Incidence, risk factors, and treatment patterns of pouchitis in pediatric ulcerative colitis

Despite advances, patients with ulcerative colitis or inflammatory bowel disease (IBD) unclassified require restorative proctocolectomy with ileal pouch-anal anastomosis (RPC-IPAA) for refractory disease. Pouchitis is the most common postoperative complication, yet its incidence, natural history, and treatment in pediatric patients are poorly defined. We characterized the clinical course of pouchitis and determined predictors of postoperative advanced IBD therapy.

We retrospectively identified patients 2.5 to 20.8 years of age with RPC-IPAA between 2010 and 2023. Data collected include demographics, preoperative disease course, operative details, postoperative pouchitis, and management.

Of our cohort of 105 patients, the median age at diagnosis was 13.4 years and the median age at colectomy was 16.0 years. Median follow-up after RPC-IPAA completion was 4.4 years. Kaplan-Meier analysis estimated a cumulative incidence of any pouchitis of 78% by 5 years and chronic pouchitis of 62% by 5 years after stoma takedown. While the 5-year probability of requiring advanced IBD therapy among patients with pouchitis was 25%, pouch failure was rare, with only 2 of 105 requiring diverting ostomy. On multivariable Cox regression, patients with chronic pouchitis who required advanced IBD therapy were more likely to have a history of IBD unclassified (hazard ratio, 3.68; P = .019) or treatment with anti-tumor necrosis factor α therapy prior to colectomy (hazard ratio, 16.5; P = .013).

Acute and chronic pouchitis are common complications following pediatric RPC-IPAA. While pouch failure is rare, a significant percentage will require postoperative advanced IBD therapy. Families should be counseled that proctocolectomy can achieve disease control but does not eliminate the need for IBD-directed medical therapy.