What is pouchitis?

After a patient has had a total proctocolectomy (removal by surgery of the large intestine and rectum), a procedure called an ileal pouch-anal anastomosis (IPAA) is performed. During the construction of an IPAA, the ileum, or lowest part of the small intestine, is connected to the anus to create a structure (pouch) that can store and eliminate stools.

The surgeon creates a J-pouch (which resembles the letter J) to provide for the storage area. Other pouch shapes (S and K) can also possibly be constructed. The pouch helps improve the patient’s quality of life by preserving the natural route of defecation, and reduces the risk of growths that could develop into cancer. However, after this surgery, some patients may get pouchitis.

Pouchitis is an inflammation (swelling) of the pouch that occurs when the pouch becomes irritated and inflamed. The inflammation can cause increased bowel frequency (having to go to the bathroom more often), abdominal cramping or bloating, lower abdominal pain, or sometimes blood in the stool. This condition should be evaluated and managed by an experienced gastroenterologist.

How common is pouchitis?

About half of patients who undergo IPAA surgery for ulcerative colitis will have pouchitis at least once in their lifetimes. Up to 40 percent of patients with IPAA develop pouchitis every year.

What causes pouchitis?

The cause of pouchitis is not entirely clear, but it almost always occurs in patients with ulcerative colitis or another form of colitis, and sometimes in those with familial adenomatous polyposis (FAP), a genetic (inherited) condition in which many polyps form in the colon.

The changes in the bowel pattern that happen during IPAA surgery may play a role in causing pouchitis. In its normal state, the ileum’s job is to absorb nutrients. After IPAA surgery, the ileum is artificially changed into a storage space for waste matter. The mucous membrane, or inner lining of the ileum, launches an immune response to the different types of bacteria it is exposed to, which leads to inflammation.

There are a number of factors associated with the development of pouchitis, including the following:

  • Genetic makeup (what you inherit from your parents and family)
  • Extensive ulcerative colitis
  • Backwash ileitis (inflammation of the ileum caused by widespread ulcerative colitis)
  • Increased number of platelets (blood-clotting structures in the blood) after a proctocolectomy
  • Inflamed and hardened bile ducts in the liver in a disease called primary sclerosing cholangitis
  • Being a smoker
  • The presence of certain antibodies in the blood
  • Use of nonsteroidal anti-inflammatory drugs (NSAIDs), especially over a long period of time
  • Other conditions, such as diabetes or heart disease

In addition, reduced blood flow to the pouch can cause ischemic pouchitis.

What are the symptoms of pouchitis?

Symptoms of pouchitis include the following:

  • Greater need to pass stools
  • Tenesmus (painful spasms and straining of the anal sphincter while passing little or no waste matter)
  • Straining during defecation
  • Blood in the stool
  • Incontinence (loss of control over bodily functions)
  • Seepage of waste matter while asleep
  • Increased frequency in nighttime bowel movements
  • Abdominal cramps
  • Discomfort in the pelvic area or lower abdomen
  • Tail bone pain

In severe cases, symptoms may also include:

  • Fever
  • Dehydration (extreme thirst), dry skin, dry lips, confusion (in severe cases) caused by the loss of electrolytes and water
  • Malnutrition that sends the patient to the emergency room or hospital
  • Iron-deficiency anemia and/or a low vitamin D level
  • Severe joint pain
  • Fatigue

Last reviewed by a Cleveland Clinic medical professional on 01/16/2019.


  • Shen B, Lashner BA. Diagnosis and Treatment of Pouchitis. Gastroenterol Hepatol (N Y) May 2008;4(5): 355–361.
  • Shen B. Pouchitis: What Every Gastroenterologist Needs to Know. Clinical Gastroenterology and Hepatology, December 2013 Volume 11, Issue 12, Pages 1538–1549. DOI: https://doi.org/10.1016/j.cgh.2013.03.033
  • Achkar J-P, Al-Haddad M, Lashner B, et al. Differentiating Risk Factors for Acute and Chronic Pouchitis. Clinical Gastroenterology and Hepatology 2005;3:60–66.
  • Gionchetti P, Calafiore A, Riso D, et al. The role of antibiotics and probiotics in pouchitis. Ann Gastroenterol. 2012; 25(2): 100–105.

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