Management of Strictures
Intestinal strictures are a commonly encountered problem in patients with Crohn's disease, resulting in bowel obstruction and eventually in repeated bowel resection and short bowel disease. Over one third of patients with Crohn's disease have a clear stenosing disease phenotype, often in the absence of luminal inflammatory symptoms . At the foundation, as in other organs and tissues, there is transformation and activation of fibroblasts and smooth muscle cells that underlie fibrogenesis in the gut. Endoscopic balloon dilation is the preferred initial therapeutic modality in anastomotic strictures. In fact, endo-scopic management with hydrostatic balloon dilation is an effective alternative to surgery in patients with endoscopically accessible lesions shorter than 7-8 cm , but careful patient selection is of great importance to ensure favourable long-term results. The presence of inflammation near the stricture should not be considered a contraindication to dilation, and intralesional steroid injection should be considered in these patients.
Among the three clinical patterns of Crohn's disease (inflammatory, penetrating/fistulising and obstructive/fibrostenotic), the latter is a frequent cause of symptoms and is an indication for surgery in over half of operations for Crohn's disease. Small-intestinal strictures are found in 21% of patients, duodenale strictures in 5% , colonic strictures range from 4% to 9% [42,43] and anorectal strictures in 7.5% . Strictures may also arise from surgical treatment for Crohn's disease, with reported rates of 17-81%.
To avoid surgery in patients with symptomatic Crohn's strictures, various endoscopic techniques have been successfully utilised: balloon dilation with or without corticosteroid injection, Savary dilation, endoscopic needle knife incisions and self-expandable metal stents, but no randomised clinical trials compare these methods for dilation. However, clinical situations in which to consider endoscopic management of Crohn's strictures are: endoscopic accessibility, multiple previous intestinal resections and short strictures (<8 cm). It is important to consider intralesional steroid injection if significant inflammation is present.
Intestinal balloon dilation is attractive due to the ability to directly apply the radial force achieved during balloon insufflation, in contrast to the shearing force applied during bougienage . Balloon dilation is the most widely reported method for nonsur-gically dilating intestinal strictures in Crohn's disease [46,47] resistant to medical therapy, with endoscopic incisions of the stricture or electroincision with or without intralesional steroid injection . The balloon, with a diameter from 18 mm to 25 mm, was inflated for 1-4 min and repeated two to four times per session . Successful dilation was generally defined as allowing the passage of a standard adult colonoscope. One author  made four radial incisions into the stricture with a standard papillotome if the colonoscope could not pass the stricture. In this way, dilation sufficient to allow passage of the adult colonoscope was achieved in every patient, with 3% of complications (minor bleeding and perforation) in a total of 137 dilations, with complete symptom relief achieved in 66% of patients over a mean follow-up of 19 months. It was suggested that the nonresponse group had more aggressive disease. Other authors performed hydrostatic balloon dilation with inflation diameters from 12 mm to 18 mm . Immediate symptomatic relief was noted in 77% of patients, with persistent long-term relief in 44% after a mean follow-up of 25 months. Longer strictures and active inflammation were characteristics that portended poor response. The same authors, in a follow-up study of a larger number of patients undergoing hydrostatic balloon dilation for symptomatic ileo-colonic stricture in Crohn's disease resistant to medical treatment and followed up over a 5-year period, suggested that dilation can be successful in the setting of inflammation . Technical success was achieved in 90% of procedures, with best results in ileocolic anastomoses. Overall relief of symptoms was achieved in 62% of patients after mean follow-up of 33.6 months, with 8% of complications and no deaths for a total of 76 dilations. Lack of success was noted in strictures with tight angulation and longer lenght.
Based on the success of using intralesional corti-costeroids in caustic lesions, dilation followed by intralesional steroid injection was performed in Crohn's strictures . Following hydrostatic dilation, approximately 5 mg betamethasone dipropi-onate diluted into 5-10 ml of normal saline as 0.5- to 1-ml aliquots was injected into the most narrowed area using a standard sclerotherapy needle. Immediate symptom relief was always achieved without complications, and 84% of patients achieved a prolonged symptom-free period during a follow-up of 6 years after combination dilation/injection without need for surgery. Use and control of a precut papillo-
tome for luminal incision, followed by injection of triamcinolone, is more difficult than hydrostatic balloon dilation and limited to short strictures although success rate is high . Another study evaluated efficacy and safety of endoscopic balloon dilation with or without intralesional steroid injection for symptomatic upper and lower gastrointestinal Crohn's disease strictures . Using a mean follow-up of 18.8 months, technical success was achieved in 96.5% of 17 patients. Recurrence rate in the steroid group was 10% and that in the nonsteroid group 31%. Overall, long-term success was achieved in 76.5% of patients, with a complication rate of 10% with no mortality.
Experience with self-expanding metal stents in Crohn's disease has been very limited , with complete relief of obstructive symptoms after placement despite stent migration some months after insertion. Similarly, minimal data exist on endoscopic treatment of gastroduodenal strictures in Crohn's disease. In one study, a 20-mm balloon was utilised, and symptomatic relief was achieved in every patient, with all responding to repeat dilation .
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