Colon Rectum. 2007;50:1450-1459.
  8. Agarwal S, Stucchi AF, Dendrinos K, et al. Is pyloric gland metaplasia in ileal pouch biopsies a marker for Crohn's disease? Dig Dis Sci. 2013; 58(10):2918-25.
  9. Gionchetti P, Rizzello F, Poggioli G, et al. Oral budesonide in the treatment of chronic refractory pouchitis. Aliment Pharmacol Ther. 2007;25(10):1231–6.
  10. Ferrante M, D’Haens G, Dewit O, et al. Efficacy of infliximab in refractory pouchitis and crohn’s disease-related complications of the pouch: a belgian case series. Inflamm Bowel Dis. 2010;16(2)243–9.
  11. Bar F, Kuhbacher T, Dietrich NA, et al. Vedolizumab in the treatment of chronic, antibiotic dependent or refractory pouchitis. Aliment Pharmacol Ther. 2018;47(5):581-587.
  12. Colombel JF, Ricart E, Loftus EV Jr, et al. Management of crohn’s disease of the ileoanal pouch with infliximab. Am J Gastroenterol. 2003;98(10):2239–44.
  13. Weaver KN, Gregory M, Syal G, et al. Ustekinumab is effective for the treatment of Crohn’s disease of the pouch in a multicenter cohort. Inflamm Bowel Dis. 2018. doi: 10.1093/ibd/izy302.
  14. Huguet M, Pereira B, Goutte M, et al. Systematic Review With Meta-Analysis: Anti-TNF Therapy in Refractory Pouchitis and Crohn's Disease-Like Complications of the Pouch After Ileal Pouch-Anal Anastomosis Following Colectomy for Ulcerative Colitis. Inflamm Bowel Dis. 2018; 24(2):261-268.
  15. Braveman JM, Schoetz DJ Jr, Marcello PW, et al. The fate of the ileal pouch in patients developing crohn’s disease. Dis Colon Rectum. 2004;47(10):1613–9.