Classification, differential diagnosis, and diagnosis of pouchitis

Evaluation of patients with ileal pouch-anal anastomosis after total proctocolectomy who present with symptoms suggestive of pouchitis requires a systematic approach. Although idiopathic pouchitis is the most common cause of symptoms, evaluation for possible secondary causes of pouch inflammation and for potential disease mimickers is essential. After appropriate testing and assessement of response to treatment, disease can be classified based on response to antibiotics and as idiopathic or secondary. A systematic approach and the use of different modalities of testing including pouch endoscopy, pathology and imaging, should lead to an appropriate diagnosis and a well-planned treatment plan. A proposed algorithm for evaluation of symptomatic patients will be outlined.