Synopsis
Explain how ileal pouch–anal anastomosis restores intestinal continuity after proctocolectomy, recognise early pelvic sepsis and later inflammatory or mechanical pouch disorders, and investigate and treat a first episode of acute pouchitis without overlooking secondary causes.
- An ileal pouch–anal anastomosis uses ileum as a reservoir after the colon and rectum are removed; it avoids a permanent stoma but does not restore normal colonic storage.
- Pouch choice belongs in a high-volume specialist discussion covering stool frequency, urgency, seepage, fertility, sexual and urinary function, pouch failure and the alternative of a permanent ileostomy.
- Fever, tachycardia, escalating pelvic or abdominal pain, ileus or purulent drain output soon after pouch surgery suggests anastomotic leak or pelvic sepsis and needs urgent CT-led source-control assessment.
Key red flags
After pouch construction, a rising pulse with fever, pelvic pain, ileus or abnormal drain fluid is a leak pattern until imaging and surgical assessment show otherwise; shock or organ dysfunction demands immediate source control.
High pouch output with oliguria, postural symptoms or rising creatinine indicates clinically important dehydration and requires same-day assessment.
A new fistula, deep ulcer, pre-pouch ileitis, obstructive pattern or failure of a correctly delivered acute course requires specialist re-phenotyping.
Investigation priorities
Exclude enteric infection before attributing increased pouch output to idiopathic inflammation.
Management branches
A 39-year-old weighing 60 kg is three years after ileal pouch–anal anastomosis for ulcerative colitis. Their stable baseline is five stools by day and none at night; over six days this rises to twelve watery stools, two nocturnal episodes, urgency and cramps. Temperature is 37.2°C, pulse 84/min and there is no guarding.
- Assess hydration, abdominal and perianal findings and medication exposure. Full blood count and creatinine are normal, CRP is 19 mg/L, and there is no postoperative sepsis pattern requiring emergency CT.
- Send stool culture and Clostridioides difficile testing; both are negative. Arrange pouchoscopy because symptoms alone cannot distinguish pouchitis from cuffitis, pre-pouch ileitis or mechanical disease.