Small Bowel Strictures Research Articles

1072 Diaphragm Disease: NSAID-Induced Small Bowel Strictures. the Challenges of Surgical management

Abstract Non-steroidal anti-inflammatory drugs (NSAIDs) are used commonly, yet there is little literature surrounding NSAID-induced small bowel strictures, particularly those requiring surgery. We present the case of a 42-year-old female treated surgically over six years. This patient had used NSAIDs for several years; she was referred due to weight loss, anaemia and abdominal pain. Computerised topography (CT) scan showed small bowel obstruction. Initial treatment was laparotomy with small bowel resection. Histology revealed six strictures in the jejunum with incomplete obstruction – attributed to NSAIDs. Despite counselling her NSAID usage persisted and over the next two years she was treated for jejunitis and had a perforated duodenal ulcer repaired. At this point the patient ceased NSAID use, however the next twelve months saw three presentations with small bowel obstruction, all managed conservatively. This case is concordant with literature suggesting strictures can continue to develop despite NSAID cessation. She was placed on the surgical waiting list but symptoms worsened – anaemia requiring transfusions; hypokalaemia requiring IV replacement and 38-kilogram weight loss. She received total parenteral nutrition before surgery. She underwent another bowel resection with anastomosis. Initially she regained weight and biochemistry stabilised, however further obstruction developed the next year at the anastomosis site. This case highlights the difficulties managing this disease – nutrition, haematology and strictures developing years after NSAID cessation. It raises questions over surgery, choice of anastomosis and how to manage this ongoing dilated small bowel segment.

Spectrum of Clinical Presentations and Surgical Management of Tuberculous Small Intestinal Obstruction

Background: The causes of acute Intestinal Obstruction vary demographically. In the developing world, tuberculosis account for more than half of all cases of small bowel obstruction. Tuberculosis is a major health burden in developing countries. It can result some medical as well as surgical emergencies. Among the surgical emergencies, small gut obstruction is the burning issue. It can show wide spectrum of presentations. Objective: To find out spectrum of clinical presentations and surgical management of tuberculous small intestinal obstruction. Methods: It was a cross- sectional study conducted in the Department of Surgery, Sher-E-Bangla Medical College Hospital from July 2015 to December 2015. A total of 100 patients were selected by purposive sampling methods. The detail history and clinical examination findings were recorded including patient’s demographic profile and clinical as well as investigation findings. Preoperative findings and post-operative complications were also observed and recorded. Results: According to the result analysis, maximum patients were young adult and the highest patients (54%) came from 21-30 year’s age group followed by 31-40 year’s age group (18%). Among the respondents, 62% were male and 38% were female patients. The male to female ratio was 1.63:1. The results of clinical presentations revealed that all (100%) patients presented with abdominal pain followed by abdominal distension (78%) as small gut obstruction was mostly prevalent. Besides, constitutional features like weight loss and low grade and evening rise of temperature were present in almost all tuberculous patients. Operative findings revealed that single/multiple small bowel stricture in 80% patients followed by bands and adhesion in 14% patients. Strictures as well as perforation were present in case of 11% patients. Maximum operative procedures performed right hemicolectomy with ileo- transverse anastomosis (58%) followed by segmental bowel resection with end ........

A Mysterious Presentation of Small Bowel Stricture

Small bowel adenocarcinoma is a rare malignancy that accounts for a small percentage of gastrointestinal cancers. Diagnosis and management of small bowel adenocarcinoma can be challenging due to its rarity and nonspecific presentation. We present a case of a 51-year-old male with a history of intravenous drug use who presented with worsening abdominal pain and was found to have a small bowel obstruction. Exploratory laparotomy revealed a stricture in the jejunum caused by an intraluminal mass, which was resected. Pathological examination confirmed the diagnosis of intestinal type, moderately differentiated adenocarcinoma. This case highlights the importance of considering small bowel adenocarcinoma as a possible etiology in patients presenting with small bowel obstruction, particularly in high-risk individuals. Early diagnosis and complete resection remain the mainstays of treatment for improved outcomes in small bowel adenocarcinoma.

Evaluation of symptomatic small bowel stricture in Crohn’s disease by double-balloon endoscopy

PurposeTo assess the efficacy of double-balloon endoscopy (DBE) for the detection of small-bowel strictures in Crohn’s disease (CD).MethodsThis tertiary-referral hospital cohort study was conducted between January 2018 and May 2022. CD patients with symptoms of small-bowel stricture were enrolled sequentially. All of the patients were subjected to both computed tomography enterography (CTE) and DBE, and their symptoms of stricture were assessed using the Crohn’s Disease Obstructive Score (CDOS). The diagnostic yield of DBE was compared to that of CTE, and the relationship between the DBE findings and CDOS was investigated. The factors influencing the DBE diagnosis were examined using Cox regression analysis.ResultsThis study included 165 CD patients. The CDOS scores were higher in 95 patients and lower in 70 patients. DBE detected 92.7% (153/165) and CTE detected 85.5% (141/165) of the strictures. The DBE diagnostic yields were 94.7% (90/95) in the high CDOS patients and 91.4% (64/70) in the low CDOS patients (P = 0.13). Patients with a history of abdominal surgery and abscess had a lower diagnosis rate in the multivariate analysis.ConclusionDBE has been demonstrated to be an efficient diagnostic method for detecting small bowel strictures in CD patients. Additionally, there was no difference in the diagnostic yields between patients with low and high obstructive scores.

Endoscopic Capsule Retention: Frequency, Causes and Risk Factors Analysis in 244 Consecutive Procedures

Introduction. Endoscopic capsule is central to the study of the small bowel. Retention is its main complication. Objective. To analyze the frequency and risk factors associated with capsule retention. Methods. 244 consecutive examinations were analyzed. The event was defined as “definitive retention” if the capsule remained in the small bowel for 3 weeks after the procedure, and as “temporary retention” if the capsule remained in the small bowel at the end of the procedure but was eliminated spontaneously in the following days. Risk factors associated with retention were inflammatory small bowel strictures, tumours and large diverticula. Result. Of 244 procedures, lesions were found in 164 (67.2%), 130 of which were in the small bowel. There were 5 and 2 patients with definitive and temporary retention, respectively. Forty-four cases had risk factors. In 7 (15.9%) there was retention of the endoscopic capsule, with definitive retention in 5 cases. The 2 cases of temporary retention occurred in Meckel's diverticulum and in peptic ulcer scar. The 5 cases of definitive retention occurred in 2 patients with Crohn’s disease, 2 patients with stenosis related with anti-inflammatory drugs use and 1 patient with actinic stenosis. None of the 11 cases of small bowel neoplasia had capsule retention. Conclusions. There was no endoscopic capsule retention inpatients without risk factors. Definitive retention was observed in approximately one-tenth of all patients with small bowel risk factors. Recognition of risk factors and their identification prior to the procedure is of utmost importance, especially in patients with suspected inflammatory strictures.

Jejunal stenosis as a sequela after laparoscopic sleeve gastrectomy for morbid obesity: a case series

Porto-mesenteric venous thrombosis (PMVT) is a rare complication that is encountered in less than 1% of patients following laparoscopic sleeve gastrectomy (LSG). This condition could be conservatively managed in stable patients with no evidence of peritonitis or bowel wall ischemia. Nonetheless, conservative management may be followed by ischemic small bowel stricture, which is poorly reported in the literature. Herein, we present our experience regarding three patients who presented with manifestations of jejunal stricture after initial successful conservative management of PMVT. Retrospective analysis of patients who developed jejunal stenosis as a sequela after LSG. The three included patients had undergone LSG with an uneventful post-operative course. All of them developed PMVT that was conservatively managed mainly by anticoagulation. After they were discharged, all of them returned with manifestations of upper bowel obstruction. Upper gastrointestinal series and abdominal computed tomography confirmed the diagnosis of jejunal stricture. The three patients were explored via laparoscopy, and resection anastomosis of the stenosed segment was performed.Bariatric surgeons should be aware of the association between PMVT, following LSG, and ischemic bowel strictures. That should help in the rapid diagnosis of the rare and difficult entity.

Closed or Unclosed Mesentery? A Meta-analysis of Internal Herniation After Laparoscopic Roux-en-Y Gastric Bypass.

During the laparoscopic Roux-en-Y gastric bypass procedure, closing mesentery or not was still controversial according to preexisted studies. So, the current meta-analysis aimed to compare the outcome of closure versus non-closure of mesenteric defects in laparoscopic Roux-en-Y gastric bypass. Fifteen studies were included, enrolling 53,488 patients. Based on the outcome of analysis, regarding internal hernia, Petersen space's IH, jejunal mesenteric's IH, hospital days, and reoperation, closure of the mesentery was better than non-closure. Besides, small bowel obstruction, anastomosis ulcer, stenosis, leakage, bleeding, gastrointestinal perforation, and postoperative BMI of patients show no difference between non-closure and closure.

Small bowel adenocarcinoma in a Crohn's disease patient presenting as small bowel obstruction: a case report

Background: Small bowel adenocarcinoma (SBA) is a rare but dreaded complication of Crohn's disease with a poor prognosis. The evidence has concluded that it is difficult to differentiate between SBA and benign strictures. Intraoperative and pathological diagnosis is the mainstay of treatment. Case presentation: The current case involves a 40-year-old male with a 12-year history of Crohn's disease who presented with symptoms of small bowel obstruction, which were confirmed by an abdominal C.T. scan. An exploratory laparotomy revealed a stricture, which raised the possibility of malignant disease. Histology revealed a well-differentiated adenocarcinoma. Conclusion: The rarity of small bowel adenocarcinoma in Crohn's disease patients necessitates a high index of suspicion in patients presenting with features of small bowel obstruction or strictures.

LONGITUDINAL COMPRESSION THERAPY FOR SMALL BOWEL STRICTURE CROHN’S DISEASE: DURABLE RESOLUTION IN SWINE MODEL

Small bowel stricture is common in Crohn’s disease (CD), both de novo and after resection. With all standard treatments having high recurrence rates, CD patients would benefit greatly from a novel and highly durable non-surgical intervention. We report the first long-term study of longitudinal compression therapy (LCT) for the treatment of anastomotic strictures in an animal CD stricture model. LCT entails progressive endoluminal compression of stricture tissue between two flange-like device components. The goal is to gradually bring about necrosis of fibrotic tissue interposed between the two flanges while allowing remodeling with minimal iatrogenic inflammation around the periphery.

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

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

A Case report Abdominal TB presented as right psoas muscle abscess

Psoas muscle abscess is an uncommon presentation of abdominal TB, we described a 55 years old Sudanese male presented with a history of constitutional symptoms and history of right groin mass. Our patient denied any history of TB infection or contact with TB patient. Computed tomography scan revealed a right psoas muscle abscess. A US guided biopsy of the abscess was carried out and sent to histopathology, which showed mycobacterium tuberculosis infection. The patient was treated with antituberculus therapy and an ultrasound guided surgical drainage of the abscess. But our patient then developed signs of acute intestinal obstruction and underwent exploratory laparotomy, in which he was discovered to have a small bowel stricture as a complication of his abdominal TB. ileostomy was done, and a couple of days later the patient was discharged on good medical condition and antituberculus therapy.

Bleeding giant Meckel diverticulum, masquerading as abdominal tuberculosis

Meckel’s diverticulum is the most common congenital anomaly of gastrointestinal(GI) tract. It’s clinical presentation varies with age and overlaps with multiple GI pathologies. We are presenting a case of 18-year old boy presenting with overt lower GI bleeding, suspected to be intestinal tuberculosis based on imaging and Mantoux test. Initially responded to anti-tubercular treatment. However, his symptoms of GI bleed recurred, and repeat computed tomography(CT) scan showed suspicion of small bowel stricture with a dilated bowel loop. Exploration revealed a giant Meckel’s diverticulum which was resected and patient remained asymptomatic in the follow-up for 2 years. Bleeding giant Meckel’s diverticulum is sparingly reported in literature. However, even in tuberculosis endemic countries it showed be suspected as a possible cause of lower GI bleeding in young age group.

P355 Motility in small bowel strictures in Crohn’s Disease measured with cine-MRI

Abstract Background Strictures develop in over half of Crohn’s Disease (CD) patients and can lead to complaints of bowel obstruction, requiring treatment. A study showed that strictures and pre-stricture small bowel (SB) have lower motility measured with cine-MRI, compared to normal bowel in CD. However, stricture motility has not been correlated with disease duration or Harvey Bradshaw Index (HBI). Investigating this correlation can provide insight in the physiologic behavior of a stricture in relation to the extent of bowel damage (disease duration) and clinical complaints (HBI). This could possibly support the clinician in treatment decisions. Our aim is to investigate correlations between stricture motility measured with cine-MRI and disease duration and HBI, respectively. Methods At a tertiary center CD patients (≥18yrs) with SB strictures were included. Patients fasted 4 hours, after which they drank 1600 mL (2.5%-mannitol-solution) in 60 minutes prior to 3T MRI. All underwent coronal dynamic 2D bFFE scans of the most stenotic SB and the pre-stenotic dilation if present, during a 20-second expiration breath-hold. Bowel motility was assessed with a validated displacement mapping technique (GIQuant, Entrolytics, Motilent, UK). Strictures (wall thickening >3mm and ≥50% luminal reduction) and pre-stenotic dilations (luminal diameter >3cm) were delineated on a reference image and motility was quantified on a motility map within these regions of interest (ROI), producing a single, numerical motility score (Arbitrary Units=AU). Stricture and pre-stenotic dilation motility scores are presented in medians [IQR]. Correlation was tested between stricture motility, disease duration and HBI by means of spearman’s rank correlation test. Results Twenty-two patients (55% male, age 37yrs [IQR 25-55], disease duration 7yrs[IQR 4-12]) were included. SB stricture motility was 57AU[IQR 48-71]. Pre-stenotic dilation motility (n=6) was 131AU[IQR 88-340]. Disease duration and stricture motility showed no correlation(r=0.2, p=0.4). HBI and stricture motility were inversely correlated(r=-0.6, p<0.01). Conclusion We found an inverse correlation between SB stricture motility and HBI. No correlation was found between SB stricture motility and disease duration. The inverse correlation between HBI and stricture motility suggests that lower motility is associated with poorer clinical condition. This finding can possibly lead to earlier endoscopic or surgical intervention, since it indicates lower motility is associated with poorer clinical condition. Interestingly, we also measured higher pre-stenotic dilation motility compared to stricture motility, presumably a physiological response of the pre-stenotic dilation to the distal stricture and ongoing proximal peristalsis.

P173 Patency capsule: A novel independent predictor for long-term outcomes among patients with quiescent Crohn’s disease

Abstract Background Patency capsule (PC) is a recommended procedure to rule-out small-bowel stenosis before video capsule endoscopy (VCE).We examined future clinical outcomes among patients with failed-PC versus patients in whom PC had passed (passed-PC). Methods A Post-hoc analysis of two prospective cohort studies of adult patients with quiescent small-bowel CD that underwent PC between 2013-2020. The primary composite-outcome was the need for intestinal-surgery or endoscopic-dilation during follow-up in patients with or without failed-PC. Results A total of 191 patients were included (47-failed PC, 144-passed PC, median follow-up 34.12 months). Patients with a failed-PC had higher rates of the primary composite-outcome (21.3% vs. 1.4%, Hazard ratio [HR] 20.4, 95% confidence interval [CI] 4.4-94.1, p<0.001) and also secondary outcomes including intestinal-surgery (14.9% vs. 0.70%, p<0.001), endoscopic-dilation (14.9% vs. 0.70%, p<0.001), admissions (23.3% vs. 5.7%, p<0.001) and clinical-flares (43.9% vs. 27.5%, p=0.005) during follow-up compared with controls. Failed-PC was the only statistically significant factor for surgery and/or endoscopic-dilation, regardless of a B2/B3 phenotype at baseline. In sensitivity-analyses restricted only to patients with stricturing phenotype (n=74), failed-PC still predicted worse long-term composite-outcome (HR 23.1 95% CI 2.3-228.0, p=0.007). Of the 191 patients ingesting a PC, only one patient with a failed-PC had 48 hours of self-limiting mild symptoms Conclusion Clinically-stable CD patients with failed-PC have worse long-term clinical outcomes than those without, independently of CD phenotype. Standalone PC may serve as a novel, safe and affordable prognostic examination to stratify patients with CD for future risk of poor outcomes and potentially guide pre-emptive management decisions.

Isolated small bowel disease and multiple lung nodules: an unusual initial presentation of pediatric Crohn’s disease

Crohn’s disease (CD) is a chronic idiopathic inflammatory disorder of the gastrointestinal tract characterized by transmural inflammation, skip lesions, and architectural changes. Isolated small bowel involvement is seen in approximately 1% of patients with CD at diagnosis. Extraintestinal manifestations can occur, with pulmonary involvement seen in <1% of all CD. We report an unusual case of a previously healthy 12-year old male who presented to hospital with acute abdominal pain, emesis, and fever. He had microcytic anemia, thrombocytosis, elevated C-reactive protein, hypoalbuminemia, digital clubbing, and poor growth. Interestingly, initial upper endoscopy and ileocolonoscopy were unremarkable. Pathology revealed colonic nonnecrotizing granulomas without inflammation. He incidentally was found to have multiple lung nodules despite the absence of respiratory symptoms, and MRE revealed five small bowel strictures. This prompted work-up for alternative etiologies including infectious and rheumatologic, which were negative. Ultimately, five months later, double balloon enteroscopy revealed ileal ulcerations at the strictures and several small aphthous ulcers in the transverse and sigmoid colon. Biopsies showed active ileitis and chronic active colitis with nonnecrotizing granulomas. He developed perianal disease, confirmed on MR pelvis, and a diagnosis of CD was made. The patient started infliximab therapy and is clinically in remission. This is a rare and unique phenotype of CD with initial presentation of multiple lung nodules and isolated small bowel disease. This case highlights the importance of recognizing that pulmonary manifestations should be considered in the absence of respiratory symptoms and that a normal first endoscopy does not preclude a diagnosis of CD.

LONGITUDINAL COMPRESSION THERAPY FOR SMALL BOWEL STRICTURE CROHN'S DISEASE: DURABLE RESOLUTION IN SWINE MODEL

Abstract INTRODUCTION Small bowel stricture is common in Crohn’s disease (CD), both de novo and after resection. With all standard treatments having high recurrence rates, CD patients would benefit greatly from a novel and highly durable non-surgical intervention. We report the first long-term study of longitudinal compression therapy (LCT) for the treatment of anastomotic strictures in an animal CD stricture model. LCT entails progressive endoluminal compression of stricture tissue between two flange-like device components. The goal is to gradually bring about necrosis of fibrotic tissue interposed between the two flanges while allowing remodeling with minimal iatrogenic inflammation around the periphery. METHODS Stable anastomotic strictures with hallmarks of CD small bowel strictures were created in 6 pigs, using an established method entailing ileocolonic anastomosis creation with a bypassed ileal segment to maintain patency of the gastrointestinal tract followed by serial injections of phenol/trinitrobenzenesulfonic acid at the anastomosis site. Instead of using LCT devices deployed wholly endoscopically, to best study stricture response to LCT in this model, we used devices with magnetic elements for compressive force generation and integrated ultraminiature sensor arrays for monitoring treatment progression; one 23 mm diameter device component was placed via a surgical enterotomy and a second was deployed endoscopically. Animals were followed for 9 weeks after LCT to gauge post-treatment stricture response. RESULTS LCT device placement was successful in all animals. Five animals reached the 9-week timepoint. One animal was sacrificed on day 12 due to urinary tract complications unrelated to the device. The initial therapeutic response took place over a 3-hour period after device placement, with LCT devices applying increasing force from 3 to 10 Newtons. In endoscopic assessments, widened lumens were noted, with openings 3.3-fold larger at 2 weeks and 3.7-fold larger at 9 weeks. In comparison, for endoscopic balloon dilation in the same animal stricture model, the openings were 2.3-fold larger at 2 weeks, declining to 1.9-fold at 9 weeks. Endoscopic and macroscopic evaluation after euthanasia demonstrated newly patent lumens after excision of stricture tissue, with healthy-appearing mucosa and no macroscopic findings of stricture. CONCLUSION Prior work by our group and others--in animal models and in a small number of treated patients--has provided favorable indications of efficacy of LCT for treating refractory strictures. To the best of our knowledge, this is the first study to include long-term follow-up of LCT in a validated animal model of Crohn’s stricture. This work provides strong preliminary support that LCT’s combination of resection and neo-epithelialization can durably resolve CD stricture. LCT clinical studies are planned as a next step. Design and operation of device systems for longitudinal compression therapy for small bowel stricture in Crohn’s. (a) Longitudinal compression therapy device systems incorporate a dual-flange design, with a mechanism for drawing the flanges together to longitudinally compress the stricture. For single-sided access, expanding flange designs can be used (inset, top left). The LCT device systems used in this study are pairs of discrete non-expanding flange components, with one flange component placed proximal to the strictured region via laparotomy; magnetic elements in the flange components supply the compressive force. This design facilitates incorporation of ultraminiature sensor arrays into the flange components for monitoring stricture response to treatment (inset bottom right). (b)-(d) Steps in longitudinal compressive therapy: (b) advancing the LCT device through the stricture; (c) stricture compression between distal flange and expanded proximal flanges; (d) completion of therapy. Representative result for LCT in the porcine model of Crohn’s small bowel stricture. (a) Before treatment, a length of bowel 15 mm long is badly strictured, with the lumen less than 10 mm at its narrowest point. (b) At 2 weeks after LCT treatment, the narrowest point is markedly larger. (c) At 9 weeks post LCT treatment—a time after which balloon dilated strictures tend to have recurred—the LCT treated stricture is even more open than at 2 weeks post, consistent with the LCT intervention having spurred healing instead of exacerbating fibrosis. Three-dimensional anatomy of strictured segments determined by impedance-based measurement (Endoflip, Medtronic).

Patency Capsule: A Novel Independent Predictor for Long-Term Outcomes Among Patients With Quiescent Crohn's Disease.

Patency capsule (PC) is a recommended procedure to rule out small bowel stenosis before video capsule endoscopy (VCE). We examined future clinical outcomes among patients with a failed PC vs patients in whom the PC had passed (passed PC). A post hoc analysis of 2 prospective cohort studies of adult patients with quiescent small bowel Crohn's disease (CD) who underwent PC between 2013 and 2020. The primary composite outcome was the need for intestinal surgery or endoscopic dilation during follow-up in patients with or without a failed PC. A total of 190 patients were included (47: failed PC and 143: passed PC, median follow-up 34.12 months). Patients with a failed PC had higher rates of the primary composite outcome (21.3% vs 1.4%, hazard ratio [HR] 20.3, 95% confidence interval [CI] 4.4-93.7, P < 0.001) and also secondary outcomes including intestinal surgery (14.9% vs 0.70%, P < 0.001), endoscopic dilation (14.9% vs 0.70%, P < 0.001), admissions (23.3% vs 5.7%, P < 0.001), and clinical flares (43.9% vs 27.7%, P = 0.005) during follow-up compared with controls. Failed PC was the only statistically significant factor for surgery and/or endoscopic dilation, regardless of a B2/B3 phenotype at baseline. In sensitivity analyses restricted only to patients with a stricturing phenotype (n = 73), a failed PC still predicted the long-term composite outcome (HR 8.68, 95% CI 1.72-43.68, P = 0.002). Of the 190 patients ingesting a PC, only 1 patient with a failed PC had 48 hours of self-limiting mild symptoms. Patients with clinically stable CD with a failed PC have worse long-term clinical outcomes than those without, independently of the CD phenotype. Standalone PC may serve as a novel, safe, and affordable prognostic examination to identify patients with quiescent CD who have a higher risk for future worse clinical outcomes.

Single-balloon Enteroscopy for Evaluation of Small Bowel Crohn Disease Strictures: Peripheral Blood Lymphocytes As a Risk Factor for Strictures.

Few reports have focused on single-balloon enteroscopy (SBE) for evaluation of small bowel Crohn disease (CD) strictures. The aim of this study was to analyze the relationships between peripheral blood inflammatory markers and small bowel CD strictures observed by SBE. CD patients who underwent SBE between January 2016 and December 2020 were enrolled. The clinical characteristics and peripheral blood inflammatory markers were collected and analyzed to screen for predictive factors significantly associated with small bowel CD strictures. A total of 221 CD patients underwent SBE. The lymphocyte (LC) counts in peripheral blood were significantly lower in the active group (n=178) than in the inactive group (n=43) according to the simple endoscopic score for CD (SES-CD), P =0.011, and was correlated with the SES-CD ( r =-0.134, P =0.047). The LC levels were significantly lower in the stricture group (n=116) than in the nonstricture group (n=105) based on whether small bowel strictures developed, P =0.000, and LC was a risk factor for strictures in the multivariate analysis [hazard ratio (HR), 2.332; 95% CI, 1.102-4.937; P =0.027]. In the subgroup analysis, LC levels notably decreased after stricture aggravation ( P =0.000). Forty-seven patients who underwent small bowel resection underwent SBE at 6 to 12 months after surgery. The LC level was significantly lower in the postoperative patients with strictures ( P =0.025), and LC (HR, 4.444; 95% CI, 1.265-15.617; P =0.020) was a risk of postoperative strictures by univariate analysis, but the age at diagnosis (HR, 6.462; 95% CI, 1.272-22.560; P =0.022) was an independent risk factor by multivariate analysis. Peripheral blood LC levels were correlated with SES-CD and gradually decreased as the intestinal stricture increased in small bowel CD patients. The LC level was also significantly lower in the postoperative CD patients with strictures. The level of LC was a risk factor for small bowel strictures. These results suggest that peripheral blood LC could be a novel marker of small bowel CD strictures to guide CD diagnosis and therapy.

S3505 A Case of Invasive Gastrointestinal Mold Infection

IntroductionL: Invasive mold infections can be devastating and are mostly seen in patients with hematologic malignancies, profound neutropenia, solid organ or hematopoietic cell transplantation, and poorly controlled diabetes mellitus. Mucormycosis is caused by a group of ubiquitous molds called Mucormycetes and characterized by tissue infarction and necrosis that results from invasion of the vasculature by hyphae. We present a rare case of a patient with invasive gastrointestinal mold infection. Case Description/Methods: A 40-year-old male with chronic inflammatory demyelinating polyneuropathy (CIDP) was admitted for autologous stem cell transplantation (ASCT). Initial hospitalization was complicated by neutropenic fever and C. difficile enteritis treated with Fidaxomicin. He was admitted one month later for nausea, vomiting and push enteroscopy revealed two circumferential deep small bowel ulcerations and a jejunal stricture too distal to be reached. Ulcer biopsies showed granulation tissue and was positive for Cytomegalovirus. He was treated with Valganciclovir and initiated on TPN. One week later, he had a third admission for intractable nausea and vomiting due to a small bowel obstruction. He failed conservative management and underwent diagnostic laparoscopy that revealed five strictures in the distal small bowel which were all resected with two small bowel resections and re-anastomosed. Histopathology of resected jejunum showed necrotizing granulomatous inflammation with aseptated fungal hyphae concerning for Mucormycosis, which was not identified on fungal PCR. He was treated with liposomal Amphotericin B then transitioned to oral Isavuconazole before making a full recovery. (Figure) Discussion: The most common presentation of Mucormycosis is a rhino-orbital-cerebral infection. Gastrointestinal infection is rare in living patients and has been estimated to occur in around 7% of all Mucormycosis cases and carries mortality as high as 85%. Our patient had a history of refractory CIDP and underwent chemotherapy for ASCT that was complicated by development of C. difficile and CMV gastrointestinal infections and small bowel obstruction necessitating endoscopic intervention which led to exploratory laparoscopy for surgical resection and the diagnosis of invasive Mucormycosis. Although invasive GI Mucormycosis is rare, in severely immunocompromised patients with unexplained gastrointestinal symptoms and multiple risk factors as presented in our patient, this infectious organism can be considered in the differential.Figure 1.: (A, B) Circumferential ulcerations seen in the small bowel on push enteroscopy. (C) Mucosal ulceration with underlying necrotizing granulomatous inflammation in the deep muscularis propria/pericolonic adipose tissue with non-septated fungal hyphae present.