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Practice Guideline
. 2024 Jan;166(1):59-85.
doi: 10.1053/j.gastro.2023.10.015.

AGA Clinical Practice Guideline on the Management of Pouchitis and Inflammatory Pouch Disorders

Edward L Barnes  1 , Manasi Agrawal  2 , Gaurav Syal  3 , Ashwin N Ananthakrishnan  4 , Benjamin L Cohen  5 , John P Haydek  6 , Elie S Al Kazzi  7 , Samuel Eisenstein  8 , Jana G Hashash  9 , Shahnaz S Sultan  10 , Laura E Raffals  11 , Siddharth Singh  3 ; AGA Clinical Guidelines Committee. Electronic address: clinicalpractice@gastro.org
Affiliations
Practice Guideline

AGA Clinical Practice Guideline on the Management of Pouchitis and Inflammatory Pouch Disorders

Edward L Barnes et al. Gastroenterology. 2024 Jan.

Abstract

Background & aims: Pouchitis is the most common complication after restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis. This American Gastroenterological Association (AGA) guideline is intended to support practitioners in the management of pouchitis and inflammatory pouch disorders.

Methods: A multidisciplinary panel of content experts and guideline methodologists used the Grading of Recommendations Assessment, Development and Evaluation framework to prioritize clinical questions, identify patient-centered outcomes, conduct an evidence synthesis, and develop recommendations for the prevention and treatment of pouchitis, Crohn's-like disease of the pouch, and cuffitis.

Results: The AGA guideline panel made 9 conditional recommendations. In patients with ulcerative colitis who have undergone ileal pouch-anal anastomosis and experience intermittent symptoms of pouchitis, the AGA suggests using antibiotics for the treatment of pouchitis. In patients who experience recurrent episodes of pouchitis that respond to antibiotics, the AGA suggests using probiotics for the prevention of recurrent pouchitis. In patients who experience recurrent pouchitis that responds to antibiotics but relapses shortly after stopping antibiotics (also known as "chronic antibiotic-dependent pouchitis"), the AGA suggests using chronic antibiotic therapy to prevent recurrent pouchitis; however, in patients who are intolerant to antibiotics or who are concerned about the risks of long-term antibiotic therapy, the AGA suggests using advanced immunosuppressive therapies (eg, biologics and/or oral small molecule drugs) approved for treatment of inflammatory bowel disease. In patients who experience recurrent pouchitis with inadequate response to antibiotics (also known as "chronic antibiotic-refractory pouchitis"), the AGA suggests using advanced immunosuppressive therapies; corticosteroids can also be considered in these patients. In patients who develop symptoms due to Crohn's-like disease of the pouch, the AGA suggests using corticosteroids and advanced immunosuppressive therapies. In patients who experience symptoms due to cuffitis, the AGA suggests using therapies that have been approved for the treatment of ulcerative colitis, starting with topical mesalamine or topical corticosteroids. The panel also proposed key implementation considerations for optimal management of pouchitis and Crohn's-like disease of the pouch and identified several knowledge gaps and areas for future research.

Conclusions: This guideline provides a comprehensive, patient-centered approach to the management of patients with pouchitis and other inflammatory conditions of the pouch.

Keywords: Evidence Synthesis; Ileal Pouch–Anal Anastomosis; Inflammatory Bowel Disease; J-Pouch; Pouchitis.

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Conflict of interest statement

Members of the guideline and evidence synthesis panel were selected based on clinical and methodological expertise and experience, and after review of all conflicts of interest in a comprehensive vetting process. The multidisciplinary guideline panel included gastroenterologists with expertise in inflammatory bowel disease (IBD), guideline methodologists and general gastroenterologists. The evidence synthesis team consisted of six members, including three content experts (Edward Barnes, Gaurav Syal, and Laura Raffals) and three GRADE methodologists (senior methodologist and Co-Chair of the guideline: Siddharth Singh; junior methodologists: Elie Al Kazzi, John Haydek). The guideline panel consisted of five members including gastroenterologists and a colorectal surgeon focusing on the management of patients with IBD (Guideline Chair: Manasi Agrawal; guideline panel members: Ashwin Ananthakrishnan, Benjamin Cohen, Jana Hashash and Samuel Eisenstein). A patient representative was also involved in the development of guideline recommendations. Panel members disclosed all conflicts of interest, which were defined and categorized per AGA policies and the National Academy of Medicine and Guidelines International Network standards. No guideline panel member was excused from participation in the process owing to disqualifying conflict. A full list of conflicts can be accessed at AGA’s National Office in Bethesda, MD.

Conflicts of Interest:

  1. Edward L. Barnes – Consulting fees from Bristol-Meyers Squibb and TARGET RWE.

  2. Manasi Agrawal – None

  3. Gaurav Syal – None

  4. Ashwin N Ananthakrishnan – Consulting fees from Sandoz

  5. Benjamin L. Cohen – Consulting fees from Abbvie, Celgene-Bristol Myers Squibb, Lilly, Pfizer, Sublimity Therapeutics, Takeda, TARGET RWE; CME Companies: Cornerstones, Vindico; Speaking: Abbvie; Educational Grant: Pfizer

  6. John Haydek – None

  7. Elie S. Al Kazzi – None

  8. Samuel Eisenstein – Consulting fees from Takeda and Ethicon Surgical Robotics

  9. Jana G. Hashash – None

  10. Laura E. Raffals – Consulting fees from Janssen Pharmaceuticals, Fresenius Kabi USA, Roivant

  11. Siddharth Singh – personal fees from Pfizer for ad hoc grant review, and research grants from Pfizer

A full list of conflicts active at the time of guideline development can be accessed at AGA’s National Office in Bethesda, MD.

References

    1. Barnes EL, Herfarth HH, Kappelman MD, et al. Incidence, Risk Factors, and Outcomes of Pouchitis and Pouch-Related Complications in Patients With Ulcerative Colitis. Clin Gastroenterol Hepatol 2021;19:1583–1591. - PMC - PubMed
    1. Lightner AL, Mathis KL, Dozois EJ, et al. Results at Up to 30 Years After Ileal Pouch-Anal Anastomosis for Chronic Ulcerative Colitis. Inflamm Bowel Dis 2017;23:781–790. - PubMed
    1. Barnes EL, Herfarth HH, Sandler RS, et al. Pouch-Related Symptoms and Quality of Life in Patients with Ileal Pouch-Anal Anastomosis. Inflamm Bowel Dis 2017;23:1218–1224. - PMC - PubMed
    1. Burr NE, Gracie DJ, Black CJ, et al. Efficacy of biological therapies and small molecules in moderate to severe ulcerative colitis: systematic review and network meta-analysis. Gut 2021. - PubMed
    1. Lasa JS, Olivera PA, Danese S, et al. Efficacy and safety of biologics and small molecule drugs for patients with moderate-to-severe ulcerative colitis: a systematic review and network meta-analysis. Lancet Gastroenterol Hepatol 2022;7:161–170. - PubMed

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