European evidence-based consensus on the management of ulcerative colitis: special situations

8.1 General Proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the procedure of choice for most patients with ulcerative colitis (UC) requiring colectomy.1 Pouchitis is a non-specific inflammation of the ileal reservoir and the most common complication of IPAA in patients with UC.2–7 Its frequency is related to the duration of the follow-up, occurring in up to 50% of patients 10 years after IPAA in large series from major referral centres.1–9 The cumulative incidence of pouchitis in patients with an IPAA for familial adenomatous polyposis is much lower, ranging from 0 to 10%.10–12 Reasons for the higher frequency of pouchitis in UC remain unknown. Whether the pouchitis more commonly develops within the first years after IPAA or whether the risk continues to increase with longer follow-up remains undefined. ECCO Statement 8A The diagnosis of pouchitis requires the presence of symptoms, together with characteristic endoscopic and histological abnormalities [EL3a, RGB]. Extensive colitis, extraintestinal manifestations (eg primary sclerosing cholangitis), being a non-smoker, p-ANCA positive serology, and non-steroidal anti-inflammatory drug use are possible risk factors for pouchitis [EL3b, RG D ]. #### 8.1.1 Symptoms After total proctocolectomy with IPAA, median stool frequency is 4 to 8 bowel movements1–4,13,14 with 700 mL of semiformed/liquid stool per day2,13,14. Symptoms related to pouchitis include increased stool frequency and liquidity, abdominal cramping, urgency, tenesmus and pelvic discomfort (2, 15). Rectal bleeding, fever, or extraintestinal manifestations may occur. Rectal bleeding is more often related to inflammation of the rectal cuff (“cuffitis”),16 than to pouchitis. Poor faecal incontinence may occur in the absence of pouchitis after IPAA, but is more common in patients with pouchitis. Symptoms of pouch dysfunction in patients with IPAA may be caused by conditions other than pouchitis, …