Ulcerative Colitis Guidelines

Updated: Feb 25, 2022
  • Author: Marc D Basson, MD, PhD, MBA, FACS; Chief Editor: BS Anand, MD  more...
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Guidelines

Guidelines Summary

In July 2021, the American Society of Colon and Rectal Surgeons published guidelines on the surgical management of ulcerative colitis (UC), [104] the WSES-AASR published guidelines on inflammatory bowel disease emergency management, [105] and the ECCO published clinical practice guidelines on infections in inflammatory bowel disease. [106] In March 2019, the American College of Gastroenterology (ACG) published recommendations on ulcerative colitis (UC) in adults. [107, 108] In January 2020, the American Gastroenterological Association (AGA) released their recommendations on the medical management of adult outpatients with moderate to severe ulcerative colitis (UC) and hospitalized adult patients with acute severe UC (ASUC). [109] In February 2019, the American Gastroenterological Association (AGA) released guidelines on the management of mild-to-moderate ulcerative colitis (UC). [110] In September 2019, the British Society of Gastroenterology released consensus guidelines on the management of inflammatory bowel disease. [111] These guidelines are summarized below.

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Ulcerative Colitis Clinical Practice Guidelines (ASCRS, 2021)

Guidelines on the surgical management of ulcerative colitis (UC) were published in July 2021 by the American Society of Colon and Rectal Surgeons. [104] Strong recommendations are outlined below unless noted otherwise.

Medically Refractory UC

For inpatients with moderate-to-severe UC undergoing escalation of medical therapy, a multidisciplinary team and early surgical consultation should guide optimal care.

Total abdominal colectomy with end ileostomy is typically recommended for patients with severe medically refractory UC, fulminant colitis, toxic megacolon, or colonic perforation.

Consider a staged approach for an ileal pouch-anal anastomosis (IPAA) in patients being treated with high-dose corticosteroids or monoclonal antibodies.

UC-Associated Colorectal Neoplasia

Endoscopic surveillance at regular intervals is recommended for patients with UC—with chromoendoscopy or high-definition white-light endoscopy typically recommended for optimal surveillance.

Endoscopic surveillance is also recommended in the setting of completely endoscopically excised visible polypoid or nonpolypoid dysplasia. For patients with visible dysplasia not amenable to endoscopic excision, invisible dysplasia in the flat mucosa surrounding a visible dysplastic lesion, or colorectal adenocarcinoma, total proctocolectomy with or without IPAA is typically recommended.

For patients with visible indefinite dysplasia not amenable to endoscopic excision or invisible indefinite dysplasia, medical treatment is typically recommended to achieve mucosal healing; referral to an experienced endoscopist is recommended for repeat colonoscopy using high-definition colonoscopy with chromoendoscopy with targeted and repeat random biopsies within 3 to 12 months.

For patients with invisible dysplasia, referral to an experienced endoscopist is typically recommended for repeat endoscopy using high-definition colonoscopy with chromoendoscopy with targeted and repeat random biopsies within 3 to 6 months. Consider total proctocolectomy when the presence of invisible multifocal, low-grade dysplasia or any invisible high-grade dysplasia is confirmed.

Perform endoscopic surveillance after IPAA.

Technical and Postoperative Considerations

For most patients with UC undergoing restorative total proctocolectomy with IPAA, a two-stage, three-stage, or modified two-stage approach is preferred.

For patients with UC undergoing elective surgery, acceptable options include total proctocolectomy with IPAA, end ileostomy, or continent ileostomy.

Total abdominal colectomy with ileorectal anastomosis may be considered in selected patients who have UC with relative rectal sparing (weak recommendation).

Counsel patients with UC undergoing proctectomy about potential effects on fertility, pregnancy, sexual function, and urinary function.

Pouchitis is common after IPAA performed in the setting of UC and is classified according to its responsiveness to antibiotics.

Potential Areas for Future Investigation

Appendectomy may reduce the need for proctocolectomy associated with medically refractory disease (weak recommendation).

In the setting of worsening, acute, severe UC, a "rescue" diverting loop ileostomy can be considered to potentially avoid an emergent total abdominal colectomy (weak recommendation).

Consider extended postoperative venous thromboembolism prophylaxis in patients with UC exposed to tofacitinib (weak recommendation).

For more information, please go to Ulcerative Colitis Imaging, and Surgical Treatment of Ulcerative Colitis.

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WSES-AAST Inflammatory Bowel Disease Emergency Management Clinical Practice Guidelines (2021)

Clinical practice guidelines on the management of emergent inflammatory bowel disease (IBD) by the World Society of Emergency Surgery and the American Association for the Surgery of Trauma were published in May 2021 in the World Journal of Emergency Surgery. [105]

Diagnosis

The following laboratory tests are recommended for assessing Crohn disease or ulcerative colitis in the urgent clinical situation: a full blood count, including hemoglobin, leukocyte count and platelet count; serum C-reactive protein level, erythrocyte sedimentation rate level, serum electrolytes, liver enzyme level, serum albumin, renal function, and fecal calprotectin level when possible. It is mandatory to exclude infectious disease by performing blood and stool cultures and toxin test for Clostridium difficile.

IV contrast-enhanced computed tomography is recommended to investigate the acute abdomen in IBD patients in the emergency setting to exclude intestinal perforation, stenosis, bleeding, and abscesses and to help guide decision making for immediate surgery or initial conservative management.

When computed tomography is not available, point-of-care ultrasonography is suggested to assess for free intra-abdominal fluid, intestinal distention, or abscess.

In stable patients with signs of GI bleeding, CT angiography is recommended to localize the bleeding site before angioembolization or surgery.

Treatment

It is recommended that antibiotics not be routinely administered to IBD patients but, rather, only in the case of superinfection, intra-abdominal abscess, and sepsis.

Antifungals should be reserved for high-risk patients, such as those who have a bowel perforation or who have recently received steroid treatment.

Venous thromboembolism prophylaxis is recommended as soon as possible with low-molecular-weight heparin (LMWH) because of the high risk of thrombotic events related to complicated IBD in the emergency setting.

It is recommended that patients be weaned off steroids (preoperatively, ideally 4 weeks) and stop immunomodulators associated with anti-TNF-α agents before surgery to decrease the risk of postoperative complications.

Emergency surgical exploration is recommended in hemodynamically unstable patients. Subtotal colectomy with ileostomy is the surgical treatment of choice in patients with acute severe ulcerative colitis, patients with massive colorectal hemorrhage, or nonresponders to medical treatment.

For more information, please go to Inflammatory Bowel Disease.

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ECCO Clinical Practice Guidelines on Infections in Inflammatory Bowel Disease (2021)

Clinical guidelines regarding infections in patients with inflammatory bowel disease (IBD), including their prevention, diagnosis, and management, were published in March 2021 by the European Crohn's and Colitis Organisation (ECCO) in the Journal of Crohn's and Colitis. [106]

IBD patients treated with immunosuppressive agents (particularly in combination) are at risk for opportunistic infections. Malnutrition, obese body mass index (BMI), comorbidities, active disease, and older age are also predictors for such infections.

It is recommended that all IBD patients undergo serologic screening for hepatitis A, B, and C; human immunodeficiency virus (HIV); Epstein-Barr virus; cytomegalovirus (CMV); varicella-zoster virus (VZV); and measles virus (with such screening taking place for the last two if the patient does not have documented evidence of past infection or has not been vaccinated). Screening should be carried out at baseline and especially before or during immunosuppressive therapy. In addition, a Pap smear should be performed to screen for human papillomavirus.

There is a significant chance that symptomatic varicella-zoster virus reactivation will occur in patients with IBD. Owing to its efficacy and safety, the preferred vaccine for patients with IBD is recombinant herpes zoster vaccine (RZV). If RZV is unavailable, it is recommended that a live zoster vaccine be administered to immunocompetent patients with IBD aged 50 years or older. Also, in patients on low-dose immunosuppression, a live zoster vaccine can be considered if RZV is not available.

The prognosis for active IBD is worsened by concurrent CMV colitis. If the IBD is refractory, the patient should be tested for CMV colitis, especially if the individual fails to respond to immunosuppressive therapy.

Do not discontinue immunosuppressive therapy in IBD patients with intestinal CMV reactivation in general. Steroid tapering should be performed, and consideration should be given to antiviral therapy in steroid-refractory IBD patients with CMV colitis. It is recommended that immunosuppressive therapy be discontinued in symptomatic disseminated CMV infection.

Appropriate antiviral treatment should be provided to immunosuppressed IBD patients with an ongoing herpes simplex virus (HSV), VZV, or influenza infection.

If, prior to biologic or small-molecule therapy or prolonged treatment with high-dose systemic steroids, a patient has been diagnosed with latent tuberculosis infection (LTBI), the individual should undergo treatment with a complete therapeutic regimen for LTBI. In other situations, seek out specialist advice. Biologic or small-molecule therapy should be delayed for at least 4 weeks post chemotherapy in a patient with active IBD who also has LTBI, except when there is greater clinical urgency (and in correlation with specialist advice).

Non-severe Clostridioides difficile infection (CDI) can be treated to equal effect with 10 days of oral vancomycin or fidaxomicin. For severe CDI, add intravenous metronidazole to oral vancomycin for 10 days. If CDI recurs, treatment includes oral vancomycin, fidaxomicin, fecal microbiota transplantation, and bezlotoxumab. Following careful risk-benefit evaluation and clinical judgement, immunosuppressant use can be maintained in patients with CDI.

The fungal infection risk in IBD is low. Though exceptional, systemic infections are associated with high mortality. Chemoprophylaxis is not indicated, except with Pneumocystis jirovecii. After a systemic fungal infection, discuss chemoprophylaxis with an infectious disease specialist.

Live vaccines are generally considered to be unsafe in patients with IBD who are undergoing immunosuppressive therapy. After immunosuppressive therapy has been terminated, a wait of at least 1-6 months is recommended before a live vaccine is administered. Case-by-case consideration should be given regarding the administration of any live vaccine.

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American College of Gastroenterology Guidelines

The American College of Gastroenterology (ACG) published recommendations on ulcerative colitis (UC) in adults in March 2019. [107, 108] The focus of management has shifted from symptom-based treatment to symptom management and mucosal healing. The ACG guideline's strong recommendations are outlined below. [107]

Diagnosis, Assessment, and Prognosis

Stool testing is recommended to exclude Clostridioides difficile when UC is suspected.

Serologic antibody testing is not recommended for the following:

  • To establish or exclude a diagnosis of UC
  • To determine the prognosis of UC

Goals for Managing Patients with UC

Treat patients with UC to achieve mucosal healing (ie, resolution of inflammatory changes [Mayo endoscopic subscore 0 or 1]) to increase the likelihood of sustained steroid-free remission and prevent hospitalizations and surgery.

UC Management

Induction and maintenance of remission in mildly active UC

Patients with, or who previously had, mildly active ulcerative proctitis are recommended to receive rectal (PR) 5-aminosalicylate (5-ASA) therapies at a dose of 1 g/d to induce or maintain remission.

To induce remission in patients with mildly active left-sided UC:

  • Rectal 5-ASA enemas at a dose of at least 1 g/d are preferred over rectal steroids.
  • In the setting of intolerance or nonresponse to oral (PO) and PR 5-ASA at appropriate doses (PO: ≥2 g/d; PR: ≥1 g/d), use PO budesonide multi-matrix (MMX) 9 mg/d.

Patients with mildly active extensive UC are recommended to receive PO 5-ASA at a dose of at least 2 g/d to induce remission.

Patients with UC of any extent whose condition fails to respond to 5-ASA therapy are recommended to receive PO systemic corticosteroids to induce remission.

Patients with mildly to moderately active UC refractory to PO 5-ASA are recommended to additionally receive budesonide MMX 9 mg/d to induce remission.

Patients with mildly to moderately active UC of any extent using 5-ASA to induce remission are recommend to receive either once-daily or more frequently dosed PO 5-ASA based on patient preference to optimize adherence, as efficacy and safety are no different.

Patients with mildly active left-sided or extensive UC are recommend to receive at least 2 g/d of PO 5-ASA therapy for maintenance of remission.

Systemic corticosteroids are not recommended to maintain remission in patients with UC.

Management of Moderately to Severely Active UC

Induction of remission

For moderately active UC, PO budesonide MMX is recommended to induce remission.

For moderately to severely active UC of any extent, PO systemic corticosteroids are recommended to induce remission.

To induce remission in patients with moderately to severely active UC, note the following:

  • Monotherapy with thiopurines or methotrexate is  not recommended.
  • Anti-tumor necrosis factor (TNF) therapy using adalimumab, golimumab, or infliximab is recommended.
  • When infliximab is used as induction therapy, combination therapy with a thiopurine is recommended.
  • Vedolizumab or tofacitinib (tofacitinib: 10 mg PO twice daily × 8 wk) is recommended (either agent is also recommended when anti-TNF therapy has failed previously).

Maintenance of remission in those with previously moderately to severely active UC

Systemic corticosteroids are not recommended to maintain remission in patients with UC.

Continue anti-TNF therapy using adalimumab, golimumab, or infliximab to maintain remission after anti-TNF induction in patients with previously moderately to severely active UC.

Continue vedolizumab to maintain remission in patients with previously moderately to severely active UC now in remission after vedolizumab induction.

Continue tofacitinib to maintain remission in patients with previously moderately to severely active UC now in remission after tofacitinib induction.

Management of Hospitalized Patients With Acute Severe UC (ASUC)

Apply deep venous thrombosis (DVT) prophylaxis to prevent venous thromboembolism (VTE).

Test for C difficile infection (CDI).

In the setting of ASUC and concomitant CDI, treat CDI with vancomycin instead of metronidazole.

Routine use of broad-spectrum antibiotics is not recommended to manage ASUC.

Use methylprednisolone 60 mg/d or hydrocortisone 100 mg 3 or 4 times daily to induce remission.

In the setting of ASUC with inadequate response to intravenous corticosteroids (IVCS) by 3-5 days, medical rescue therapy with infliximab or cyclosporine is recommended.

When remission is achieved with infliximab treatment, maintain remission with infliximab.

Colorectal Cancer Prevention in UC

When using standard-definition colonoscopes in those with UC undergoing surveillance, dye spray chromoendoscopy with methylene blue or indigo carmine is recommended to identify dysplasia.

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American Gastroenterological Association Guidelines (2020)

In January 2020, the American Gastroenterological Association (AGA) released their recommendations on the medical management of adult outpatients with moderate to severe ulcerative colitis (UC) and hospitalized adult patients with acute severe UC (ASUC). [109] The focus of the guidelines is on immunomodulators, biologic agents, and small molecules for induction and maintenance of remission (for moderate to severe UC) and reducing the risk of colectomy (for ASUC).

Adult Outpatients With Moderate-Severe UC

The AGA makes a strong recommendation for using infliximab, adalimumab, golimumab, vedolizumab, tofacitinib, or ustekinumab over no treatment.

For patients who are naïve to biologic agents, the AGA recommends that tofacitinib only be used in the setting of a clinical or registry study (no recommendation). (Updated FDA recommendations [07/26/2019] on indications for use of tofacitinib in UC recommends its use only after failure of, or intolerance to, tumor necrosis factor-alpha [TNFα] antagonists.)

Conditional recommendations

For adult outpatients with moderate-severe UC who are naïve to biologic agents, the AGA suggests using infliximab or vedolizumab, rather than adalimumab, for induction of remission.

In adult outpatients with moderate-severe UC with previous exposure to infliximab, particularly those with primary nonresponse, the AGA suggests using ustekinumab or tofacitinib, rather than vedolizumab or adalimumab, for induction of remission.

In adult outpatients with active moderate-severe UC, the AGA suggests against using thiopurine monotherapy for INDUCTION of remission. However, in adult outpatients with moderate-severe UC in remission, the AGA suggests using thiopurine monotherapy, rather than no treatment, for MAINTENANCE of remission.

In adult outpatients with moderate-severe UC, the AGA suggests against using methotrexate monotherapy, for induction or maintenance of remission.

In adult outpatients with active moderate-severe UC, the AGA conditionally suggests using biologic monotherapy (TNFα antagonists, vedolizumab, ustekinumab) rather than thiopurine monotherapy for INDUCTION of remission, whereas in those with moderate-severe UC in remission, the AGA makes no recommendation in favor of, or against, using biologic monotherapy (TNFα antagonists, vedolizumab or ustekinumab), rather than thiopurine monotherapy for MAINTENANCE of remission.

In adult outpatients with moderate-severe UC, the AGA suggests combining TNFα antagonists, vedolizumab, or ustekinumab with thiopurines or methotrexate, rather than biologic monotherapy or thiopurine monotherapy.

In adult outpatients with moderate-severe UC, the AGA suggests early use of biologic agents with or without immunomodulator therapy, rather than gradual step-up after failure of 5-aminosalicylates.

In adult outpatients with moderate-severe UC who have achieved remission with biologic agents and/or immunomodulators, or tofacitinib, the AGA suggests against continuing 5-aminosalicylates for induction and maintenance of remission.

Hospitalized Patients With ASUC

In hospitalized adult patients with ASUC refractory to intravenous (IV) corticosteroids that is being treated with infliximab, the AGA makes no recommendation on routine use of intensive versus standard infliximab dosing.

Conditional recommendations

In hospitalized adults with ASUC, the AGA suggests using an IV methylprednisolone dose equivalent of 40 to 60 mg/d rather than higher dose IV corticosteroids.

In hospitalized adults with ASUC without infections, the AGA suggests against adjunctive antibiotics.

In hospitalized adults with ASUC refractory to IV corticosteroids, the AGA suggests using infliximab or cyclosporine.

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American Gastroenterological Association Guidelines (2019)

The American Gastroenterological Association (AGA) released new guidelines on the management of mild-to-moderate ulcerative colitis (UC) in February 2019, [110] with a focus on the use of oral (PO) and topical 5-aminosalicylates (5-ASA) agents, rectal (PR) corticosteroids, and PO budesonide. [110, 112]

Strong Recommendations

Patients with extensive mild-moderate UC: The AGA recommends using either standard-dose mesalamine (2-3 g/d) or diazo-bonded 5-ASA rather than low-dose mesalamine, sulfasalazine, or no treatment. (Patients already on sulfasalazine in remission or patients with prominent arthritic symptoms may reasonably choose sulfasalazine 2-4 g/d if alternatives are cost-prohibitive, albeit with higher rate of intolerance.)

Patients with mild-moderate ulcerative proctitis who choose rectal therapy over oral therapy: The AGA recommends using mesalamine suppositories.

Conditional Recommendations

Patients with extensive or left-sided mild-moderate UC: The AGA suggests adding rectal mesalamine to oral 5-ASA.

Patients with mild-moderate UC with a suboptimal response to standard-dose mesalamine or diazo-bonded 5-ASA or with moderate disease activity: The AGA suggests using high-dose mesalamine (>3 g/d) with rectal mesalamine.

Patients with mild-moderate UC being treated with oral mesalamine: The AGA suggests using once-daily dosing rather than multiple times per day dosing.

Patients with mild-moderate UC: The AGA suggests using standard-dose oral mesalamine or diazo-bonded 5-ASA, rather than budesonide MMX (Multi-Matrix System) or controlled ileal release budesonide for induction of remission.

Patients with left-sided mild-moderate ulcerative proctosigmoiditis or proctitis: The AGA suggests using mesalamine enemas (or suppositories) rather than oral mesalamine. (Patients who have a higher value for convenience of oral medication administration and a lower value on effectiveness could reasonably choose oral mesalamine.)

Patients with mild-moderate ulcerative proctosigmoiditis who choose rectal therapy over oral therapy: The AGA suggests using mesalamine enemas rather than rectal corticosteroids. (Patients who place a higher value on avoiding difficulties associated with mesalamine enemas and a lower value on effectiveness may reasonably select rectal corticosteroid foam preparations.)

Patients with mild-moderate ulcerative proctosigmoiditis or proctitis being treated with rectal therapy who are intolerant of or refractory to mesalamine suppositories: The AGA suggests using rectal corticosteroid therapy rather than no therapy for induction of remission.

Patients with mild-moderate UC refractory to optimized oral and rectal 5-ASA, regardless of disease extent: The AGA suggests adding either oral prednisone or budesonide MMX.

No Recommendations

The AGA makes no recommendations for the use of probiotics in those with mild-moderate UC, nor for the use of curcumin in patients with mild-moderate UC despite 5-ASA therapy.

In patients with mild–moderate UC without Clostridium difficile infection, the AGA recommends fecal microbiota transplantation be performed only in the context of a clinical trial.

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British Society of Gastroenterology Guidelines

Consensus guidelines on the management of ulcerative colitis in adults were released in September 2019 by the British Society of Gastroenterology. [111]

Ulcerative Colitis

In circumstances in which ulcerative colitis is diagnosed by sigmoidoscopy, the recommended procedure is a full ileocolonoscopy to delineate the extent of disease and the severity of inflammation, as well as to exclude Crohn disease.

The target of medical therapy for ulcerative colitis is symptomatic remission combined with mucosal healing.

For the initial treatment of active mild-to-moderate ulcerative colitis with 5-aminosalicylic acid (5-ASA), oral 5-ASA at 2-3 g/day is recommended; 5-ASA enemas are also recommended, rather than oral treatment alone. All patients treated with 5-ASA should undergo monitoring for nephrotoxicity, with baseline renal function testing repeated after 2-3 months, and then annually thereafter.

For corticosteroid treatment in mild-to-moderate ulcerative colitis in patients in whom 5-ASA therapy has failed or is not tolerated, oral prednisolone is recommended. Also recommended is topically acting oral corticosteroids (eg, budesonide MMX).

For corticosteroid treatment in moderate-to-severe ulcerative colitis, oral corticosteroids (eg, prednisolone at 40 mg/d with weaning over 6-8 wk) is recommended.

5-ASA is recommended as standard maintenance medical therapy. Considerations for the choice of formulation include patient preference, likelihood of adherence, and cost. Once-daily dosing is considered effective and may help improve adherence.

In cases of 5-ASA treatment failure, options to consider include thiopurine, anti–tumor necrosis factor therapy, vedolizumab, or tofacitinib. Considerations for choice of drug include clinical factors, patient choice, cost, likelihood of adherence, and local infusion capacity.

Regarding surgical management for ulcerative colitis, it is generally suggested that surgical resection of the colon and rectum should be offered to those patients with chronic active symptoms that are refractory to optimal medical therapy.

Proctitis in ulcerative colitis

The recommended treatment for mild or moderately active ulcerative proctitis is a 1-g 5-ASA suppository.

If patients do not respond to or are intolerant of 5-ASA suppositories and oral 5-ASA, they can be switched to corticosteroid suppositories.

In refractory proctitis, it is suggested that patients may require treatment with corticosteroids, immunomodulators, and/or biological therapy.

Acute severe ulcerative colitis

The recommended treatment for acute severe ulcerative colitis is high-dose intravenous corticosteroids (eg, methylprednisolone at 60 mg/day or hydrocortisone at 100 mg q6h), along with prophylactic low-molecular-weight heparin. Do not delay corticosteroid treatment for patients with suspected acute severe ulcerative colitis pending results of stool cultures and Clostridium difficile assay.

If patients do not respond by day 3, rescue therapy with intravenous infliximab or cyclosporine should be offered for patients in whom previous thiopurine therapy has failed. If patients treated with infliximab have not responded sufficiently to a 5-mg/kg dose 3-5 days after the first infusion, offer an accelerated induction regimen after a colorectal surgical consult to determine if an emergency colectomy is required.

In patients with acute severe ulcerative colitis who do not respond to rescue therapy with infliximab or cyclosporine within 7 days, or in those who deteriorate or experience complications (including severe hemorrhage, perforation, or toxic megacolon) before 7 days, subtotal colectomy and ileostomy, with preservation of the rectum, are required. Note that a delay in surgery increases the risk of surgical complications; therefore, early referral and direct involvement with specialist colorectal surgical and stoma care teams is required.

Pouches and pouchitis

The recommend first-line treatment for acute pouchitis is a 2-week course of ciprofloxacin or metronidazole. Ciprofloxacin may be better tolerated and more effective than metronidazole.

The suggested treatment for chronic pouchitis is combination antibiotic therapy (ciprofloxacin, metronidazole, tinidazole, rifaximin), oral budesonide, or oral beclomethasone.

In chronic refractory pouchitis that does not respond to antibiotics or locally acting corticosteroids, reassess the patient and consider other factors. If other factors can be excluded, the suggested next step is to offer patients biologics.

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Resources

For more information, go to Inflammatory Bowel Disease and Crohn Disease.

For more Clinical Practice Guidelines, go to Guidelines.

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