Crohn's disease associated strictures

Abstract

Crohn's disease (CD) is a chronic relapsing and remitting disease that can affect any segments of the gastrointestinal tract. More than 50% of patients with CD develop stricturing or penetrating complications within the first 10 years after diagnosis. Strictures can lead to intestinal obstruction, which is a common indication for surgery. Despite significant advances in the understanding of the pathogenesis of intestinal fibrostenosis, imaging and therapeutic armamentarium of CD, the risk of intestinal surgery remained significantly high. Endoscopic balloon dilation is a promising first-line alternative to surgery as it is less invasive and could preserve intestinal length. In this review, we will evaluate the literature on the mechanism of intestinal fibrosis, emerging imaging techniques, and management strategies for CD associated strictures.

Fibrostenotic strictures in Crohn’s disease

“…Inflamed bowel tissue has a higher cellular density limiting water diffusion and is expressed by a low ADC and a high signal on MR images. 13,128,129 In a study of 20 CD patients undergoing surgery, there was a trend toward a decrease in ADC values being correlated with acute inflammation, but this was not significant. Interestingly, the decrease in ADC values was significantly (P = 0.023) associated with histologic fibrosis, which suggests that the increase in fibrosis decreases the extracellular space and, therefore, restricts the diffusion of water molecules in the strictured bowel wall.…”

“…Intestinal fibrosis results from dysregulated wound healing of the bowel wall. 13,14 In physiologic wound healing, tissue repair mechanisms restore normal structure from damaged tissues by a controlled response. 15 On the other hand, fibrosis results from an aberrant wound healing characterized by excessive deposition of the ECM, which is promoted by an increase in the number of mesenchymal cells, including fibroblasts, myofibroblasts, and smooth muscle cells.…”

“…2 Due to the transmural inflammation in CD, both fibrosis and smooth muscle hyperplasia/hypertrophy can affect all layers of the intestine from mucosa to serosa. 13,16,19 Among these layers, fibrosis appears to be the most prominent in the submucosa, followed by the mucosa, but minimal in the muscularis propria. In contrast, smooth muscle hyperplasia/hypertrophy appears to be predominant in the muscularis mucosa and propria.…”

String sign of Kantor in a patient with Crohn�s disease

“…Stricturing CD can be classified according to whether or not there is a previous history of surgery ( de novo or anastomotic) and according to the composition of strictures (inflammatory, fibrotic and mixed types) (1). It is the second indication for surgery, after failure of medical treatment.…”

“…Cristina Rubín-de-Célix-Vargas 1 , Paula Martín-García 1 , Lourdes de-Campo 2 and Luisa García-Buey 1 Departments of 1 Gastroenterology y 2 Radiology. Hospital Universitario de la Princesa.…”