Endoscopic and Medical Management of Fibrostenotic Crohn's Disease

Abstract

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.

Clinical Factors and Disease Course Related to Diagnostic Delay in Korean Crohn’s Disease Patients: Results from the CONNECT Study

“…As for intestinal stenosis, abdominal surgery is only one of the therapeutic options. The other options are anti-inflammatory medication and endoscopic balloon dilation [ 28 , 29 ]. Endoscopic dilation is an effective and safe alternative to surgical management, especially in short stenosis [ 29 ].…”

Systematic review: predicting and optimising response to anti‐TNF therapy in Crohn's disease – algorithm for practical management

“…There are no data to demonstrate that radiological findings are predictive of primary nonresponse to anti‐TNF therapy. However, in clinical practice, the identification of strictures is known to be associated with a lack of response to anti‐TNF therapy . Moreover, cross‐sectional imaging is important to determine contraindications to anti‐TNF therapy such as collections complicating penetrating disease.…”

Treatment of Crohn’s Disease Anastomotic Stricture With a Lumen-apposing Metal Stent

“…1 Endoscopic management has historically relied on serial balloon dilations, but symptomatic recurrence is common. 2 A few studies have examined the efficacy and safety of self-expanding metal stents in Crohn's disease strictures; however, durable success was limited because of high rates of stent migration and impaction, and none used lumen-apposing stents. 3 As demonstrated in this case, novel TTS, lumen-apposing, fully covered stents have lower risks of stent migration and impaction and hold promise as an alternative to surgical and medical management.…”