Fibrotic Strictures Research Articles

Hybrid imaging in Crohn's disease: from SPECT/CT to PET/MR and new image interpretation criteria.

Crohn's disease is a chronic relapsing disease characterized by mucosal inflammation, lymphocytes infiltration and fibrotic strictures. Usually, the assessment of location, extension, inflammatory activity and severity of intestinal lesions is complex and invasive with endoscopic methods or histological and biochemical investigations. Thus, the diagnosis remains a challenge for the management of patients. Nuclear medicine techniques, in particular hybrid and molecular imaging, might offer a valid option for the evaluation and determination of the prognosis of the disease. Indeed, imaging methods provide a non-invasive, reproducible and quantitative analysis. An overview of the currently available multimodality imaging techniques in Crohn's disease are reviewed, with particular regard to positron-emission tomography/magnetic resonance and the choice of the best evaluation Score, explaining advantages and disadvantages of each one, with particular regard to their potential role for the assessment of disease activity and extent of inflammation in order to improve the diagnosis. We propose new interpretation criteria for PET/MR images.

A biodegradable non-covered self-expandable stent to treat pancreatic duct strictures in chronic pancreatitis: a proof of principle

In chronic pancreatitis (CP), fibrotic pancreatic duct (PD) strictures pose a therapeutic challenge, because endoscopic dilatation requires multiple procedures with suboptimal results. Biodegradable self-expandable stents (BD-SESs) may serve as an alternative in this setting. Patients with CP were eligible for this proof-of-principle study if at least 6 months of endoscopic dilatation with plastic stents had failed to resolve their PD stricture. The non-covered BD-SESs were expected to degrade within 3 to 6 months. Patients were followed at 3-monthly intervals for 1 year. Placement success and safety were the primary outcome parameters. Stricture resolution was assessed by ERCP after 6 months. BD-SESs were successfully placed in all 19 patients without adverse events. In 2 cases, stent occlusion with sludge and stones was treated by a balloon swipe. One stent disintegrated during this procedure, after which placement of the plastic stent was resumed. A hyperplastic response was observed in 2 patients but did not result in functional obstruction. Stricture resolution was accomplished in 11 patients (technical success rate 58%). Six patients required further treatment of their PD stricture, 4 endoscopically and 2 surgically. Three additional patients underwent surgery for other reasons: 2 Whipple procedures for CP-related adverse events and one tail resection for an intraductal papillary mucinous neoplasm. The remaining 10 patients did not require further PD drainage (clinical success rate 52%). These preliminary results show that BD-SESs are safe to use and able to resolve fibrotic PD strictures in CP. These encouraging outcomes warrant further testing.

Hiatus Hernia as a Cause of Dysphagia.

This review aims to discuss the putative relationship between hiatus hernia and dysphagia. Proposed mechanisms of dysphagia in patients with hiatus hernia are usually difficult to identify, but recent advances in technology (high-resolution manometry with or without concomitant impedance, ambulatory pH with impedance, videofluoroscopy, and the endoluminal functional lumen imaging probe (EndoFLIP)) and methodology (inclusion of swallows of various consistencies and volumes or shifting position during the manometry protocol) can help induce symptoms and identify the underlying disorder. Chronic reflux disease is often associated with hiatus hernia and is the most common underlying etiology. Dysmotility because of impaired contractility and vigor can occur as a consequence of repeated acid exposure from the acid pocket within the hernia, and the resultant poor clearance subsequently worsens this insult. As such, dysphagia appears to be more common with increasing hiatus hernia size. Furthermore, mucosal inflammation can lead to fibrotic stricture formation and in turn obstruction. On the other hand, there appears to be a difference in the pathophysiology of smaller sliding hernias, in that those with dysphagia are more likely to have extrinsic compression at the crural diaphragm as compared to those with reflux symptoms only. Sliding hiatus hernia, especially when small, does not commonly lead to dysmotility and dysphagia; however, in those patients with symptoms, the underlying etiology can be sought with new technologies and, in particular, the reproduction of normal eating and drinking during testing.

Crohn’s Strictures—Moving Away from the Knife

Crohn’s disease (CD) is a lifelong inflammatory bowel disease with a rapidly rising incidence in the pediatric population. A common complication of CD is the development of fibrotic strictures, which may be present at initial diagnosis or develop many years later. Clinical presentation depends on stricture location and degree of obstruction, and strictures frequently contain a mixture of inflammatory and fibrotic tissue. Histological examination of Crohn’s strictures shows thickening of the muscular layers and the submucosa, where increased collagen deposition by activated myofibroblasts is concentrated around islands of smooth muscle cells and at the superficial margin of the muscularis propria. No antifibrotic therapies for Crohn’s strictures exist. Profibrotic transforming growth factor-β (TGFβ)/bone morphogenetic protein signaling stimulates myofibroblast differentiation and extracellular matrix deposition. Understanding and targeting TGFβ1 downstream signaling is the main focus of current research, raising the possibility of specific antifibrotic therapy in CD becoming available in the future.

Differentiation of Inflammatory from Fibrotic Ileal Strictures among Patients with Crohn's Disease through Analysis of Time–Intensity Curves Obtained after Microbubble Contrast Agent Injection

The aim of the study described here was to assess whether the analysis of time–intensity curves obtained after microbubble contrast agent injection could differentiate inflammatory from fibrotic ileal strictures among patients with Crohn's disease. Sixty-five consecutive patients (40 male and 25 female; mean age ± SD, 42.2 ± 12.22 y) with stricture of the terminal ileal loop from Crohn's disease were scanned after microbubble injection. Time–intensity curves were obtained from quantitative analysis, and peak enhancement, rise time, time to peak, area under the time–intensity curve (AUC), AUC during wash-in (AUCWI) and AUC during wash-out (AUCWO) were compared between patients with inflammatory strictures and patients with fibrotic strictures. Inflammatory (n = 40) and fibrotic (n = 25) strictures differed (p < 0.05) in peak enhancement, wash-in rate, wash-in perfusion index, AUC, AUCWI and AUCWO. The quantitative analysis of small bowel wall contrast enhancement after microbubble contrast agent injection may differentiate inflammatory from fibrotic ileal strictures in patients with Crohn's disease.

Salivary duct stenosis: diagnosis and treatment.

SUMMARYThe management of stenoses of the major salivary glands had undergone a significant change during the last 15-20 years. Accurate diagnosis forms the basis of adapted minimal invasive therapy. Conventional sialography and MR-sialography are useful examination tools, and ultrasound seems to be a first-line investigational tool if salivary duct stenosis is suspected as cause of gland obstruction. Sialendoscopy is the best choice to establish final diagnosis and characterise the stenosis in order to plan accurate treatment. In all major salivary glands, inflammatory stenosis can be distinguished from fibrotic stenosis. In the parotid duct system, an additional stenosis associated with various abnormalities of the duct system has been reported. Conservative therapy is not sufficient in the majority of cases. The development of a minimally invasive treatment regime, in which sialendoscopy plays a major role, has made the preservation of the gland and its function possible in over 90% of cases. Ductal incision procedures are the most important measure in submandibular duct stenoses, but sialendoscopy becomes more important in the more centrally located stenoses. Sialendoscopic controlled opening and dilation is the dominating method in parotid duct stenoses. In 10-15% of cases, success can be achieved after a combined treatment regime had been applied. This review article aims to give an overview on the epidemiology, diagnostics and current state of the art of the treatment of salivary duct stenoses.

Prevention of esophageal stricture after endoscopic submucosal dissection using RNA-based silencing of carbohydrate sulfotransferase 15 in a porcine model.

Background and study aims Endoscopic submucosal dissection (ESD) for esophageal carcinoma frequently causes fibrotic strictures that require treatment. A possible preventive effect of small interfering RNA (siRNA) targeting carbohydrate sulfotransferase 15 (CHST15) on esophageal stricture formation after ESD was investigated in 3 pigs. Materials and methods Two half-circumferential ESD ulcers were created in the oral and anal ends of the esophagus. CHST15 siRNA was injected submucosally in one of the two ESD ulcers. Endoscopic, macroscopic, histological, and polymerase chain reaction analyses were performed. Results On post-operative day 14, the non-treated ulcers were found to show histological fibrosis and increased expression of the CHST15 messenger RNA. A single endoscopic injection of CHST15 siRNA alleviated stricture development in post-ESD ulcers with significant reduction in the mucosal contraction rate. The deposition of collagen and accumulation of fibroblasts and myofibroblasts were diminished in ulcers treated with CHST15 siRNA, where significant suppression of CHST15, transforming growth factor-beta (TGF-β), and collagen-1 messenger RNAs was also seen. Conclusion CHST15 siRNA alleviated esophageal post-ESD stricture formation via repression of fibrosis, revealing a novel therapeutic role for antifibrotic agents in the prevention of post-ESD strictures.

CEUS in Crohn’s Disease

Ultrasonography has advanced the diagnostic potential of ultrasound in the assessment of Crohn’s disease. Ultrasonography is not only a method used by radiologists, but also a clinical tool that can be applied to evaluate the patient bedside. The GI wall is most often visualized as a layered structure normally consisting of 3-9 layers, depending on the frequency applied, but usually 5 layers are observed. When examining the intestines, it is preferable to use frequencies above 7.5 MHz to enable optimal visualisation of wall layers, thickened bowel walls and target lesions. Disease activity in Crohn’s disease using bowel wall thickness and Doppler measurements as a marker of inflammation can also be obtained by ultrasound. By adding CEUS, enhancement in different wall layers can be evaluated and quantified in Crohn’s disease and this correlates to clinical activity index (CDAI) with good sensitivity and specificity. Quantitative measurements of bowel enhancement obtained by CEUS also correlate with severity grade determined at endoscopy. In patients with a stricture of the bowel and resultant bowel obstruction, it is important to determine if there is active inflammation at the site of stricture or if the obstructed segment is fibrotic. Preliminary studies indicate that CEUS appears to be useful in the recognition of a cicatricial stenosis in patients with Crohn's disease. Using CEUS, the active inflammatory components will enhance whereas the fibrotic stricture will enhance less. Distinguishing abscesses from inflammatory infiltrates is an important clinical task in the management of Crohn’s disease. If the tissue close to an affected bowel loop is completely devoid of microbubble signals, most likely this lesion represents avascular abscesses rather than inflammatory infiltrates. In the upcoming update of EFSUMB guidelines on CEUS, new indications are monitoring of treatment response and follow-up of transplanted patients. In conclusion, CEUS is a useful clinical tool in the management of patients with Crohn’s disease, particularly to estimate disease activity and to diagnose complications.

Bowel Thickening in Crohn's Disease: Fibrosis or Inflammation? Diagnostic Ultrasound Imaging Tools.

The high frequency of intestinal strictures in patients with Crohn's disease and the different treatment approaches specific for each type of stenosis make the differentiation between fibrotic and inflammatory strictures crucial in management of the disease. However, there is no standardized approach to evaluate and discriminate intestinal strictures, and until now, there was no established cross-sectional imaging modality to detect fibrosis. New techniques, such as contrast-enhanced ultrasound and sonoelastography allow the assessment of vascularization and mechanical properties of stenotic bowel tissue, respectively. These techniques have shown great potential to characterize strictures in Crohn's disease. The aim of this review is to sum up the current knowledge on bowel ultrasound tools to discriminate inflammatory from fibrotic stenosis in Crohn's disease considering the most recent published studies in the field.

Curcumin Suppresses Intestinal Fibrosis by Inhibition of PPARγ-Mediated Epithelial-Mesenchymal Transition.

Intestinal fibrotic stricture is a major complication of Crohn's disease (CD) and epithelial-to-mesenchymal transition (EMT) is considered as an important contributor to the formation of intestinal fibrosis by increasing extracellular matrix (ECM) proteins. Curcumin, a compound derived from rhizomes of Curcuma, has been demonstrated with a potent antifibrotic effect. However, its effect on intestinal fibrosis and the potential mechanism is not completely understood. Here we found that curcumin pretreatment significantly represses TGF-β1-induced Smad pathway and decreases its downstream α-smooth muscle actin (α-SMA) gene expression in intestinal epithelial cells (IEC-6); in contrast, curcumin increases expression of E-cadherin and peroxisome proliferator-activated receptor γ (PPARγ) in IEC-6. Moreover, curcumin promotes nuclear translocation of PPARγ and the inhibitory effect of curcumin on EMT could be reversed by PPARγ antagonist GW9662. Consistently, in the rat model of intestinal fibrosis induced by 2,4,5-trinitrobenzene sulphonic acid (TNBS), oral curcumin attenuates intestinal fibrosis by increasing the expression of PPARγ and E-cadherin and decreasing the expression of α-SMA, FN, and CTGF in colon tissue. Collectively, these results indicated that curcumin is able to prevent EMT progress in intestinal fibrosis by PPARγ-mediated repression of TGF-β1/Smad pathway.

From acute pulmonary embolism to chronic thromboembolic pulmonary hypertension: Pathobiology and pathophysiology

Chronic thromboembolic pulmonary hypertension (CTEPH) represents a unique subtype of pulmonary hypertension characterized by the presence of mechanical obstruction of the major pulmonary vessels caused by venous thromboembolism. CTEPH is a progressive and devastating disease if not treated, and is the only subset of PH potentially curable by a surgical procedure known as pulmonary endarterectomy. The clot burden and pulmonary embolism recurrence may contribute to the development of CTEPH however only few thrombophilic factors have been found to be associated. A current hypothesis is that CTEPH results from the incomplete resolution and organization of thrombus modified by inflammatory, immunologic and genetic mechanisms, leading to the development of fibrotic stenosis and adaptive vascular remodeling of resistance vessels. The causes of thrombus non-resolution have yet to be fully clarified. CTEPH patients often display severe PH that cannot be fully explained by the degree of pulmonary vascular obstruction apparent on imaging studies. In such cases, the small vessel disease and distal obstructive thrombotic lesions beyond the sub-segmental level may contribute for out of proportion elevated PVR. The processes implicated in the development of arteriopathy and micro-vascular changes might explain the progressive nature of PH and gradual clinical deterioration with poor prognosis, as well as lack of correlation between measurable hemodynamic parameters and vascular obstruction even in the absence of recurrent venous thromboembolism. This review summarizes the most relevant up-to-date aspects on pathobiology and pathophysiology of CTEPH.

A Wolf in Sheepʼs Clothing: A Unique Case of Zollinger-Ellison Syndrome Masquerading as Ileal Crohnʼs Disease

Zollinger-Ellison Syndrome (ZES) often presents with peptic ulcer disease, symptoms of gastroesophageal reflux disease (GERD) and chronic diarrhea. This is the result of gastric acid hypersecretion secondary to ectopic gastrin production, typically, from a pancreatic or duodenal neuroendocrine tumour (NET). This report presents a unique case of a patient initially thought to have small bowel Crohn's disease (CD). Incidental discovery of a gastrinoma led to a diagnosis of ZES. A 57 year old male was referred to an outside gastroenterology clinic for evaluation and management of a longstanding history of dyspeptic symptoms and diarrhea. On review of his history, he had a repair of a perforated jejunal ulcer 3 years prior, presumed to have been related to intermittent use of non-steroidal anti-inflammatory drugs. He remained on chronic proton-pump inhibitor therapy, with adequate control of his dyspepsia. As part of his work-up for chronic diarrhea, he underwent upper endoscopy and colonoscopy. The upper tract was grossly normal, and biopsies showed mild chronic gastritis. Colonoscopy showed a grossly and histologically normal colon, but the terminal ileum could not be intubated. Subsequent CT enterography showed 2 fibrotic strictures of the distal ileum, leading to a diagnosis of Crohn's disease, and prompting referral to our Inflammatory Bowel Diseases Clinic. Incidental note was made of a 5cm mass at the tail of the pancreas, consistent with a probable NET, prompting immediate surgical referral. By the time of his presentation to our clinic, he was 2 months post the resection of his tumour, which was proven histologically to be a gastrin-producing NET. He reported complete resolution of his chronic diarrhea and dyspepsia. A diagnosis of ZES was entertained and a work-up for MEN-1 was initiated. Brain MRI demonstrated a 2 mm pituitary microadenoma, consistent with possible MEN-1. In the literature, 75% of gastrointestinal ulceration in ZES occur in the first portion of the duodenum with ulcers less likely in the distal duodenum and jejunum. There are no reports of ZES associated ulceration occurring in the ileum. This patient's ileal strictures are hypothesized to be secondary to ulcers due to the gastrinoma. This would offer a unifying diagnosis for this patient's findings and would explain the resolution of his symptoms with resection of his tumour.

The Comparison of Two Surgical Techniques In The Treatment Of The Anal Stricture Posthemorrhoidectomy Milligan-Morgan

Surgical treatment of anal in open posthemorrhoidectomy brings various complications to open hemorrhoidectomy in 5%-10% of cases. In books it is widely known as the fibrotic benign stricture or as iatrogenic Clinically, it is manifested with pain during defecation, minimal rectoragy and abdominal discomfort accompanied with a feeling of not having adequately emptied bowels. Locally, it is manifested in form of a rigid ring where even small finger can hardly be penetrated. These symptoms can severely affect quality of life in patients. Depending on grade of anal canal stricture, we can say that anal is found on three grades: light anal stricture, moderated anal and expressed anal stricture. All our patients resulted in expressed anal stricture. In our research we have compared two operative techniques which were applied for surgical treatment of pathology. Partial posterior internal sphincterotomy technique with anoplastic in open wound (SIPA) and plastic with skin flap and closed internal lateral sphincterotomy, V-Y advancement flap (PLSL). Each technique aims at relaxing anal canal with as less continence damage as possible and faster rehabilitation of patient. The patients were divided into two groups: Group A of 15 patients treated with SIPA technique and Group B of 14 patients treated with PLSL technique. The study was conducted during February 2006 - March 2014. The results favored PLSL technique.

Eosinophilic Esophagitis-Associated Chemical and Mechanical Microenvironment Shapes Esophageal Fibroblast Behavior.

Eosinophilic esophagitis (EoE) is an immune-mediated allergic disease characterized by progressive esophageal dysmotility and fibrotic stricture associated with chronic esophageal fibroblast activation. It remains unknown how esophageal fibroblasts respond to EoE-relevant matrix stiffness or inflammatory cytokines. Immunofluorescence was used to evaluate α-smooth muscle actin (α-SMA) expression in endoscopic esophageal biopsies. Primary esophageal fibroblasts from adult and pediatric patients with or without EoE were exposed to transforming growth factor (TGF)β to determine gene expression, collagen-matrix contractility, and cytoskeletal organization. The influence of matrix stiffness upon fibroblast behavior was assessed on the engineered surface of polyacrylamide gels with varying stiffness. Fibroblast traction forces were measured using microfabricated-post-array-detectors. EoE esophageal fibroblasts had enhanced α-SMA expression. TGFβ not only stimulated enhanced fibroblast-specific gene expression but also promoted fibroblast-mediated collagen-matrix contraction, despite disease state or age of patients as the origin of cells. Unlike conventional monolayer cell, culture conditions using plastic surface (1 GPa) that activates fibroblasts constitutively, our engineered platforms recapitulating physiologically relevant stiffness (1-20 kPa) revealed that matrix stiffness defines the extent of α-SMA expression, intracellular collagen fibril organization, SMAD3 phosphorylation, and fibroblast traction force. Matrix stiffness may critically influence TGFβ-mediated gene expression and functions of esophageal fibroblasts ex vivo independent of age and disease conditions. These findings provide a novel insight into the pathogenesis of fibrostenotic disease in EoE.

Uretroplastia término-terminal para el tratamiento primario de la estenosis de uretra: experiencia del Hospital General Dr. Manuel Gea González

BackgroundUrethral stricture is a urologic disease that has significant morbidity. Direct visual internal urethrotomy is used for the majority of cases in the United States, but end-to-end urethroplasty is the most successful technique. The choice of primary management is controversial. Direct visual internal urethrotomy is widely accepted in the majority of Mexican hospital centers. However, it is reported to have lower long-term success rates. Urethroplasty is indicated for long, densely fibrotic strictures. Diagnosis is based on radiologic studies (nuclear magnetic resonance or ultrasound, with contrast medium). Scales (Urethral Stricture Score) describing stricture complexity are employed to choose surgical treatment. AimsTo communicate the results of primary treatment for urethral stricture in patients at the Hospital General Dr. Manuel Gea González that underwent end-to-end urethroplasty. Materials and MethodsA descriptive study was conducted that reviewed the case records of 210 patients with urethral stricture, selecting the 58 cases that underwent end-to-end urethroplasty as primary treatment within the time frame of January 1, 2007 and December 31, 2013. ResultsThe median age of the patients was 46.4 years. Stricture etiology: traumatic 23%, iatrogenic 58%, idiopathic 17%, and infectious 2%. The most frequent stricture location was at the bulbar level (87.9%) (51), mean length was 2.12cm, 3 cases presented with double-site stricture, 11% (19) of the cases had urinary retention, and the mean urethral stricture score was 5.8. There were 10 recurrences, 9 re-interventions (urinary tract infection), and one augmented urethroplasty. Preoperative Qmax was 5.7-10ml/sec and postoperative Qmax was 13-16ml/sec. Cure was achieved in 82.7% of the cases. ConclusionsUrethroplasty success rates worldwide are reported at 84-97%. Results are related to stricture complexity and surgical experience. There is still no consensus on success parameters. Urethroplasty presents less recurrence compared with direct visual internal urethrotomy, promoting long-term quality of life.

Characterizing intestinal inflammation and fibrosis in Crohn's disease by photoacoustic imaging: feasibility study.

The pathology of Crohn's disease (CD) is characterized by obstructing intestinal strictures because of inflammation (with high levels of hemoglobin), fibrosis (high levels of collagen), or a combination of both. The accurate characterization of the strictures is critical for the management of CD. This study examines the feasibility of characterizing intestinal strictures by Photoacoustic imaging (PAI) without extrapolation from superficial biopsies. Ex vivo normal rat colon tissue, inflammatory and fibrotic intestinal strictures in rat trinitrobenzene sulfonic acid (TNBS) model were first differentiated by a PA-US parallel imaging system. Surgically removed human intestinal stricture specimens were afterwards imaged by a multiwavelength acoustic resolution PA microscope (ARPAM). The experiment results suggest that PAI is a potential tool for the diagnosis of the diseased conditions in intestinal strictures.

TNF-α stimulates colonic myofibroblast migration via COX-2 and Hsp27

BackroundCrohn's disease (CD) is a chronic inflammatory enteropathy characterized by fibrotic strictures. Myofibroblasts (MFBs) are stromal cells of the gastrointestinal tract found in increased numbers in patients with CD and represent the key effector cells involved in pathologic fibrosis. MFB is a known target of tumor necrosis factor alpha (TNF-α), a proinflammatory cytokine strongly implicated in the pathophysiology of CD. However, the precise mechanisms through which TNF-α contributes to fibrosis remain incompletely understood. Here, we demonstrate for the first time that TNF-α increases MFB migration through the cyclooxygenase 2 (COX-2) and heat-shock protein 27 (Hsp27) pathways. Materials and methodsThe human colonic MFB cell line 18Co was grown to confluence on 35 × 10 mm cell culture dishes and used from passages 8-14. An in vitro scratch assay assessed the effect of TNF-α (10 ng/mL) on MFB migration over 24 h in the presence or absence of several inhibitors (NS398, SB203580, Hsp27 siRNA). ResultsTNF-α significantly increased MFB migration over 24 h. TNF-α also led to the increased expression of COX-2 and stimulated rapid phosphorylation of Hsp27 at serine 82. TNF-α-induced COX-2 expression, Hsp27 phosphorylation, and MFB migration were all significantly inhibited by the P38 MAPK inhibitor SB203580 (P < 0.05). TNF-α-induced MFB migration was also significantly inhibited by NS398 (P < 0.05), a direct inhibitor of COX-2, and by siRNA targeting Hsp27 (P < 0.05). ConclusionsTNF-α stimulates colonic MFB migration through P38 MAPK-mediated activation of COX-2 and Hsp27. Further elucidating these inflammatory signaling pathways may lead to novel therapeutic targets for the treatment of CD-related fibrosis and strictures.

Endoscopic treatment of food intolerance after a banded gastric bypass: inducing band erosion for removal using a plastic stent.

Ring complications after a banded Roux-en-Y gastric bypass (RYGB) are usually managed surgically. The aim of this study was to analyze the safety and effectiveness of endoscopic removal of noneroded rings after banded-RYGB, by inducing intragastric erosion of the ring using a self-expandable plastic stent (SEPS). A total of 41 patients with banded RYGB who had noneroded rings and food intolerance were prospectively enrolled. Patients were treated with endoscopic SEPS placement and ring removal. Data from time of stenting, resolution of symptoms, need for endoscopic dilation, and complications were recorded. Successful ring removal was possible in all patients. In 21 cases, the SEPS induced complete erosion, and in 17 cases the ring was removed a month later because of incomplete erosion at the time of SEPS removal. Nine patients (22.0 %) needed endoscopic dilation after stent removal in order to treat fibrotic strictures. Food tolerance was observed in 32 patients (78.0 %) after the procedure. No patient needed surgery and there were no deaths. Endoscopic removal of the ring using SEPS appeared to be safe and effective after a banded RYGB.

Predictors of success of treatment of distal two thirds common bile duct strictures: A retrospective Cohort study over two years

BackgroundDistal biliary stricture is a challenging clinical condition that requires a co-ordinated multidisciplinary approach. The aim of this workwas to evaluate the predictors of success of different treatment modalities of distal two thirds CBD strictures. Patients and methodsData were retrieved retrospectively from the medical records of the patients with distal biliary strictures treated in the Main Alexandria University Hospital from June 2013 to June 2015. Patients were classified into three groups according to the intervention performed: (endoscopic, open surgical, and percutaneous). In addition to the forth group that was followed up without intervention. ResultsThe study included 282 patients. The mean age was 61.1 ± 10.8 years (25–78) years. The most frequent presenting symptom was jaundice. Pancreatic adenocarcinoma was the most common cause followed by fibrotic stricture secondary to stones. ConclusionIn univariate analysis, the success of treatment was significantly associated with the pathology of the stricture of the distal two thirds CBD. In the multivariate analysis, only two factors were affecting the success of the treatment; the stricture length and site.

Inflammatory bowel disease imaging: Current practice and future directions.

The purpose of this paper is to evaluate the role of imaging in inflammatory bowel disease (IBD), including detection of extraluminal complications and extraintestinal manifestations of IBD, assessment of disease activity and treatment response, and discrimination of inflammatory from fibrotic strictures. IBD is a chronic idiopathic disease affecting the gastrointestinal tract that is comprised of two separate, but related intestinal disorders; Crohn's disease and ulcerative colitis. The paper discusses, in detail the pros and cons of the different IBD imaging modalities that need to be considered in order to optimize the imaging and clinical evaluation of patients with IBD. Historically, IBD evaluation of the bowel has included imaging to assess the portions of the small bowel that are inaccessible to optical endoscopic visualization. This traditionally was performed using barium fluoroscopic techniques; however, cross-sectional imaging techniques (computed tomography and magnetic resonance imaging) are being increasingly utilized for IBD evaluation because they can simultaneously assess mural and extramural IBD manifestations. Recent advances in imaging technology, that continue to improve the ability of imaging to noninvasively follow disease activity and treatment response, are also discussed. This review article summarizes the current imaging approach in inflammatory bowel disease as well as the role of emerging imaging modalities.