ENDOSCOPIC BALLOON DILATATION OF CROHN’S STRICTURES

A 26 year old female was diagnosed with terminal ileal Crohn’s disease 18 years ago.
7 yrs ago: ileo-caecal resection and strictureplasty
4 yrs ago: started on 6-Mercaptopurine
2 yrs ago: colonoscopy showed anastomotic stricture
18 months ago: small bowel MRI showed 2.5cm anastomotic stricture
12 months ago: abdominal pain, treated with 15mm CRE balloon dilatation of anastomotic and neo-terminal ileal strictures.

After initial improvement in symptoms, there has been a recent recurrence of abdominal pain. She was referred for a further endoscopic balloon dilatation (see video)…

She went home after the procedure but was readmitted 12 hours later with rectal bleeding (with 2g/dl drop in Hb). Another colonoscopy showed altered blood/ clots throughout the colon but no active bleeding from the dilated anastomosis/ stricture. She was managed conservatively and went home after a couple of days.

Symptomatic intestinal strictures develop in more than one third of patients with Crohn’s disease (CD) within 10 years of onset of disease [1]. Strictures can be inflammatory, fibrotic or mixed and result in a significant decline in quality of life, frequently requiring surgery for palliation of symptoms. Patients under the age of 40 with perianal disease are more likely to suffer from disabling ileocolonic disease thus may have a greater risk for fibrostenotic strictures. Treatment options for fibrostenotic strictures are limited to endoscopic and surgical therapy.

Endoscopic balloon dilatation (EBD) for small bowel strictures secondary to CD provides not only short-term success but also long-term efficacy. In one study, cumulative surgery-free rate after initial EBD was 79% at 2 years and 73% at 3 years, respectively [2]. However, the high re-dilation rate is one of the clinical problems of this procedure.

In a meta-analysis of 24 studies (1163 patients), the median duration from the initial diagnosis of CD to the first EBD was 10.2-17.0 years [3]. The majority of strictures (69%) treated were anastomotic, while the remaining strictures were naive (primary). Surgical intervention rate over a median follow-up period of 15-70 months in the reported studies was 27%. The surgical intervention rate after dilation of anastomotic strictures was 18% versus 29% for primary strictures. The risk ratio for the surgical requirement of anastomotic versus primary strictures was [0.88 (95% confidence interval [CI] 0.59-1.32); p = 0.54]. Stricture length less than 4 cm was associated with a significantly decreased risk of surgical intervention [risk ratio = 0.48 (95 % CI 0.26-0.90); p = 0.02]. EBD resulted in major adverse events (perforation, haemorrhage necessitating intervention or blood transfusion, abscess, fistula, and/or sepsis) in 4 % of the patients.

An ideal candidate is a patient with a long history of CD (at least 15 years) who is likely to develop a fibrostenosis as opposed to an inflammatory stenosis, one with a short stenosis (less than 4 cm) with minimal inflammation and no history of surgery, or a patient in whom a clinical complication is attributable to a single anastomotic stricture [4]. Malignancy or high-grade dysplasia must be ruled out, and the strictures should be straight, in line with the bowel lumen, without a fistula orifice close to it.

REFERENCES

1. Bessissow T et al, World J Gastroenterol. 2018 May 7; 24(17): 1859–1867. Endoscopic management of Crohn’s strictures
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5937203/

2. Hirai F et al Dig Endosc. 2014 Jul;26(4):545-51, Long-term outcome of endoscopic balloon dilation for small bowel strictures in patients with Crohn's disease.
https://www.ncbi.nlm.nih.gov/pubmed/24528293#

3. Navaneethan U et al Surg Endosc. 2016 Dec;30(12):5434-5443. Endoscopic balloon dilation in the management of strictures in Crohn's disease: a systematic review and meta-analysis of non-randomized trials.
https://www.ncbi.nlm.nih.gov/pubmed/27126619

4. Klag T, Wehkamp J, and Goetz M, Clin Endosc. 2017 Sep; 50(5): 429–436. Endoscopic Balloon Dilation for Crohn’s Disease-Associated Strictures
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5642070/