Introduction Intestinal strictures are a known complication of Crohn's disease (CD) and may be inflammatory (in part), fibrostenotic or post-operative (anastomotic). Treatment options include a combination of medical, endoscopic or surgical interventions. We performed a retrospective analysis of our radiological assessment and endoscopic management of CD related strictures. Methods A retrospective review of adult patients who underwent balloon dilatation of CD related strictures by a single endoscopist at our institution. All patients underwent MR enterography prior to endoscopic assessment. Where necessary strictures were dilated under fluoroscopic screening. Endoscopic success was defined as the ability to traverse the stricture endoscopically after dilatation. Clinical success was defined as improvement in patients symptoms at follow-up. Complications, need for escalation of medical therapy, further dilatation or surgical intervention were recorded. Results A total of 56 dilatations were performed in 30 patients (range 1e5). Mean age was 47.5 years. 16 were females. Mean duration of disease was 209 months (range 14e444). Mean follow-up was 29.5 months (range 1e135). 27/30 (90%) had at least one previous CD surgical resection (range 0e6, mean 1.96 per patient). The site of the strictures were ileo-colonic in 21/30 (70%), colonic 3/30 (10%), gastro-duodenal 3/30 (10%), ileo-rectal 2/30 (7%) and ileal pouch stricture in 1/30 (3%). Stricture lengths at MRE were 6 cm, a length deemed significant as this is the length of the colonoscopic balloons. At MRE 17 (57%) of strictures were deemed to have an inflammatory component and 13 (43%) fibrostenotic. There was correlation between MRE and endoscopic findings of the nature of the stricturing (inflammatory vs fibrostenotic) in 26/30 (87%) of cases. Fluoroscopic screening was used in 21/30 (70%) of cases. Dilatation endoscopically successful in 27/30 (90%) cases and clinically successful in 26/30 (87%) of cases. No dilatation was performed in one case due to technical difficulties and this patient ultimately required surgical resection. Fourteen patients (47%) required repeated dilatations for symptom recurrence (range 2e5 dilatations). 17 patients (57%) had an escalation of their medical therapy after dilatation. A total of 5/30 (17%) ultimately required elective surgery for symptom recurrence. Conclusion MRE enterographic assessment of CD related strictures correlates well with endoscopic findings. Fluoroscopic screening facilitates safe and effective dilatation of CD related strictures which, together with optimising medical therapy, can reduce the need for surgical intervention.
Introduction Previous studies with anti-TNF drugs 1-3 for Crohn's disease (CD) showed a reduction in cost by reducing hospitalisations, examinations under anaesthetic (EUA) and diagnostic procedures. However no study has looked at the effect of anti-TNF drug dosing schedule on outcomes and resource use. Methods Retrospective study using patient records, in 5 UK hospitals. Consenting patients aged>18 with a diagnosis of CD who had started any anti-TNF drug >1 year prior to study, with records for >2 years pre-anti-TNF were included. Data were collected for 2 years pre-anti-TNF and 1 year post-anti-TNF initiation on hospital resource use associated with CD. Outcomes measured were change in steroid use, rates of surgery and change in disease state at 1 year versus baseline. Results Of 142 patients in the study (61% female) 121 (85%) started anti-TNF drug in [2005][2006][2007][2008][2009]. The prescribing pattern changed from 78% episodic dosing (ED) in 2003 to 79% maintenance dosing (MD) in 2009. Anti-TNF was started a median of 8.7 years (IQR 12.6 years) after diagnosis, with patient median age at initiation 34 years (IQR 18 years). At 1 year, 77% of patients had improved disease, 12% worse and 11% remained the same. Steroids were stopped in 23% and reduced in 23% at 1 year; more in the MD group (32%) than in the ED group (12%). Rates of major abdominal surgery were similar pre-anti-TNF and post-anti-TNF (0.06 in Y-1 and 0.10 in Y+1). Overall, NHS resource use was similar pre-anti-TNF and post-anti-TNF, for all visit types except day case visits which increased (mean 0.7/year pre vs 5.9/year post) for infl iximab infusions. In the MD group there was a NS trend to fewer admissions (mean 0.65/year pre vs 0.42/year post), bed days (4.9 vs 3.6/year), OP visits (7.5 vs 6.4), EUA (1.1 vs 0.8) and A&E visits (0.2 vs 0.1) post-anti-TNF and 72% of MD patients had reduced non-drug direct costs in the post-anti-TNF year. Conclusion In this study CD of patients treated with antiTNFs improved and steroid use was reduced, particularly with MD but it did not show the reduction in resource use or major surgery seen in previous work. [1][2][3] Results were affected by two very high cost patients, highlighting variability in disease course. Prospective studies are needed to fully explore differences between ED and MD. However, this study suggests that outcomes and costs may be better with MD than ED, supporting latest NICE guidance. 4
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