In a proposed algorithm for treatment of pouchitis, once diagnosis is confirmed by endoscopy and histology, and other causes of inflammation or pouch dysfunction have been excluded, the main treatment consists of metronidazole 250 mg three times/day or ciprofloxacin 500 mg b.i.d. for at least 2 weeks. In case of a subsequent prompt relapse, the patients can

Fig. 1. Proposal for a treatment algorithm

be treated with a prolonged course of the same antibiotic or with a combined antibiotic treatment; in case of positive response we suggest starting maintenance treatment with highly concentrated probiotics. In refractory pouchitis, patients should be treated with other antibiotics or prolonged combined antibiotic treatment. Again, in case of response, maintenance probiotic treatment after the stopping of antimicrobial agents is suggested. When no positive response is obtained one should try other types of treatment such as topical corticosteroids, immuno-suppressive agents, or topical bismuth. Patients who are refractory to all forms of medical treatment should be referred to a surgeon for a pouch reconstruction or pouch excision (Fig. 1).

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