Personalized Approach to Chronic Antibiotic-Refractory Pouchitis: A Case Report and Review of the Literature

Abstract

Patients who undergo restorative proctocolectomy and ileoanal anastomosis can develop pouchitis as a common chronic complication. A rare subset of patients fails to respond to multiple antibiotic therapies and develop chronic antibiotic-refractory pouchitis (CARP). We present a case of a 45-year-old male with pouchitis refractory to chronic antibiotic therapy and histology demonstrating chronic inflammatory changes. Management involved mesalamine and probiotics, resulting in a positive clinical response and symptom absence on follow-up. This case highlights the intricacies of treating chronic pouchitis post ileoanal anastomosis, showcasing the efficacy of a personalized approach using mesalamine and probiotics. CARP is emerging as an entity associated with poor quality of life and increased healthcare costs. CARP fails to respond to multiple courses of antibiotic therapy. Therefore, the management of CARP is difficult and limited. Current literature on the management of CARP is scarce and mainly involves immunomodulatory therapy and probiotics. It is essential to keep this differential diagnosis in mind in patients with recurrent pouchitis episodes and start them on immunomodulator treatment and probiotics rather than repeated courses of antibiotics.

Keywords: antibiotic refractory; carp (chronic antibiotic refractory pouchitis); chronic pouchitis; ileoanal anastomosis; immunomodulatory therapy; mesalamine; probiotics; ulcerative colitis.

Figure 1. (A & B) Histopathology showing edema and acute and chronic inflammation in the ileal villi. (C) Colonoscopy image demonstrating gross inflammation of the colonic mucosa.