Dangers associated with endoscopic management of strictures in IBD

Abstract

A clear cause and cure for Crohn's disease (CD) continues to elude caregivers and researchers alike, much to the frustration of these frequently youthful and usually very symptomatic patients. The experienced clinician recognizes that he or she is frequently treating only the complications of CD and not the disease itself. Thus, drugs are used to quell mucosal inflammation and to treat foci of sepsis (fistuli and abscesses) without knowing what is actually causing the inflammation or abscesses.One of the most symptomatic of CD complications is intestinal obstruction brought about by either severe inflammation compromising the lumen of the bowel or a fibrotic stricture, the result of "burnt out" inflammation and scarring. Such bowel obstruction can present as an acute emergency but more often is manifest as recurrent, crampy abdominal pain aggravated by oral intake, especially of high-fiber foods. Twenty percent of CD patients will have small bowel strictures, usually near the terminal ileum, while about another 10% will have colonic strictures. 1 Such symptomatic strictures, when inflammatory, should be treated with appropriate antiinflammatory medications. When nonresponsive to medical management or when fixed and fibrotic, surgical resection and anastomosis can provide dramatic relief, especially in the case of ileocolic disease. However, such surgery will commonly be followed by recurrence of disease, initially inflammatory, subsequently fibrotic, precipitating the need for recurrent surgery in Ϸ50% of patients at 10 years. 2-4 Such recurrence is more a failure of effective medical management than it is of surgery. Regardless, this repetitive cycle of relapsing inflammation, stricturing, and the need for surgical resection can potentially result in short gut with the associated cumulative risk of numerous surgical procedures. In this context the concept of a nonsurgical endoscopic technique to relieve the obstructive symptoms of intestinal stricturing has intuitive appeal. Unfortunately, this attractive first impression must be tempered with some of the realistic problems associated with the technique. SUMMARY OF TECHNIQUE AND OUTCOMESThe technique of endoscopic balloon dilatation is widely variable, based largely on the preference and experience of the endoscopist. 5 Obviously, the stricture must be reachable, so most are either colonic or ileocolic and not infrequently an anastomotic stricture after previous operative ileocolectomy. Some clinicians dilate using balloon diameters to as large at 25 mm 3 , but most will dilate only to 18 or 20 mm, citing a lower complication rate. Insufflation is usually held for several (1-4) minutes, and then the balloon is deflated and the process repeated several times until an adequate lumen is appreciated visually. Sometimes successful dilatation is defined by the subsequent passage of the colonoscope (about 13 mm in diameter) through the stricture, but this is inconsistent in the literature and not necessarily associated with a higher symptomatic relief rate. Frequently,...

Endoscopic management of intestinal strictures in Crohnʼs disease

“…physician who will not immediately operate on a bowel perforation in these usually immunosuppressed and relatively malnourished patients.… It is a challenge for the surgeon to successfully salvage these individuals and then safely return their gastrointestinal tract to continuity."). 1 An invaluable observation here, though, is that the acutely or chronically ill patient is at high risk of complications from any aggressive intervention.…”

“…1,2 The salient, albeit limited and uncontrolled, series are cited and reviewed, and there is agreement on the most important practical consideration, that is, the type of patient and type of stricture most likely to benefit from endoscopic dilation-a symptomatic, relatively short, straight, endoscopically accessible, benign, preferably fibrotic (rather than inflammatory and ulcerated) stricture, in a patient who is not acutely ill. These features are most commonly found in a patient with a stricture at a postsurgical ileocolic anastamosis.…”

Endoscopic Balloon Dilation for Crohn’s Disease-Associated Strictures

“…The advantage of an EBD is that it is a safe and bowel-conserving procedure, particularly useful in the treatment of short stenosis [ 9 ]. However, disadvantages of an EBD include the probable need for repeated dilations, as well as the need for surgery following dilation in a significant number of patients [ 10 ]. These controversial points of view have led to differing/variable indications for an EBD in clinical practice as shown by Bettenworth et al, indicating that surgeons, when compared to gastroenterologists, favor surgery for de novo strictures [ 11 ].…”

Role of Biologics and Other Therapies in Stricturing Crohn’s Disease: What Have We Learnt So Far?

“…The management of anastomotic (post-surgical) strictures by endoscopic dilation in selected patients with a short fibrotic narrowing, favorable anatomy and in the absence of severe inflammation has been proven relatively effective and safe [60, 61] even though the procedure must often be repeated with time [62]. The use of this technique in the other CD-related strictures (see below) remains controversial [63, 64]. In a purely inflammatory stenosis the evidence reviewed above suggests that infliximab may not only be effective but it may actually represent the indication of choice.…”