Pouchitis

The exact cause is not fully understood. It is thought to involve a change in the gut bacteria in the pouch together with an overactive immune response in people who are prone to it. Smoking and some medicines, such as anti-inflammatory painkillers (NSAIDs), may play a role in some people. Other conditions can cause similar symptoms, such as infections, narrowing at the pouch, Crohn disease of the pouch, or poor blood supply, so assessment by a specialist is important.

Pouchitis is common among people with a pouch made for ulcerative colitis, and many people will have at least one episode. It is much less common in people whose pouch was made for other reasons. Most episodes respond to treatment, while a smaller group develops chronic or recurring pouchitis.

Diagnosis is based on symptoms, endoscopic appearance and biopsies. A pouchoscopy (a short flexible scope passed into the pouch) shows redness, swelling or ulcers, and small samples are taken. Stool tests rule out infection, and blood tests can show inflammation or anaemia. Other conditions that mimic pouchitis are checked for, and scans or further tests may be used. Your doctor decides which tests are needed.

Small habits help you spot problems early and look after your pouch.

• Track your usual number of stools per day and night so you notice early when it changes

• Do not smoke

• Avoid anti-inflammatory painkillers (like ibuprofen) unless your doctor agrees

• Look after the skin around the anus with gentle cleaning and a barrier cream if sore

• Do not use anti-diarrhoea medicines for long periods without telling your team

Eating well keeps you hydrated and nourished. There is no single pouchitis diet; people have different triggers.

• Drink plenty of fluids, especially during a flare, because loose stools can dehydrate you

• Notice which foods seem to worsen your symptoms (for example very spicy, fatty or high-sugar foods, large amounts of caffeine or alcohol) and limit them

• Eat smaller, more frequent meals if large meals trigger urgency

• Ask a dietitian if you lose weight or suspect vitamin deficiencies, for example low vitamin B12 or iron

Medicines are prescribed by your specialist. Do not take leftover antibiotics or start them on your own.

• A short course of antibiotics is the usual first treatment for acute pouchitis

• For repeated episodes, longer or alternating antibiotic courses may be used under specialist supervision

• Anti-inflammatory or biologic IBD medicines may be used for chronic pouchitis that does not respond to antibiotics

• Probiotics may be suggested by some specialists; ask which product, if any, is appropriate

Most people with pouchitis do not need a procedure other than a scope to confirm the diagnosis.

• Pouchoscopy with biopsies to confirm the diagnosis and rule out other causes

• Dilation through the scope if there is a narrowing at the pouch outlet

• Surgery to repair complications such as fistulas, abscesses or severe narrowing

• For severe, treatment-resistant disease, removal of the pouch and a permanent ileostomy can be considered as a last resort

Pouchitis is often classified by how it behaves: acute (settles with a short course of treatment), recurrent, or chronic (persisting or relapsing quickly). People with chronic pouchitis who do not respond to antibiotics may be offered other anti-inflammatory or immune-targeting treatments, including some IBD biologics. Probiotic preparations have been studied mainly for keeping pouchitis from returning; opinions differ, so ask your specialist.

Most people with pouchitis feel much better with treatment and can live normally. Some have occasional flares, and a minority need long-term treatment. In rare cases of severe, untreatable pouchitis, a permanent ileostomy (a stoma) may be discussed. Your team will work with you to find the best approach.

• Is this pouchitis or something else, and do I need a pouchoscopy?

• Which antibiotic course is suitable and for how long?

• What can I do to prevent it from returning?

• If antibiotics do not work, what are the next options?

• Which symptoms mean I should come in straight away?

This guide comes from the Saudi Gastroenterology Association (SGA) patient library, prepared by the Approved for publication by SGA; individual clinician review is ongoing. Last reviewed: 2026-04-24. It is for education and does not replace your doctor's advice.