Appropriateness of Medical and Surgical Treatments for Chronic Pouchitis Using RAND/UCLA Appropriateness Methodology

Gaurav Syal, Miles P. Sparrow, Fernando Velayos, Adam S. Cheifetz, Shane Devlin, Peter M. Irving, Gilaad G. Kaplan, Laura E. Raffals, Thomas Ullman, Krisztina B. Gecse, Phillip R. Fleshner, Amy L. Lightner, Corey A. Siegel, Gil Y. Melmed

Research output: Contribution to journalArticlepeer-review


Background and Aims: The treatment of chronic pouchitis remains a challenge due to the paucity of high-quality studies. We aimed to provide guidance for clinicians on the appropriateness of medical and surgical treatments in chronic pouchitis. Methods: Appropriateness of medical and surgical treatments in patients with chronic pouchitis was considered in 16 scenarios incorporating presence/absence of four variables: pouchitis symptoms, response to antibiotics, significant prepouch ileitis, and Crohn’s disease (CD)-like complications (i.e., stricture or fistula). Appropriateness of permanent ileostomy in patients refractory to medical treatments was considered in eight additional scenarios. Using the RAND/UCLA appropriateness method, international IBD expert panelists rated appropriateness of treatments in each scenario on a 1–9 scale. Results: Chronic antibiotic therapy was rated appropriate only in asymptomatic antibiotic-dependent patients with no CD-like complications and inappropriate in all other scenarios. Ileal-release budesonide was rated appropriate in 6/16 scenarios including patients with significant prepouch ileitis but no CD-like complications. Probiotics were considered either inappropriate (14/16) or uncertain (2/16). Biologic therapy was considered appropriate in most scenarios (14/16) and uncertain in situations where significant prepouch ileitis or CD-like complications were absent (2/16). In patients who are refractory to all medications, permanent ileostomy was considered appropriate in all scenarios (7/8) except in asymptomatic patients with no CD-like complications. Conclusions: In the presence of significant prepouch ileitis or CD-like complications, chronic antibiotics and probiotics are inappropriate. Biologics are appropriate in all patients except in asymptomatic patients with no evidence of complications. Permanent ileostomy is appropriate in most medically refractory patients.

Original languageEnglish
Pages (from-to)4687-4694
Number of pages8
JournalDigestive Diseases and Sciences
Issue number10
StatePublished - Oct 2022
Externally publishedYes


  • Biologics
  • Budesonide
  • Chronic antibiotics
  • Chronic pouchitis
  • Crohn’s disease-like complications
  • Permanent ileostomy
  • Prepouch ileitis
  • Probiotics
  • RAND appropriateness methodology


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