Multidisciplinary Management of Gastrointestinal Fibrotic Stenosis in Crohn’s Disease

Abstract

Crohn's disease (CD) is a chronic inflammatory bowel disease that can involve virtually any part of the gastrointestinal tract. CD complications are the main indications for surgery. A large proportion of these interventions are due to stricturing disease. Although immunosuppressive treatments have been used more frequently during the last 25 years, there is no significant decrease in the need for surgery in patients with CD. Unfortunately, surgery is not curative, as the disease ultimately reoccurs in a substantial subset of patients. To best identify the patients who will require a specific treatment and to plane the most appropriate therapeutic approach, it is important to precisely define the type, the size, and the location of CD stenosis. Diagnostic approaches aim to distinguish fibrotic from inflammatory strictures. Medical therapy is required for inflammatory stenosis. Mechanical treatments are required when fibrotic CD strictures are symptomatic. The choice between endoscopic balloon dilation, stricturoplasty, and laparoscopic or open surgery is based on the presence of perforating complications, the remaining length of small bowel, and the number and length of strictures. The non-hierarchical decision-making process for the treatment of fibrotic CD therefore requires multidisciplinary clinical rounds with radiologists, gastroenterologists, interventional endoscopists, and surgeons.

Can Contrast‐Enhanced Sonography Detect Bowel Wall Fibrosis in Mixed Inflammatory and Fibrotic Crohn Disease Lesions in an Animal Model?

“…Pathologic bowel wall fibrosis is the result of aberrant healing secondary to recurrent bouts of intestinal inflammation and associated damage . The detection of bowel wall fibrosis is paramount, as areas of intestinal narrowing that are primary inflammatory may be sufficiently managed with medical (eg, anti‐inflammatory or immunosuppressive) therapy, whereas strictures containing considerable fibrosis require mechanical treatments, such as intestinal resection, stricturoplasty, or endoscopic balloon dilation …”

“…3 The detection of bowel wall fibrosis is paramount, as areas of intestinal narrowing that are primary inflammatory may be sufficiently managed with medical (eg, antiinflammatory or immunosuppressive) therapy, whereas strictures containing considerable fibrosis require mechanical treatments, such as intestinal resection, stricturoplasty, or endoscopic balloon dilation. 3,5 Unfortunately, the detection and measurement of intestinal fibrosis using conventional radiologic tests is difficult. A study by Adler et al 6 showed that whereas computed tomography can effectively detect active bowel wall inflammation, it performs suboptimally when trying to predict intestinal fibrosis.…”

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease

“…Some researchers suggested that the presence of ulcers, stricture site and length are the determinants of the success of the procedure. However, a systematic review of 353 strictures stated that the only predictor of a surgery‐free outcome was a short stricture . The same findings were supported by another review that included 3252 strictures in 1500 patients; those authors noted that steroid injection and increased length of stricture made earlier surgical re‐intervention more likely .

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Clinical Example of Efficiency of the Multidisciplinary Approach to the Management of a Patient with Crohn's Disease Complicated by Perianal Lesions

“…с использованием анти-цитокиновых препаратов, потребность в хирургиче-ском лечении при болезни Крона за последние 25 лет не уменьшилась [2]. До 50% пациентов с такой патологи-ей по крайней мере один раз в течение жизни нуждаются в операции по причине развившегося осложнения [3,4]. В то же время хирургические методы не гарантируют отсутствие обострений заболевания в будущем, и после оперативного этапа требуется обязательная противоре-цидивная терапия [5].…”