Endoscopic Phenotype of the J Pouch in Patients With Inflammatory Bowel Disease: A New Classification for Pouch Outcomes

Shintaro Akiyama, Jacob E. Ollech, Victoria Rai, Laura R. Glick, Yangtian Yi, Cindy Traboulsi, Joseph Runde, Russell D. Cohen, Kinga B. Skowron, Roger D. Hurst, Konstantin Umanskiy, Benjamin D. Shogan, Neil H. Hyman, Michele A. Rubin, Sushila R. Dalal, Atsushi Sakuraba, Joel Pekow, Eugene B. Chang, David T. Rubin*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review


Background & Aims: Pouchitis is a common complication of ileal pouch–anal anastomosis (IPAA) in patients with ulcerative colitis who have undergone colectomy. Pouchitis has been considered a single entity despite a broad array of clinical and endoscopic patterns. We developed a novel classification system based on the pattern of inflammation observed in pouches and evaluated the contributing factors and prognosis of each phenotype. Methods: We identified 426 patients (384 with ulcerative colitis) treated with proctocolectomy and IPAA who subsequently underwent pouchoscopies at the University of Chicago between June 1997 and December 2019. We retrospectively reviewed 1359 pouchoscopies and classified them into 7 main pouch phenotypes: (1) normal, (2) afferent limb involvement, (3) inlet involvement, (4) diffuse, (5) focal inflammation of the pouch body, (6) cuffitis, and (7) pouch with fistulas noted 6 months after ileostomy takedown. Logistic regression analysis was used to assess factors contributing to each phenotype. Pouch survival was estimated by the log-rank test and the Cox proportional hazards model. Results: Significant contributing factors for afferent limb involvement were a body mass index of 25 or higher and hand-sewn anastomosis, for inlet involvement the significant contributing factor was male sex; for diffuse inflammation the significant contributing factors were extensive colitis and preoperative use of anti–tumor necrosis factor drugs, for cuffitis the significant contributing factors were stapled anastomosis and preoperative Clostridioides difficile infection. Inlet stenosis, diffuse inflammation, and cuffitis significantly increased the risk of pouch excision. Diffuse inflammation was associated independently with pouch excision (hazard ratio, 2.69; 95% CI, 1.34–5.41; P = .005). Conclusions: We describe 7 unique IPAA phenotypes with different contributing factors and outcomes, and propose a new classification system for pouch management and future interventional studies.

Original languageEnglish
Pages (from-to)293-302.e9
JournalClinical Gastroenterology and Hepatology
Issue number2
StatePublished - Feb 2022
Externally publishedYes


FundersFunder number
AbbVie Laboratories
GI Research Foundation of Chicago
Prometheus Laboratories
RedHill Biopharma
National Institute of Diabetes and Digestive and Kidney DiseasesRC2DK122394, P30 DK42086
Crohn's and Colitis Foundation of America
Eli Lilly and Company
Schawarz Pharma
Gilead Sciences
Boler Family Foundation
Takeda Pharmaceuticals U.S.A.
American College of Gastroenterology
Boehringer Ingelheim
Janssen Pharmaceuticals
Blank Family Foundation


    • Endoscopic Phenotype
    • Ileal Pouch–Anal Anastomosis
    • Inflammatory Bowel Disease
    • Pouch Prognosis
    • Pouchitis


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