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Catassi G, Marmo C, Gasbarrini A, Riccioni ME. Role of Device-Assisted Enteroscopy in Crohn's Disease. J Clin Med 2024; 13:3919. [PMID: 38999485 PMCID: PMC11242258 DOI: 10.3390/jcm13133919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 06/03/2024] [Accepted: 06/13/2024] [Indexed: 07/14/2024] Open
Abstract
Crohn's Disease (CD) is a chronic inflammatory disorder of the gastrointestinal tract, posing diagnostic and management challenges due to its potential involvement of any segment from the mouth to the anus. Device-assisted enteroscopy (DAE) has emerged as a significant advancement in the management of CD, particularly for its ability to access the small intestine-a region difficult to evaluate with conventional endoscopic methods. This review discusses the pivotal role of DAE in the nuanced management of CD, emphasizing its enhanced diagnostic precision and therapeutic efficacy. DAE techniques, including double-balloon enteroscopy (DBE), single-balloon enteroscopy (SBE), and the now-withdrawn spiral enteroscopy, enable comprehensive mucosal assessment, targeted biopsies, and therapeutic interventions like stricture dilation, bleeding control, and foreign body removal. Despite its benefits, DAE carries risks such as perforation, bleeding, and pancreatitis, which require careful procedural planning and a skilled execution. The review highlights DAE's impact on reducing surgical interventions and improving patient outcomes through minimally invasive approaches, thereby enhancing the quality of life for patients with CD. Continuous improvement and research are essential in order to maximize DAE's utility and safety in clinical practice.
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Affiliation(s)
- Giulia Catassi
- Digestive Endoscopy Unit, IRCCS "Agostino Gemelli" University Hospital, Catholic University of Rome, Largo A. Gemelli 8, 00168 Rome, Italy
- Pediatric Gastroenterology and Liver Unit, Umberto I Hospital, Sapienza University of Rome, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Clelia Marmo
- Digestive Endoscopy Unit, IRCCS "Agostino Gemelli" University Hospital, Catholic University of Rome, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Antonio Gasbarrini
- Internal Medicine, Gastroenterology and Liver Unit, "Agostino Gemelli" University Hospital, Catholic University of Rome, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Maria Elena Riccioni
- Digestive Endoscopy Unit, IRCCS "Agostino Gemelli" University Hospital, Catholic University of Rome, Largo A. Gemelli 8, 00168 Rome, Italy
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2
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Gala K, Brunaldi V, Abu Dayyeh BK. Endoscopic Management of Surgical Complications of Bariatric Surgery. Gastroenterol Clin North Am 2023; 52:719-731. [PMID: 37919023 DOI: 10.1016/j.gtc.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
Bariatric surgery, although highly effective, may lead to several surgical complications like ulceration, strictures, leaks, and fistulas. Newer endoscopic tools have emerged as safe and effective therapeutic options for these conditions. This article reviews post-bariatric surgery complications and the role of endoscopy in their management.
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Affiliation(s)
- Khushboo Gala
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street South West, Rochester, MN 55905, USA
| | - Vitor Brunaldi
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street South West, Rochester, MN 55905, USA
| | - Barham K Abu Dayyeh
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street South West, Rochester, MN 55905, USA.
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Oliva S, Thomson M, de Ridder L, Martín-de-Carpi J, Van Biervliet S, Braegger C, Dias JA, Kolacek S, Miele E, Buderus S, Bronsky J, Winter H, Navas-López VM, Assa A, Chong SKF, Afzal NA, Smets F, Shaoul R, Hussey S, Turner D, Cucchiara S. Endoscopy in Pediatric Inflammatory Bowel Disease: A Position Paper on Behalf of the Porto IBD Group of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 2018; 67:414-430. [PMID: 30130311 DOI: 10.1097/mpg.0000000000002092] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Endoscopy is a central tool for the evaluation and management of inflammatory bowel disease (IBD). In the last few decades, gastrointestinal (GI) endoscopy has undergone significant technological developments including availability of pediatric-size equipment, enabling comprehensive investigation of the GI tract in children. Simultaneously, professional organization of GI experts have developed guidelines and training programs in pediatric GI endoscopy. This prompted the Porto Group on Pediatric IBD of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition to develop updated guidelines on the role of GI endoscopy in pediatric IBD, specifically taking into considerations of recent advances in the diagnosis, disease stratification, and novel therapeutic targets in these patients.
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Affiliation(s)
- Salvatore Oliva
- Pediatric Gastroenterology and Liver Unit, Sapienza-University of Rome, Italy
| | - Mike Thomson
- Centre for Paediatric Gastroenterology, Sheffield Children's Hospital, Sheffield, United Kingdom
| | - Lissy de Ridder
- Pediatric Gastroenterology, Erasmus Medical Center/Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Javier Martín-de-Carpi
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Hospital Sant Joan de Déu, Barcelona, Spain
| | | | - Christian Braegger
- Division of Gastroenterology and Nutrition, University Children's Hospital, Zurich, Switzerland
| | - Jorge Amil Dias
- Pediatric Gastroenterology Unit, Hospital Sao João, Porto, Portugal
| | - Sanja Kolacek
- Children's Hospital Zagreb, Faculty of Medicine, Zagreb, Croatia
| | - Erasmo Miele
- Department of Translational Medical Science, Section of Pediatrics, "Federico II," University of Naples, Italy
| | | | - Jiri Bronsky
- Department of Paediatrics, University Hospital Motol, Prague, Czech Republic
| | - Harland Winter
- Department of Pediatrics, Massachusetts General Hospital, Boston, MA
| | | | - Amit Assa
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, affiliated to the Sackler faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sonny K F Chong
- Queen Mary's Hospital for Children, Epsom & St Helier University Hospitals NHS Trust, Carshalton, Surrey
| | - Nadeem Ahmad Afzal
- Department of Paediatric Gastroenterology, University Hospital Southampton, Southampton, UK
| | - Francoise Smets
- Pediatric Gastroenterology and Hepatology Unit, IREC, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | | | - Séamus Hussey
- National Children's Research Centre and Royal College of Surgeons of Ireland, Dublin, Ireland
| | - Dan Turner
- Institute of Paediatric Gastroenterology, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Salvatore Cucchiara
- Pediatric Gastroenterology and Liver Unit, Sapienza-University of Rome, Italy
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4
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Kurahara LH, Hiraishi K, Hu Y, Koga K, Onitsuka M, Doi M, Aoyagi K, Takedatsu H, Kojima D, Fujihara Y, Jian Y, Inoue R. Activation of Myofibroblast TRPA1 by Steroids and Pirfenidone Ameliorates Fibrosis in Experimental Crohn's Disease. Cell Mol Gastroenterol Hepatol 2017; 5:299-318. [PMID: 29552620 PMCID: PMC5852292 DOI: 10.1016/j.jcmgh.2017.12.005] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Accepted: 12/07/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS The transient receptor potential ankyrin 1 (TRPA1) channel is highly expressed in the intestinal lamina propria, but its contribution to gut physiology/pathophysiology is unclear. Here, we evaluated the function of myofibroblast TRPA1 channels in intestinal remodeling. METHODS An intestinal myofibroblast cell line (InMyoFibs) was stimulated by transforming growth factor-β1 to induce in vitro fibrosis. Trpa1 knockout mice were generated using the Clustered regularly interspaced short palindromic repeats (CRISPR)/CRISPR-associated 9 (Cas9) system. A murine chronic colitis model was established by weekly intrarectal trinitrobenzene sulfonic acid (TNBS) administration. Samples from the intestines of Crohn's disease (CD) patients were used for pathologic staining and quantitative analyses. RESULTS In InMyoFibs, TRPA1 showed the highest expression among TRP family members. In TNBS chronic colitis model mice, the extents of inflammation and fibrotic changes were more prominent in TRPA1-/- knockout than in wild-type mice. One-week enema administration of prednisolone suppressed fibrotic lesions in wild-type mice, but not in TRPA1 knockout mice. Steroids and pirfenidone induced Ca2+ influx in InMyoFibs, which was antagonized by the selective TRPA1 channel blocker HC-030031. Steroids and pirfenidone counteracted transforming growth factor-β1-induced expression of heat shock protein 47, type 1 collagen, and α-smooth muscle actin, and reduced Smad-2 phosphorylation and myocardin expression in InMyoFibs. In stenotic intestinal regions of CD patients, TRPA1 expression was increased significantly. TRPA1/heat shock protein 47 double-positive cells accumulated in the stenotic intestinal regions of both CD patients and TNBS-treated mice. CONCLUSIONS TRPA1, in addition to its anti-inflammatory actions, may protect against intestinal fibrosis, thus being a novel therapeutic target for highly incurable inflammatory/fibrotic disorders.
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Key Words
- AITC, allyl isothiocyanate
- CD, Crohn’s disease
- Crohn’s Disease
- EGTA, ethylene glycol-bis(β-aminoethyl ether)-N,N,N′,N′-tetraacetic acid
- HSP47, heat shock protein 47
- InMyoFib, intestinal myofibroblast cell line
- Intestinal Fibrosis
- KO, knockout
- MT, Masson trichrome
- Myofibroblast
- PBS, phosphate-buffered saline
- PCR, polymerase chain reaction
- RT-PCR, reverse-transcription polymerase chain reaction
- TGF, transforming growth factor
- TNBS, trinitrobenzene sulfonic acid
- TNF, tumor necrosis factor
- TRP, transient receptor potential
- TRPA1, transient receptor potential ankyrin 1
- TRPC, transient receptor potential canonical
- Transient Receptor Potential Ankyrin 1
- WT, wild-type
- mRNA, messenger RNA
- sgRNA, single-guide RNA
- siRNA, small interfering RNA
- α-SMA, α smooth muscle actin
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Affiliation(s)
- Lin Hai Kurahara
- Department of Physiology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan,Correspondence Address correspondence to: Lin Hai Kurahara, PhD, Department of Physiology, Faculty of Medicine, Fukuoka University, Fukuoka 814-0180, Japan. fax: (81) 92-865-6032.Department of PhysiologyFaculty of MedicineFukuoka UniversityFukuoka814-0180Japan
| | - Keizo Hiraishi
- Department of Physiology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Yaopeng Hu
- Department of Physiology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Kaori Koga
- Department of Pathology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Miki Onitsuka
- Department of Pathology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Mayumi Doi
- Department of Physiology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan,Department of Clinical Pharmacology and Therapeutics, Faculty of Medicine, Oita University, Oita, Japan
| | - Kunihiko Aoyagi
- Department of Gastroenterology, Japanese Red Cross Fukuoka Hospital, Fukuoka, Japan
| | - Hidetoshi Takedatsu
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Daibo Kojima
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Yoshitaka Fujihara
- Research Institute for Microbial Diseases, Osaka University, Osaka, Japan
| | - Yuwen Jian
- College of Letters and Science, University of California—Davis, Davis, California
| | - Ryuji Inoue
- Department of Physiology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
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Annese V, Daperno M, Rutter MD, Amiot A, Bossuyt P, East J, Ferrante M, Götz M, Katsanos KH, Kießlich R, Ordás I, Repici A, Rosa B, Sebastian S, Kucharzik T, Eliakim R. European evidence based consensus for endoscopy in inflammatory bowel disease. J Crohns Colitis 2013; 7:982-1018. [PMID: 24184171 DOI: 10.1016/j.crohns.2013.09.016] [Citation(s) in RCA: 540] [Impact Index Per Article: 49.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 09/20/2013] [Indexed: 02/08/2023]
Affiliation(s)
- Vito Annese
- Dept. Gastroenterology, University Hospital Careggi, Largo Brambilla 3, 50139 Florence, Italy.
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Bevan R, Rees CJ, Rutter MD, Macafee DAL. Review of the use of intralesional steroid injections in the management of ileocolonic Crohn's strictures. Frontline Gastroenterol 2013; 4:238-243. [PMID: 28839732 PMCID: PMC5370054 DOI: 10.1136/flgastro-2012-100297] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Revised: 03/06/2013] [Accepted: 03/07/2013] [Indexed: 02/04/2023] Open
Abstract
Most patients with Crohn's disease present with either terminal ileal or colonic disease, with 70% requiring surgery by 10 years after diagnosis. Recurrent stricturing at the anastomotic site is common, often symptomatic and can require re-operation with its inherent risks. Balloon dilation has been shown to provide good symptom relief from such strictures. However, repeat dilations may be required, and further surgical intervention to an anastomotic stricture is needed in up to 30% of cases. Injection of corticosteroids has been suggested as an adjunct to dilation in order to improve outcomes. This paper reviews the current literature on the use of intralesional steroid injections following endoscopic balloon dilation of anastomotic and de novo Crohn's strictures. There have been only two randomised placebo controlled trials and five small non-controlled or retrospective studies. Study numbers vary from 10 to 29 patients. The two randomised trials conflict in their conclusions and numbers are small in these studies. Currently therefore, no firm support can be given to the routine use of intralesional steroid injections.
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Affiliation(s)
- Roisin Bevan
- Northern Region Endoscopy Group, UK,Department of Gastroenterology, South Tyneside District General Hospital, South Shields, UK
| | - Colin J Rees
- Northern Region Endoscopy Group, UK,Department of Gastroenterology, South Tyneside District General Hospital, South Shields, UK,Durham University, Durham, UK
| | - Matthew D Rutter
- Northern Region Endoscopy Group, UK,Durham University, Durham, UK,Department of Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, UK
| | - David A L Macafee
- Northern Region Endoscopy Group, UK,James Cook University Hospital, Middlesbrough, UK
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Lorenzo-Zúñiga V, García-Planella E, Moreno De Vega V, Domènech E, Boix J. [Endoscopic management of luminal stenosis in inflammatory bowel disease]. GASTROENTEROLOGIA Y HEPATOLOGIA 2012; 35:404-10. [PMID: 22341673 DOI: 10.1016/j.gastrohep.2011.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Accepted: 12/09/2011] [Indexed: 11/27/2022]
Abstract
Luminal stenosis is frequent in Crohn's disease (CD) due to transmural involvement. Before any endoscopic treatment, the presence of neoplastic stenosis should always be excluded. Endoscopic balloon dilatation has been used in several series to treat benign stenosis, mainly in CD with involvement of the distal ileon, colon or surgical anastomosis, with success rates of 51% to 85%, although recurrence is high. The concomitant use of injected steroids (triamcinolone) after endoscopic dilatation produces longer-lasting results, but there are few published reports. In patients with luminal stenosis refractory to conventional endoscopy, three emerging techniques may be useful: self-expanding metallic stents, biodegradable endoprostheses and intralesional infliximab injection.
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Affiliation(s)
- Vicente Lorenzo-Zúñiga
- Unidad de Endoscopias, Servicio de Aparato Digestivo, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, España.
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Rieder F, Fiocchi C. Intestinal fibrosis in inflammatory bowel disease - Current knowledge and future perspectives. J Crohns Colitis 2008; 2:279-90. [PMID: 21172225 DOI: 10.1016/j.crohns.2008.05.009] [Citation(s) in RCA: 121] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2008] [Accepted: 05/19/2008] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Intestinal fibrosis is a common complication of IBD that can become seriously symptomatic and may require surgical intervention if stricture formation ensues. This review discusses existing and developing knowledge of intestinal fibrosis and its implications for therapy. METHODS Review of the literature, personal communications, unpublished observations. RESULTS Known mechanisms of intestinal fibrosis include fibroblast proliferation and migration, activation of stellate cells, and extraintestinal fibroblast recruitment. However, novel mechanisms are being uncovered, including epithelial-to-mesenchymal transition, endothelial-to-mesenchymal transition, pericyte differentiation, and fibrocyte recruitment. Most of the traditional and novel mechanisms underlying intestinal fibrosis are associated to the presence of chronic inflammation, but is also possible that fibrosis develops independently of persistent immune activation in the gut. At the moment, the development of preventive, non-interventional, and more effective management of intestinal fibrosis is hampered by the lack of a greater knowledge of its basic pathophysiology and predisposing factors. CONCLUSIONS It is reasonable to expect that therapy of IBD-associated fibrosis will radically improve once the underlying mechanisms are better understood, and therapeutic modalities will emerge that prevent or reverse this complication of IBD.
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Affiliation(s)
- Florian Rieder
- Department of Internal Medicine I, University of Regensburg, Regensburg, Germany; Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, USA; Department of Pathobiology, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, USA
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Burke JP, Ferrante M, Dejaegher K, Watson RWG, Docherty NG, De Hertogh G, Vermeire S, Rutgeerts P, D'Hoore A, Penninckx F, Geboes K, Van Assche G, O'Connell PR. Transcriptomic analysis of intestinal fibrosis-associated gene expression in response to medical therapy in Crohn's disease. Inflamm Bowel Dis 2008; 14:1197-204. [PMID: 18452219 DOI: 10.1002/ibd.20482] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Glucocorticoids and monoclonal antibodies to tumor necrosis factor reduce inflammation in Crohn's disease (CD). Rapid luminal healing, however, may promote intestinal stricture formation. The aim of this study was to examine fibrosis-associated gene expression in the intestine of patients with CD and correlate expression levels with prior medical therapies. METHODS In all, 37 patients with stricturing CD and 18 non-CD controls underwent a transmural biopsy at the time of elective intestinal resection. Quantitative real-time polymerase chain reaction (PCR) was conducted to determine differential mRNA expression of TGF-beta(1), Smad-7, CTGF, collagen-1alpha, fibronectin, BMP-7, and MIF. Intestinal fibroblasts were treated in vitro with dexamethasone. RESULTS Relative to control, strictured CD intestinal tissue expressed increased TGF-beta(1), CTGF, collagen-1alpha, and BMP-7 (all P < 0.05). TGF-beta(1) gene expression positively correlated with the expression of its downstream targets (all P < 0.001). Preoperative infliximab exposure was not associated with increased expression in any of the target genes nor did the number of infliximab infusions correlate with gene expression. The number of cycles of corticosteroid treatment preoperatively was positively associated with CTGF (r = 0.486, P = 0.016) and MIF (r = 0.524, P = 0.009) expression. Intestinal fibroblasts treated in vitro with dexamethasone upregulated CTGF expression (P = 0.023). CONCLUSIONS Exposure to infliximab does not appear to induce a profibrotic transcriptional response in the CD intestine. Previous corticosteroid treatment is associated with increased expression of CTGF and MIF. Treating intestinal fibroblasts in vitro with steroids upregulates CTGF expression.
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Affiliation(s)
- John P Burke
- Department of Surgery, Mater Misericordiae University Hospital, University College Dublin, Ireland
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Abstract
PURPOSE OF REVIEW Intestinal fibrosis is a potentially serious complication of inflammatory bowel disease and its pathophysiology is still unclear. This review will discuss recent developments relating to sources of fibroblasts in intestinal inflammation, mediators that modulate fibroblast activation and function, as well as new clinical, laboratory, endoscopic and radiological studies aimed at improving diagnosis and management of intestinal fibrosis in inflammatory bowel disease. RECENT FINDINGS The fibroblast remains the central cell responsible for intestinal fibrosis in inflammatory bowel disease and transforming growth factor-beta1 is still the most potent pro-fibrogenic cytokine. Novel mediators, however, are being identified that modulate fibroblast function, such as interleukin-13, interleukin-21, galectin-3, osteopontin, Wnt and toll-like receptor ligands, and anti-tumor necrosis factor-alpha agents. New fibroblast sources are being identified, such as fibrocytes, and new mechanisms of fibroblast generation, like epithelial- and endothelial-to-mesenchymal transition. Animal models of intestinal fibrosis are still few, but new ways to induce gut fibrosis are being explored. Serological markers indicating a clinically complicated course that includes intestinal fibrosis are promising and are being tested in adult and pediatric populations, particularly in Crohn's disease. Video capsule endoscopy, the Given Patency capsule, double balloon enteroscopy, and computed tomographic enteroscopy are some of the new modalities being developed to assess the risk and improve the diagnosis of intestinal fibrosis. Novel therapeutic approaches include endoscopic balloon dilatation with conventional and double balloon enteroscopy, and local injection of glucocorticoids and tumor necrosis factor-alpha blockers, showing partial but encouraging success. SUMMARY More studies are needed to improve knowledge of the pathophysiology of intestinal fibrosis if better preventive, diagnostic and therapeutic measures are to be expected in the near future.
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