A 40-year-old woman underwent restorative proctocolectomy with ileal pouch anal anastomosis for medically refractory ulcerative colitis two years ago. She now reports increased stool frequency up to ten per day, nocturnal seepage, urgency, and crampy pelvic pain. Pouchoscopy shows diffuse pouch inflammation with superficial ulceration. What is the first-line treatment?
- A Restoration of a temporary diverting loop ileostomy
- B Infliximab induction
- C Oral ciprofloxacin or metronidazole ✓
- D Long-term oral prednisolone
Explanation
Acute pouchitis is the commonest long-term complication after ileal pouch anal anastomosis for ulcerative colitis, presenting with increased stool frequency, urgency, and endoscopic pouch inflammation. First-line therapy is a quinolone such as ciprofloxacin or metronidazole for two weeks, which resolves most episodes. Antibiotics are also useful for maintaining remission in relapsing disease. Anti-TNF agents are reserved for chronic antibiotic-refractory pouchitis, diverting stoma is a last resort before pouch excision, and systemic steroids are not first-line for this condition.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.