Strictures In Inflammatory Bowel Disease Research Articles

S1463 Alternatives to Endoscopic Balloon Dilation: Endoscopic Stricturotomy and Endoscopic Stenting in treatment of strictures in Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis

S1463 Alternatives to Endoscopic Balloon Dilation: Endoscopic Stricturotomy and Endoscopic Stenting in treatment of strictures in Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis

WEO Newsletter: Tips and tricks: Assessment and endoscopic dilation of strictures in inflammatory bowel disease (IBD).

WEO Newsletter: Tips and tricks: Assessment and endoscopic dilation of strictures in inflammatory bowel disease (IBD).

S944 Assessing the Precision of MRI in Identifying Strictures in Inflammatory Bowel Disease: A Comprehensive Systematic Review and Meta-Analysis

S944 Assessing the Precision of MRI in Identifying Strictures in Inflammatory Bowel Disease: A Comprehensive Systematic Review and Meta-Analysis

Colonic Strictures in Inflammatory Bowel Disease: Epidemiology, Complications, and Management.

The management of colorectal stricture complicating inflammatory bowel disease [IBD] remains a challenging condition. Stricture raises concern about neoplastic complications, which cannot be fully ruled out by negative endoscopic biopsies. Also, impassable strictures restrict the endoscopic monitoring of upstream disease activity and dysplasia. Surgery remains the 'gold standard' treatment for colonic strictures but is associated with high morbidity. Over the past few decades, our therapeutic arsenal for IBD has been reinforced by biologics and therapeutic endoscopy. Few studies have focused on colonic strictures, and so current therapeutic strategies are based on a low level of evidence and applied by analogy with the treatment of ileal strictures. With a view to facilitating the decision making process in clinical practice, we reviewed the literature on the epidemiology, natural history, and management of colonic strictures in IBD.

NADPH oxidase 4 is protective and not fibrogenic in intestinal inflammation

Dysregulated redox signaling and oxidative injury are associated with inflammatory processes and fibrosis. H2O2 generation by NOX4 has been suggested as a key driver in the development of fibrosis and a small molecule drug is under evaluation in clinical trials for idiopathic pulmonary fibrosis and primary biliary cholangitis. Fibrosis is a common complication in Crohn's disease (CD) leading to stricture formation in 35–40% of patients, who require surgical interventions in the absence of therapeutic options. Here we assess NOX4 expression in CD patients with inflammatory or stricturing disease and examine whether loss of NOX4 is beneficial in acute and fibrotic intestinal disease. NOX4 was upregulated in inflamed mucosal tissue of CD and ulcerative colitis (UC) patients, in CD ileal strictures, and in mice with intestinal inflammation. Nox4 deficiency in mice promoted pathogen colonization and exacerbated tissue injury in acute bacterial and chemical colitis. In contrast, in two chronic injury models aberrant tissue remodeling and fibrosis-related gene expression did not differ substantially between Nox4−/− mice and wildtype mice, suggesting that Nox4 is dispensable in TGF-β1-driven intestinal fibrogenesis. While animal models do not recapitulate all the hallmarks of CD fibrosis, the tissue-protective role of Nox4 warrants a cautious approach to pharmacological inhibitors.

Role of non-inflammatory factors in intestinal fibrosis.

Intestinal fibrosis is a common complication of inflammatory bowel disease (IBD), resulting in strictures and ultimately obstruction, which is a significant clinical problem. Fibrosis is mainly triggered by local chronic inflammation and occurs when excessive extracellular matrix deposition is caused by activated mesenchymal cells. Despite the advance of anti-inflammatory therapies in IBD, the incidence and preventive strategies of intestinal fibrosis and strictures in IBD have not significantly changed over time. This shows that inflammation is necessary for fibrosis, but it does not necessarily affect the fibrotic progression. This review summarizes current knowledge about the non-inflammatory mechanisms implicated in the gut fibrotic process of IBD, which may pave the way for new mechanisms and anti-fibrotic therapies.

Endoscopic stricturotomy in the treatment of anastomotic strictures in inflammatory bowel disease (IBD) and non-IBD patients.

BackgroundsEndoscopic stricturotomy (ESt) has been shown to be effective in treating inflammatory bowel disease (IBD)-associated anastomotic strictures. However, the outcome of ESt in benign, non-IBD conditions has not been described. The aim of this study was to evaluate the outcome of ESt in the management of IBD and non-IBD-associated strictures.MethodsData of all consecutive IBD and non-IBD patients with benign anastomotic strictures treated with ESt from 2009 to 2016 were extracted. The primary outcomes were surgery-free survival and procedure-related complications.ResultsA total of 49 IBD and 15 non-IBD patients were included in this study. The IBD group included 25 patients with Crohn’s disease and 24 with ulcerative colitis and ileal pouches. Underlying diseases in the non-IBD group included colorectal cancer (n = 7), diverticulitis (n = 5), large bowel prolapse (n = 2), and constipation (n = 1). Immediate technical success was achieved in all patients in both groups. Bleeding complications occurred on five occasions (4.7% per procedure) in the IBD group, while no complication occurred in the non-IBD group (P = 0.20). Stricture improvement on follow-up endoscopy was found in 10 (20.4%) and 5 (33.3%) patients in the IBD and non-IBD groups, respectively (P = 0.32). Six (12.2%) patients in the IBD group and four (26.7%) patients in the non-IBD group eventually required stricture-related surgery (P = 0.23). IBD patients appeared to have a higher tendency for maintaining surgery-free after the procedure than non-IBD patients (P = 0.08).ConclusionsEndoscopic stricturotomy was shown to have comparable outcomes, though non-IBD patients seem to have a higher need for subsequent surgery but a lower complication rate than IBD patients.

Long-Term Outcomes of Endoscopic Balloon Dilation for Benign Strictures in Patients with Inflammatory Bowel Disease.

Background/AimsBenign intestinal strictures are common complications in patients with inflammatory bowel disease (IBD). This study aimed to assess the long-term prognosis of endoscopic balloon dilation (EBD) to treat benign strictures in IBD patients.MethodsPatients with IBD who had benign strictures and who underwent EBD in four tertiary referral university hospitals between January 2004 and February 2014 were retrospectively reviewed. Technical success was defined as the ability to pass the scope through the stricture after balloon dilation, and clinical success was defined as improved obstructive symptoms.ResultsForty-two benign strictures were identified in 30 patients (15 males and 15 females). Technical success was achieved in 26 patients (86.7%) at the first EBD attempt and in all 30 patients (100%) at the second EBD attempt. Clinical success was seen in 28 patients (93.3%). The median follow-up duration was 134.8 months (range, 10.2 to 252.0 months), and recurrence occurred in eight patients (26.7%), who required repeat EBD. The median duration to relapse was 1.7 months (range, 0.2 to 6.3 months). During repeat EBD, perforation occurred in two cases (6.7%), which were both clipped successfully. Finally, only one patient (3.3%) underwent surgery for the relief of recurrent obstructive symptoms during the follow-up period.ConclusionsThe experience of 10 years shows that EBD is safe and effective for the treatment of benign strictures in IBD patients. Importantly, EBD may allow long-term effective palliation of the symptoms associated with benign intestinal strictures in IBD patients.

P158 Outcome of inflammatory bowel disease strictures

P158 Outcome of inflammatory bowel disease strictures

Incidence of Dysplasia and Cancer in Colonic Strictures in IBD

Colorectal strictures in inflammatory bowel disease (IBD) can sometimes hide cancers. Strictures should systematically undergo biopsy, and strictures that are symptomatic, are located in the proximal colon, or occur in ulcerative colitis should be viewed with particular suspicion. In the current multicenter study, researchers retrospectively assessed the risk for cancer or dysplasia in 248 patients with Crohn disease and 39 with ulcerative colitis who underwent resection for strictures. In all patients, preoperative biopsy specimens showed negative results for cancer and dysplasia. The surgical pathology …

Epithelial Dysplasia and Cancer in IBD Strictures

Introduction: The presence of colonic strictures and epithelial dysplasia are both known risk factors for the occurrence of colorectal cancer in patients with inflammatory bowel disease (IBD). The aim of the present study was to assess the risk of colonic stricture for the occurrence of epithelial dysplasia and colonic adenocarcinoma. Methods: Miraca Life Sciences' database is an electronic repository of histopathologic patient records. Biopsy specimens are submitted by approximately 1,500 gastroenterologists from private practices distributed throughout the United States. For the purpose of the present study, the database was searched for all records of IBD patients who underwent a colonoscopy between January 2008 and December 2014. In a case-control study among 53,568 IBD patients undergoing colonoscopy, we compared the prevalence of strictures among cases with dysplasia or adenocarcinoma and controls without such complications by calculating odds ratios (OR) and their 95% confidence intervals (CI). Multivariate logistic regressions were used to assess the joint influence of multiple predictor variables (age, sex, IBD type, and stricture) on the occurrence of colonic dysplasia or adenocarcinoma. Results: The database contained a total of 1,285 IBD patients with strictures and 1,507 IBD patients with dysplasia. A total of 31 patients were found to harbor both stricture and dysplasia. In 10 of 31 patients, the dysplasia was found within the stricture itself. In 10 patients with stricture and cancers, 7/10 cancers were located within the stricture itself. The prevalence of strictures was 1.06% in ulcerative colitis and 8.71% in Crohn's disease (OR 11.09, CI 9.72-12.70). The prevalence of dysplasia was 3.22% in ulcerative colitis and 2.08% in Crohn's disease (OR 0.75, 0.65-0.86). The prevalence of dysplasia was similar in IBD patients with and without stricture: 2.82% vs. 2.41%, respectively. The prevalence of cancer was higher in IBD patients with than without stricture: 0.78% vs. 0.11%, respectively (OR 6.87, 3.30-12.89). In the multivariate analysis, old age, male sex, and ulcerative colitis, but not stricture, were all significantly and independently associated with dysplasia. Old age, dysplasia, and stricture were significantly and independently associated with cancer. Conclusion: The prevalence of epithelial dysplasia is not generally increased in IBD patients with strictures.

Epithelial Dysplasia and Cancer in IBD Strictures.

Colonic strictures and epithelial dysplasia are both known risk factors for the occurrence of colorectal cancer in inflammatory bowel disease (IBD) patients. The aim of the present work was to study colonic stricture as a risk factor for the occurrence of epithelial dysplasia and colonic adenocarcinoma. In a case-control study among 53568 IBD patients undergoing colonoscopy, we compared the prevalence of strictures among cases with dysplasia or adenocarcinoma and controls without such complications by calculating odds ratios (ORs) and their 95% confidence intervals (CIs). Multivariate logistic regressions were used to assess the joint influence of multiple predictor variables (age, sex, IBD type and stricture) on the occurrence of colonic dysplasia or adenocarcinoma. The prevalence of strictures was 1.06% in ulcerative colitis (UC) and 8.71% in Crohn's disease (CD, OR 11.09, 95% CI 9.72-12.70). The prevalence of dysplasia was 3.22% in UC and 2.08% in CD (OR 0.75, 95% CI 0.65-0.86). The prevalence of dysplasia was similar in IBD patients with and without stricture: 2.82 and 2.41%, respectively. The prevalence of cancer was higher in IBD patients with than without stricture: 0.78 and 0.11%, respectively (OR 6.87, 95% CI 3.30-12.89). In the multivariate analysis, old age, male sex and UC, but not stricture, were all significantly and independently associated with dysplasia. Old age, dysplasia and stricture were significantly and independently associated with cancer. The prevalence of epithelial dysplasia is not generally increased in IBD patients with strictures.

553 Risk of Dysplasia and Cancer Complicating Colonic Strictures in Inflammatory Bowel Disease: A GETAID Study

DOP095 Risk of dysplasia and cancer complicating colonic strictures in inflammatory bowel disease: a GETAID study M. Fumery1 *, A. Amiot2, X. Hebuterne3, S. Nancey4, V. Abitbol5, C. Stefanescu6, J.-P. Le Mouel1, A. Bressenot7, Y. Bouhnik6, L. Peyrin-Biroulet7. 1CHU Amiens, Gastroenterologie France, 80, Amiens, France, 2Hopital Henri-Mondor, Gastroenterologie, Creteil, France, 3CHU de Nice, Gastroenterologie, Nice, France, 4Hospices Civils de Lyon, Lyon-Sud hospital, Gastroenterology, Pierre Benite, France, 5Hopital Cochin, Gastroenterology, Paris, France, 6Hopital Beaujon APHP, Gastroenterologie, Clichy, France, 7CHU de Nancy, Gastroenterologie, Vandoeuvre-les-Nancy, France

DOP095 Risk of dysplasia and cancer complicating colonic strictures in inflammatory bowel disease: a GETAID study

DOP095 Risk of dysplasia and cancer complicating colonic strictures in inflammatory bowel disease: a GETAID study

Efficacy and safety of endoscopic treatment of ileal pouch strictures

Endoscopic management of ileal pouch strictures has not been systemically studied. The aim was to evaluate endoscopic balloon therapy of pouch strictures in inflammatory bowel disease (IBD) patients with ileal pouches and to identify risk factors for pouch failure for those patients. Consecutive IBD patients with pouches from the Pouchitis Clinic who underwent nonfluoroscopy-guided outpatient endoscopic therapy were studied. The location, number, degree (range 0-3), and length of strictures and balloon size were documented. Efficacy and safety were evaluated with univariate and multivariate analyses. A total of 150 patients with pouch strictures were studied. Stricture locations were at the pouch inlet (n = 96), outlet (n = 73), afferent limb (n = 33), and pouch body (n = 2). A cumulative of 646 strictures were endoscopically dilated, with a total of 406 pouchoscopies. The median stricture score was 1 (interquartile range [IQR] 1-2); the median stricture length was 1 (IQR 0.5-1.25) cm, and the median balloon size was 20 (IQR 18-20) mm. Of 406 therapeutic endoscopies performed, there were two perforations (0.46%) and four transfusion-required bleeding (0.98%). The 5-, 10-, and 25-year pouch retention rates were 97%, 90.6%, and 85.9%, respectively. In a median follow-up of 9.6 (IQR 6-17) years, 131 patients (87.3%) were able to retain their pouches. The number of strictures and underlying diagnosis were independent risk factors for pouch failure in the Cox regression model. Endoscopic treatment of pouch stricture appears to be efficacious and generally safe to perform in experienced hands. Underlying diagnosis of Crohn's disease of the pouch and surgery-related strictures and multiple strictures were the risk factors for pouch failure.

W1622: Clinical Utility of Double-Balloon Endoscopy in the Treatment of Small-Bowel Strictures in Inflammatory Bowel Disease

W1622: Clinical Utility of Double-Balloon Endoscopy in the Treatment of Small-Bowel Strictures in Inflammatory Bowel Disease

Long-term Follow-up of the Endoscopic Treatment of Strictures in Pediatric and Adult Patients With Inflammatory Bowel Disease

Strictures are a common complication of inflammatory bowel disease (IBD) and are usually treated by surgical resection or strictureplasty. As an alternative to surgery, endoscopic balloon dilation and steroid injection have been used to relieve symptoms. To assess patient or stricture characteristics that may predict a better outcome and duration of response as endoscopic therapy is not without its risks. A retrospective review of patients with IBD strictures who underwent dilations between 1996 and 2005 was performed. The patients were followed in the adult and pediatric IBD clinics at a single center. Information was collected from medical records. Strictures were identified in the small and large bowel of 24 patients (22 adult and 2 pediatric). The majority had Crohn's disease (22/24). In total, 71 dilations were performed on 29 strictures; 46 dilations for 17 strictures were augmented with triamcinolone. Mean duration of follow-up was 32 months. This study included 1 stomal, 12 anastomotic, and 16 de novo strictures. Of 12 anastomotic strictures, 6 were complex. Endoscopic dilation was uneventful in 22/24 patients. Bleeding and perforation occurred on separate occasions in 1/6 complex stricture patients and rupture of a paracolonic abscess in another patient with a de novo sigmoid stricture. Surgery was performed on 2 patients, 1 for refractory disease and 1 for noncompliance with therapy. Endoscopic dilation can provide long-term effective palliation of symptoms with minimal risk in patients with simple strictures. Complex anastomotic strictures are technically more challenging compared with de novo strictures.

Outcomes and Long-Term Follow-Up of the Endoscopic Treatment of Strictures in Pediatric and Adult Patients with Inflammatory Bowel Disease (IBD)

Background: Strictures are a challenging complication of IBD, especially in Crohn's disease (CD). Surgical resection of strictures may lead to short bowel syndrome, adhesions, fistulas, leaks and more strictures. Endoscopic management with TTS (through-the-scope) balloon dilation and steroid injection have been used to provide relief of symptoms when strictures occur. However, more details regarding patient or stricture characteristics which may predict a better outcome and duration of response are needed as endoscopic therapy is not without its risks. Methods: We performed a retrospective review of patients with IBD strictures who have had endoscopic dilations at a single tertiary care center between 1996 and 2005. The patients have been followed in our adult and pediatric IBD clinics. Information was collected from the patients' medical records, endoscopy reports, and radiologic studies. Results: 23 IBD patients (21 adult and 2 pediatric) were identified to have strictures in the small and large bowel. 17 patients (74%) were women and 21 (91%) had CD. 69 dilations were performed on 28 strictures. 44 dilations (64%) for 16 strictures were augmented with triamcinolone injection. Median follow-up after dilation was 33 months (1 - 87 months). Our study included 12 anastomotic, 15 de novo and 1 stomal strictures. 6 of the anastomotic strictures were complex, defined as an end-side, side-side, or anatomically aberrant from an end-end anastomosis. 21/23 patients (91%) did not suffer a complication post dilation. 6/28 strictures required more than 2 dilations. 1/6 complex stricture patients had a perforation and 1/6 died from a postsurgical complication for refractory disease. One other perforation occurred in a paracolonic abscess in a de novo sigmoid stricture for an overall perforation rate of 3%. 2/23 patients had surgery, one for refractory disease later developing short bowel syndrome and a pediatric patient who was noncompliant. Family history for IBD, diabetes, age, and disease duration did not portend a worse outcome. Interestingly 2 out of 3 patients not on infliximab therapy either perforated or required surgery. All 5 patients who were already on infliximab at the time of stricture diagnosis did well. Use of an immunosuppressive drug was not protective of complications. Conclusions: Endoscopic dilation of strictures with steroid injection can provide long term effective palliation of symptoms with minimal risk of perforation in patients with simple strictures. Complex anastomotic strictures were associated with a higher risk of adverse outcomes as compared to de novo strictures.

The role of endoscopy in the evaluation and management of intestinal strictures in inflammatory bowel disease

The prevalence of intestinal strictures in Crohn’s disease is quite high, especially for those with ileal or ileocolonic disease. Strictures resulting in obstructive symptoms are the indication for surgery in a significant portion. In the modern era, the prevalence of colorectal strictures in ulcerative colitis has decreased, perhaps to as low as 3%. In general, the finding of a stricture in Crohn’s disease is less ominous than in ulcerative colitis in terms of the risk of malignancy. Endoscopy allows for direct visualization and biopsy of colorectal strictures and may help patients avoid surgery; however, cases of malignant strictures with negative endoscopic biopsies have been reported. Numerous case series have demonstrated that endoscopic balloon dilation of Crohn’s-related colorectal or anastomotic strictures is technically feasible, relatively safe, and in many cases effective in preventing or delaying surgical resection or stricturoplasty. Local injection of corticosteroids such as betamethasone or triamcinolone following balloon dilation may provide additional benefit, although this has not been definitively proven. Other endoscopic techniques that may ultimately prove effective but need further study include the use of electrocautery or laser phototherapy.