Introduction. The incidence of acute pouchitis after total proctocolectomy with ileal pouch reconstruction is currently at 20% after 1 year, and more than 30% after 5 years. The current guidelines in pouchitis include recurrent bouts of antibiotic treatment, and in spite of this, more than 10% of patients will develop antibiotic refractory pouchitis, which represents a therapeutic challenge. Case report. A 59-years old female patient, diagnosed with severe ulcerative pancolitis which required total colectomy with ileo-rectal pouch anastomosis after developing toxic megacolon (1995) presents to the Gastroenterology Department with 8-10 semsiolid stools per day, rectorrhagia and fatigue. Paraclinical examination showed a severe iron deficiency anemia (Hgb 6,5 g/dL, HCT 27%), increased inflammatory markers (CRP, ESR, fibrinogen count, and fecal calprotectin of 1200 ug/g). Rectoscopy with intubation of the ileal pouch shoed fibrin-covered pouch ulceration (1,5-2 cm in diameter), perilesional edema and acute congestion, with the presence of loss of vascular markings, superficial erosions at the level of the rectal stump. She received treatment with IV corticosteroids and prolonged bouts of antibiotic treatment, together with Rifaximin and probiotic therapy. Repeated rectoscopy at 2 months showed a slight decrease of the fibrin-covered pouch ulceration but the persistence of perilesional edema and of mucosal changes at the level of the rectal stump and recurrent anemic syndrome resistant to iron supplementation and repeated blood transfusions. Discussions. Current guidelines recommend initial cephalosporins and for non-responders, such as our patient, ciprofloxacin plus rifaximin. In the case of chronic antibiotic refractory pouchitis, current guidelines recommend the use of immunomodulator treatments and biological agents such as Vedolizumab, Ustekinumab and Infliximab, which show promising results, but were all administered off label or in clinical trials. Conclusions. Pouch complications are increasingly common and require urgent care, especially in chronic antibiotic refractory pacients. Effective national guidelines are required in order to allow an easier access to optimal medical care. [ABSTRACT FROM AUTHOR]