Primary Care Management of Ileal Pouch Disorders: Diagnosis, Treatment, and Referral

Ileal pouch-anal anastomosis (IPAA) is the preferred surgical treatment of patients with ulcerative colitis and familial adenomatous polyposis. As the incidence of ulcerative colitis rises globally, increasing numbers of patients live long term with IPAA. Whereas most patients with IPAA achieve good functional outcomes, studies suggest that up to 80% will experience pouchitis during their lifetime, among other inflammatory and structural pouch-related complications. Patients with pouch disorders present with nonspecific gastrointestinal symptoms that may include increased stool frequency, urgency, abdominal or pelvic discomfort, tenesmus, rectal bleeding, and difficulty in evacuating the pouch. Common inflammatory conditions include acute or intermittent pouchitis, chronic antibiotic-dependent pouchitis, chronic antibiotic-refractory pouchitis, cuffitis, and Crohn-like disease of the pouch. Structural complications, such as anastomotic leaks, strictures, and fistulas, may also occur and be manifested with obstructive or infectious symptoms. Primary care clinicians play an important role in the early recognition and initial management of pouch-related complications. For example, patients with mild suspected pouchitis and no alarm features may be treated with empirical antibiotic therapy with close follow-up. Topical mesalamine may be used for suspected cuffitis. However, persistent symptoms, recurrent pouchitis, suspected Crohn-like disease of the pouch, or signs of structural complications warrant prompt referral to subspecialist care.