International practice patterns in the management of pouchitis: results from a global survey

Pouchitis is the most frequent long-term complication after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis. This study aimed to describe current international practices, definitions, and treatment strategies among experienced clinicians.

An international web-based survey was conducted in 2025, following CROSS guidelines, exploring diagnostic, monitoring, and therapeutic practices. Responses were anonymized and analyzed descriptively.

A total of 412 physicians from 49 countries completed the survey, mostly gastroenterologists involved in IBD care (362/412, 87.8%). Most clinicians (156/412, 37.9%) estimated a pouchitis prevalence of 26%-50% among patients with IPAA, typically occurring within the first postoperative year. Follow-up was scheduled every 3-6 months by 164/412 (39.8%) physicians, with nearly half (47.6%) reporting the use of the pouch disease activity index (PDAI). Fecal calprotectin was the preferred non-invasive monitoring tool (326/412, 79.1%), whereas intestinal ultrasound was selected by 130/412 respondents (31.69%). Endoscopy was the primary diagnostic and follow-up modality (398/412, 96.6%), with biopsies routinely taken (364/412, 88%), although 46.7% of respondents reported not using a standardized histological scoring system. Prophylactic therapy was prescribed by 222/412 (53.9%), mainly probiotics (27.7%) and rectal mesalazine (18.2%). In acute pouchitis, ciprofloxacin plus metronidazole was the preferred first-line regimen (218/412, 52.9%). For chronic antibiotic-dependent or refractory pouchitis, advanced therapies were the predominant first-line option (254/412, 61.7%), with vedolizumab (198/412, 48.1%), and infliximab (170/412, 41.3%) most frequently selected. Ustekinumab, selective IL-23 inhibitors, JAK inhibitors and S1P receptor modulators were increasingly used in refractory cases. Treatment targets were primarily clinical (156/412, 37.9%) and endoscopic (124/412, 30.1%) remission, and most respondents (246/396, 62.1%) reported performing endoscopic assessment within 3-6 months after advanced treatment initiation.

This international survey demonstrates substantial heterogeneity in pouchitis diagnosis, monitoring, and treatment, highlighting important gaps in standardized disease assessment and treatment strategies. The findings support the need for consensus-based approaches and prospective, pouch-specific studies to improve the standardization of pouchitis care.