Pouchitis & Cuffitis

Inflammation can occur after ulcerative colitis surgery that creates an ileal pouch‑anal anastomosis (IPAA or J‑pouch). When the pouch lining gets inflamed, it is called pouchitis. When the small rim of rectal tissue left behind gets inflamed, it is called cuffitis. Both can cause urgency, frequency, and bleeding. Most cases respond to medicine, and treatment depends on the exact problem and cause. (gastro.org)

Key takeaways

• Pouchitis is inflammation of the J‑pouch, cuffitis is inflammation of the tiny rectal cuff. They are treated differently. (gastro.org)

• First‑line therapy for acute pouchitis is a short course of antibiotics. (gastro.org)

• Cuffitis often responds to rectal mesalamine or rectal steroid therapy, similar to ulcerative proctitis. (mayoclinic.elsevierpure.com)

• Recurrent or antibiotic‑refractory pouchitis may need advanced medicines, such as vedolizumab, anti‑TNF agents, or ustekinumab. (gastro.org)

• Infections like C. difficile or CMV can mimic refractory pouchitis, so testing may be needed before escalating therapy. (pubmed.ncbi.nlm.nih.gov)

What are pouchitis and cuffitis

• Pouchitis is inflammation of the small intestine pouch that takes over for the removed colon and rectum. It is the most common long‑term issue after IPAA. Symptoms include more bowel movements, urgency, night leakage, pelvic discomfort, and sometimes fever. Diagnosis is based on symptoms plus pouchoscopy with biopsies. The Pouchitis Disease Activity Index (PDAI) combines symptoms, endoscopic findings, and histology. (gastro.org)

• Cuffitis affects the short rectal cuff left when a stapled pouch is used. It often causes bright red bleeding, urgency, and tenesmus. On scope, inflammation is limited to the cuff near the anus, while the pouch body may look normal. Treatment follows ulcerative colitis proctitis principles. (mayoclinic.elsevierpure.com)

Why do these problems happen

Many factors can contribute:

• Changes in bacteria within the pouch.

• Reduced immune tolerance in the pouch lining.

• Triggers like nonsteroidal anti‑inflammatory drugs (NSAIDs). People with primary sclerosing cholangitis (PSC) and some extraintestinal issues have a higher risk of chronic pouchitis. (academic.oup.com)

Infections can also cause pouch symptoms. Clostridioides difficile can infect the pouch and should be checked in symptomatic patients. Cytomegalovirus (CMV) is a less common cause but can mimic hard‑to‑treat pouchitis, and it needs antiviral therapy. (pubmed.ncbi.nlm.nih.gov)

How are pouch symptoms evaluated

• History and exam, including diet, recent antibiotics, and NSAID use.

• Lab tests, often including stool checks for C. difficile.

• Pouchoscopy with biopsies to confirm inflammation, define location, and rule out CMV. PDAI or modified PDAI may be used to standardize findings.

• If there is severe pain, fever, or suspected abscess, imaging may be needed. (academic.oup.com)

Treatment at a glance

Evidence notes: The American Gastroenterological Association (AGA) suggests antibiotics for acute pouchitis, optional multi‑strain probiotics after antibiotics to prevent recurrence, and advanced immunosuppressive therapy for recurrent or antibiotic‑refractory disease. For cuffitis, AGA recommends topical mesalamine or topical corticosteroids as initial therapy. (gastro.org)

Advanced and special situations

• Chronic antibiotic‑refractory pouchitis: If symptoms do not improve with antibiotics, biologic or small‑molecule therapy may be used. Vedolizumab has a specific regulatory approval in the European Union for chronic pouchitis after antibiotic failure. Anti‑TNF therapy and ustekinumab are also used based on observational data and guideline consensus. Decisions consider prior drug exposure and safety. (takeda.com)

• Crohn’s‑like disease of the pouch: Some people develop fistulas, strictures, or pre‑pouch ileitis. Treatment follows Crohn’s disease strategies, often with biologics, sometimes with short courses of steroids. (gastro.org)

• Infection‑related pouchitis: Treat confirmed C. difficile with guideline‑directed antibiotics. Treat biopsy‑proven CMV with antivirals. Reassess before adding immunosuppression. (pubmed.ncbi.nlm.nih.gov)

Self‑care and prevention tips

• Limit or avoid NSAIDs unless a clinician advises otherwise.

• Stay hydrated, especially during flares.

• Review probiotics with the care team, since evidence for prevention is mixed, and products differ in strength and quality.

• Keep routine follow‑up. Pouchoscopy intervals depend on symptoms and risk, for example PSC or prior dysplasia may need closer surveillance. (gastro.org)

When to seek urgent care

Call the care team or seek urgent evaluation for any of the following:

• High fever, shaking chills, or severe pelvic or abdominal pain.

• Heavy or persistent bleeding.

• Signs of dehydration such as dizziness, very dark urine, or fainting.

• Sudden inability to pass stool with severe cramps.

FAQs

How long does a typical antibiotic course last for acute pouchitis

Most initial courses are short, about 2 weeks. The exact drug and duration are chosen by the clinician based on symptoms, history, and side effects. (gastro.org)

Are probiotics helpful

After an antibiotic course, AGA suggests multi‑strain probiotics may help prevent recurrence in some people, but the evidence is mixed and product quality varies. Discuss options with the care team. (gastro.org)

What if symptoms keep returning after antibiotics

This pattern is called antibiotic‑dependent pouchitis. Options include rotating or near‑continuous antibiotics and moving to advanced therapies if quality of life is poor or side effects build up. (gastro.org)

Is cuffitis dangerous

Cuffitis is usually manageable and often responds to rectal mesalamine. Persistent cuffitis should be reassessed, since some people may need therapies used for ulcerative colitis. (mayoclinic.elsevierpure.com)

Does vedolizumab treat pouchitis

Yes, in Europe vedolizumab IV is approved for chronic pouchitis that has not responded to antibiotics. In other regions it may be used off‑label based on clinician judgment and local policies. (takeda.com)