Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is a surgical procedure that involves removal of the entire colon and rectum with preservation of the anal sphincter complex. In contrast to a total proctocolectomy with end ileostomy, the IPAA re-establishes intestinal continuity and provides a reservoir for intestinal contents. Typically, this intervention is reserved for patients with Ulcerative Colitis (UC) who have failed medical management, specific cases of Crohn's disease or indeterminate colitis, hereditary colon cancer syndromes such as familial adenomatous polyposis (FAP), and certain instances of synchronous colon cancers.1 Nevertheless, post-surgical inflammation of this reservoir, known as "pouchitis," may occur in up to 70-80% of patients, and there is a reported incidence of pouch failure necessitating diverting ileostomy or pouch excision in up to 10% of patients.2, 3, 4, 5 This comprehensive review will explore the clinical manifestations, pathogenesis, diagnosis, and both medical and surgical management of this challenging condition.