Efficacy of drug and endoscopic treatment of Crohn's disease strictures: A systematic review

Abstract

Background and Aims Strictures are the commonest complication in Crohn's disease. Surgery and endoscopic dilation are the mainstays of treatment, while drug therapy has often been considered contraindicated. The benefit of nonsurgical treatments, particularly drug and endoscopic therapy, need to be defined. Methods Ovid MEDLINE, Embase, Emcare, PsycINFO, CINAHL and the Cochrane Library (inception until August 30, 2019) were searched. Studies with ≥ 10 patients with Crohn's disease strictures, reporting on outcomes following medication or endoscopic treatment, were included. Results Of 3480 records, 85 studies met inclusion criteria and formed the basis of this analysis. Twenty‐five studies assessed drug therapy; none were randomized trials. Despite study heterogeneity anti‐tumor necrosis factor (TNF) therapy appeared effective, with 50% of patients avoiding surgery after 4 years of follow up. No other drug therapy was of demonstrable benefit. Sixty studies assessed endoscopic therapy including 56 on endoscopic balloon dilation, two assessed needle knife stricturotomy, and two stent insertion. Dilation was equally effective for de novo and anastomotic strictures ≤ 5 cm in length, with most studies reporting a subsequent surgical rate of 30% to 50%. Repeat dilation was required in approximately half of all patients. Conclusions Anti‐TNF drug therapy and endoscopic balloon dilation are effective strategies for avoiding surgery in patients with stricturing Crohn's disease. Additional endoscopic therapies require further evaluation. Early data suggest that combining these therapies may provide greater benefit than individual therapies. Optimization of current drug and endoscopic therapy, and the incorporation of newer therapies, are needed for stricturing Crohn's disease.

Ultrasound Elastography in the Assessment of the Intestinal Changes in Inflammatory Bowel Disease—Systematic Review

“…Despite the huge progress in the implementation of novel therapeutic agents into clinical practice, it was demonstrated that they do not influence the occurrence of fibrosis. In a recently published systematic review on nonsurgical therapy of CD-related strictures from among drug therapy only, anti-TNFα agents appeared to be effective in preventing surgery as during 4 years of follow-up, 50% of patients could escape operation [ 37 ]. Unfortunately, antifibrotic therapy is not available.…”

Intestinal stricture in Crohn's disease: A 2020 update

“…However, results of the combination of anti‐TNF therapy and endoscopic treatment or surgery are still conflicting. Several studies have found that anti‐TNF agents applied before or after endoscopic balloon dilatation (EBD) contribute to a lower risk of bowel surgery and intestinal stricture recurrence 75‐77 . In contrast, a comparative pilot study has demonstrated that there is an increased risk of fibrosis in patients who undergo preoperative anti‐TNF‐α treatment 78 .…”

The Use of Fecal Calprotectin and Intestinal Ultrasound in the Evaluation and Management of Stricturing Crohn’s Disease in Pregnancy

“…Obstructive symptoms such as postprandial pain, early satiety, nausea, and vomiting are reliable clinical predictors of need for surgery in stricturing CD. 1 Unfortunately, the latter are common symptoms in pregnancy, with nausea and vomiting of pregnancy (NVP) and pregnancy-related constipation affecting up to 80% and 35% of women respectively. 3 Furthermore, abdominal examination is of limited sensitivity due to displacement of abdominal structures by the gravid uterus.…”

“…2 Evidence supporting corticosteroid use for symptomatic strictures is limited, even in nonpregnant CD patients. 1 Approximately two-thirds of hospitalized nonpregnant patients treated with corticosteroids for symptomatic stricturing CD progress to surgical intervention during their index admission. 1 If prednisolone response is suboptimal, symptoms flare on steroid wean ,or repeated courses are required, immediate escalation to anti-TNF treatment is recommended.…”

“…1 Approximately two-thirds of hospitalized nonpregnant patients treated with corticosteroids for symptomatic stricturing CD progress to surgical intervention during their index admission. 1 If prednisolone response is suboptimal, symptoms flare on steroid wean ,or repeated courses are required, immediate escalation to anti-TNF treatment is recommended. The commencement of thiopurines in pregnancy is not advised due to their slow onset of action and side effects including hepatitis and acute pancreatitis.…”