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You have full access to this open access article. The anatomical location of inflammation in and around the ileal pouch affects the pouch survival rate, and diffuse inflammation has poor pouch survival rates. We aimed to clarify the symptoms and histological findings of diffuse inflammation of the pouch. We evaluated the symptoms, treatment, and histological findings according to the endoscopic phenotypes of diffuse inflammation, focal inflammation, and normal as the pouch body phenotype and afferent limb involvement, inlet involvement, cuffitis, and fistula as the peripheral findings.

Of the pouchoscopies, 47 had diffuse inflammation, had focal inflammation, and 70 were normal. Symptomatic patients had diffuse inflammation more frequently Antibiotics and steroids were higher rate administered in cases of diffuse inflammation, but not in cases of focal inflammation or in normal cases. The number of symptomatic patients increased as the number of peripheral inflammatory findings increased. Pouches with diffuse inflammation are more symptomatic, have a higher use of therapeutic agents, and have more severe histological inflammation, IBD-specific finding, and colonic metaplasia accompanying peripheral inflammatory findings than the other groups.

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The higher the overlap of inflammatory findings in the surrounding tissues, the more symptomatic the patients will appear. Inflammation of the pouch pouchitis is a common complication of ileal pouch-anal anastomosis IPAA. The pouchitis disease activity index PDAI and pouchitis activity score PAS are widely used in the diagnosis and severity of pouchitis [ 1 , 2 ]; however, the long-term impact and prognosis of pouchitis are not well understood.

Recently, the prognosis of ileal pouches has been shown to differ depending on the site of inflammation [ 3 ]. The Chicago classification focuses on the inflammation site of the ileal pouch, and patients with diffuse inflammation in the pouch and patients with overlapping classifications have low pouch survival rate [ 4 ].

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Reports based on the Chicago classification have been published in recent years [ 5 , 6 ]. However, the clinical symptoms and histological findings of Chicago classification in these patients are not clear, and it is unclear why diffuse inflammation have a poor long-term prognosis.

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