Pre-pouch Ileitis is Associated with Development of Crohn's Disease-like Complications and Pouch Failure

 Crohns Colitis. 2021 Jun 22;15(6):960-968. doi: 10.1093/ecco-jcc/jjaa251.

Gaurav Syal 1 2, Ron Shemtov 3, Nirupama Bonthala 1 2, Eric A Vasiliauskas 1 2, Edward J Feldman 1 2, Karen Zaghiyan 4, Christina Y Ha 1 2, Dermot P B McGovern 1 2, Stephan R Targan 1 2, Gil Y Melmed 1 2, Phillip R Fleshner 1 4


Author information

  • 1F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
  • 2Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
  • 3Sackler School of Medicine, Tel Aviv, Israel.
  • 4Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.


Background and aims: It is unclear whether pre-pouch ileitis heralds an aggressive inflammatory pouch disease in patients with ileal pouch-anal anastomosis [IPAA]. We compared outcomes of patients with pouchitis and concomitant pre-pouch ileitis with those with pouchitis alone.

Methods: Patients undergoing IPAA surgery for inflammatory bowel disease, who subsequently developed pouchitis with concomitant pre-pouch ileitis [pre-pouch ileitis group], were matched by year of IPAA surgery and preoperative diagnosis [ulcerative colitis or inflammatory bowel disease-unclassified] with patients who developed pouchitis alone [pouchitis group]. Primary outcomes were development of Crohn's disease [CD]-like complications [non-anastomotic strictures or perianal disease >6 months after ileostomy closure] and pouch failure. Secondary outcomes were need for surgical/endoscopic interventions and immunosuppressive therapy. Log-rank testing was used to compare outcome-free survival, and Cox regression was performed to identify predictors of outcomes.

Results: There were 66 patients in each group. CD-like complications and pouch failure developed in 36.4% and 7.6% patients in the pre-pouch ileitis group and 10.6% and 1.5% in pouchitis group, respectively. CD-like complications-free survival [log-rank p = 0.0002] and pouch failure-free survival [log-rank p = 0.046] were significantly lower in the pre-pouch ileitis group. The pre-pouch ileitis group had a higher risk of requiring surgical/endoscopic interventions [log-rank p = 0.0005] and immunosuppressive therapy [log-rank p <0.0001]. Pre-pouch ileitis was independently associated with an increased risk of CD-like complications (hazard ratio [HR] 3.8; p = 0.0007), need for surgical/endoscopic interventions [HR 4.1; p = 0.002], and immunosuppressive therapy [HR 5.0; p = 0.0002].

Conclusions: Pre-pouch ileitis is associated with a higher risk of complicated disease and pouch failure than pouchitis. It should be considered a feature of CD.

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