Ileal Stricture Research Articles

L’entérite kystique profonde

Enteritis cystica profunda is a rare and benign disease defined as the invagination of the intestinal epithelium into the submucosa and more profound layers of intestinal wall leading to the formation of mucin-filled cystic spaces. We reported the case of a 45-year-old female, suffering from a Crohn's disease, with a Koenig's syndrome, diarrhea, abdominal pain and weight loss. The colonoscopy and the abdominopelvic scan showed a terminal ileal stenosis, with parietal calcifications. A surgical ileocecal resection was decided. Gross examination of the ileocecal resection showed a thickening of the ileal wall, with many mucin-filled cysts measuring 1mm to 2cm, with some calcifications. The ileal mucosa was ulcerated, and showed a stenotic sector extending over 3cm. Histological examination showed acute ulcerated ileitis lesions, with chronic ileitis lesions and stenosis, compatible with the known diagnosis of Crohn's disease. There were also many cysts into the ileal wall. They were lined with a regular ileal epithelium. The cysts contained mucus, with some calcifications. Some cysts were ruptured, with extravasation of mucus within the wall. Cystica profunda can be found anywhere along the digestive tract. The physiopathology is not yet well understood, but it seems to be favored by chronic aggression of the intestinal wall. This pathology most often coexists with Crohn's disease. The main differential diagnosis is mucinous adenocarcinoma. Cystica profunda does not require any specific treatment.

A192 EFFICACY OF USTEKINUMAB IN SMALL BOWEL STRICTURES OF FIBROSTENOTIC CROHN'S DISEASE AS ASSESSED BY INTESTINAL ULTRASOUND

Abstract Background Small bowel Crohn’s disease (CD) strictures can lead to debilitating obstructive symptoms and the deterioration of quality of life. Imaging modalities such as intestinal ultrasound (IUS) are invaluable in the diagnosis of strictures. The use of IUS in CD is rapidly growing, is cost-effective, easily repeatable, and similar in accuracy to magnetic resonance enterography. Evidence for medical management of fibrostenotic CD has been limited to anti-tumor necrosis factor biologics. Studies on the efficacy of other biologic therapies for strictures such as ustekinumab, a p40/interleukin 12 and 23 inhibitor, are lacking. Purpose The objective of this study was to evaluate the efficacy of ustekinumab in the treatment of small bowel strictures on IUS. Method This retrospective cohort study evaluated the IUS changes of terminal ileal (TI) CD strictures at baseline and 12 months following ustekinumab initiation from 2016 to 2020 at a single tertiary care center. Strictures identified were defined as 1) increased bowel wall thickness (BWT) > 3mm, 2) narrowed luminal apposition, and 3) presence of pre-stenotic dilation (PSD) or the inability to pass the colonoscope through the narrowed area. Changes in sonographic parameters (BWT, luminal size, PSD, length, hyperemia, inflammatory fat, dysfunctional peristalsis) were recorded at baseline prior to initiation of ustekinumab and compared 12 months after treatment. Differences from baseline to 12 months were paired within-person and statistical analysis was performed using paired T-tests for continuous variables and McNemar’s test for categorical variables. Result(s) Of the 18 patients identified, 55% (n = 10) were male, median age was 49 years (Q1-Q3: 33-63 years) at initial scan, with median CD duration of 10 years (Q1-Q3: 8-20 years). The majority of TI strictures were surgically naïve (67%, n = 12). Between pre- and 12-month post ustekinumab therapy scans, there was significant improvement in BWT [8.2 mm vs 7.2 mm, p = 0.048], however there was no significant difference in the presence of peri-enteric inflammatory fat (p = 0.10), mean stricture length (17.7 vs 21.7 cm, p = 0.18), and mean stricture lumen diameter (3.3 mm vs 2.7 mm, p = 0.44) (Table 1). There was also no significant difference in the presence of stricture-associated peri-enteric fat (89% vs 67%, p = 0.10), stricture-associated hyperemia (83% vs 89%, p = 0.65) or dysfunctional peristalsis (50% vs 61%, p = 0.41) (Table 1). Image Conclusion(s) Our study is the first to report the efficacy of ustekinumab in small bowel CD strictures using IUS at baseline and 12 months. This study shows that although ustekinumab leads to improvement in overall sonographic appearance of bowel thickness, it does not improve luminal narrowing nor PSD, two hallmark criteria of fibrostenosis. More extensive studies with larger sample sizes evaluating ustekinumab, or combination therapies, are required to identify their role in stricturing CD. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

A107 VISCERAL ADIPOSE TISSUE VOLUME DIFFERENTIATES BETWEEN FIBROSTENOTIC AND INFLAMMATORY CROHN’S DISEASE

Abstract Background Creeping fat, a form of visceral adipose tissue (VAT) that wraps the intestinal wall, influences the formation of Crohn’s disease (CD) strictures. The degree of fat wrapping from intestinal stricture resections is correlated with the extent of chronic inflammation, fibrosis, stricture formation, and response to biologic therapy. VAT and subcutaneous adipose tissue (SAT) ratios from CTE (computed tomography) scans are elevated in CD strictures. However, the definition of strictures in these studies has been poorly defined and not included current well-recognized criteria: 1) bowel wall thickness (BWT), 2) narrowed luminal diameter, and 3) pre-stenotic dilation. (PSD). Purpose The objective of this pilot study was to assess the relationship of 2D and 3D VAT:SAT ratios with CT stricture parameters in patients with terminal ileal (TI) CD strictures. Method 2D VAT:SAT ratios from CT’s of CD patients with TI strictures defined as increased BWT, narrowed luminal diameter (< 50% relative to normal adjacent distended loop), and PSD greater than the stricture diameter were retrospectively obtained from a database and chart review. CT’s from fibrostenotic CD patients were sex and BMI matched to patients with only TI inflammatory behaviour. Patient demographics, medication, smoking, and surgical history were also obtained. Analyses were adjusted for age, sex, and BMI covariates. Unpaired t-tests and multi-variable logistic regression analyses were conducted. Result(s) Twenty-eight patients with stricturing CD had a significantly greater mean VAT:SAT volume ratio than 29 non-stricturing CD (41.5 cm3 vs 34.2 cm3, p=0.03). Thirty-six percent (10/28) of CD stricture patients had prior ileocolic resection with a mean disease duration of 13.5 years (range 0-48). The median ileal BWT (7.0 mm, range 4.0-13.0 mm) for the stricturing group was significantly greater than those with inflammatory behaviour (BWT 2.0 mm, p<0.0001). The median luminal diameter and PSD for the stricture group was 2.0 mm (range 0 - 14.0 mm), and 3.0 cm (range 1.0 - 7.3 cm), respectively. Image Conclusion(s) Fibrostenotic TI CD patients have increased VAT:SAT ratios in comparison to those with only inflammatory behaviour. These pilot VAT:SAT results provide an initial foundation for further studies to assess its predictive role in responsiveness of medical or surgical therapies in stricturing CD. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

A225 QUANTIFICATION OF BONE DENSITY AND DIETARY RISK FACTORS FOR BONE FRAGILITY IN INFLAMMATORY BOWEL DISEASE

Abstract Background Nutrition and bone fracture risk are intimately related in inflammatory bowel disease (IBD). Crohn’s disease (CD) patients are at increased risk of low bone mineral density (BMD) and fractures. This may be due to chronic inflammation, corticosteroid exposure, inadequate consumption of nutrients and minerals such as calcium (ie. lactose intolerance), food aversion, bowel symptoms, and/or possible altered absorption. Fibrostenotic CD is characterized by debilitating strictures where patients are known to alter food intake to avoid obstructive symptoms. However, relationships between food intake patterns and BMD have not been well delineated according to CD phenotypes. Purpose Our study evaluated 1) BMD as measured by dual X-ray absorptiometry (DXA), and 2) energy intake, dietary components and/or micronutrients in CD patients with strictures versus inflammatory (non-stricture) behaviour. Method In this prospective pilot study, patients > 55 years old with ileal CD strictures or inflammatory behavior were recruited from the University of Calgary IBD clinic. All patients completed hip and spine DXA scans and two dietary assessment questionnaires: 1) The Automated Self-Administered 24-hour Dietary Assessment Tool (ASA24) and 2) the Diet History Questionnaire III (DHQ III). Additional data collected included past fracture history, medication (glucocorticoid exposure), smoking, and surgical history. Standard of care laboratory investigations obtained included C-reactive protein, parathyroid hormone, calcium, albumin, and 25-hydroxyvitamin D. Patients with celiac disease, cirrhosis, heart failure, kidney disease, short gut, estrogen use, and dysphagia were excluded. Independent samples t-test and multi-variable regression analyses was conducted. Result(s) Seventeen patients had stricturing and twelve had non-stricturing CD (demographics Table 1). The mean BMD for non-stricturing CD patients was not significantly different from those with a stricturing CD phenotype (p =0.140). Non-stricture patients consumed significantly more dairy, calcium, and phosphate. For all CD patients, there was a positive correlation with BMD and intake of fat (p=0.03), carbohydrates (p=0.01), fiber (p=0.01), and alcohol (p=0.01). There was no statistically significant difference in corticosteroid exposure or smoking status. 74.7% (11/17) patients with stricturing CD had past bowel resection compared to only one patient with non-stricturing CD. Image Conclusion(s) In this pilot study, there was no difference in BMD between CD patients with and without small bowel strictures despite inflammatory behaviour patients having less surgical resections and consuming more calcium rich foods known to improve BMD. Further studies may delineate the dietary differences among CD phenotypes and provide information for interventions for nutrient supplementation, and a greater understanding of their relationships with BMD. Please acknowledge all funding agencies by checking the applicable boxes below Other Please indicate your source of funding; Koopmans Memorial Research Fund Disclosure of Interest None Declared

P311 Reliability of computed tomography enterography for evaluation of stricturing Crohn’s disease: Development of a Crohn’s disease stricture index

Abstract Background Computed tomography enterography (CTE) is frequently used to assess stricturing Crohn’s disease (CD). However, the reliability of CTE items used for assessment has not been established and there is no validated radiologic stricture severity index. Methods We conducted a retrospective study of 43 patients with symptomatic, terminal ileal stricturing CD. Four radiologists assessed a comprehensive list of pre-defined radiologic items potentially associated with stricture severity in 48 CTE scans in two separate rounds in random order. Reliability was quantified using the intraclass correlation coefficient (ICC). Items with at least moderate (ICC≥0.41) inter-rater reliability that were correlated with a visual analogue scale of overall stricture severity were candidate items for the development of a CTE stricture index. Results Inter-rater reliability was almost perfect for assessment of luminal diameter of pre-stenotic dilation (ICC 0.817 [95% confidence interval 0.703, 0.878]), substantial for stricture length (ICC 0.628 [0.419, 0.797]), and moderate for stricture wall thickness (0.482 [0.330, 0.601]). Intra-rater reliability was almost perfect (ICC ≥ 0.850) for all three items. A stricture severity index was derived and was well calibrated (optimism-adjusted calibration slope = 1.009), with scores calculated as the sum of stricture length (cm) + luminal diameter of pre-stenotic dilation (mm) + 5 x stricture wall thickness (mm). Conclusion Stricture length, prestenotic dilation, and stricture wall thickness can be reliably assessed, and are component items for a novel CTE stricture index (CTE-SI) of stricture severity for CD-related terminal ileal strictures. Additional external index validation for clinical and research contexts is required.

Areca nut ingestion–An unusual cause of presentation of chronic abdominal pain

A 42-year-old female patient, presented with recurrent abdominal pain, over 5 years. She had undergone abdominal hysterectomy 12 years ago, suggesting possible band obstruction. X-rays revealed a densely radio-opaque shadow, rounded in outline, with a relatively less opaque central portion. CT abdomen located it intra-luminally in the ileum, without significant evidence of obstruction. Laparotomy revealed an intact areca nut with a thick rim of calcification, proximal to an ileal stricture.

ASSESSMENT OF RISK FACTORS FOR SURGERY TREATMENT OF CROHN'S DISEASE: A HOSPITAL COHORT.

New therapies have revolutionized the treatment of Crohn's disease (CD), but in some countries, the surgery rate has not changed, the frequency of emergency surgery is underestimated, and surgical risk is poorly studied. The aim of this study was to identify risk factors and clinical indications for primary surgery in CD patients at the tertiary hospital. This was a retrospective cohort of a prospectively collected database of 107 patients with CD from 2015 to 2021. The main outcomes were the incidence of surgery treatment, types of procedures performed, surgical recurrence, surgery free time, and risk factors for surgery. Surgical intervention was performed in 54.2% of the patients, and most of the procedures were emergency surgeries (68.9%). The elective procedures (31.1%) were performed over 11 years after diagnosis. The main indications for surgery were ileal stricture (34.5%) and anorectal fistulas (20.7%). The most frequent procedure was enterectomy (24.1%). Recurrence surgery was most common in emergency procedures (OR 2.1; 95%CI 1.6-6.6). Montreal phenotype L1 stricture behavior (RR 1.3; 95%CI 1.0-1.8, p=0.04) and perianal disease (RR 1.43; 95%CI 1.2-1.7) increased the risk of emergency surgeries. The multiple linear regression showed age at diagnosis as a risk factor for surgery (p=0.004). The study of surgery free time showed no difference in the Kaplan-Meier curve for Montreal classification (p=0.73). The risk factors for operative intervention were strictures in ileal and jejunal diseases, age at diagnosis, perianal disease, and emergency indications.

The Utility of Contrast Enhanced Ultrasound and Elastography in the Early Detection of Fibro-Stenotic Ileal Strictures in Children with Crohn's Disease.

Crohn's disease (CD) is a chronic, idiopathic bowel disorder that can progress to partial or complete bowel obstruction. At present, there are no reliable diagnostic tests that can readily distinguish between acute inflammatory, purely fibrotic and mixed inflammatory and fibrotic. Our aim is to study the utility of contrast enhanced ultrasound (CEUS) in combination with shear wave elastography (SWE) to differentiate fibrotic from inflammatory strictures in children with obstructive CD of the terminal ileum. Twenty-five (19 male) children between 2016-2021 with CD of the terminal ileum were recruited into the study. Among these patients, 22 had CEUS kinetic measurements of tissue perfusion, including wash-in slope (dB/sec), peak intensity (dB), time to peak intensity (sec), area under the curve (AUC) (dB sec), and SWE. In total, 11 patients required surgery due to bowel obstruction. Histopathologic analysis was performed by a pathologist who was blinded to the CEUS and SWE test results. Patients that underwent surgical resection had significantly higher mean area under the curve on CEUS compared to patients responsive to medical therapy (p=0.03). The AUC also correlated with the degree of hypertrophy and the percent fibrosis of the muscularis propria, as determined by histopathologic grading (p<0.01). There was no difference in the mean elastography measurements between these two patient groups. CEUS is a useful radiological technique that can help identify pediatric patients with medically refractory obstructive fibrotic strictures of the terminal ileum that should be considered for early surgical resection.

A rare case of jejunal diverticula with bone causing sub-acute intestinal obstruction

Jejunal diverticula is a rare condition, usually remains asymptomatic though sometimes presents as vague abdominal pain and in the rare case may present as a life-threatening gastrointestinal (GI) bleed. In this case, the patient presented with features of subacute intestinal obstruction and contrast enhanced computed tomography (CECT) abdomen suggested intraluminal obstruction due to impacted bone in the small bowel. The patient underwent exploratory laparotomy, there were jejunal diverticula with bone as a foreign body, and a was ileal stricture causing an obstruction. Jejunal diverticula with bone as a foreign body is a rare case, requiring high suspicion index and relevant investigations for reaching a diagnosis.

Intestinal obstruction caused by acute perforated appendicitis misdiagnosed as Hirschsprung’s disease in a 31-month-old boy

Symptomatic abdominal distension in young children requires a differential diagnosis, such as overeating, constipation or surgical emergency. If the distension is associated with intestinal obstruction, clinicians should determine the cause, such as adhesion, hernia, tumor or inflammatory lesions. Herein, the author reports a case of intestinal obstruction caused by acute perforated appendicitis. A 31-month-old boy was referred with a 10-day history of abdominal distension and a presumptive diagnosis of Hirschsprung’s disease. He had undergone an unsuccessful enema. Initial plain radiography and computed tomography showed severely dilated bowel loops with the colon collapsed. During laparotomy, the perforated appendix was found attached to the retroperitoneum and mesentery, which resulted in ileal stenosis with ischemia. The author resected 10 cm of the ileum, and performed ileocecectomy. Postoperatively, the boy recovered uneventfully, except wound seroma. Due to the low incidence and vague symptoms, it is difficult to diagnose intestinal obstruction caused by appendicitis, particularly in young children. This case may serve as a reminder that acute perforated appendicitis can cause sudden onset of intestinal obstruction in young children without a history of surgery.

7360 Surgical Management of Ileocecal Endometriosis, 6 Cases Treated with Laparoscopic Ileocecal Resection

<h3>Study Objective</h3> To present and discuss clinical features of ileocecal endometriosis (ICE) and feasibility of laparoscopic surgery for ICE. <h3>Design</h3> Retrospective cohort study. <h3>Setting</h3> Gynecology and Obstetrics department of a general hospital. <h3>Patients or Participants</h3> All patients who underwent laparoscopic surgery for ICE. <h3>Interventions</h3> Between December 2010 and January 2021, 6 patients underwent laparoscopic ileocecal resection for ICE. <h3>Measurements and Main Results</h3> A total of 6 patients (median age 37.0) underwent laparoscopic ileocecal resection. Five of the six cases had preoperative symptoms from ileocecal lesions such as bowel obstruction and abdominal pain. Three cases were diagnosed with ileal stenosis by contrast X-ray with nasointestinal tubes, and the other three were diagnosed with ICE by colonoscopy or double contrast barium enema (DCBE). All 6 patients had concomitant rectal endometriosis and underwent simultaneous laparoscopic lower anterior resection. In one case, ureteral stent placement was required for ureteral injury, and in one case, intestinal obstruction occurred postoperatively, but both cases improved without sequel. Postoperative hormone therapy with dienogest was performed in five patients. One patient underwent bilateral adnexectomy. No recurrence was observed in all patients (the median observation time: 48 month). <h3>Conclusion</h3> All patients with ileocecal endometriosis had rectal endometriosis and required two segmental intestinal resections. Laparoscopic surgery for ICE needs deep understanding of the gastrointestinal tract and advanced techniques of laparoscopic surgery, as well as cooperation with surgeons.

Variables associated with progression of moderate-to-severe Crohn’s disease

ObjectiveDetermine the variables associated with hospitalisations in patients with Crohn’s disease and those associated with surgery, intestinal resection, hospital readmission, need for multiple operations and immunobiological agent use.DesignA cross-sectional study...

Validation of stricture length, duration and obstructive symptoms as predictors for intervention in ileal stricturing Crohn's disease.

Risk factors for intervention in terminal ileal (TI) stricturing Crohn's disease (CD) are poorly defined. Novel and rigorous definitions for TI strictures recently became available. We aimed to describe the rates of symptoms or need for endoscopic balloon dilation (EBD) or surgery as well as risk factors of progression in a well-defined stricturing CD cohort. Consecutive adult patients with non-penetrating stricturing TI CD, as defined by centrally-read magnetic resonance enterography CONSTRICT criteria, were separated into a derivation and validation cohort. Clinical and imaging characteristics were collected following prespecified scoring conventions. Primary outcome was a composite endpoint of EBD or surgery ("intervention"). Multivariable analysis was performed. Eighty-six patients (48.8% female, median age 36years) met selection criteria, 17.4% had prior EBD, 59.3% previously received biologics and 58.1% of strictures were anastomotic. Median follow-up was 63.4 [95% CI: 57, 68.9] months. In the derivation cohort, at 12 and 48months, 26% and 45% of patients had intervention, respectively. Multivariable analysis showed obstructive symptoms (Hazard ratio [HR] 1.444; 95% CI 1.126-1.852), stricture duration (HR 0.974; 95% CI, 0.954-0.995) and length (HR 1.039; 95% CI, 1.011-1.069) predicted intervention. The concordance index for split-sample validation was 0.74 and 0.67, respectively. Biologics were not associated with intervention. An online risk calculator was constructed. In patients with TI stricturing CD, 26% and 45% required intervention at 1 and 4years. Obstructive symptoms, stricture duration and length were independent and validated predictors of the need for intervention. These findings are important for clinical practice and aid in the design of future trials for CD strictures.

“COMPARATIVE STUDY OF CONSERVATIVE VERSUS OPERATIVE MANAGEMENT IN CASES OF ABDOMINAL KOCH'S”

Background: Abdominal tuberculosis is sixth most common type of extra- pulmonary tuberculosis. It can affect any intra-abdominal organ and any part of the intestinal tract. Patients are managed conservatively and Surgery in patients with Abdominal Tuberculosis is reserved for those with acute surgical complications including intestinal obstruction, perforation, abscess, colocutaneous stula, excessive bleeding and patients who are not responding to medical management. Our study was conducted on 65 Patients of abdom Methods: inal tuberculosis admitted in department of general surgery RD Gardi Medical College, Ujjain between December 2019 to July 2021. Out of 65 patients, 66.2% were managed Results: surgically and 33.8% managed conservatively. Exploratory laparotomy With Segmental Bowel Resection due to multiple ileal strictures with ileostomy with ileostomy closure after 3 months of ATT is done in 30.23% patient in our study. Exploratory laparotomy with loop ileostomy for ileocaecal mass and abdominal abscess 2ndstage surgery after 3 months of ATT right hemicolectomy with ileotransverse anstomosis done in 20.93 % patients. Exploratory laparotomy With Resection Of ileocaecal Mass with ileoascending anastomosis is done in 20.93% of patients in our study In our study, exploratory laparotomy with adhesiolysis with release of bands with loop ileostomy. 2ndstage surgery done after 3 months of ATT, reexploration with right hemicolectomy with ileotransverse anastomosis done in 11.62 % patients.Exploratory laparotomy with right hemicolectomy with ileotransverse anastomosis is done in 10.76 % patients.In our study, slight seroma discharge from wound site is the most common complication seen post operatively (35%). In our study, fecal stula is seen only in 5% of patients. In our study, there are complications developed during and after ATT in which 6 patients required surgery Abdominal tuberculos Conclusions is is an increasingly common disease that poses diagnostic challenge despite advances in diagnostic modalities, as the symptoms and signs of the disease are nonspecic, which may lead to diagnostic delays and eventually lead to development of complications. Therefore, a high index of suspicion is an important factor in early diagnosis. Patients are managed conservatively and Surgery in patients with Abdominal Tuberculosis is reserved for those with acute surgical complications.

S3370 Chronic Intestinal Obstruction in Surgically Treated Hirschsprung’s Disease: A Rare Presentation

Introduction: Hirschsprung’s Disease (HD) is exceedingly rare and represents a failure of ganglion cell migration to the gut. Longitudinal studies examining long-term outcomes of surgically treated HD are extremely limited. We discuss a patient who underwent surgical treatment for HD as an infant and presented in adulthood with severe abdominal pain and weight loss. Case Description/Methods: A 34-year-old female presented with severe abdominal pain and 15-pound weight loss over 1 month. She had a history of HD that involved the entire colon diagnosed at 6 months which was treated with the Duhamel procedure at age 1. Her postoperative course was complicated by recurrent small bowel obstruction (SBO) requiring multiple surgeries for adhesiolysis. She continued to pass gas; bowel movements were at baseline. Physical exam revealed mild distention and tenderness in the periumbilical region. CT showed marked small bowel dilation proximal to the anastomosis, multiple areas of focal narrowing, and significant stool burden (Figure A). Endoscopy revealed nonobstructive ileal stenosis proximal to the anastomosis and ileal ulcerations with biopsies showing acute and chronic inflammation with cryptitis (Figure B). Empiric treatment for small intestinal bacterial overgrowth and Hirschsprung-associated enterocolitis were initiated without improvement. She was also trialed on mesalamine with no benefit. Manometry revealed impaired recto-anal inhibitory reflex possibly due to residual HD and Type 1 dyssynergic defecation. She was started on prucalopride with some improvement of her abdominal pain. Providing non-invasive venting options remains an ongoing challenge. Discussion: The curative treatment for HD is surgical resection and the limited studies on long-term outcomes of these patients have demonstrated that constipation or diarrhea are common, and obstructive symptoms or dyssynergia are rare. Potential reasons for the complications presented in this case include mechanical obstruction from strictures and possible residual aganglionosis from insufficient resection. Additionally, prolonged bowel dilation may lead to impaired motility, evacuation difficulties, chronic dilation, and ischemic changes. There is a need for longitudinal studies at dedicated colorectal centers to provide effective transition of care from childhood to adulthood as well as a formalized approach to the management of postoperative complications of HD in adulthood, especially as these issues closely relate to functional status and quality of life.Figure 1.: A: CT demonstrating areas of narrowing and marked dilation proximal to the anastomosis B: Endoscopic view of the ileum demonstrating ulceration and stenosis at the anastomosis site.

Successful Resolution of Refractory Post-tubercular Ileocecal Stricture by Lumen Apposing Metal Stent

Abstract Tuberculosis is one of the common causes of benign small bowel obstruction and endoscopic management mainly relies on serial balloon dilatation. In this report, we describe a 35 year male with refractory post-tubercular ileal stricture that was successfully treated with a lumen apposing metal stent

NOD2 in Crohn's Disease-Unfinished Business.

Studies of Crohn's disease have consistently implicated NOD2 as the most important gene in disease pathogenesis since first being identified in 2001. Thereafter, genome-wide association, next-generation sequencing and functional analyses have all confirmed a key role for NOD2, but despite this, NOD2 also has significant unresolved complexity. More recent studies have reinvigorated an early hypothesis that NOD2 may be a single-gene cause of disease, and the distinct ileal stricturing phenotype seen with NOD2-related disease presents an opportunity for personalized diagnosis, disease prediction and targeted therapy. The genomics of NOD2 has much that remains unknown, including the role of rare variation, phasing of variants across the haplotype block and the role of variation in the NOD2-regulatory regions. Here, we discuss the evidence and the unmet needs of NOD2 research, based on recently published evidence, and suggest methods that may meet these requirements.

Ultrasound shear wave elastography in pediatric stricturing small bowel Crohn disease: correlation with histology and second harmonic imaging microscopy.

Preclinical animal as well as small exploratory ex vivo and in vivo human studies have suggested that bowel wall shear wave speed (SWS) measurements may be a noninvasive biomarker of intestinal damage. To evaluate the relationships between bowel wall stiffness, measured using ultrasound shear wave elastography (SWE), and intestinal fibrosis and smooth muscle hypertrophy as determined by (1) histology and (2) second harmonic imaging microscopy (SHIM) in surgically resected ileal strictures from pediatric Crohn disease patients. Nineteen pediatric Crohn disease patients with symptomatic ileal strictures underwent research ultrasound examinations before surgical resection between December 2017 and September 2020. Two-dimensional SWE was performed through the area of the most severe stenosis, with measurements obtained from the bowel wall at the 9:00, 12:00 and 3:00 o'clock locations with 0%, 10% and 20% abdominal strain. Overall right lower quadrant stiffness also was documented. Median bowel wall and overall right lower quadrant SWS measurements were correlated with bowel wall histological scores of inflammation, fibrosis and smooth muscle proliferation as well as SHIM collagen signal. Diagnostic ultrasound SWE imaging was obtained from 18 participants. The median age was 16.8 years. There were negative correlations between histological mucosal active inflammation and both bowel wall SWS with 10% abdominal strain (r=-0.50, P = 0.04) and overall right lower quadrant SWS with 20% abdominal strain (r=-0.69, P = 0.002). There were positive correlations between histological muscularis propria inner layer smooth muscle hypertrophy and both median bowel wall SWS with 10% abdominal strain (r = 0.72, P = 0.002) and overall right lower quadrant SWS with 20% abdominal strain (r = 0.71, P = 0.002). There were no associations between ultrasound stiffness metrics and bowel wall SHIM collagen measurements. Bowel wall and overall right lower quadrant ultrasound stiffness measurements correlate with mucosal active inflammation and muscularis propria smooth muscle hypertrophy in pediatric stricturing ileal Crohn disease, but not with intestinal fibrosis.

The Surgical Management of Ileal Pouch Strictures.

Total proctocolectomy with IPAA reconstruction is the surgical approach of choice in ulcerative colitis, indeterminate colitis, familial adenomatous polyposis, and selected patients with Crohn's disease. Pouch stricture is a common complication after IPAA. This study aims to identify surgical management options for pouch stricture and offer a treatment algorithm. A computer-assisted search of the online bibliographic databases MEDLINE and Embase from 1990 to 2021 was performed. Randomized controlled trials, cohort studies, observational studies, and case reports were considered. Mechanical dilation, strictureplasty, stapler resection, pouch advancement, bypass, and repeat IPAA were included. Twenty-three articles were considered eligible. Overall incidence of strictures varied from 5% to 38%. Strictures were categorized into 3 areas: pouch inlet (with a reported incidence of 9% to 56%), mid-pouch (with a reported incidence of 2%), and pouch-anal anastomosis (with a reported incidence of 43% to 87%). Pouch-anal strictures were initially managed using bougie or Hegar dilation, with various surgical procedures advocated when initial dilation failed. Mid-pouch strictures are relatively unstudied with scant data. Pouch inlet strictures can be surgically managed by various transabdominal techniques' including resection and reconnection, strictureplasty, or bypass. Pouch-anal strictures should be managed in a step-up strategy as conservative procedures are associated with acceptable success rates. Initial mechanical dilation using bougie or Hegar dilation has a success rate of >80%, although it is likely to require repeat dilations. When these measures fail, transanal surgical approaches using strictureplasty, stapler resection' or pouch advancement should be offered. Transabdominal pouch revision should be offered to patients refractory to a transanal approach. In mid-pouch strictures, the treatment of choice is pouch revision and reanastomosis. Pouch inlet strictures can be managed by resection, strictureplasty, or bypass depending on the location and length of the stricture and surgeon experience. Studies were often small and retrospectively analyzed. There were no randomized controlled trials or comparison between different treatment options.

Crohn’s Disease Complicated by Rare Types of Intestinal Obstruction: Two Case Reports

Intestinal obstruction is one of the most common complications of Crohn’s disease (CD), jeopardizing the quality of life of patients. Numerous factors may contribute to intestinal obstruction in CD. Thus far, the primary reason has been identified as intestinal fibrosis caused by repeated chronic inflammation during the active phase of CD. Herein, we report two rare complicated CD cases and provide a reference for the clinical diagnosis and treatment of similar patients. Case one involves capsule endoscope retention in the small intestine of one CD patient concurrent with intestinal obstruction. Case two is a CD patient with intestinal obstruction caused by a mesangial hernia and ileal stenosis. Individualized and minimally invasive surgical intervention ultimately resulted in the successful management of these two patients. The two cases serve as an excellent guide for diagnosing and treating CD patients who present with similar symptoms.