Ulcerative Colitis Patients with Pyoderma Gangrenosum Have Worse Outcomes with J-Pouch Surgery, Study Finds

Pyoderma gangrenosum (PG) is a rare extraintestinal manifestation of ulcerative colitis that leads to severe skin ulcers and is considered a marker of inflammatory status. Now, a new study by Cleveland Clinic physicians shows that it is associated with worse outcomes after ileal pouch-anal anastomosis (IPAA) surgery, or “J-pouch” surgery.

Patients with pyoderma gangrenosum had an almost six times higher risk of pouch failure. The study, which tracked patients for 10 years after surgery, also found that patients with PG had a significantly higher risk of developing fistulas and of experiencing Crohn’s-like changes in the future. It’s the first study to look at IPAA outcomes in these patients.

“I don’t want to send a message that if a patient has pyoderma gangrenosum, then they can’t have a J-pouch,” says senior author Olga Lavryk, MD, PhD, a colorectal surgeon at the Cleveland Clinic. “But identifying high-risk patients for pouch failure, like this group, is really important because they can be counseled and make an informed decision. Our findings from this study indicate that patients with PG may have a different, more inflammatory phenotype of their disease, which gives us an idea that these patients may be at higher risk of developing Crohn ’s-like changes in the future.”

Study design and findings

PG affects fewer than 2% of patients with ulcerative colitis, but symptoms can be severe. Patients develop deep, painful skin ulcers that can appear anywhere on the body, but they are especially challenging when they occur around the stoma area. When this happens, it can make it difficult or extremely painful to insert the ostomy appliance, change the bag or seal the area. In extreme cases, the stoma may need to be relocated.

IPAA surgery involves creating a pouch from the small intestine to replace the rectum. This can restore bowel movements and eliminate the need for a permanent ostomy bag. It is typically offered to patients with severe ulcerative colitis who have exhausted medical therapy, but it is not recommended for patients with Crohn’s disease.

In the retrospective study, researchers compared 30 patients with PG who underwent IPAA surgery and compared them with a control group of patients without PG. Patients were closely matched for age, gender, diagnosis, disease duration, surgery year, technique, and length of follow-up, along with other factors.

Pouch failure was significantly more common in the PG group (21%) than in the group without PG, which had only a 3% failure rate. More than 34% of the PG patients developed pouch-related fistulas, compared to 10% of the control patients.

Long-term, 55% of the group who had been diagnosed with PG prior to surgery were ultimately diagnosed with Crohn’s disease, compared to 45% of the group without PG.

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Example of pyoderma gangrenosum

Impact of the research

While the study was small, she noted that researchers looked at data from more than 3,800 patients who underwent IPAA dating back to 1983 to find 30 who had PG, pointing to the rarity of the condition.

The findings should be used to help counsel patients and guide shared decision-making, Dr. Lavryk says.

“IPAA surgery is not a must-do,” she explains. “Now that we know how to do this surgery, the next step is learning how to identify high-risk patients who may not do well with the surgery and improving patient satisfaction. These new findings are just a small piece in the big puzzle.”

The study, “Pyoderma Gangrenosum — a Risk Factor for IPAA Failure? A Matched Cohort Analysis,” was presented May 11, 2026, at the American Society of Colon Rectal Surgeons Annual Meeting.