Pouchitis is the most common long-term morbidity associated with ileal pouch/anal anastomoses [110– 113]. For unknown reasons, this condition occurs more frequently in patients who have had ulcerative colitis than in those with familial polyposis; and the incidence is even higher if pancolitis or extraintesti­nal manifestations were present. Among the many theories to explain this phenomenon are pouch outfl ow obstruction, stasis and bacterial overgrowth, abnormal mucus secretion, reduced levels of free fatty acids in the pouch, oxygen free radical injury secondary to ischemia, presence of antineutrophil cytoplasmic antibodies, and pouches that are created “too” large [110]. Clinically, patients present with low grade fever, fatigue and malaise, and frequent loose stools or frank diarrhea occasionally with passage of blood or associated with pelvic pain, cramps, and urgency, often with soiling and inconti­nence. The mucosa becomes infl amed with progres­sion to ulceration in severe cases. In more than 50% of patients the fi rst episode occurs within the fi rst year of surgery, with the initial risk highest during the fi rst 6 months after surgery [111,112].