A 22-year-old female presented to our department reporting a new on a series of episodes of pouchitis. Restorative proctocolectomy with ileal pouch-anal anastomosis had become necessary 7 years previously as a result of severe refractory extensive ulcerative colitis. She was first diagnosed with pouchitis 1 year after surgery and had been suffering from recurrent episodes since that time. Initially she was taking antibiotics and prednisolone (for more severe episodes) but since it was a case of chronic refractory disease the treating physicians at that time decided to administer infliximab followed by adalimumab, both of which she discontinued after an early severe allergic reaction and a loss of response attributed to antibody formation, respectively. During the last year she had managed several relapses using antibiotics and prednisolone. Laboratory tests on admission showed white blood cells 12,500/mm³, hemoglobin 10.3 g/dL, erythrocyte sedimentation rate 58 mm/h, and C-reactive protein 5.47 mg/dL. A pouchoscopy revealed multiple ulcers, edema, loss of vascular pattern and the presence of fistulas (Fig. 1A). The Pouchitis Disease Activity Index (PDAI) endoscopic subscore was 6 and the histology was compatible with chronic pouchitis. Vedolizumab was subsequently initiated, together with a single course of antibiotics, and the patient experienced improvement in clinical symptoms and laboratory results with no documented relapse since then. A new pouchoscopy at week 33 showed significant improvement (Fig. 1B), with scars and small ulcerations (PDAI endoscopic subscore 2).
Figure 1 Endoscopic appearance of pouch (A) before vedolizumab treatment and (B) after 33 weeks of treatment with vedolizumab
This impressive endoscopic improvement highlights the emerging role of vedolizumab as a treatment option for chronic, antibiotic-dependent or refractory pouchitis, validating the existing case series and reports [1-3].