A Challenging Case of Crohns Colitis with Severe Colonic Strictures Failing Multiple Therapy

Abstract

Stricturing Crohns Disease (CD) can occur in the colon as it does in the small intestine and is associated with increased risk of development of perianal complications.1 Endoscopic balloon dilation is a novel modality that may offer a bowel-sparing therapeutic alternative. We present a clinically challenging case of CD with colonic strictures resistant to multiple therapies that improved with balloon dilation.2 A 30-year-old male who presented with abdominal pain, recurrent diarrhea and weight loss was found to have an anal abscess and fistula that were treated surgically. Endoscopic and histologic findings were suggestive of CD. The patient was started on adalimumab, with good response initially but two years later had a relapse. Ileocolonoscopy showed severe disease from the rectum to the splenic flexure, with patches in the transverse and ascending colon and small ulceration in the terminal ileum, and histology confirmed active colitis. The patient tried multiple therapies including mesalamine, 6-MP, certolizumab and vedolizumab with inability to achieve clinical, endoscopic or histologic remission. Infliximab showed promise, but he later presented with abdominal pain and was found to have severe colonic strictures involving the rectum and transverse colon. However, the patient responded well to infliximab and serial endoscopic balloon dilation. Resistant CD increases the risk of strictures and can be very challenging to control. In cases of colon strictures, colon cancer needs to be ruled out due to the increased risk in such patients.1 Although efficacy is not well understood, stricturoplasty through endoscopic balloon dilation is a safe modality that can help avoid surgical interventions.2 1. Mills, S. and Stamos, M. (2007). Colonic Crohn's Disease. Clinics in Colon and Rectal Surgery 2.Rueda Guzmán, A., Wehkamp, J., Kirschniak, A., Naumann, A., Malek, N. and Goetz, M. (2016). Endoscopic balloon dilatation of Crohn's-associated intestinal strictures2095_A Figure 1. Sigmoid colon stenosis and stricture2095_B Figure 2. Sigmoid colon after dilatation