Endoscopic Management of IBD-Related Strictures. Update in Inflammatory Bowel Disease

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1 Endoscopic Management of IBD-Related Strictures Update in Inflammatory Bowel Disease John F. Valentine, MD University of Florida Baltimore, MD Nov 19, 2010

2 Repeated Cycles of Inflammation and Healing Result in Fibrosis and May Lead to Stricture Formation Strictures in patients with ulcerative colitis are malignant in up to 30% of cases. Malignancy must always be excluded. It is necessary to survey the mucosa proximal to a stricture. Strictures develop in 30-40% of Crohn s patients and are a common indication for surgery. Multiple retrospective series suggest that endoscopic dilation of anastomotic and primary strictures is safe and can result in symptomatic improvement and avoidance of surgery.

3 The data is difficult to interpret due to the admixture of: Types of strictures: primary vs anastomotic Location: Anal, colonic, ileocolonic, duodenal, jejunal Stricture length Presence of active inflammation Technique: radiographic documentation, under fluoroscopic guidance, size of dilation, steroid injection Clearly symptomatic vs unexpected

4 Medline search Review of 13 studies, 347 Crohn s patients, Mean follow up 33 months Hassan et al. Aliment Pharmacol Ther 2007;26:

5 Efficacy = surgery free at end of follow-up N=347 Surgery required 144 (42%) Major complications 14 (2%) Perforation 13 Hassan et al. Aliment Pharmacol Ther 2007;26:

6 Prognostic Factors Retrospective review pts, 51 stricture dilated 17 month median follow-up 39% required repeat dilation 24% required surgery On univariant analysis: Smoking Ulcers in the stricture were more likely to require repeat dilation or surgery Hoffmann et al. Int J Colorectal Dis 2008;23:689-96

7 Endoscopic Dilation of CD Strictures at U FL Retrospective review of all TTS balloon dilations done over a 4 year period in patients with a variety of CD related strictures (n=29 dilations, 17 pts). Technical success was defined as the ability of the scope to traverse the stricture post-dilation. Long-term success was claimed if a patient remained asymptomatic for > 1 year post-dilation. Singh, Draganov, Valentine. J Clin Gastroenterol 2005;39:

8 Sigmoid 14% Colo-colonic anastomosis 5% Duodenal 14% Desc Colon 5% Cecal 10% Ileum 5% Ileal-colonic 19% Rectal 28% Mean stricture length was 2 cm (range, 1-5 cm). Technical success was achieved in 29 of 30 procedures (96.7%). Long-term long-term success rate of 76.5% by intent-to-treat analysis Complication rate (perforation) 10% (3 of 29). Singh, Draganov, Valentine. J Clin Gastroenterol 2005;39:

9 Stricture Recurrence Rates with Steroid Injection Four-quadrant triamcinolone injections (40 mg/ml in 0.5- to 1-mL aliquots) using standard TTS sclerotherapy needle (N=11) % Recurrence % Steroids No-Steroids % Singh, Draganov, Valentine. J Clin Gastroenterol 2005;39:

10 A Pilot Study of Intrastricture Steroid vs Placebo Injection After Balloon Dilation of Crohn s Strictures N=13; 7 randomized to steroids, 6 to placebo 40 mg total triamcinolone injected into the stricture 1 of 6 in the placebo group required repeat dilation 5 of 7 in the steroids group required repeat dilation, p=0.07 East et al. Clin Gastroenterol Hepatol 2007:5;

11 Intralesional Steroid Injection after EBD in Pediatric Crohn s Disease with Stricture Prospective, randomized, double-blind controlled trial 29 peds CD pts, 15 to CS, 14 to placebo Obstructive symptoms with narrowing and prestenotic dilation on imaging Stricture lengths cm Balloon dilation plus 40 mg Triamcinolone in 5 ml vs placebo 12 month follow up including follow up imaging Result: 1 of 15 receiving CS required repeat dilation 5 of 14 receiving placebo required repeat dilation None in CS group required surgery 4 of 14 in placebo group went on to surgery (all after a second dilation) No perforations De Nardo et al. Gastointest Endosc 2010

12 Di Nardo et al. Gastointest Endosc 2010

13 Long-term outcome of endoscopic dilatation in patients with Crohn's disease is not affected by disease activity or medical therapy. Between 1995 and 2006, 237 dilatations where performed for clinically obstructive strictures (<5 cm, 84% anastomotic). 138 patients (mean age 50.6+/-13.4, 56% female) Immediate success of a first dilatation: 97% 5% serious complication rate; 6 perforations in 237 dilations (2.5%) 6 perforations in 138 pts (4.3%) After a median follow-up of 5.8 years (IQR ), recurrent obstructive symptoms led to a new dilatation in 46% or surgery in 24%. No influence of type of medical therapy post dilation on need for repeat dilation or surgery Thienpont C et al. Gut. 2010;59:320-4.

14 Thienpont C et al. Gut. 2010;59:320-4.

15 Approach must consider: Stricture length <10cm (?) ideally < ~4cm shorter is better Location Implications of perforation Angulated, filiform, or associated with a fistula = increase risk of perforation

16 Anal/Rectal Strictures Symptoms: difficulty passing stool, increasing need to strain, anal seepage, overflow diarrhea Dilation Techniques: Digital Balloon dilators Hegar dilators

17 Balloon dilation Anal/Rectal Strictures Hegar dilation

18 Case 53-year-old woman diagnosed with ileocolonic Crohn's disease complicated by perianal fistulas in Had a total proctocolectomy and ileostomy in She has done well with no medical therapy for her Crohn s for 28 years. She presented with postprandial bloating and vomiting over the last year that had worsened in the last three months. Her weight has been stable. An upper endoscopy performed that revealed multiple gastric nodules, multiple ulcers in the duodenum, and a 3 mm diameter stricture in the fourth portion of the duodenum. She was seen by a surgeon who recommended a total gastrectomy with jejunal esophageal anastomosis. She sought a second opinion concerning options for treating her Crohn's disease and stricture.

19

20 Case Upper endoscopy revealed multiple polyps in her stomach, four small antral ulcers, erosions in the bulb, and a tight stricture in the third portion of the duodenum. Pathology: Duodenal stricture biopsy: Mild to moderate non-specific duodenitis. No granulomas. Antral ulcers biopsy: Patchy non-specific inflammation. Gastric nodules: Patchy non-specific inflammation.

21 Before Post dilation and Aza

22 47 yo WM, CD, total colectomy and ileostomy. Now with symptomatic stricture in 4th portion of duodenum Prior 1st f/u 2 weeks after dilation 10 month f/u after 2 dilations

23

24 36 yo AAM, Crohn s dx in 1990, ileocecal resection, on going diarrhea. CT without evidence of stricture or bowel dilation one year prior. Ileocolonic anastomosis, balloon dilation with 15, 16.5, 18mm balloons.

25 52-year-old white gentleman with ileocolonic Crohn's disease of over 30 years' duration, as well as perianal fistulizing disease. He had an extensive small bowel resection in 1992, and a partial colectomy with colostomy. The scope was inserted into the anal canal. The anus was open but there is only about 2.5 cm of anus/rectum. The mucosa appeared atrophic consistent with diversion colitis. Very little if any rectal mucosa was seen.

26 Self Expanding Metal Stents Controversial, temporizing measure Several case reports only Stent migration, perforation, and fistula formation have been reported If poor surgical candidate, what happens if has perforation? Martines et al. Inflamm Bowel Dis 2008:14;291-2

27 Thinking Outside the Box You are here

28 Take Home Points Retrospective data: Primary and anastomotic strictures can be safely dilated, provide symptomatic improvement, and avoidance of surgery. Short (<4 cm), straight strictures increase success rate Take into consideration surgical implications Treat on-going active inflammation Ulcerations in the stricture and smoking are risk for recurrence (but not in all studies) Intra-lesion injection of steroids may improve long-term success rate. Needs more study!

29 University of Florida Health Science Center

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