Endoscopic therapy in inflammatory bowel diseases (with videos)

Endoscopic therapy of stoma closure site strictures in ileal pouches is safe and effective

Background

Strictures are a common complication after ileal pouch surgery with the most common locations being at the anastomosis, pouch inlet, and stoma closure site. No previous literature has described endoscopic therapy of stoma site stricture. This study aimed to assess the safety and efficacy of endoscopic therapy in the treatment of stoma closure site strictures.

Method

Patients diagnosed with stoma closure site strictures following ileal pouch surgery who underwent endoscopic treatment at the Center for Colorectal Diseases, Inflammatory Bowel Disease (IBD), and Ileal Pouch between 2018 and 2022 were analysed. Primary outcomes (technical success and surgery-free survival) were compared between endoscopic balloon dilation (EBD) and stricturotomy and/or strictureplasty.

Results

A total of 30 consecutive eligible patients were analysed. Most patients were female (66.7%) and most patients were diagnosed with IBD (93.3%). Twenty patients (66.7%) had end-to-end anastomosis. A total of 52 procedures were performed, with EBD in 16 (30.8%) and stricturotomy and/or strictureplasty in 36 (69.2%). The mean stricture length was 1.7 ± 1.0 cm. Immediate technical success was achieved in 47 of 52 interventions (90.4%). During a mean follow-up of 12.7 ± 9.9 months, none of the patients underwent surgical intervention for the stricture. Fourteen (46.7%) required endoscopic re-intervention for their strictures with an interval between index and re-interventional pouchoscopy of 8.8 ± 6.3 months. Post-procedural complications were reported in 2 (6.7%) with bleeding and none with perforation. Upon follow-up, 20 (66.7%) patients reported improvement in their symptoms.

Conclusion

EBD and endoscopic stricturotomy and/or strictureplasty are safe and effective in treating stoma closure site strictures in patients with ileal pouches, providing symptomatic relief in most patients as well as avoiding surgery.

Endoscopic Management of Colonic Obstruction

Large bowel obstruction is a serious event that occurs in approximately 25% of all intestinal obstructions. It is attributed to either benign, malignant, functional (pseudo-obstruction), or mechanical conditions. Benign etiologies of colonic obstructions include colon volvulus, anastomotic strictures, radiation injury, ischemia, inflammatory processes such as Crohn's disease, diverticulitis, bezoars, and intussusception.

Unmet Challenges in Patients with Crohn's Disease

Patients with Crohn's disease can present with a variety of clinical manifestations; treatment strategies should focus on long-term remission and improvement of quality of life. There is no standardized process of diagnosing, predicting prognosis, and treating the disease. This narrative review was based on a literature search using PubMed, Embase, and Science Direct. Data on unmet challenges in patients with Crohn's disease were extracted from identified manuscripts. The aim was to discuss present research on standardized processes in the management of patients with Crohn's disease and to identify the unmet needs in clinical evaluation and treatment approaches. There is no consensus on standardized diagnostic, treatment, and surveillance algorithms, particularly in assessing complications of Crohn's, such as stricturing disease, intestinal cancer risk, and cutaneous manifestations. Complications and treatment failure rates of conventional, interventional, and surgical therapy place emphasis on the need for standardized treatment algorithms, particularly in the case of acute complications of the disease. Research on standardized clinical approaches, reliable biomarkers for disease diagnosis and therapy monitoring, and new treatment agents is necessary to improve therapy and reduce complications in patients with Crohn's disease.

The Promise of Single-Cell RNA Sequencing to Redefine the Understanding of Crohn's Disease Fibrosis Mechanisms

Crohn's disease (CD) is a chronic inflammatory bowel disease with a high prevalence throughout the world. The development of Crohn's-related fibrosis, which leads to strictures in the gastrointestinal tract, presents a particular challenge and is associated with significant morbidity. There are currently no specific anti-fibrotic therapies available, and so treatment is aimed at managing the stricturing complications of fibrosis once it is established. This often requires invasive and repeated endoscopic or surgical intervention. The advent of single-cell sequencing has led to significant advances in our understanding of CD at a cellular level, and this has presented opportunities to develop new therapeutic agents with the aim of preventing or reversing fibrosis. In this paper, we discuss the current understanding of CD fibrosis pathogenesis, summarise current management strategies, and present the promise of single-cell sequencing as a tool for the development of effective anti-fibrotic therapies.

A Review of Colonoscopy in Intestinal Diseases

Since the development of the fiberoptic colonoscope in the late 1960s, colonoscopy has been a useful tool to diagnose and treat various intestinal diseases. This article reviews the clinical use of colonoscopy for various intestinal diseases based on present and future perspectives. Intestinal diseases include infectious diseases, inflammatory bowel disease (IBD), neoplasms, functional bowel disorders, and others. In cases of infectious diseases, colonoscopy is helpful in making the differential diagnosis, revealing endoscopic gross findings, and obtaining the specimens for pathology. Additionally, colonoscopy provides clues for distinguishing between infectious disease and IBD, and aids in the post-treatment monitoring of IBD. Colonoscopy is essential for the diagnosis of neoplasms that are diagnosed through only pathological confirmation. At present, malignant tumors are commonly being treated using endoscopy because of the advancement of endoscopic resection procedures. Moreover, the characteristics of tumors can be described in more detail by image-enhanced endoscopy and magnifying endoscopy. Colonoscopy can be helpful for the endoscopic decompression of colonic volvulus in large bowel obstruction, balloon dilatation as a treatment for benign stricture, and colon stenting as a treatment for malignant obstruction. In the diagnosis of functional bowel disorder, colonoscopy is used to investigate other organic causes of the symptom.

Endoscopic Evaluation and Management of Perianal Disease

Perianal Crohn's disease is associated with decreased quality of life, high morbidity, and high health care use. Treatment goals are to provide infection control, stop fistula drainage, and heal fistula tracts while preserving the anorectal sphincter. Treatment includes a combination of medical and surgical intervention, but new techniques are using interventional endoscopy to act as either a bridge to surgery or to decrease the need for surgical intervention. The decision on which approach to pursue requires knowledge of prior surgery, altered anatomy, prior fistula treatment, and imaging and endoscopic evaluation of fistula complexity, mucosal involvement, and associated stricture or abscess.

Intraoperative Endoscopic Interventions of Inflammatory Bowel Disease

Gastrointestinal endoscopy provides detailed information for diagnosis, differential diagnosis, and disease monitoring and delivers therapy for inflammatory bowel disease. Inflammatory bowel diseases are associated with complications such as strictures, gastrointestinal hemorrhage, fistula, perforation, and abscesses. Endoscopic intervention is a valid therapeutic modality for intestinal strictures and other morbidities. The multisegmental involvement of Crohn's disease, surgically altered bowel anatomy, and the postoperative extensive adhesions have made conventional diagnostic and therapeutic enteroscopy difficult. Intraoperative enteroscopy offers a feasible option for diagnosis and therapy. We report intraoperative enteroscopy in the management of small intestinal strictures and other intestinal morbidities.

Management of Crohn's stricture: medical, endoscopic and surgical therapies

Patients with Crohn's disease are at high risk of presenting with or developing a bowel stricture during the course of their disease. The available therapeutic options to manage a symptomatic Crohn's stricture include medical therapy (mainly biologics), surgical resection and endoscopic interventions. The choice of therapeutic modality depends on the clinical presentation of the stricture, the nature of the stricture (inflammatory vs fibrotic, primary vs anastomotic) and its anatomical characteristics on endoscopy and imaging (length, number, location of strictures and severity of obstruction). The aim herein is to provide an overview of the comprehensive assessment of a Crohn's stricture and to review the indications of the different therapeutic modalities, their success rates and their limitations to help clinicians properly evaluate and manage Crohn's strictures.

Therapeutic Endoscopy in Postoperative Pouch Complications

Ileal pouch-anal anastomosis (IPAA) or "J"-pouch as it is commonly referred to, is the treatment of choice in patients with medically refractory ulcerative colitis. IPAA can have infectious, inflammatory, and mechanical complications. Currently, there are no Food and Drug Administration-approved medical therapies for these complications. Surgery that may be eventually required can have significant morbidities due to the complexity of IPAA. Endoscopy is fast emerging as a leading modality of treatment for some of these pouch complications. Endoscopy in adjunct with medical treatment can help manage the majority of pouch-related disorders and improve the outcome.

The Pathogenesis and Clinical Management of Stricturing Crohn Disease

Stricturing of the gastrointestinal tract is a common complication in Crohn disease and is a significant cause of morbidity and mortality among this population. The inflammatory process initiates fibrosis, leading to aberrant wound healing and excess deposition of extracellular matrix proteins. Our understanding of this process has grown and encompasses cellular mechanisms, epigenetic modifications, and inherent genetic predisposition toward fibrosis. Although medications can improve inflammation, there is still no drug to attenuate scar formation. As such, management of stricturing disease requires a multidisciplinary and individualized approach including medical management, therapeutic endoscopy, and surgery. This review details the current understanding regarding the pathogenesis, detection, and management of stricturing Crohn disease.

Endoscopic management of stricturing Crohn's disease

The natural history of Crohn's disease (CD) usually begins with primary intestinal inflammation, which progresses gradually to stricturing lesions. Stricture is a complicated, intractable but very common clinical problem in the management of CD. Difficulties remain in treating stricturing CD because of the limited efficacy of drug therapy and relapse of stricturing lesions cannot be completely avoided by surgery. Endoscopic management is a bridging therapy between drug therapy and surgical intervention, mainly including endoscopic balloon dilatation and endoscopic stricturotomy, and has been found to be effective for treating stricturing CD. Its explicit curative effect, less invasiveness and high safety performance make endoscopic management more acceptable by both the physician and patient. Although some patients require repeated endoscopic treatment and ultimately cannot avoid surgery, yet it can significantly delay the time to surgery and improve the quality of life. Physicians carrying out the endoscopic procedure need to be trained for performing this procedure. In this review we summarized the diagnosis and endoscopic treatment of stricturing CD.

Endoscopic stricturotomy and ileo-colonic resection in patients with primary Crohn's disease-related distal ileum strictures

Background

Stricture is a common presentation of Crohn’s disease with the site of prevalence being the distal ileum. This study aimed to compare the efficacy and safety of patients with primary distal ileum stricture treated with endoscopic stricturotomy (ESt) vs ileo-colonic resection (ICR).

Methods

All consecutive patients with primary distal ileum stricture that were treated with ESt and/or ICR were extracted from the interventional inflammatory bowel disease (i-IBD) unit from 2001 to 2016. All patients with a stricture >5 cm or those with anastomotic strictures were excluded from the study. The primary outcomes were surgery-free survival and post-procedural complications.

Results

A total of 13 patients receiving ESt and 32 patients receiving ICR were included in this study. Although the length of the stricture is comparable between the two groups (2.4 ± 0.9 vs 3.0 ± 1.1 cm, P = 0.17), patients who received surgery had a more complicated obstruction presented by the high pre-stenosis proximal dilation rate (67.7% vs 9.1%, P = 0.001). All patients in both groups achieved immediate technical success after treatment. The median follow-up durations were 1.8 and 1.5 years in the ESt and ICR groups, respectively. The subsequent surgery rates were similar between the two groups (15.4% vs 18.8%, P = 0.79) and the overall surgery-free survival was also comparable between the two groups (P = 0.98). Post-procedural adverse events were seen in 2/29 ESt procedures (6.9% per procedure) and 8/32 (25.0%) patients receiving ICR (P = 0.05).

Conclusions

ESt achieved comparable stricture-related surgery-free survival as ICR, while ESt had a numerically lower post-operative complication rate.

Endoscopic stricturotomy versus ileocolonic resection in the treatment of ileocolonic anastomotic strictures in Crohn's disease

BACKGROUND AND AIMS

Endoscopic stricturotomy (ESt) is a novel technique in the treatment of anastomotic strictures in Crohn's disease (CD). The aim of this study was to compare the outcome of patients with ileocolonic anastomotic stricture treated with ESt versus ileocolonic resection (ICR).

METHODS

This historical cohort study included consecutive CD patients with ileocolonic anastomotic stricture treated with ESt or ICR from 2010 to 2017. The primary outcomes were surgery-free survival and postprocedural adverse events.

RESULTS

Thirty-five patients treated with ESt and 147 patients treated with ICR were analyzed. Median follow-up was .8 years (interquartile range [IQR], .2-1.7) and 2.2 years (IQR, 1.2-4.4) in the ESt and ICR groups, respectively (P < .001). Subsequent stricture-related surgery was needed in 4 patients (11.3%) receiving ESt and in 15 patients (10.2%) receiving ICR (P = .83). Kaplan-Meier analysis also showed no statistical difference regarding surgery-free survival between the 2 groups (P = .24). Procedure-related major adverse events were documented in 5 of 49 patients (10.2% per procedure) undergoing ESt and 47 patients (31.9%) undergoing ICR (P = .003). Risk factors for decreased surgery-free survival on multivariate analysis included preprocedural corticosteroids (hazard ratio [HR], 2.8; 95% confidence interval [CI], 1.0-8.1), multiple strictures (HR, 4.9; 95% CI, 1.7-14.2), and increased disease-related hospitalizations (HR, 4.0; 95% CI, 1.2-13.0).

CONCLUSIONS

With the limitation of a shorter follow-up, ESt achieved comparable surgery-free survival with a decreased morbidity when compared with ICR.

Clinical outcomes of endoscopic balloon dilatation of intestinal strictures in patients with Crohn's disease

Intestinal strictures are common complications of Crohn's disease (CD). Endoscopic balloon dilatation (EBD) constitutes an alternative therapy to surgery, but associated factors of procedure success are inconclusive. Therefore, we aimed to evaluate the EBD success rate and its associated factors in CD patients.This is a retrospective cohort study of consecutive EBDs that were conducted between 2006 and 2014 among patients with CD with lower gastrointestinal tract strictures. Patients' and stricture characteristics, short term procedure success and related complications at 1 week follow-up, and long-term clinical endpoints were documented.A total of 138 dilatations were performed on 64 CD patients. The overall dilatation success rate was 84.8%, with no difference between primary or anastomotic strictures, or between first or recurrent dilatation procedures. Long strictures (≥4 cm) were negatively associated with successful EBDs, but not with perforations. A multivariate analysis adjusting for age, sex, smoking, and disease duration revealed that a maximal dilatation diameter of ≥15 mm was positively associated with a successful EBD, while an inflamed stricture was negatively associated with procedure success. Strictures which were both long and inflamed were associated with the lowest EBD success rates compared with other strictures. Only 32.8% of patients required surgery during the follow-up period. Long-term prevention of surgery was negatively associated with stricture length and with a successful EBD.EBD is highly successful in treating intestinal strictures and in prevention of surgery in CD patients. Although EBD of long strictures is safe, it will not prevent surgery in the majority of cases.

Ultrasonographic and histopathological features in 8 cats with fibrotic small intestinal stricture

Benign stricture is an uncommon cause of chronic small intestinal obstruction in the cat. The purpose of this retrospective case series was to describe the ultrasonographic features, histopathological findings, and clinical presentation in a group of cats with benign small intestinal stricture. Inclusion criteria were cats presenting during the period 2010-2017, and that had ultrasonography and small intestinal stricture confirmed at surgery. For each cat, clinical data and ultrasonographic findings were retrieved from the medical record, and histopathology, where available, was reviewed. Eight cats met the inclusion criteria. The location of strictures was duodenum (1/8), mid- to distal jejunum (4/8), and ileum (3/8). Ultrasonographic findings included gastric distension (8/8) and generalized (3/8) or segmental (5/8) intestinal dilation consistent with mechanical obstruction. Ingesta did not propagate beyond the strictured segment. Wall thickening was mild to moderate (3-6 mm). Normal wall layering was disrupted in all cats. Strictures were predominantly hypoechoic (7/8) and associated with hyperechoic peri-intestinal mesentery (6/8). Annular strictures (5/8) were less than 15 mm in length whereas long-segment strictures (3/8) were greater than 15 mm in length. Histopathology showed transmural disease with fibrosis and inflammation (8/8), often (6/8) extending into the bordering mesentery. The mucosa was the most severely affected layer and epithelial injury accompanied the mucosal fibrosis/inflammation. Clinical presentation reflected delayed diagnosis of chronic bowel obstruction with debilitation (8/8), marked weight loss (8/8), and prerenal azotemia (5/8). Benign fibrostenotic stricture should be considered a differential diagnosis in debilitated young cats presenting with chronic bowel disease and ultrasonographic features of intestinal obstruction.

Long-Term Outcomes of Endoscopic Balloon Dilation for Benign Strictures in Patients with Inflammatory Bowel Disease

Background/Aims

Benign intestinal strictures are common complications in patients with inflammatory bowel disease (IBD). This study aimed to assess the long-term prognosis of endoscopic balloon dilation (EBD) to treat benign strictures in IBD patients.

Methods

Patients with IBD who had benign strictures and who underwent EBD in four tertiary referral university hospitals between January 2004 and February 2014 were retrospectively reviewed. Technical success was defined as the ability to pass the scope through the stricture after balloon dilation, and clinical success was defined as improved obstructive symptoms.

Results

Forty-two benign strictures were identified in 30 patients (15 males and 15 females). Technical success was achieved in 26 patients (86.7%) at the first EBD attempt and in all 30 patients (100%) at the second EBD attempt. Clinical success was seen in 28 patients (93.3%). The median follow-up duration was 134.8 months (range, 10.2 to 252.0 months), and recurrence occurred in eight patients (26.7%), who required repeat EBD. The median duration to relapse was 1.7 months (range, 0.2 to 6.3 months). During repeat EBD, perforation occurred in two cases (6.7%), which were both clipped successfully. Finally, only one patient (3.3%) underwent surgery for the relief of recurrent obstructive symptoms during the follow-up period.

Conclusions

The experience of 10 years shows that EBD is safe and effective for the treatment of benign strictures in IBD patients. Importantly, EBD may allow long-term effective palliation of the symptoms associated with benign intestinal strictures in IBD patients.

Role of interventional inflammatory bowel disease in the era of biologic therapy: a position statement from the Global Interventional IBD Group

Interventional (or therapeutic) inflammatory bowel disease (IBD) endoscopy has an expanding role in the treatment of disease and surgical adverse events. Endoscopic therapy has been explored and used in the management of strictures, fistulas/abscesses, colitis-associated neoplasia, postsurgical acute or chronic leaks, and obstructions. The endoscopic therapeutic modalities include balloon dilation, stricturotomy, stent placement, fistulotomy, fistula injection and clipping, sinusotomy, EMR, and endoscopic submucosal dissection. With a better understanding of the disease course of IBD, improved long-term impact of medical therapy, and advances in endoscopic technology, we can foresee interventional IBD becoming an integrated part of the multidisciplinary approach to patients with complex IBD.

Management of Crohn's Disease and Complications in Patients With Ostomies

Fecal diversion with ostomy construction can be a temporary or definitive surgical measure for the treatment of refractory inflammatory bowel disease (IBD). However, the fecal diversion surgery is associated with various stoma, peristomal complications, and recurrence or occurrence of de novo small bowel Crohn's disease (CD). Stoma complications often need enterostomal therapy or surgical revision. Peristomal cutaneous lesions, such as pyoderma gangrenosum, usually require immunomodulator or biological therapy. Routine monitoring for occurrence or recurrence of CD with endoscopy or imaging should be performed, and prophylaxis with mesalamines, antibiotics, immunomodulators, or anti-TNFα or anti-integrin agents is needed for patients at risk. Those agents, along with corticosteroids, may also be used for the treatment of CD of the neo-small intestine, particularly inflammatory and fistulizing phenotypes. Endoscopic balloon dilation or endoscopic stricturotomy via stoma is safe and feasible to treat short (<4-5 cm), straight strictures in the neo-small intestine. Medically or endoscopically refractory fibrostenotic disease usually requires surgical intervention, with bowel-sparing stricturoplasty being the surgical treatment of choice.

Interventional IBD: The Role of Endoscopist in the Multidisciplinary Team Management of IBD

Inflammatory bowel disease (IBD) has been traditionally managed by IBD medical doctors or IBDologists and colorectal surgeons. Complications related to IBD and IBD surgery, such as stricture, fistula, and abscess, are common. For the past decade, endoscopic therapy has emerged as a valid treatment option for those complications. Endoscopic therapy provides more effective therapy for those structural complications than medical treatment, while being a less invasive approach than surgery. Endoscopic therapy plays a growing role in bridging medical and surgical therapies and is becoming an important component in the multidisciplinary approach to complex IBD. In fact, endoscopic therapy has become the treatment of choice for anastomotic stricture and anastomotic sinus. The role of endoscopic resection of colitis-associated neoplasia is currently being explored. Interventional IBD is intellectually and technically challenging. We are calling for proper teaching and training of our next generation of IBD interventionists.

Fecal marker levels as predictors of need for endoscopic balloon dilation in Crohn’s disease patients with anastomotic strictures

AIM

To evaluate the accuracy and best cut-off value of fecal calprotectin (FC) and fecal lactoferrin (FL) to predict disease recurrence in asymptomatic patients presenting with anastomotic strictures.

METHODS

This was a longitudinal single tertiary center study based on prospectively collected data (recorded in a clinical database created for this purpose) performed between March 2010 and November 2014. Crohn’s disease (CD) patients with anastomotic stricture who submitted to postoperative endoscopic evaluation were included. Stools were collected on the day before bowel cleaning for FC and FL. Endoscopic balloon dilation (EBD) was performed if the patient presented an anastomotic stricture not traversed by the colonoscope, regardless of patients’ symptoms. Successful dilation was defined as passage of the colonoscope through the dilated stricture into the neotermimal ileum. Postoperative recurrence was defined as a modified Rutgeerts score of ≥ i2b.

RESULTS

In a total of 178 patients who underwent colonoscopy, 58 presented an anastomotic stricture, 86% were asymptomatic, and 48 (54% male; median age of 46.5 years) were successfully dilated. Immediate success rate was 92% and no complications were recorded. FC and FL levels correlated significantly with endoscopic recurrence (P < 0.001) with an optimal cut-off value of 90.85 µg/g (sensitivity of 95.5%, specificity of 69.2%, positive predictive value (PPV) of 72.4%, negative predictive value (NPV) of 94.7% and accuracy of 81%] for FC and of 5.6 µg/g (sensitivity of 77.3%, specificity of 69.2%, PPV of 68%, NPV of 78.4% and accuracy of 72.9%) for FL.

CONCLUSION

Fecal markers are good predictors of CD endoscopic recurrence in patients with asymptomatic anastomotic stricture. FC and FL may guide the need for EBD in this context.

Endoscopic Fistulotomy Heals a Y-Shaped Entero-Entero-Cutaneous Fistula

Patients may develop fistulas due to Crohn’s disease or as a postoperative complication after restorative proctocolectomy with ileal pouch anal anastomosis. Unfortunately, the treatment of fistulas can be challenging. The current standard of care may include medical therapy and/or surgical intervention. However, endoscopic treatment for postoperative pouch complications has emerged as a valid alternative option. We describe a case of persistent drainage from a Y-shaped entero-entero-cutaneous fistula that resolved after endoscopic fistulotomy with needle knife.

Complementary roles of interventional radiology and therapeutic endoscopy in gastroenterology

Acute upper and lower gastrointestinal bleeding, enteral feeding, cecostomy tubes and luminal strictures are some of the common reasons for gastroenterology service. While surgery was initially considered the main treatment modality, the advent of both therapeutic endoscopy and interventional radiology have resulted in the paradigm shift in the management of these conditions. In this paper, we discuss the patient’s work up, indications, and complementary roles of endoscopic and angiographic management in the settings of gastrointestinal bleeding, enteral feeding, cecostomy tube placement and luminal strictures. These conditions often require multidisciplinary approaches involving a team of interventional radiologists, gastroenterologists and surgeons. Further, the authors also aim to describe how the fields of interventional radiology and gastrointestinal endoscopy are overlapping and complementary in the management of these complex conditions.

A review of endoscopic balloon dilatation techniques for treating Crohn's strictures: time to standardise therapy

Endoscopic balloon dilatation (EBD) is a recognised treatment for symptomatic Crohn's disease strictures. Over 3000 procedure are reported in the literature and yet the long term benefits are unclear. This is largely because of different populations, study designs, techniques, types of strictures, the outcome measures used and follow-up periods. Areas covered: We summarised the techniques reported in the literature based on a systematic review and key factors that may influence outcome: pre-intervention imaging, stricture length and type, balloon size in relation to intestinal lumen diameter, duration of dilatation, frequency of repeat dilatation and instructions on follow-up. Expert commentary: We noted that shorter, non-ulcerated and anastomotic strictures fare better and 2 mins dilatation duration was the commonest technique used without an increased risk of complications. The findings were translated into a standardised protocol and a management pathway to guide clinicians on the therapeutic strategy for Crohn's strictures. To resolve the uncertainty about long-term benefits, future studies should adopt a replicable standardised EBD technique, define degree of fibrosis to decide therapy accordingly, compare it to alternative interventions (strictureplasty or stents) within a randomised controlled trial and apply a validated outcome measure to include intestinal damage and quality of life.

Heterogeneity in endoscopic treatment of Crohn's disease-associated strictures: An international inflammatory bowel disease specialist survey

BACKGROUND

Crohn's disease (CD) is frequently complicated by intestinal strictures, which are commonly treated by endoscopic balloon dilation (EBD). However, available data on this area of treatment is limited. The aim of this study was to depict the heterogeneity of endoscopic management of CD-associated strictures among international CD specialists to identify common treatment standards.

METHODS

IBD experts of the International Organization for the Study of Inflammatory Bowel Disease (IOIBD), the European Crohn's and Colitis Organization (ECCO), and from the Prospective Value In IBD trials (PROVIT) completed a web-based questionnaire to evaluate their endoscopic experience, practice setting, and number of EBDs performed annually. Additionally, two case scenarios and technical practice parameters were investigated.

RESULTS

A total of 126 subjects from 15 countries completed the survey. The maximal length of dilated stricture was 4.5 ± 1.7 cm. The most commonly used maximal balloon size was graded as 15-18 mm. While 87.2 % of the participants favored EBD for anastomotic strictures, only 58.6 % did so in the case of naïve strictures. Only 35.7 % of physicians dilated actively inflamed strictures. Interventional endoscopists were more likely to dilate only clinically symptomatic strictures (p = 0.046). Surgeons favored surgical treatment of de novo ileocecal strictures compared to gastroenterologists (p = 0.026), reported a shorter stricture length being amendable by EBD (p = 0.045), and more frequently used concomitant therapies (p = 0.001). Operator experience increased the likelihood of EBD use in actively inflamed strictures (p = 0.002), maximum length of stricture, and maximum balloon size (p = 0.001).

CONCLUSIONS

EBD is a widely used treatment approach for stricturing CD. Individual approaches differ significantly based on background of the operator, experience level, and practice setting.

Endoscopic Evaluation and Management of the Postoperative Crohn's Disease Patient

Approximately 70% of patients with Crohn's disease (CD) undergo surgical resection for the treatment of medically refractory disease or its complications. The sickest cohort of CD patients experience rapid postoperative relapse at the anastomotic site. Over the past 2 decades, the types of surgical anastomoses used in CD reconstruction have changed; end-to-side and end-to-end anastomoses have been surpassed by the more rapidly created side-to-side anastomoses. This article provides a review of the timing and purpose of endoscopic evaluation in postoperative CD patients and pragmatic information regarding interpretation of endoscopic findings at the different types of surgical anastomoses after ileocecal resection.

Endoscopy in the Diagnosis and Management of Complications of Inflammatory Bowel Disease

The role of endoscopy in inflammatory bowel disease (IBD) has grown over the last decade in both diagnostic and therapeutic realms. It aids in the initial diagnosis of the disease and also in the assessment of the extent and severity of disease. IBD is associated with development of multiple complications such as strictures, fistulae, and colon cancers. Endoscopy plays a pivotal role in the diagnosis of colon cancer in patients with IBD through incorporation of chromoendoscopy for surveillance. In addition, endoscopic resection with surveillance is recommended in the management of polypoid dysplastic lesions without flat dysplasia. IBD-associated benign strictures with obstructive symptoms amenable to endoscopic intervention can be managed with endoscopic balloon dilation both in the colon and small intestine. In addition, endoscopy plays a major role in assessing the neoterminal ileum after surgery to risk-stratify patients after ileocolonic resection and assessment of a patient with ileoanal pouch anastomosis surgery and management of postsurgical complications. Our article summarizes the current evidence in the role of endoscopy in the diagnosis and management of complications of IBD.

Biodegradable stents for the treatment of bowel strictures in Crohn's disease: technical results and challenges

BACKGROUND AND STUDY AIMS

In patients with Crohn's disease, the idea of biodegradable stents for treatment of bowel strictures with limited effect of endoscopic balloon dilation is tempting and initial results have been promising. The aim of this study was to evaluate the technical and clinical success of biodegradable stents for treatment of inflamed Crohn's strictures refractory to endoscopic balloon dilatation.

PATIENTS AND METHODS

Consecutive patients treated with biodegradable stents due to Crohn's disease and inflamed bowel strictures refractory to endoscopic balloon dilatation were included. Technical and clinical success were evaluated.

RESULTS

Six patients were included in the study. Technical success was obtained in five patients (83 %). Clinical success was limited to one patient (20 %); failure was observed due to mucosal overgrowth (n = 2), stent migration (n = 1), and stent collapse (n = 1).

CONCLUSIONS

In Crohn's disease, it is technically feasible to treat bowel strictures with biodegradable stents. However, we have stopped using biodegradable stents due to lack of clinical success and side effects such as mucosal overgrowth and stent collapse.

Assessment of stricturing Crohn's disease: Current clinical practice and future avenues

Crohn’s disease (CD) is a chronic remittent idiopathic disease. Although the early phase of the disease is commonly characterized by inflammation-driven symptoms, such as diarrhea, the frequency of fibrostenotic complications in patients with CD increases over the long-term course of the disease. This review presents the current diagnostic options for assessing CD-associated strictures. In addition to the endoscopic evaluation of CD strictures, this review summarizes the currently available imaging modalities, including ultrasound and cross-sectional imaging techniques. In addition to stricture detection, differentiating between the primarily inflammatory strictures and the predominantly fibrotic ones is essential for selecting the appropriate treatment strategy (anti-inflammatory medical treatment vs endoscopical or surgical approaches). Therefore, recent imaging advances, such as contrast-enhanced ultrasound and ultrasound elastography, contribute to the development of non-invasive non-radiating imaging of CD-associated strictures. Finally, novel magnetic resonance imaging techniques, such as diffusion-weighted, motility and magnetization transfer imaging, as well as ¹⁸F-FDG PET/CT, molecular imaging approaches and biomarkers, are critically reviewed with regard to their potential role in assessing stricturing CD.

Endoscopic balloon dilatation of Crohn's-associated intestinal strictures: High patient satisfaction and long-term efficacy

INTRODUCTION

Stricture formation is a common long-term complication of Crohn's disease. Endoscopic balloon dilatation offers a bowel-sparing treatment option, but long-term outcome and its association with patient-, stricture-, and procedure-related factors is only poorly understood. Patient satisfaction with endoscopic balloon dilatation is largely unknown.

METHODS

We performed a retrospective review of all endoscopic balloon dilatation for Crohn's disease-related strictures between January 2005 and January 2013. Long-term outcome, complication rates and predictive factors were evaluated. Patient satisfaction was assessed using a questionnaire and telephone interviews.

RESULTS

A total of 118 balloon dilatations were performed for 69 strictures in 46 patients. One patient was excluded from further analysis due to malignancy. Median time from diagnosis of Crohn's disease to symptomatic stricture formation was 19 years. Technical success, defined as passage of the endoscope after dilatation, was reportedly obtained in 95 of 106 procedures (89.6%). Two perforations occurred, one of which could be managed conservatively. No episodes of severe bleeding were recorded (procedure-related complication rate: 2/118; 1.7%). During a median follow-up of 4.8 years (range 0.4-8.7), 55.6% (25/45) of patients were able to avoid surgery. Of the patients, 35.6% (16/45) did not need any further intervention, 40.0% (18/45) underwent more than one dilatation, and 24.4% (11/45) were operated after the first dilatation. The percentage of patients who were satisfied with the procedure and would again opt for balloon dilation as first line therapy was 83.3% (35/42). None of the risk factors examined in this study correlated with the necessity for subsequent surgery.

DISCUSSION

Endoscopic balloon dilatation is a safe and effective first line therapy for Crohn's disease-related strictures. No technical, stenosis-, or patient-related factor reliably predicted sustained dilatation success. Patient satisfaction was high.

Endoscopic Therapy in Inflammatory Bowel Diseases

Background

Endoscopy is an essential diagnostic and therapeutic modality in the clinical care of inflammatory bowel disease (IBD) patients. Endoscopic therapy can be used for treatment of disease-related strictures, surveillance and resection of intraepithelial neoplasia, and treatment of fistulas or disease-related complications, and is currently being evaluated regarding its capacity in in vivo molecular imaging procedures.

Methods

A literature search using Medline and Science Citation Index was performed in March 2015. All studies on endoscopic therapy in IBD published from 1980 to 2015 (March) were reviewed. Potential studies were initially screened by title and abstract. The terms ‘endoscopy IBD’, ‘endoscopy therapy IBD’, ‘dilatation IBD’, ‘strictureplasty Crohn's disease’, ‘endoscopy therapy fistula’, ‘endoscopy toxic megacolon’, ‘endoscopy dysplasia IBD’, ‘endoscopy complications IBD’, and ‘molecular imaging IBD’ were used in the search. A total of 115 articles were studied to construct this review.

Results

Dilatation is most useful in short anastomotic strictures, but can be also undertaken in colonic strictures. Strictures in ulcerative colitis are always suspicious for neoplasia and should be evaluated carefully. Lesions with intraepithelial neoplasia can be resected when complete removal can be assured. The finding of carcinoma or high-grade dysplasia in a random biopsy is an indication for colectomy. If intraepithelial neoplasia is present in random biopsy specimens, colectomy should similarly be recommended. Endoscopic therapy of Crohn's fistulas is a possible emerging technology. In vivo molecular imaging is currently being studied in IBD patients and offers promising therapeutic opportunities.

Conclusion

Therapeutic endoscopy is indispensable in the management of IBD. It has to be carefully evaluated against alternative surgical options but often offers an effective therapeutic approach.

© 2015 S. Karger GmbH, Freiburg

Therapeutic Armamentarium for Stricturing Crohn's Disease: Medical Versus Endoscopic Versus Surgical Approaches

One-third of patients with Crohn's disease (CD) present as stricturing phenotype characterized by progressive luminal narrowing and obstructive symptoms. The diagnosis and management of these patients have been intriguing and challenging. Immunomodulators and biologics have been successfully used in treating inflammatory and fistulizing CD. There are issues of efficacy and safety of biological agents in treating strictures in CD. Rapid mucosal healing from potent biological agents may predispose patients to the development of new strictures or worsening of existing strictures. On the other hand, strictures constitute one-fifth of the reasons for surgery in patients with CD. Disease recurrence is common at or proximal to the anastomotic site with the majority of these patients developing new endoscopic lesions within 1 year of surgery. The progressive nature of the disease with repetitive cycle of inflammation and stricture formation results in repeated surgery, with a risk of small bowel syndrome. There is considerable quest for bowel conserving endoscopic and surgical strategies. Endoscopic balloon dilation and stricturoplasty have emerged as valid alternatives to resection. Endoscopic balloon dilation has been shown to be feasible, safe, and effective for the short primary or anastomotic strictures. However, repeated dilations are often needed, and long-term outcomes of endoscopic balloon dilation remain to be investigated. The introduction of stricturoplasty has added another dimension to bowel saving strategy. Although postoperative recurrence rate after stricturoplasty is comparable with surgical resection, there are concerns for increased risk of malignancy in preserved bowel. Laparoscopic surgery has widely been performed with similar outcomes to open approach with fewer complications, quicker recovery, better cosmesis, and lower cost. All of these issues should be considered by physicians involved in the management of patients with stricturing CD.

Endoscopic Therapy in Crohn's Disease: Principle, Preparation, and Technique

Stricture and fistula are common complications of Crohn's disease. Endoscopic balloon dilation and needle-knife stricturotomy has become a valid treatment option for Crohn's disease-associated strictures. Endoscopic therapy is also increasingly used in Crohn's disease-associated fistula. Preprocedural preparations, including routine laboratory testing, imaging examination, anticoagulant management, bowel cleansing and proper sedation, are essential to ensure a successful and safe endoscopic therapy. Adverse events, such as perforation and excessive bleeding, may occur during endoscopic intervention. The endoscopist should be well trained, always be cautious, anticipate for possible procedure-associated complications, be prepared for damage control during endoscopy, and have surgical backup ready. In this review, we discuss the principle, preparation, techniques of endoscopic therapy, as well as the prevention and management of endoscopic procedure-associated complications. We propose that inflammatory bowel disease endoscopy may be a part of training for "super" gastroenterology fellows, i.e., those seeking a career in advanced endoscopy or in inflammatory bowel disease.

Endoscopic evaluation of surgically altered bowel in patients with inflammatory bowel diseases

Patients with inflammatory bowel diseases often undergo surgical procedures for medically refractory disease or colitis associated dysplasia. Endoscopic evaluation of the surgically altered bowel is often needed to assess for disease recurrence, its severity, and for therapy. It is important to obtain and review the operative report and abdominal imaging before performing the endoscopy. Diagnostic and therapeutic endoscopy can be safely performed in most patients with inflammatory bowel disease with altered bowel anatomy under conscious sedation without fluoroscopy. Carefully planned stricture therapy with balloon dilation or needle knife stricturotomy can be performed for simple, short, and fibrotic strictures. A multidisciplinary approach involving a team of endoscopist, endoscopy nurse, colorectal surgeon, gastrointestinal pathologist, and gastrointestinal radiologist is important for a safe and effective endoscopy. We attempt to review the aspects that need consideration before the endoscopy, the technique of endoscopy, and briefly the therapies that can be performed during endoscopy of the bowel through an ileostomy, a colostomy, in the diverted large bowel or ileal pouch, and small bowel after stricturoplasty and bowel bypass surgery in patients with inflammatory bowel diseases.

Intestinal stricture in Crohn's disease

Crohn's disease (CD) is a disease with chronic inflammation of unknown etiology involving any part of the gastrointestinal tract. The incidence and prevalence of CD are increasing recently in Asia. Half of the CD patients will have intestinal complications, such as strictures or fistulas, within 20 years after diagnosis. Twenty-five percentage of CD patients have had at least one small bowel stricture and 10% have had at least one colonic stricture and lead to significant complications. Most of these patients will require at least one surgery during their lifetime. Early diagnosis and evaluation with adequate managements for the patients can prevent disability and mortality of these patient. Here, we reviewed the current incidence of CD with stricture, the etiology of stricture, and how to diagnose and manage the stricture.

Endoscopic and medical management of fibrostenotic Crohn's disease

Crohn's disease (CD) is a disease characterized by acute inflammation at diagnosis which evolves toward a more fistulizing and fibrostenotic disease phenotype over time. This leads to a high risk of bowel resections and ultimately short bowel with diarrhea and malabsorption, which represents a major part of the burden inflicted by CD. Bowel-conserving endoscopic and surgical procedures have therefore been developed. Specific antifibrotic medical therapies are currently lacking. Through-the-scope endoscopic balloon dilation has been described in several cohorts as an alternative to surgical resection or stricturoplasty in selected patients. Efficacy of endoscopic dilation is high, with an immediate success rate of 78% (between 73 and 100%), defined as the ability to pass with the scope through the stricture. However, symptomatic recurrence is frequent, with need for new dilatation in 41% and need for surgery in 42%, with a mean interval of 15 months. Adjunctive techniques such as local steroid or anti-TNF injections or stenting have not been conclusively proven to be of added benefit. We usually reserve endoscopic dilation for patients with short strictures (<5 cm) and nonpenetrating disease, preferably at the ileocolonic anastomosis. Similar to other interventions in endoscopy, endoscopic dilation has an intrinsic risk of complications which can be estimated at 2%. Balloon size and patient selection can serve to increase safety.

Comparison of noncontrast MRI magnetization transfer and T2 -Weighted signal intensity ratios for detection of bowel wall fibrosis in a Crohn's disease animal model

PURPOSE

To compare the abilities of magnetization transfer magnetic resonance imaging (MT-MRI) and T2 -weighted signal intensity (T2 WSI) ratios to detect intestinal fibrosis in a Crohn's disease animal model.

MATERIALS AND METHODS

Ten rats ("Group 1") received one trinitrobenzenesulfonic acid enema to induce acute colonic inflammation, while 10 additional animals ("Group 2") received multiple enemas to induce colonic inflammation and fibrosis. Gradient recalled-echo MT-MRI (5 and 10 kHz off-resonance) and T2 -weighted spin-echo imaging were performed 2 days after the last enema. MT ratios (MTR) and T2 WSI ratios were calculated in the area of greatest colonic thickening. Bowel wall MTR, bowel wall MTR normalized to paraspinous muscle MTR ("normalized MTR"), and T2 WSI ratios were compared between animal groups using Student's t-test.

RESULTS

At 10 kHz off-resonance, mean bowel wall MTR for Group 1 was 24.8 ± 3.1% vs. 30.3 ± 3.2% for Group 2 (P = 0.001). Mean normalized MTR was 0.45 ± 0.05 for Group 1 and 0.58 ± 0.08 for Group 2 (P = 0.0003). At 5 kHz off-resonance, mean bowel wall MTR for Group 1 was 34.7 ± 5.2% vs. 40.3 ± 3.6% for Group 2 (P = 0.015). Mean normalized MTR was 0.53 ± 0.08 for Group 1 and 0.64 ± 0.07 for Group 2 (P = 0.003). Mean T2 WSI ratio was 5.32 ± 0.98 for Group 1 and 3.01 ± 0.66 for group 2 (P < 0.0001). Mean T2 WSI ratio/MTR (10 kHz off-resonance) was 12.06 ± 2.70 for Group 1 and 5.22 ± 1.29 for Group 2 (P < 0.0001), with an ROC c-statistic of 0.98.

CONCLUSION

MTR and T2 WSI ratios detect bowel wall fibrosis in a Crohn's disease animal model.

Endoscopic treatment of Crohn's complications

The progression to fistula and strictures is part of the natural history of Crohn's disease (CD) and these complications negatively affect the quality of life of CD patients. Surgery is the traditional treatment of CD strictures. However, due the chronicity of the inflammatory process and the associated fibrosis, postoperative recurrence occurs frequently. The lack of specific drug to treat fibrotic strictures and their irreversible nature has drawn the attention to less invasive and bowel-sparing therapeutic modalities. Endoluminal therapies may provide effective option in relieving symptoms associated with CD complications and reduce the need for repeated surgery with substantial clinical benefit. This review will discuss the current use and efficacy of the endoscopic treatment of CD complications. New endoscopic modalities and recent advances will be also evaluated.

Comparable short- and long-term outcomes of colonoscopic balloon dilation of Crohn's Disease and benign non-Crohn's Disease strictures

BACKGROUND

The response of Crohn's disease (CD) stricture to endoscopic therapy compared with non-CD stricture is unknown. Our aim was to compare the short- and long-term outcomes of endoscopic management of those strictures.

METHODS

All eligible patients with benign non-CD strictures who underwent the endoscopic balloon dilation between January 2002 and September 2013 were included. Patients with CD strictures were randomly selected with a ratio (CD versus non-CD strictures) of 2:1.

RESULTS

A total of 90 patients were included, including 30 (33.3%) with non-CD strictures and 60 (66.7%) with CD strictures. Patients with CD strictures were younger than those with non-CD strictures at the time of disease diagnosis (25.8 ± 11.1 versus 50.5 ± 17.5; P < 0.001) and at the time of the first dilation (43.9 ± 12.4 versus 55.8 ± 13.9; P < 0.001). There were no significant differences in characteristics of strictures and their endoscopic treatments between the CD and non-CD groups, except for the percentage of patients who were ever treated with intralesional corticosteroid injection (25.0% versus 6.7%, P = 0.046). Patients in the 2 groups had similar technical success rates (94.0% versus 93.9%, P = 1.00). Few patients in CD stricture group required emergency room visits due to obstructive symptoms from recurrence of disease (1.7% versus 16.7%, P = 0.02). There were on procedure-related complications in either of the 2 groups.

CONCLUSIONS

The efficacy and safety of endoscopic balloon dilation in the treatment of CD and non-CD strictures seemed to be comparable.