Are Probiotics Helpful For Pouchitis?

Pouchitis is a condition that can affect people who have had j-pouch (ileal pouch-anal anastomosis [IPAA]) surgery for ulcerative colitis. The mechanism of pouchitis is not well understood, and it is thought that it might include several different types of disease. It is the most common complication in people with j-pouches.

Symptoms of pouchitis can include:

• more frequent and urgent bowel movements
• abdominal cramping
• rectal bleeding
• fever

Pouchitis typically responds to treatment with antibiotics but can recur in about two-thirds of patients. About 10% of patients experience recurring pouchitis that does not respond to antibiotic therapy. These recurring bouts of pouchitis can cause a decrease in the quality of life for people with a j-pouch.

Getting treatment for pouchitis, especially in the period right after surgery, is very important. Anyone who has had pelvic pouch surgery should contact their doctor right away when the pouch seems "off" and there are symptoms of pain, fever, and blood in the stool.

Why Would Probiotics Help?

Researchers discovered that people who experience pouchitis have fewer beneficial bacteria, namely lactobacilli and bifidobacteria, in their digestive tract. The next logical step was to conduct trials to see whether increasing the beneficial bacteria in the digestive tract would help improve the symptoms of pouchitis. Supplements of these beneficial bacteria are called "probiotics" and may include a wide variety of live bacterial strains.

The Evidence For the Use of Probiotics

The American Gastroenterology Association released a 2020 consensus that an 8-strain probiotic formulation showed potential benefit for treatment or prevention of pouchitis in adults. 

Two double-blind, placebo-controlled trials were conducted to see if a combination of lyophilized bacteria—four strains of Lactobacillus, three strains of Bifidobacterium and one strain of Streptococcus—(known as VSL#3) would help with relieving pouchitis symptoms. One trial found that after 9 months, 85% of patients who took VSL#3 did not experience a relapse of pouchitis. All of the 20 patients who received a placebo experienced a relapse. In a second trial, 85% of patients taking VSL#3 did not experience a relapse after one year of therapy. All but one of the patients receiving a placebo had a relapse. The results of the two studies provide good support that probiotics which contain certain strains of bacteria may be helpful for those people with j-pouches who have recurrent pouchitis.

In another study, 16 of 23 patients with active, mild pouchitis achieved remission after four weeks of high-dose VLS#3. While the authors of the study conclude that probiotics are effective for mild pouchitis, they call for more research.

More trials have tested other probiotic formulations, including Lactobacillus rhamnosus GG and Lactobacillus acidophilus along with Bifidobacterium lactis. These studies did not show that these probiotics had any positive effect on active pouchitis; however, one trial showed that L rhamnosus GG was helpful in delaying the first bout of pouchitis when treatment was started immediately after j-pouch surgery.

The Bottom Line

While the medical evidence is sparse on the topic of probiotics, it is fair to say that while probiotics may help for maintaining remission, they are not necessarily helpful in treating acute pouchitis. Your physician will be able to help you determine when probiotics are useful for pouchitis, as well as which product to use, and how much to take.

Important points to remember:

• Probiotics may be helpful for maintaining remission after pouchitis has been treated with antibiotics or in delaying the initial onset of pouchitis
• Probiotics have not yet proven helpful in treating acute, severe pouchitis
• It is important to discuss the use of probiotics with a physician to ensure that the proper type and amounts are taken
• The evidence for use of probiotics is not yet complete, and results of future studies may change use of probiotics for pouchitis