What Is Pouchitis, and Can You Prevent It?

To understand pouchitis, you first need to know how an ileal pouch works.

Pouchitis means that J-shaped area has become inflamed. “Inflammation of the ileal pouch (‘J pouchitis’) in patients with inflammatory bowel disease [who have undergone ileoanal anastomatosis] can either be acute or chronic,” says Sandhya Shukla, MD, a gastroenterologist with Atlantic Coast Gastroenterology Associates in Brick Township, New Jersey.

• Lower abdominal pain
• Intestinal cramping
• Urgent bowel movements
• More frequent bowel movements
• Inability to hold in poop
• Straining to poop from pain or blockage
• Feeling like you need to poop but can’t
• Blood in the stool
• Fever or chills

“Patients often describe [pouchitis] as a ‘return of UC-like symptoms’ despite having had surgery,” says Ekta Gupta, MBBS, the chief of gastroenterology at the University of Maryland Medical Center in Baltimore.

Sometimes, symptoms are subtle and confused with other causes, including potential complications of J-pouch surgery like cuffitis (inflammation of the rectal remnant left after pouchitis surgery), irritable pouch syndrome, or bacterial overgrowth, says Gupta.

• Genetics
• Feces sitting in one spot for long periods (known as fecal stasis)
• Immune system issues
• Surgical technique used
• Not enough oxygen reaching the pouch
• Using nonsteroidal anti-inflammatory drugs (NSAIDs)
• Infection with Clostridioides difficile (C. diff)

• Viral infection
• Fungal infection
• Immunosuppression from other health conditions or medications
• Primary sclerosing cholangitis, an autoimmune disease that damages bile ducts in the liver

For recurrent pouchitis that responds to antibiotics but comes back after you finish the course of antibiotics, called chronic antibiotic-dependent pouchitis, the American Gastroenterological Association suggests either chronic or cyclical antibiotics at the lowest possible dose that alleviates your symptoms, says Shukla.

• Biologic therapies like anti-tumor necrosis factor (TNF) agents, such as vedolizumab (Entyvio) and ustekinumab (Stelara)
• Systemic steroids like budesonide (Uceris)
• Immunosuppressants to lessen chronic inflammation
• Mesalamine enemas, also known as 5-aminosalicylic acid (5-ASA), a first-line medication therapy for UC
• Bismuth enemas, which can improve symptoms
• Fecal microbiota transplant to treat a C.diff infection and improve balance in the gut microbiome
• Hyperbaric oxygen therapy for people with fistulas or abscesses

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• Emerging therapies and participation in clinical trials when available

In some cases, you can prevent recurrent pouchitis the same way you treat it — with antibiotics — though they’re not recommended for preventing pouchitis in the first place.

• Limit the overuse of antibiotics, according to your provider’s instructions.
• Avoid NSAIDs, like ibuprofen.
• Use multi-strain probiotics, like the De Simone Formulation, formerly known as VSL#3.
• Identify and manage your triggers.
• Treat infections like C.diff quickly.
• Consider asking a registered dietitian about modifying your diet.
• Follow up with your provider frequently.

For pouchitis prevention, ask your doctor or a registered dietitian about following a low-FODMAP diet. It involves temporarily limiting or avoiding foods low in certain types of carbohydrates known as FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols).

FODMAPs can cause uncomfortable digestive symptoms for some people. Following a low-FODMAP diet for a set period and then gradually reintroducing higher-FODMAP foods can help you determine which ones may be triggering your symptoms.

Everyone reacts to food differently, so it may take some trial and error before you find a diet that best prevents pouchitis for you.

• Pouchitis is the inflammation of a pouch placed to connect your small intestine and anus after your colon and rectum are removed to treat ulcerative colitis.
• Symptoms of pouchitis may include lower abdominal pain and cramping; urgent, frequent, or incontinent stools; straining to poop; blood in the stool; and fever or chills.
• You can treat pouchitis with antibiotics, probiotics, and regular checkups with your healthcare provider.
• Lifestyle habits, like following a low-FODMAP diet, avoiding NSAIDs, and treating infections quickly, can help prevent this condition.