How do you treat this diversion ileitis and pouchitis?

A 43-year-old woman was admitted due to tenesmus and perianal pain caused by a severe perianal skin ulcer (figure 1A). Fifteen years previously, she underwent a total proctocolectomy with ileal pouch–anal anastomosis due to pancolitis-type UC. Three years prior, she had two episodes of pouchitis responding to antibiotic therapy. Her laboratory tests revealed anaemia (haemoglobin level, 96 g/L), elevated C reactive protein level (11.9 mg/dL) and decreased serum albumin level (25 g/L). Figure 1 Clinical findings and microbiota before the treatment. The perianal skin ulcer (A), the diversion ileitis and pouchitis ((B) and (C)) and normal afferent ileal loop (D) could be seen before the treatment. Difference in the intestinal microbiota between the afferent ileal loop and the ileal pouch (E). We could detect a decrease in the frequency of firmicutes and an increase in the frequency of …