Chronic pouchitis (CP) after ileal pouch-anal anastomosis is a significant clinical problem. Adipose tissues produce antiinflammatory cytokines and chemokines. We evaluated the association between abdominal visceral fat area (VFA) and CP. Patients with a preoperative CT evaluation were included. The diagnosis of CP was confirmed in all cases by endoscopy with afferent ileal limb intubation. Patients were allocated into groups of high VFA and low VFA. The study cohort of 52 patients had a median body mass index of 22 (range, 14-32). Indications for surgery were medically refractory disease in 46 (88%) patients and cancer/dysplasia in six (12%) patients. Median VFA was 27.1 (range, 1-144). Six (12%) patients developed CP. Low VFA patients were significantly younger (29 vs 45 years; P < 0.0001), had lower body mass index (20.4 vs 24.7; P < 0.0001), had surgery more commonly for medically refractory disease than for cancer or dysplasia (100 vs 77%; P = 0.02), and had a higher incidence of CP than high VFA patients (23 vs 0%; P = 0.02). Multiple linear regression analysis demonstrated that only low VFA was associated with CP (P = 0.009). An association is present between VFA and CP after ileal pouch-anal anastomosis, implicating adipocytes in the pathogenesis of inflammatory bowel disease.