Bowel Strictures In Patients Research Articles

P1180 Long-Term Outcomes of Enteroscopic Balloon Dilatation and Risk Factors for Surgery in Small Bowel Stricturing Crohn's Disease: A Prospective Observational Study

Abstract Background The long-term outcomes of enteroscopic balloon dilatation (EBD) for small bowel strictures in patients with Crohn's disease (CD) are not well understood. Although Crohn's strictures can be classified into web-like, ulcerated, and spindle-shaped strictures based on endoscopic findings, the outcomes of EBD according to the shape of Crohn’s strictures have not been analyzed. The primary outcome was to evaluate the cumulative surgery-free rate, and the secondary outcome is to evaluate the risk factor for subsequent surgery after EBD. Methods This prospective, longitudinal, observational study enrolled patients with CD who underwent EBD for small bowel strictures using single-balloon enteroscopy between 2015 and 2023 at Samsung Medical Center, Seoul, Korea. Results A total of 150 consecutive patients who underwent 238 EBDs were included in this study with mean follow-up of 42.4±19.1 months. Thirty-one patients (20.7%) underwent surgery after EBD, and the cumulative 1-, 3-, and 5-year surgery-free rates were 86.7%, 80.4%, and 76.6%, respectively. The cumulative surgery-free rates of EBD for web-like, ulcerated, and spindle-shaped strictures were 96.3%, 91.0%, and 73.3% at 1 year, 96.3%, 84.9%, and 63.0% at 3 years, and 96.3%, 78.3%, and 63.0% at 5 years, respectively (p=0.001). Multivariate Cox regression analysis identified spindle-shaped stricture (vs. web-like stricture: hazard ratio [HR], 10.97; 95% confidence interval [CI], 1.23-97.74, p=0.032) and starting/switching biologics (vs. no biologics: HR, 0.33; 95% CI, 0.12-0.89; p=0.029) as risk factors for surgery after EBD. The major complication rate of EBDs was 2.7% (4/150) on per-patient analysis and 1.7% (4/238) on per-procedure analysis. Conclusion EBD for small bowel strictures in patients with CD may be an effective and safe alternative to surgery. EBD for web-like strictures showed favorable outcomes, while EBD for spindle-shaped strictures showed poor outcomes.

Role of Ultrasound Elastography in the Detection of Fibrotic Bowel Strictures in Patients with Crohn's Disease: Systematic Review and Meta-Analysis.

To perform a systematic review with meta-analysis to assess whether ultrasound elastography can have a diagnostic role in detecting fibrotic bowel strictures in patients with Crohn's disease. MEDLINE via the PubMed, Ovid Embase, Scopus and Cochrane Library databases, and abstracts of international conference proceedings were searched up to March 31, 2018. Studies were included if they assessed the performance of abdominal ultrasound elastography in detecting fibrotic bowel strictures in patients with Crohn's disease using histology or the need for surgery after medical treatment as a reference standard. The quality of the studies was assessed using Quality Assessment of Diagnostic Accuracy Studies. 6 studies including a total of 217 patients with Crohn's disease and 231 bowel segments, of which 76 were bowel segments with fibrotic stricture, were selected. Three studies used strain ratio and three studies used strain value as parameters of bowel stiffness. Both the pooled standardized mean strain ratio and the pooled standardized mean strain value were higher in bowel segments with fibrotic strictures than in those without fibrotic strictures with a standardized mean difference of 0.85 (95 % confidence level [CI]: 0 to 1.71; p = 0.05) and 1.0 (95 % CI: -0.11 to 2.10; p = 0.08), respectively. There was a high heterogeneity between studies. All studies were at "high risk" or "unclear risk" of bias. Ultrasound elastography could be able to detect fibrotic bowel strictures in patients with Crohn's disease. Well-designed high quality diagnostic studies with a large sample size are needed.

Efficacy of Endoscopic Balloon Dilation for Small Bowel Strictures in Patients With Crohn's Disease: A Nationwide, Multi-centre, Open-label, Prospective Cohort Study.

Endoscopic balloon dilation [EBD] is an alternative to surgery for Crohn's strictures. However, there have been no prospective studies of EBD for small bowel strictures in patients with Crohn's disease [CD]. The aim of this study was to clarify the efficacy and safety of EBD using balloon-assisted enteroscopy for small bowel strictures in CD. This was a nationwide, multi-centre, open-label, prospective cohort study. The subjects were CD patients with at least one symptom [abdominal pain, abdominal bloating, nausea] attributable to small bowel stricture. The primary endpoint related to short-term outcomes was the level of improvement of symptoms evaluated using a 10-cm visual analogue scale [VAS]. Cases in which VAS scores for all symptoms improved 4 weeks after EBD compared with baseline were considered to have short-term symptomatic improvement. Factors related to short-term treatment outcomes and safety were investigated as secondary endpoints. A total of 112 patients were enrolled. Seventeen were later excluded because they did not meet the criteria, and the analysis was conducted with the remaining 95 patients. Of these 95 patients, procedure failure occurred in six [6.3%], and short-term symptomatic improvement was achieved in 66 patients [69.5%]. Adverse events were seen in five patients [5%] and all of these improved with conservative treatment. A large dilation diameter of the balloon was a factor contributing to the success of EBD. EBD using balloon-assisted enteroscopy for small bowel strictures in CD patients was shown to be an effective and safe procedure. UMIN000005946.

Predictive factors for malignancy in undiagnosed isolated small bowel strictures.

Background/AimsPatients with small bowel strictures have varied etiologies, including malignancy. Little data are available on the demographic profiles and etiologies of small bowel strictures in patients who undergo surgery because of intestinal obstruction but do not have a definitive pre-operative diagnosis.MethodsRetrospective data were analyzed for all patients operated between January 2000 and October 2014 for small bowel strictures without mass lesions and a definite diagnosis after imaging and endoscopic examinations. Demographic parameters, imaging, endoscopic, and histological data were extracted from the medical records. Univariate and multivariate analyses were conducted to identify factors that could differentiate between intestinal tuberculosis (ITB) and Crohn's disease (CD) and between malignant and benign strictures.ResultsOf the 7,425 reviewed medical records, 89 met the inclusion criteria. The most common site of strictures was the proximal small intestine (41.5%). The most common histological diagnoses in patients with small bowel strictures were ITB (26.9%), CD (23.5%), non-specific strictures (20.2%), malignancy (15.5%), ischemia (10.1%), and other complications (3.4%). Patients with malignant strictures were older than patients with benign etiologies (47.6±15.9 years vs. 37.4±16.4 years, P=0.03) and age >50 years had a specificity for malignant etiology of 80%. Only 7.1% of the patients with malignant strictures had more than 1 stricture and 64% had proximally located strictures. Diarrhea was the only factor that predicted the diagnosis of CD 6.5 (95% confidence interval, 1.10–38.25; P=0.038) compared with the diagnosis of ITB.ConclusionsMalignancy was the cause of small bowel strictures in approximately 16% patients, especially among older patients with a single stricture in the proximal location. Empirical therapy should be avoided and the threshold for surgical resection is low in these patients.

Feasibility of real-time strain elastography in colonic diseases.

Real-time strain elastography is not routinely performed in clinical practice for characterizing gastrointestinal tract diseases, and there are few studies in the literature on the subject. The recent EFSUMB guidelines suggest the use of this method in the diagnosis of neoplastic lesions and in the characterization of bowel strictures in patients with Crohn's disease. The purpose of this pictorial essay is to evaluate the feasibility of strain elastography in some pathologies of the colon frequently encountered in daily clinical practice and to compare elastography images with corresponding endoscopic and radiographic images. In our opinion, strain elastography is useful for characterizing diseases of the colon as it can add valuable diagnostic information to grayscale ultrasound imaging. However, diagnostic accuracy and clinical relevance of this information should be confirmed by further prospective research-targeted studies.

Long‐term outcome of endoscopic balloon dilation for small bowel strictures in patients with Crohn's disease

Endoscopic balloon dilation (EBD) is an alternative to surgery for small bowel strictures of patients with Crohn's disease (CD). However, little is known about the long-term efficacy of EBD. The aim of the present study was to clarify the long-term outcome of EBD for small bowel strictures in patients with CD. Subjects comprised 65 patients with CD who underwent EBD for small intestinal strictures and were followed up for at least 6 months. All subjects had obstructive symptoms as a result of small bowel strictures. Short-term success was defined as technical success and the disappearance of obstructive symptoms. The short-term success rate of EBD, its safety profile, the cumulative surgery-free rate and the cumulative redilation-free rate were investigated. Short-term success rate was 80.0% (52/65). Complications were encountered in six of the 65 patients (9.2%). Seventeen patients (26.2%) underwent surgery during the observation period of this study. Cumulative surgery-free rate after initial EBD was 79% at 2 years and 73% at 3 years, respectively. EBD successful cases showed significantly higher surgery-free rates than unsuccessful cases (P < 0.0001). In 52 of the successful cases, the cumulative redilation-free rate after initial EBD was 64% at 2 years and 47% at 3 years, respectively. EBD for small bowel strictures secondary to CD provides not only short-term success but also long-term efficacy. However, the high redilation rate is one of the clinical problems of this procedure.

Small Bowel Endoscopy in Inflammatory Bowel Disease

Crohn disease (CD) is a chronic inflammatory bowel disease that affects the entire gastrointestinal tract but is most frequently localized to the large and small bowel. Small bowel endoscopy helps with the differential diagnosis of CD in suspected CD patients. Early diagnosis of CD is preferable for suspected CD conditions to improve chronic inflammatory infiltrates, fibrosis. Small bowel endoscopy can help with the early detection of active disease, thus leading to early therapy before the onset of clinical symptoms of established CD. Some patients with CD have mucosal inflammatory changes not in the terminal ileum but in the proximal small bowel. Conventional ileocolonoscopy cannot detect ileal involvement proximal to the terminal ileum. Small bowel endoscopy, however, can be useful for evaluating these small bowel involvements in patients with CD. Small bowel endoscopy by endoscopic balloon dilation (EBD) enables the treatment of small bowel strictures in patients with CD. However, many practical issues still need to be addressed, such as endoscopic findings for early detection of CD, application compared with other imaging modalities, determination of the appropriate interval for endoscopic surveillance of small bowel lesions in patients with CD, and long-term prognosis after EBD.

CT Enterography: Principles, Trends, and Interpretation of Findings

Computed tomographic (CT) enterography is an emerging alternative to traditional fluoroscopy for the assessment of disorders of the small bowel. The greatly improved spatial and temporal resolution provided by multidetector CT scanners, combined with good luminal distention provided by negative oral contrast agents and with good bowel wall visualization, have made CT enterography the main imaging modality not only for investigating proved or suspected inflammatory bowel disease but also for detecting occult gastrointestinal tract bleeding, small bowel neoplasms, and mesenteric ischemia. CT enterography is particularly useful for differentiating between active and fibrotic bowel strictures in patients with Crohn disease, thus enabling selection of the most appropriate treatment (medical management or intervention) for an improved outcome. CT enterography allows excellent visualization of the entire thickness of the bowel wall and depicts extraenteric involvement as well, providing more detailed and comprehensive information about the extent and severity of the disease process.

ENDOSCOPIC BALLOON DILATATION USING DOUBLE‐BALLOON ENDOSCOPY IS A USEFUL AND SAFE TREATMENT FOR SMALL INTESTINAL STRICTURES IN CROHN'S DISEASE

Endoscopic balloon dilatation (EBD) is a therapeutic option for intestinal strictures of Crohn's disease (CD). Double-balloon endoscopy (DBE) enables EBD to be performed even for deep-situated strictures of the small intestine. The aim of this study was to clarify the efficacy and safety of EBD using DBE for small bowel strictures in patients with CD. The subjects comprised 25 patients with CD who underwent EBD using DBE for small intestinal strictures for which a colonoscope or gastrointestinal scope could not be inserted. All subjects had obstructive symptoms due to strictures that were confirmed using small intestinal enteroclysis. They were observed for at least 6 months after the initial EBD. The short-term success rate of EBD using DBE, the complication rate and the long-term outcome were investigated. This procedure was successful with regard to short-term dilatation in 18 of the 25 CD patients (72%). Long strictures measuring more than 3 cm were seen in six out of seven (85.7%) of the unsuccessful EBD cases, compared with two out of 18 (11.1%) of the successful EBD cases (P=0.001). Complications were encountered in two of the 25 patients (8%). The cumulative surgery-free rate for all the subjects was 83% and 72% at 6 and 12 months, respectively. EBD using DBE is a useful and safe procedure for small intestinal short strictures in CD patients. We conclude that this procedure is a therapeutic option that should be attempted before resorting to surgical therapy.

Meta‐analysis: capsule enteroscopy vs. conventional modalities in diagnosis of small bowel diseases

Prospective trials support the role of capsule enteroscopy as an improvement in diagnosing mucosal lesions in the small bowel. To determine the diagnostic yield and safety of capsule enteroscopy vs. alternative diagnostic modalities (such as push enteroscopy, small bowel follow-through or enteroclysis) in patients with small bowel diseases. A search for prospective studies comparing capsule enteroscopy vs. other diagnostic tests in adults was performed between 1966 and 2005. Selected articles were included in a meta-analysis. Three analyses were run separately, all included studies and studies having occult gastrointestinal bleeding or Crohn's disease as main outcome. Seventeen studies (526 patients) met inclusion criteria. The rate difference (i.e. the absolute pooled difference in the rate of positive findings) between capsule enteroscopy and alternative modalities for small bowel disease was 41% (95% CI 35.6-45.9); 37% (95% CI 29.6-44.1) for occult gastrointestinal bleeding; and 45% (95% CI 30.9-58.0) for Crohn's disease. Failure to visualize the caecum occurred in 13%, significantly more often in occult bleeders (17%) than in patients with Crohn's disease (8%) (P < 0.006). Adverse events were recorded in 29 patients (6%). Capsule retention was more frequent in patients with Crohn's disease (3% vs. 1%, OR 4.37). Capsule enteroscopy proved significantly superior to push enteroscopy and small bowel radiology in the diagnosis of ileal diseases. Capsule enteroscopy is safe, though prior radiology is still necessary to rule out small bowel strictures in patients with known or suspected Crohn's disease.