Pouchitis (pouch ileitis)

Construction of a continent ileostomy or ileo-anal reservoir after (procto)colectomy has provided many patients suffering from inflammatory bowel disease-in particular ulcerative colitis or polyposis coli--with a major improvement in their social wellbeing. However, complications are rather frequent and pouchitis is one of the most important chronic ones, to be defined as the combination of bothersome clinical symptoms (abdominal pain, bloating, increased faecal output, sometimes fever) with evident endoscopic abnormalities of the reservoir ileal mucosa (oedema, reddened mucosa, minor flat up to large irregular ulcerations). The contribution of pouch biopsies is limited, because chronic inflammation is always demonstrable and evidence of acute inflammation is only rarely present. Although backwash ileitis does not promote the occurrence of pouchitis, the immunological mechanism might be highly comparable. Cultures of faecal content for specific pathogens is necessary; bacterial anaerobic or aerobic overgrowth appears to be of no major significance in the development of pouchitis. Nevertheless, a short-term course with metronidazole is nearly always effective, although recurrences are far from rare. In this situation a course of corticosteroid enemas or even maintenance therapy (2-3 wk) should be advised. Experience with mesalazine compounds is limited and should be expanded.