How do you treat this diversion ileitis and pouchitis?

Introduction

A 43-year-old woman was admitted due to tenesmus and perianal pain caused by a severe perianal skin ulcer (figure 1A). Fifteen years previously, she underwent a total proctocolectomy with ileal pouch–anal anastomosis due to pancolitis-type UC. Three years prior, she had two episodes of pouchitis responding to antibiotic therapy. Her laboratory tests revealed anaemia (haemoglobin level, 96 g/L), elevated C reactive protein level (11.9 mg/dL) and decreased serum albumin level (25 g/L).

While the perianal skin ulcer finally improved after multidisciplinary treatment including ileostomy, severe diversion ileitis and pouchitis became obvious about 13 months after the ileostomy (figure 1B-D). Biopsies from pouch and efferent ileal loop revealed acute and chronic severe inflammation with cryptitis, consistent with diversion pouchitis and ileitis. Antibiotics (metronidazole and ciprofloxacin), corticosteroids and immunosuppressive agents (azathioprine) were not effective for diversion ileitis and pouchitis. There was a significant difference between the intestinal microbiota of the ileal pouch...

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