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Last decades led to a revolution in the management of ulcerative colitis (UC), due to the development of novel advanced therapies and the identification of increasingly ambitious therapeutic goals. Nevertheless, a subset of patients, refractory to available therapies, still requires proctocolectomy with ileal pouch-anal anastomosis (IPAA). Pouchitis, an inflammatory condition of the ileal pouch, is the most common long-term complication of IPAA, affecting almost one-half of patients in the first 10 years after surgery. Symptoms of pouchitis include increased stool frequency, urgency, and abdominal discomfort, significantly affecting patients' quality of life. Traditionally the mainstay treatment of acute pouchitis involves the use of antibiotics, but one-fifth of patients develop chronic pouchitis (CP), which may be dependent or resistant to antibiotics, posing significant challenges in the management of this condition. Currently, there is still no consensus on the optimal management for CP, though recent progress in understanding the pathophysiology of pouchitis has paved the way for innovative therapeutic approaches, based on biological therapies and small molecules. This review aims to discuss the recent advanced therapies available for pouchitis and provide a comprehensive review on the topic to guide physicians in their clinical practice. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Pouchitis and Crohn’s-like disease of the pouch (CLDP) are common in patients who undergo ileal pouch anal anastomosis for ulcerative colitis. We conducted separate systematic reviews to evaluate the effectiveness of available interventions to prevent and treat pouchitis and CLDP. METHODS: Through systematic literature reviews, we identified studies that evaluated the effectiveness of probiotics, antibiotics, 5-aminosalicylates, nonsystemic oral corticosteroids, and advanced therapies for prevention and treatment of pouchitis and CLDP for meta-analysis. Primary outcomes were occurrence of pouchitis for pouchitis prevention and clinical response for pouchitis and CLDP treatment. We estimated the relative effectiveness of these interventions using the existing placebo response rates or hypothetical spontaneous improvement rates derived from clinical trials of pouchitis, ulcerative colitis, and Crohn’s disease. RESULTS: Probiotics were effective for primary (relative risk [RR] 0.18; 95% confidence interval [CI] 0.05–0.62) and secondary prevention (RR 0.17; 95% CI 0.09–0.34) of pouchitis. Antibiotics were effective for treatment of acute and chronic pouchitis (12 cohorts; RR 1.67; 95% CI 1.34–2.01; response rate 65%; 95% CI 52–75) with ciprofloxacin and metronidazole-based regimens being more effective than rifaximin. Advanced therapies were effective for treatment of chronic antibiotic-refractory pouchitis (31 cohorts; RR 1.71; 95% CI 1.28–2.56; response rate 50%; 95% CI 43–57) and CLDP (10 cohorts; RR 2.49; 95% CI 1.87–3.73; response rate 74%; 95% CI 68–79) without significant difference between classes. DISCUSSION: Multiple medical interventions are effective for prevention and treatment of pouchitis and CLDP. Given the overall low quality of data, further research is needed to confirm these findings. [ABSTRACT FROM AUTHOR]

Acute severe ulcerative colitis (ASUC) often requires surgical intervention, such as proctocolectomy with ileal pouch–anal anastomosis (IPAA). While IPAA improves patient outcomes, it can be associated with pouchitis, a common and debilitating complication characterized by inflammation of the pouch. The development of pouchitis is closely linked to dysbiosis—an imbalance in the gut microbiota. Understanding the role of the microbiota in pouch health has spurred interest in probiotics as a therapeutic strategy. Probiotics represent a promising avenue in the management of pouchitis, offering a natural and targeted approach to improving outcomes for UC patients. This review explores the role of probiotics in the management of UC patients, with a specific focus on preventing and treating pouchitis. We compare the microbiota of healthy pouches to those with pouchitis, highlighting key microbial shifts linked to disease onset and discussing the growing evidence for probiotics as a prevention and therapeutic approach. Future directions should prioritize advancing research to optimize probiotic therapies and establish personalized approaches based on individual microbiome profiles, highlighting their significant potential as a promising treatment strategy for pouchitis. [ABSTRACT FROM AUTHOR]

Chronic pouchitis affects 13% to 17% of patients with ileal pouch-anal anastomosis and ulcerative colitis, and 20% with a history of acute pouchitis. It is classified by antibiotic responsiveness into chronic antibiotic-dependent pouchitis and chronic antibiotic-refractory pouchitis. Pathogenesis of chronic pouchitis can range from microbially mediated to more antibiotic-resistant and immune-mediated processes. A diagnostic index combining clinical, endoscopic, and histologic components is essential for clinical practice and research. In chronic antibiotic-dependent pouchitis, remission is managed with microbiota- or immune-targeted therapies. For chronic antibiotic-refractory pouchitis, immune-directed therapy is primary, with vedolizumab recommended for first-line treatment. Other advanced therapies rely on less definitive evidence, and efficacy may be reduced by precolectomy exposure. This article reviews the pathogenesis, diagnosis, and management of chronic pouchitis. [ABSTRACT FROM AUTHOR]

INTRODUCTION: The aim of this study was to report the frequency and impact of endoscopic response and remission on the risk of subsequent pouchitis in patients with Crohn’s disease–like pouch inflammation (CDLPI) on therapy. METHODS: This was a single-center retrospective study of patients older than 18 years with CDLPI on therapy. RESULTS: Among 110 included patients with CDLPI in clinical remission, endoscopic remission was not significantly associated with a reduced risk of subsequent pouchitis when compared with endoscopic response. DISCUSSION: Endoscopic response, not remission, is sufficient to reduce the risk of subsequent pouchitis in patients with CDLPI. [ABSTRACT FROM AUTHOR]

Pouchitis is one of the most common long-term complications after ileal pouch–anal anastomosis (IPAA) surgery, with a reported incidence rate of up to 50%. Identifying specific bacteria involved in the pathogenesis has important implications for clinical management. Indeed, antibiotic therapy is a common treatment option, but antibiotic choice and treatment duration can vary depending on the severity of symptoms and the bacteria involved. Ansamycins are effective in the management of antibiotic-dependent pouchitis. Therefore, this study aimed to test the in vitro antibacterial activity of a novel rifamycin gel solution, specifically intended for treating infections associated with pouchitis, with the agar diffusion assay. Furthermore, the in vitro antibacterial activity of rifamycin sodium salt against several bacterial strains involved in pouchitis was compared with the gel formulation. Rifamycin’s in vitro anti-microbial characteristics were not affected by the gel formulation. These results, although preliminary, support the potential of the Rifamycin Gel formulation as a valuable addition to the therapeutic armamentarium for this challenging condition.

Introduction: Pouchitis remains the most common complication after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (IPAA). Despite the burden of pouchitis, our ability to recognize the patients at greatest risk for pouchitis and to offer early intervention for the prevention or early treatment is limited., Areas Covered: In this review, we will discuss the diagnostic categories of pouchitis, as well as the common approaches to treatment. We will then discuss gaps in research and clinical care. These include opportunities to improve our understanding of the risk factors associated with the development of pouchitis as well as the role that primary and secondary prevention may play in the management of patients after IPAA to prevent pouchitis. We will then discuss future research goals to decrease the burden of pouchitis., Expert Opinion: Although the burden of pouchitis is well recognized, we have an opportunity to improve our methods of risk stratification to offer early intervention to those patients at the greatest risk for developing pouchitis. Understanding which preventive therapies, in which populations, and under which treatment settings offer the most benefit will be critical issues to address in the near future to improve care of patients after IPAA for UC.

Background: Ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) can incur in complications. The impact of histological activity on the development of pouch-related complications is poorly studied., Aim: To assess the association between histology and long-term outcomes in UC-IPAA., Methods: Single-center, ambidirectional cohort study including UC-IPAA patients undergoing pouchscopy after ileostomy closure. Histological activity was defined as a Pouchitis Disease Activity Index histology subscore ≥2. The primary outcomes were: (i) development of chronic pouchitis, (ii) need of therapy escalation (azathioprine/biologics), and (iii) a composite outcome of treatment with biologics/azathioprine, pouch-related hospitalization or pouch failure., Results: A total of 104 patients were included. After pouchoscopy, the median patient follow-up was 2.3 years (IQR, 1.3-4.0). Eighteen patients (17.3 %) developed chronic pouchitis, 20 (19.2 %) initiated biologics/azathioprine, and 25 (24 %) experienced the composite outcome. After adjusting for confounders, histological activity was significantly associated with development of chronic pouchitis (aHR=4.44; 95 % CI, 1.43-13.80; p=0.010), the treatment with biologics/azathioprine (aHR=4.74; 95 % CI, 1.53-14.71; p=0.007), and the composite outcome (aHR=3.94; 95 % CI, 1.53-10.13; p=0.004)., Conclusion: Histological activity is associated with the development of chronic pouchitis and the need for azathioprine/biologics in UC-IPAA patients, highlighting its potential role in guiding long-term management., Competing Interests: Conflicts of interest A. Armuzzi has received consulting fees from AbbVie, Allergan, Amgen, Arena, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Celltrion, Eli-Lilly, Ferring, Galapagos, Gilead, Janssen, MSD, Mylan, Pfizer, Protagonist Therapeutics, Roche, Samsung Bioepis, Sandoz and Takeda; speaker's fees from AbbVie, Amgen, Arena, Biogen, Bristol-Myers Squibb, Eli-Lilly, Ferring, Galapagos, Gilead, Janssen, MSD, Novartis, Pfizer, Roche, Samsung Bioepis, Sandoz, Takeda, and Tigenix; and research support from Biogen, MSD, Takeda, and Pfizer. C. Bezzio received lecture fees and served as a consultant for Takeda, MSD, Ferring, Abbvie, Galapagos and Janssen. R. Gabbiadini has received speaker's fees from Pfizer, MSD, Ferring, Lilly and Celltrion and consultant fees for Pfizer. A. Dal Buono has received speaker's fees from AbbVie, Ferring, Lilly, Galapagos and Celltrion. A. Spinelli has received consultation fees from Takeda, Pfizer, and Sofar. A. Repici received consulting fees for Fuji, Olympus, and Medtronic and received research grant and speaker fees from Boston Scientific, ERBE, Alfasigma, Norgine. P. Spaggiari, M. Iuzzolino, D. Piovani, G. Figlioli, S. Bonovas declare no conflicts of interest., (Copyright © 2025. Published by Elsevier Ltd.)

Background: The patient experience after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) remains poorly defined, resulting in heterogeneity in clinical assessments and research. We performed a qualitative study to better understand the experience of patients after IPAA for UC, with a focus on the symptoms experienced by patients and the resultant effects on quality of life (QoL)., Methods: We conducted semi-structured focus groups among patients who had undergone IPAA for UC. We invited patients with a variety of pouch-related conditions, including patients reporting normal pouch function and those with diagnosed inflammatory conditions of the pouch. We included questions on patients' experiences and symptoms after IPAA based on 4 thematic areas identified by a previously performed systematic review: bowel symptoms, activities, general issues and quality of life, and psychosocial., Results: We interviewed 15 individuals over the course of 4 focus groups. Participants described the significant impact that bowel symptoms after IPAA had on other activities including work and daily life, and their subsequent relation to QoL themes. Participants noted symptoms of frequency, urgency, and incontinence after IPAA, and many shared how these symptoms required them to change their lifestyle, particularly by altering their daily schedule or changing their diet. Nevertheless, most participants reported QoL improvement after IPAA., Conclusions: In this qualitative study evaluating the experience of patients after IPAA, multiple bowel-related symptoms impact other areas of life and overall QoL. Patients undergoing IPAA for UC represent a unique patient population, and thus patient-centered outcome measures should be designed to standardize their assessment., Competing Interests: Edward L. Barnes has served as a consultant for AbbVie, Boomerang, Pfizer, Eli Lilly, Takeda, and Target RWE. Hans H. Herfarth has served as a consultant for Alivio, AMAG, BMS, Boehringer, ExeGi Pharma, Finch, Gilead, Janssen, Lycera, Merck, Otsuka, Pfizer, PureTech, Seres and research support from Allakos, Artizan, NovoNordisk, Pfizer. Michael D. Kappelman has served as a consultant for Abbvie, Takeda, Janssen, Pfizer, and Eli Lilly and has received research support from Abbvie and Janssen. Marcella H. Boynton, Darren A. DeWalt, and Erica J. Brenner have no relevant conflicts of interests., (© The Author(s) 2025. Published by Oxford University Press on behalf of Crohn's & Colitis Foundation.)

Background: Many patients with medically refractory ulcerative colitis undergo ileal pouch-anal anastomosis, which typically includes the creation of a temporary loop ileostomy. The impact of the interval between ileal pouch-anal anastomosis and loop ileostomy closure regarding endoscopic pouch inflammation has not been well defined. The aim for this project was to assess if delayed loop ileostomy closure increases patients' risk of endoscopic pouch inflammation., Methods: This is a cohort study of patients with ulcerative colitis who underwent ileal pouch-anal anastomosis between 01/2010 and 12/2020. Patients were divided into groups-early (12-116 days) or late closure (>180 days)-based on interval between ileal pouch-anal anastomosis and loop ileostomy closure. The late closure group was further sub-divided by indication for delay which included post-operative complications and non-medical reasons. The primary outcome was development of endoscopic inflammatory pouch disease, which was a composite of pouch disease activity index score of ≥ 4, mucosal breaks beyond anastomotic lines, and diffuse pouch inflammation., Results: Two-hundred ninety patients were included which comprised early and late cohorts of 217 and 73 patients, respectively. Compared to early closure, late closures for non-medical and pouch-related surgical complications were both not found to be associated with development of our composite outcome ( P  = .43 and P  = .80, respectively)., Conclusions: Delaying ileostomy closure due to patient preference or logistical limitations did not result in an increased risk of endoscopic pouch inflammation, but there appears to be an association of extraintestinal manifestations with endoscopic inflammatory pouch disease, suggesting the need for a vigilant surveillance in these patients., Competing Interests: M.Z. has no conflicts of interest or disclosures. J.C.P. has received the Crohn’s and Colitis Foundation Student Research Fellowship Award. K.W.C., E.D., R.S., and Q.Y. reveal no relevant conflicts of interest or disclosures. T.H. indicated no relevant financial disclosures. B.L.C. serves on the advisory board and as a consultant for AbbVie and TARGET RWE. He also serves as a speaker for AbbVie. He has received an educational grant from Pfizer. T.Q. serves on the advisory board and review panel for AbbVie, as well as a member of the Speaker’s Bureau. He is also an advisor and review panel member for BMS, as well as a member of the Speaker’s Bureau. He is an advisor and review panel member for Iterative Scope. He is a speaker for Janssen., (© The Author(s) 2025. Published by Oxford University Press on behalf of Crohn's & Colitis Foundation.)

Background: Patients with inflammatory bowel disease (IBD) who undergo proctocolectomy with ileal pouch-anal anastomosis may develop pouchitis. We previously proposed a novel endoscopic classification of pouchitis describing 7 phenotypes with differing outcomes. This study assessed phenotype transitions over time., Methods: We classified pouch findings into 7 main phenotypes: (1) normal, (2) afferent limb (AL) involvement, (3) inlet (IL) involvement, (4) diffuse, (5) focal inflammation of the pouch body, (6) cuffitis, and (7) pouch-related fistulas noted more than 6 months after ileostomy takedown. Among 2 endoscopic phenotypes, the phenotype that was first identified was defined as the primary phenotype, and the phenotype observed later was defined as the subsequent phenotype., Results: We retrospectively reviewed 1359 pouchoscopies from 426 patients (90% preoperative diagnosis of ulcerative colitis). The frequency of primary phenotype was 31% for AL involvement, 42% for IL involvement, 28% for diffuse inflammation, 72% for focal inflammation, 45% for cuffitis, 18% for pouch-related fistulas, and 28% for normal pouch. The most common subsequent phenotype was focal inflammation (64.8%), followed by IL involvement (38.6%), cuffitis (37.8%), AL involvement (25.6%), diffuse inflammation (23.8%), normal pouch (22.8%), and pouch-related fistulas (11.9%). Subsequent diffuse inflammation, pouch-related fistulas, and AL or IL stenoses significantly increased the pouch excision risk. Patients who achieved subsequent normal pouch were less likely to have pouch excision than those who did not (8.1% vs 15.7%; P = .15)., Conclusions: Pouch phenotype and the risk of pouch loss can change over time. In patients with pouch inflammation, subsequent pouch normalization is feasible and associated with favorable outcome., (© The Author(s) 2024. Published by Oxford University Press on behalf of Crohn’s & Colitis Foundation. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Introduction: To better inform the risk of cuffitis in patients with ulcerative colitis (UC), we aimed to identify its occurrence and associated precolectomy factors in a large multicenter cohort of patients who underwent restorative proctocolectomy (RPC) with stapled ileal pouch-anal anastomosis (IPAA)., Methods: This study was a retrospective cohort analysis of individuals diagnosed with UC or indeterminate colitis who underwent RPC with IPAA for refractory disease or dysplasia at Mount Sinai Hospital or the University of Chicago followed by at least 1 pouchoscopy with report of the pouch-anal anastomosis. The primary outcome was cuffitis defined as ulceration of the cuff as reported in each pouchoscopy report., Results: The pouch-anal anastomosis was mentioned in the pouchoscopy reports of 674 patients, of whom 525 (77.9%) had a stapled anastomosis. Among these, cuffitis occurred in 313 (59.6%) patients a median of 1.51 (interquartile range 0.59-4.17) years after final surgical stage. On multivariable analysis, older age (hazard ratio [HR], 1.01; 95% confidence interval [CI], 1.01-1.02), extensive disease (HR, 1.34; 95% CI, 1.01-1.78), exposure to biologics before colectomy (HR, 2.51; 95% CI, 1.93-3.27), and exposure to at least 2 or more biologics before colectomy (HR, 2.18; 95% CI, 1.40-3.39) were significantly associated with subsequent cuffitis., Conclusions: In this multicenter study of patients who underwent RPC with stapled IPAA and at least 1 follow-up pouchoscopy, cuffitis occurred in approximately 60% and was significantly associated with extensive disease and exposure to multiple biologics precolectomy., (© The Author(s) 2024. Published by Oxford University Press on behalf of Crohn’s & Colitis Foundation. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)