Endoscopic treatment of Crohn’s complications

Abstract

The progression to fistula and strictures is part of the natural history of Crohn’s disease (CD) and these complications negatively affect the quality of life of CD patients. Surgery is the traditional treatment of CD strictures. However, due the chronicity of the inflammatory process and the associated fibrosis, postoperative recurrence occurs frequently. The lack of specific drug to treat fibrotic strictures and their irreversible nature has drawn the attention to less invasive and bowel-sparing therapeutic modalities. Endoluminal therapies may provide effective option in relieving symptoms associated with CD complications and reduce the need for repeated surgery with substantial clinical benefit. This review will discuss the current use and efficacy of the endoscopic treatment of CD complications. New endoscopic modalities and recent advances will be also evaluated.

Keywords::

• Crohn’s disease
• endoscopic balloon dilation
• fistula
• stent positioning
• strictures

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Endoscopic dilation is effective and safe in the treatment of short (<4 cm), single and uncomplicated Crohn’s disease strictures; long-term benefit can be obtained in either naïve or postsurgical anastomotic strictures.

• Stricture and patient selection are of paramount importance; imaging is recommended before therapeutic endoscopy.

• Dilation protocol should be standardized with a multistep progressive inflation and maximum balloon diameter <20 mm.

• Smoking has a negative effect on long-term outcome, whereas neither inflammation nor medical treatment influence ED efficacy; adjuvant therapy with intralesional injection of steroids is associated with inconsistent results.

• Deep enteroscopy has expanded the proportion of strictures treatable with through-the-scope ED; cross-sectional imaging and CO₂ inflation improves success rate and reduces complications.

• Endoluminal stricturoplasty by stent insertion could be an option for selected strictures after ED has failed.