Stricturing Crohn's disease

Stricturing Crohn's disease

Predominantly no evidence of active inflammation (biomarkers &/or radiology &/or endoscopy with histology), though fibrotic and inflammatory disease may co-exist, hence actively treat co-existent inflammatory disease

Look for evidence functional abnormality (obstruction, weight loss)

Classify stricturing disease

Perianal

  • Strictures occur following repeated cycles of inflammation
  • Occur in ≈10-15% of those with Crohn's colitis
  • 2-7% strictures are malignant (c.f. <1% patients without strictures)
Colonic

Ileo-caecal

  • Strictures often multi-focal
  • Small bowel MR best diagnostic test to “map” disease
  • Capsule endoscopy contra-indicated in small bowel stricturing Crohn's disease
  • Consider empiric treatment for bacterial overgrowth if surgery contra-indicated
Small bowel

Perianal

Perianal stricturing

  • MRI pelvis and physical examination (+/- EUA)
Confirm anatomy

  • Absence of associated complex fistula or severely distorted anatomy
Simple stricture

 

  • Associated complex fistula &/or severely distorted anatomy
Complex disease

  • Self-dilation using Hegar dilators
  • Gradually increase dilator diameter
  • Diet / laxatives may be needed to maintain soft stool
Self-dilation

 
 
 
 

Dilation @ EUA

Intermittent self-dilation

 

  • Surgery can be an effective therapy for localized disease, mandating close liaison between patient, physician and surgeon; and must be considered at an early stage in complicated disease
  • Type of stoma depends on extent of associated disease (colostomy easier to manage than ileostomy)
Stoma +/- proctectomy

Optimise medical therapy to prevent neo-fibrosis

Colonic

Colonic stricturing

ECCO Statement 7H (CD 2016)

Endoscopic dilatation is a preferred technique for the management of symptomatic and short anastomotic strictures It should only be attempted in institutions with surgical back-up [EL3]

Further information

  • Endoscopic balloon dilation is effective for strictures < /= 4cm and successful in 80% for up to 3y. Major complication in 2%, therefore only attempt if easy access to emergency surgery
  • The technique allows biopsy of the stricture, to screen for dysplasia
Endoscopic dilation

 

ECCO Statement 7A (CD 2016)

Surgery is the preferred option in patients with localised ileocaecal Crohn’s disease with obstructive symptoms, but no significant evidence of active inflammation [EL4]

Further information

  • Dilation of strictures > 4cm less successful, with higher complication rates
  • Surgery also indicated for endoscopically irresectable DALM (dysplasia associated lesion or mass) or (low- or high-) grade mucosa located within flat mucosa
Schedule surgery

 

  • Dysplasia located within flat mucosa, including from non-targeted biopsies, mandates colectomy as high probability of synchronous cancer
  • Extensive stricturing or active disease mandates colectomy (IRA if rectum unaffected)
Panproctocolectomy or IRA

ECCO Statement 7G (CD 2016)

If surgery is necessary for localised colonic disease (less than a third of the colon involved) then resection of the affected part only is preferable [EL3]. Two segmental resections can be considered for a patient with an established indication for surgery when macroscopic disease affects two separate segments of the colon [EL3]. Strictureplasty in the colon is not recommended [EL3]

Further information

  • Segmental resection of localized disease (<1/3 of colon) or two segmental resections if disease affects both ends of the colon is preferable, providing improved functional outcome compared with colectomy, mandating close liaison between patient, physician and surgeon; and must be considered at an early stage in complicated disease
Segmental resection

Optimise medical therapy to prevent neo-fibrosis

Ileo-caecal or small bowel

Ileo-caecal or small bowel stricturing

 

Ileo-caecal

 

  • Strictures often multi-focal
  • Small bowel MR best diagnostic test to “map” disease
  • Capsule endoscopy contra-indicated in small bowel stricturing Crohn's disease
  • Consider empiric treatment for bacterial overgrowth if surgery contra-indicated
Small bowel

ECCO Statement 7A (CD 2016)

Surgery is the preferred option in patients with localised ileocaecal Crohn’s disease with obstructive symptoms, but no significant evidence of active inflammation [EL4]

Further information

  • Dilation of strictures > 4cm less successful, with higher complication rates
  • Surgery also indicated for endoscopically irresectable DALM (dysplasia associated lesion or mass) or (low- or high-) grade mucosa located within flat mucosa
Schedule surgery

 
 

Determine length stricture(s)

ECCO Statement 7A (CD 2016)

Surgery is the preferred option in patients with localised ileocaecal Crohn’s disease with obstructive symptoms, but no significant evidence of active inflammation [EL4]

ECCO Statement 7C (CD 2016)

Strictureplasty is a safe alternative to resection in jejuno-ileal Crohn’s disease, including ileocolonic recurrence, with similar short-term and long-term results. Conventional strictureplasty is advised when the length of the stricture is <10 cm. However, in extensive disease with long strictured bowel segments where resection would compromise the effective small bowel length, non-conventional stricturoplasties may be attempted [EL3]

ECCO Statement 7D (CD 2016)

Wide lumen stapled ileocolic side-to-side (functional end-to-end) anastomosis is the preferred technique [EL1]

ECCO Statement 7F (CD 2016)

A laparoscopic approach is to be preferred for ileocolic resections in Crohn’s disease [EL 2] where appropriate expertise is available. In more complex cases or recurrent resection, there is insufficient evidence to recommended laparoscopic surgery as the technique of first choice [EL3]

Further information

  • Laparoscopic ileo-colonic resection reduces complications, recovery time, and mortality; but not recurrence rates. Laparoscopic resection for complex disease (intra-abdominal abscesses, fistulae) or recurrent resection should only be attempted in specialized centres
Right hemi-colectomy

ECCO Statement 7H (CD 2016)

Endoscopic dilatation is a preferred technique for the management of symptomatic and short anastomotic strictures It should only be attempted in institutions with surgical back-up [EL3]

Further information

  • Effective for strictures < /= 4cm
  • Allows extensive biopsy to screen for dysplasia
  • Double or single balloon endoscopy may be required to access stricture
Endoscopic dilation

ECCO Statement 7C (CD 2016)

Strictureplasty is a safe alternative to resection in jejuno-ileal Crohn’s disease, including ileocolonic recurrence, with similar short-term and long-term results. Conventional strictureplasty is advised when the length of the stricture is <10 cm. However, in extensive disease with long strictured bowel segments where resection would compromise the effective small bowel length, non-conventional stricturoplasties may be attempted [EL3]

Further information

  • Surgery an effective therapy for localized disease, mandating close liaison between patient, physician and surgeon; and must be considered at an early stage in complicated disease
  • Stricturoplasty conserves intestinal length
  • Can be performed multiple times during one operation
Stricturoplasty

ECCO Statement 7C (CD 2016)

Strictureplasty is a safe alternative to resection in jejuno-ileal Crohn’s disease, including ileocolonic recurrence, with similar short-term and long-term results. Conventional strictureplasty is advised when the length of the stricture is <10 cm. However, in extensive disease with long strictured bowel segments where resection would compromise the effective small bowel length, non-conventional stricturoplasties may be attempted [EL3]

Further information

  • Surgery can be an effective therapy for localized disease, mandating close liaison between patient, physician and surgeon; and must be considered at an early stage in complicated disease
  • Resection undertaken if multiple strictures in a short segment, phlegmon in bowel wall, carcinoma, or bleeding mucosal disease. A side-to-side rather than end-to-end anastomosis should be used
  • Perform non-conventional stricturoplasty in extensive disease to avoid compromising effective small bowel length
Surgical resection

Optimise medical therapy to prevent neo-fibrosis

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