Chronic Antibiotic-Refractory Pouchitis: Management Challenges

An Outtier, Marc Ferrante Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, BelgiumCorrespondence: Marc FerranteDepartment of Gastroenterology and Hepatology, University Hospitals Leuven, Herestraat 49, Leuven, 3000, BelgiumTel +32 16 34 42 18Fax +32 16 33 07 23Email marc.ferrante@uzleuven.beBackground: Pouchitis is the most common long-term complication in patients with ulcerative colitis who underwent restorative proctocolectomy with ileal pouch-anal anastomosis. The incidence of acute pouchitis is 20% after 1 year and up to 40% after 5 years. Chronic antibiotic-refractory pouchitis develops in approximately 10% of patients.Aim: To present a narrative review of published literature regarding the management of chronic antibiotic-refractory pouchitis.Methods: Current relevant literature was summarized and critically evaluated.Results: Clear definitions should be used to classify pouchitis into acute versus chronic, and responsive versus dependent versus refractory to antibiotics. Before treatment is started for chronic antibiotic-refractory pouchitis, secondary causes should be ruled out. There is a need for validated scoring systems to measure the severity of the disease. Because chronic antibiotic-refractory pouchitis is a rare condition, only small studies with often a poor study design have been performed. Treatments with antibiotics, aminosalicylates, steroids, immunomodulators and biologics have shown to be effective and safe for chronic antibiotic-refractory pouchitis. Also, treatments with AST-120, hyperbaric oxygen therapy, tacrolimus enemas, and granulocyte and monocyte apheresis suggested some efficacy.Conclusion: The available data are weak but suggest that therapeutic options for chronic antibiotic-refractory pouchitis are similar to the treatment strategies for inflammatory bowel diseases. However, randomized controlled trials are warranted to further identify the best treatment options in this patient population.Keywords: chronic antibiotic-refractory pouchitis, inflammatory bowel disease, biologics