Small Bowel Strictures Research Articles

Accuracy of the Patency Capsule to Exclude Small Bowel Strictures in Crohnʼs Disease: Is it Better to be Safe or Sorry?

Purpose: Capsule endoscopy (CE) is now a well established investigation for suspected Crohn's disease (CD). Its use in established CD has been limited, due in part to the relatively high risk (˜5%) of capsule retention. Barium radiography (SBFT) has not been found to be reliable to assure small bowel patency prior to CE in CD. The use of a patency capsule has thus been proposed as an alternate screening test for this purpose. Evacuation of the dummy capsule from the small bowel within a 30 h window indicates small bowel patency, whereas its retention beyond this time has been taken to imply a potential luminal stricture, contraindicating CE. The purpose of this study was to evaluate the clinical utility and safety of the patency capsule in established CD. Methods: Outcomes of consecutive CD cases referred for CE were reviewed before and after the systematic use of a patency capsule to screen for small bowel patency. Plain abdominal radiology (AxR) was used to localize the patency capsule 30 +/− 2 hr after ingestion. Results: Before the FDA approved introduction of the Agile patency capsule in 2006, we carried out small bowel CE in 31 CD patients without obstructive symptoms or any strictures seen on SBFT. Capsule retention occurred in 2 (6.7%) of these cases. Subsequently, 37 consecutive CD patients first underwent the patency capsule exam. Among these, 5 were denied CE because the patency capsule was localized to the small bowel radiologically 30 h after ingestion. Among the 32 others who underwent the CE exam, capsule retention occurred in 1 (3.2%) case. For the most recent 4 CD patients in whom the patency capsule position was deemed to be in the small bowel or its location was doubtful at 30 h, a second AxR was carried out at 48-60 h. In 3 of the latter, the repeat imaging showed that the patency capsule was eliminated intact from the small bowel. All 3 subsequently underwent a successful CE exam. CE was denied in the 1 remaining case with prolonged small bowel retention of the patency capsule. Conclusion: Subclinical intestinal stenoses are frequent in CD and conventional radiologic investigations have a low sensitivity for their detection. Use of a patency capsule use appears to reduce, but not completely eliminate the risk of capsule retention. However, the “safe” reliance on a 30 hour cut-off for patency capsule elimination from the small bowel may preclude a clinically worthwhile CE study. Further trials are required to validate the safety and clinical value of a delayed cut-off (˜48 hr) for intact patency capsule passage. Disclosure: Dr Ernest G Seidman- Consultant, member of Speaker's Bureau, and recipeint of research support from Given Imaging Inc. Given Imaging Inc. supplied a small number of patency capsules free of charge.

Small Bowel Cancer in Crohnʼs Disease: A Case Series and Review of Literature

Purpose: To increase awareness of the potential for malignant transformation in the small bowel of patients with Crohn's disease (CD), a rare but an existential complication. We briefly describe four patients with small bowel adenocarcinoma (SBA). Methods: Clinical features of CD patients who were found to have SBA and were under our care between 2006 and 2009 were tabulated. We reviewed entries discussing “Crohn Disease” and “small bowel cancer” on MEDLINE using MeSH terms “Crohn Disease” and “Carcinoma”, focusing on the last 10 years. Results: In our patients, as summarized in the table, half were female and were diagnosed with SBA on surgical pathology. The two male patients presented with a small bowel obstruction (SBO) leading to surgery. The two women presented with pain that led to further investigations (one by colonoscopy and the other by a barium study) that led to surgical intervention revealing the diagnosis. The two patients who had obstruction had invasive disease with very poor prognosis. The two patients without invasive disease are currently doing well at 1 year and 2 years post-operation without evidence of recurrence. The literature review revealed a cumulative incidence of SBA in CD is 0.2% at 10 years and 2.2% at 20 years, being almost as high as the well-established incidence of colorectal carcinoma in Crohn's colitis. Diagnosis is often delayed, as SBA symptoms mimic active or obstructive CD. Most common SBA site is ileum. Prognosis is poor, with a 5-year survival of 20-30%.Table: Summary of patientsConclusion: CD has become a well-recognized risk factor for SBA. Our cases reflect the potential of malignant transformation in CD, especially in the setting of a small bowel stricture. The clinical presentation observed in our cases is similar to that described in published literature. A high index of suspicion is required in CD patients with strictures who fail to respond to medical management. We should be suspicious of this rare diagnosis when CD with patients fail to respond to medical management. Other imaging modalities such as PET/CT, CT enterography, capsule endoscopy, double balloon enteroscopy may aid in the preoperative diagnosis of these lesions.

Effective dilation of small-bowel strictures by double-balloon enteroscopy in patients with symptomatic Crohn's disease (with video)

Crohn's disease (CD)-related small-bowel strictures remain a major cause of morbidity, frequently requiring surgery. Assessment of the feasibility and effectiveness of CD small-bowel stricture dilation by DBE. Prospective case series. Single, tertiary referral center. Outcome data on cases of DBE-assisted CD small-bowel stricture dilation were prospectively collected from 2005. Dilation was performed by using controlled radial expansion balloon dilators. A 10-cm visual analogue scale (VAS) was used to assess obstructive symptoms and dietary restriction before DBE stricture dilation and at follow-up. A total of 13 DBEs were performed in 11 consecutive patients (mean +/- SD age 46.4 +/- 7.8 years). Eighteen small-bowel stricture dilations were performed in 9 of 11 patients. The mean dilation diameter was 15.4 mm (range 12-20 mm). In 2 cases, stricture dilation was not performed because adhesions made reaching the strictures impossible. One case was complicated by a delayed perforation. In the other 8 patients, stricture dilation was successful; VAS scores improved dramatically and none of the patients has required surgery (mean follow-up 20.5 months; range 2-41 months). During follow-up, 2 patients required repeated dilation (at 6.5 and 13 months, respectively) because of symptom recurrence. Clinical improvements in before and after VAS scores were significant (mean 8.8 vs 1.8, respectively; P < .001). Small case series; single tertiary referral center. DBE-assisted small-bowel stricture dilation for selected patients with CD is potentially of significant benefit and should be considered as a useful and effective alternative to surgery. Larger studies are required to confirm this benefit.

Dilatation of Small Bowel Strictures By Double Balloon Enteroscopy: Further Results from the UK

Introduction: Double balloon enteroscopy (DBE) facilitates endotherapy of deep SB pathology. Our preliminary prospective proof of concept analysis on DBE dilatation of Crohn's Disease (CD) SB strictures was presented to the ASGE at DDW 2008. We now report further on our prospective data of DBE stricture dilatation in an expanding cohort of patients with CD and NSAID induced SB strictures from the UK. Aims and Methods: Since introduction of DBE to our unit in 2005, data on cases of DBE SB stricture dilatation were prospectively collected for outcome, need for repeat dilatation and surgery. The DBEs were performed using the EN-450T5 scope (Fujinon, Saitama, Japan). Balloon ilatation was performed using controlled radial expansion (CRE)balloon dilators. A standardised 10cm visual analogue scale (VAS) characterised symptoms and dietary restriction before DBE stricture dilatation and at follow-up. Results: A total of 14 DBEs were done in 12 consecutive cases (mean age 46.4 ± 7.8 years). In all but 2 cases, the strictures were characterised radiologically before DBE. In 11 of the cases, the SB strictures were CD related, in 1 case they were NSAID induced. Twenty six SB stricture dilatations were performed in 10 of 12 patients. The patient with NSAID related strictures had successful dilatation of 8 strictures in one session. In another case of CD SB strictures, a retained video capsule was retrieved after dilatation of the culprit strictures. Mean stricture dilatation diameter was 14.5mm (range 12-20mm). In the 2 cases where stricture dilatation was not performed, DBE hindrance by adhesions made reaching the strictures impossible. These two cases were then managed surgically. One case of complex CD stricture dilatation was complicated by a delayed perforation. This case required a temporary jejunostomy which has since been reversed. In the other 9 cases SB stricture dilatation by DBE was an unhindered success; the symptom and dietary restriction scores improved dramatically and to date (mean follow up 19.4; range 1-40 months) none of these cases has required surgery for SB strictures. At follow-up, 2 patients required a repeat straightforward DBE dilatation (at 6.5 and 13 months respectively) due to recurrence of some of their symptoms. Although the numbers in this series are small, the clinical improvements in pre and post DBE VAS scores were large enough (means of 9.2 vs 1.7 respectively; p<0.001). Conclusion: This series adds to the growing body of published evidence that DBE SB stricture dilatation can be very effective, with the potential to help avoid the risks of surgery, small bowel resection and the associated risks of short bowel syndrome.

Small-Bowel Neoplasms: Prospective Evaluation of MR Enteroclysis

To prospectively evaluate the accuracy of magnetic resonance (MR) enteroclysis in the detection of small-bowel neoplasms in symptomatic patients, with conventional endoscopy, tissue specimen, capsule endoscopy, conventional enteroclysis, and follow-up findings as reference standards. The study protocol was approved by the human research committee, and all patients gave written informed consent. One hundred fifty patients (83 male, 67 female; mean age, 42.6 years; age range, 17-84 years) who were clinically suspected of having small-bowel neoplasm and whose previous upper and lower gastrointestinal endoscopy findings were normal underwent MR enteroclysis. The MR enteroclysis findings were prospectively evaluated for the presence of focal bowel wall thickening, small-bowel masses, and small-bowel stenosis. Positive MR enteroclysis findings were compared with histopathologic examination results obtained after surgical (n = 19) or endoscopic (n = 2) procedures. Negative MR enteroclysis results were compared with the results of enteroscopy (n = 5), capsule endoscopy (n = 53), or conventional enteroclysis with subsequent clinical follow-up (n = 71). The diagnostic performance of MR enteroclysis was analyzed on a per-patient basis. MR enteroclysis was successfully completed in all 150 patients and enabled correct detection of 19 small-bowel neoplasms, which were confirmed at histopathologic examination: three carcinoid neoplasms, two adenocarcinomas, two stromal tumors, five lymphomas, one angiomatous mass, three small-bowel metastases, one leiomyoma, one adenoma, and one lipoma. Overall sensitivity, specificity, and accuracy in identifying patients with small-bowel lesions were 86% (19 of 22), 98% (126 of 128), and 97% (145 of 150), respectively. Two MR enteroclysis examinations yielded false-positive findings, and three yielded false-negative findings. MR enteroclysis is an accurate modality for detecting small-bowel neoplasms in symptomatic patients.

Severe Legionella pneumophila pneumonia following infliximab therapy in a patient with Crohnʼs disease

Immunosuppressive therapy with anti-TNF-alpha antibodies is effective in patients with inflammatory bowel disease (IBD). However, there is an increased risk for infections associated with this therapy. Here, we report the case of a 58-year-old patient with Crohn's disease (CD) treated with steroids and azathioprine who developed severe Legionella pneumophila pneumonia after 3 infusions of infliximab. The patient presented at our IBD department with severe active CD complicated by inflammatory small bowel stenoses and entero-enteral fistulas despite long-term high-dose steroid therapy. To achieve steroid tapering and control of disease activity, immunosuppressive therapy with azathioprine was initiated. Due to persistent symptoms, infusion therapy with the anti-TNF-alpha antibody infliximab was started, subsequently leading to significant clinical improvement. However, after the third infliximab infusion the patient was hospitalized with fever, severe fatigue, and syncope. Laboratory findings and chest X-ray revealed left-sided pneumonia; cultural analysis showed L. pneumophila serogroup 1 leading to respiratory insufficiency, which required mechanical ventilation for 2 weeks in the intensive care unit. After discontinuation of all immunosuppressive agents and immediate antibiotic therapy the patient recovered completely. To our knowledge, this is the third case of L. pneumophila pneumonia in an IBD patient treated with infliximab. Similar to other published cases, concomitant treatment of immunosuppressives and anti-TNF agents is a major risk factor for the development of L. pneumophila infection, which should be ruled out in all cases of pneumonia in patients with such a therapeutic regimen. Appropriate prevention strategies should be provided in these patients.

P151 - How variable is the Mayo score between observers and might this affect trial recruitment or outcome?

P151 - How variable is the Mayo score between observers and might this affect trial recruitment or outcome?

P152 - Double balloon enteroscopy: advancing the management of Crohn's disease small bowel strictures

P152 - Double balloon enteroscopy: advancing the management of Crohn's disease small bowel strictures

P020 - RDW — a new diagnostic and activity marker for inflammatory bowel disease

P020 - RDW — a new diagnostic and activity marker for inflammatory bowel disease

Influence of Phenotype at Diagnosis and of Other Potential Prognostic Factors on the Course of Inflammatory Bowel Disease

Disease course in inflammatory bowel disease (IBD) is variable and difficult to predict. To optimize prognosis, it is of interest to identify phenotypic characteristics at disease onset and other prognostic factors that predict disease course. The aim of this study was to evaluate such factors in a population-based IBD group. IBD patients diagnosed between 1 January 1991 and 1 January 2003 were included. A follow-up questionnaire was developed and medical records were reviewed. Patients were classified according to phenotype at diagnosis and risk factors were registered. Disease severity, cumulative medication use, and "surgical" and "nonsurgical" recurrence rates were calculated as outcome parameters. In total, 476 Crohn's disease (CD), 630 ulcerative colitis (UC), and 81 indeterminate colitis (IC) patients were diagnosed. In CD (mean follow-up 7.6 years), 50% had undergone resective surgery. In UC (mean follow-up 7 years), colectomy rate was 8.3%. First year cumulative recurrence rates per 100 patient-years for CD, UC, and IC were 53, 44, and 42%, respectively. In CD, small bowel localization and stricturing disease were negative prognostic factors for surgery, as was young age. Overall recurrence rate was increased by young age and current smoking. In UC, extensive colitis increased surgical risk. In UC, older age at diagnosis initially increased recurrence risk but was subsequently protective. This population-based IBD study showed high recurrence rates in the first year. In CD, small bowel localization, stricturing disease, and young age were predictive for disease recurrence. In UC, extensive colitis and older age at diagnosis were negative prognostic predictors.

Current state of double balloon endoscopy: The latest approach to small intestinal diseases

Recent developments of capsule endoscopy and double balloon endoscopy (DBE) have made endoscopic examination of the entire small bowel practical, and changed the diagnostic algorithm for small bowel diseases. Double balloon endoscopy uses two balloons, one attached to the tip of the endoscope and another at the distal end of an overtube. By using these balloons to grip the intestinal wall, the endoscope can be inserted further without forming redundant loops of intestine. Total inspection by DBE is usually achieved by combination of sequential oral and anal intubations; success rates are reported to be 40-80%. Indications for DBE include scrutiny for obscure gastrointestinal bleeding, small bowel tumor, small bowel stricture and following up evaluation of previously diagnosed small bowel diseases. Because DBE has an accessory channel and good maneuverability in the distal small intestine, it enables endoscopic treatment, including hemostasis, balloon dilation, polypectomy, mucosal resection, retrieval of foreign bodies and endoscopic retrograde cholangiopancreatography (in the case of post-operative anastomoses). Double balloon endoscopy is also useful for cases of difficult colonoscopy, providing success rates of total colonoscopy between 88-100%. Although it has been a few years since its development, the usefulness of DBE is now well recognized. This challenging procedure has become popular rapidly and is currently used in many countries.

Clinical outcomes of self-expandable metal stents in palliation of malignant anastomotic strictures caused by recurrent gastric cancer

To examine the technical feasibility and clinical outcomes of the endoscopic insertion of a self-expandable metal stent (SEMS) for the palliation of a malignant anastomotic stricture caused by recurrent gastric cancer. The medical records of patients, who had obstructive symptoms caused by a malignant anastomotic stricture after gastric surgery and underwent endoscopic insertion of a SEMS from January 2001 to December 2007 at Kangnam St Mary's Hospital, were reviewed retrospectively. Twenty patients (15 male, mean age 63 years) were included. The operations were a total gastrectomy with esophagojejunostomy (n = 12), subtotal gastrectomy with Billroth-I reconstruction (n = 2) and subtotal gastrectomy with Billroth-II reconstruction (n = 8). The technical and clinical success rates were 100% and 70%, respectively. A small bowel or colon stricture was the reason for a lack of improvement in symptoms in 4 patients. Two of these patients showed improvement in symptoms after another stent was placed. Stent reobstruction caused by tumor ingrowth or overgrowth occurred in 3 patients (15%) within 1 mo after stenting. Stent migration occurred with a covered stent in 3 patients who underwent a subtotal gastrectomy with Billroth-II reconstruction. Two cases of partial stent migration were easily treated with a second stent or stent repositioning. The median stent patency was 56 d (range, 5-439 d). The median survival was 83 d (range, 12-439 d). Endoscopic insertion of a SEMS provides safe and effective palliation of a recurrent anastomotic stricture caused by gastric cancer. A meticulous evaluation of the presence of other strictures before inserting the stent is essential for symptom improvement.

Small intestinal strictures as a complication of mesenteric vessel thrombosis: two case reports

IntroductionSmall intestinal strictures secondary to mesenteric vessel thrombosis are a rare entity and thus often result in delayed diagnosis. We present two cases of ischaemic small bowel strictures secondary to mesenteric vessel thrombosis, and describe how they were subsequently managed.Case presentationWe present two cases of abdominal pain, one acute and one chronic, in which the eventual diagnosis was of bowel strictures secondary to arterial and venous vessel thrombosis. In both patients, a Caucasian male aged 67 and a Caucasian female aged 78, the diagnosis was delayed because of the infrequency of their presentation. Both patients eventually underwent a resection of the affected portion of bowel with primary anastamosis and made uneventful recoveries.ConclusionThere are multiple medical and surgical management options for small bowel strictures and these depend on the aetiology of the stricture. Ischaemic small bowel strictures represent a difficult diagnosis and the potential resulting delay may be partially responsible for increased morbidity. Barium small bowel follow-through should be used in making the diagnosis.

Balloon Dilation of Postoperative Small Bowel Stricture in an Infant

Balloon Dilation of Postoperative Small Bowel Stricture in an Infant

Obstructive mesenteric cyst is not always the cause of obstruction

BACKGROUND: In newborns presenting with clinical signs of obstruction of the small bowel, atresia of the small bowel as well as mesenteric cyst can be one of the differential diagnoses. Whereas clinically these two different diagnoses cannot be distinguished from each other, the operative therapy is different. Mesenteric cysts should, if possible, be enucleated, whereas small bowel atresias should be resected and anastomosed. METHODS (CASE REPORT): We describe the case of a newborn, where not only atresias of the small bowel but also multiple mesenteric cysts of the small bowel were intraoperatively found. RESULTS: During surgery multiple mesenteric cysts, which are the cause of small bowel stenosis, were found in the proximal part of the small bowel. Nevertheless, the rest of a small bowel was evaluated and further 2 isolated type I atresias, clearly distally to the mesenteric cysts, were found. CONCLUSIONS: To our knowledge, this has been the first case described where concomitantly small bowel atresia type I and mesenteric cysts were found in one patient. Even knowing that this is a rare combination of diagnosis we would like to point out that an enucleation of mesenteric cyst in case of bowel obstruction might not be enough and that the small bowel should always be carefully evaluated for further pathologies.

Primary Small-Bowel Enterolithiasis

A 53-year-old woman with a 2-year history of intermittent abdominal pain, diarrhea, and constipation presented for evaluation. Her medical history was significant for congenital imperforate anus requiring a colostomy at birth with reanastomosis at the age of 2 years. Radiography (Panel A) and computed tomography (Panel B) of the upper gastrointestinal tract showed filling defects (arrows in both panels) and a small bowel stricture (arrowhead in Panel A). During surgical exploration, it was noted that 20 cm of ileum was inflamed, with two diverticuli containing multiple stones and an associated stricture (Panel C, arrow). This portion of the ileum was . . .

Use of Video Capsule Endoscopy in the Setting of Recurrent Subacute Small-Bowel Obstruction

Video capsule endoscopy (VCE) can be used to diagnose subacute intestinal obstruction in patients with otherwise negative imaging studies. Nine patients with symptoms consistent with intermittent small-bowel obstruction who received a VCE and ultimately required surgical intervention. Patients were identified who had symptoms consistent with subacute bowel obstruction and a negative diagnostic work-up prior to VCE. All 9 patients underwent several radiologic and endoscopic examinations with no clear etiology for their symptoms. Ultimately, in every case, a stricture or mass was found to be the cause of the obstruction at either the time of VCE or exploratory laparotomy/laparoscopy. Patients can have a small-bowel stricture or mass that can cause symptoms of subacute small-bowel obstruction. Diagnosis of the lesion may be difficult in these patients and can often result in multiple nondiagnostic radiologic and endoscopic examinations. VCE can be helpful in finding these lesions, leading to surgical resection of the diseased bowel and a cure for the patient's signs and symptoms.

Modern imaging of Crohn's disease: A comparison of wireless capsule endoscopy and small intestine contrast ultrasonography (SICUS) in paediatric patients

Background. Wireless capsule endoscopy (WCE) and small intestine contrast ultrasonography (SICUS) can non-invasively assess the small bowel. However in patients (pts) with known or suspected small bowel pathology the presence of small bowel strictures contraindicates WCE examination. In adult subjects SICUS following the ingestion of 375ml macrogol solution enables to visualize and to measure wall thickness and lumen diameter at any level of the small bowel. SICUS accurately assesses presence, number, extension, and sites of Crohn's disease (CD) lesions identifiable as increased wall thickness (>3mm) and strictures as reduced luminal diameter (<1cm).

Gossypibom

A 48-year-old woman with a history of five previous laparotomies had symptoms of nonspecific abdominal pain and recurrent postoperative paralytic ileus six months after her last operation. Because of her as yet undiagnosed abdominal pain admission to a psychosomatic hospital was suggested. MRI was performed because of increasing abdominal pain. It revealed an intraabdominal large surgical towel retained in the abdomen (gossypiboma: gossypium [Latin]:cotton; boma [Swahili]: place of concealment). The surgical towel, accidentally left behind at one of the previous intraabdominal operation) was removed through a previous appendectomy scar. An abscess was additionally found at the operation. Three days later, a second laparotomy became necessary because of multiple intraabdominal interenteric abscesses. A segmental resection had to be performed for a chronic small-bowel stricture. Postoperatively, a subcutaneous wound infection developed. The patient was discharged home on 12th postoperative day. Retained surgical towel (gossypiboma) is a rare but well known complication of surgery. It presents a diagnostic problem if there are no symptoms for a long time. To make the correct diagnosis it is important to simply to consider the possibility of gossypiboma after a complicated or unsatisfactory postoperative course.

Cryptogenic, Multifocal, Ulcerous, and Stenosing Enteritis as a Manifestation of Enterocolic Venopathy

Cryptogenic, multifocal, ulcerous and stenosing enteritis (CMUSE) is a poorly understood and exceptionally rare disease typically characterized by the presence of multifocal persistent small bowel ulceration and stenosis (1). Some of the features of CMUSE point to a vascular etiology, although to da