Intestinal fibrostenosis is a debilitating complication; even in this era of potent biologic therapies, the mechanisms promoting the underlying fibrosis in IBD are still misunderstood. From a conservative point of view, the target of therapy in this field is TGFb and its intracellular mediators (SMAD proteins) and, theoretically, interleukin 10 could be the ideal cytokine to be used in IBD, since it has been proven to be a potent anti-inflammatory and anti-fibrogenic agent. Nevertheless, clinical data about IL-10, antibodies against TGFb and SMAD proteins, Ca2+ blocking and cyclic nucleotides to modulate collagen production gave no results.
Drugs are useful in reducing the inflammatory component of the stricture, but once the fibrosis has scared the lumen, there are only two options: endoscopic balloon dilation or surgical intervention, which means either strictureplasty or resection.
Endoscopic balloon dilation has been proven to be very effective, safe and repeatable when used in short and anastomotic strictures. A recent trial on endoscopic management of CD upper and lower strictures in association with local steroid injection had very good results: technical success (ability of the scope to pass the stenosis) of 29 dilations on 17 patients was 96.5%, the long-term success (mean follow-up 18.8 months, 5-50) was 70% if the dilation was<15 mm and 68.4% for dilations >15 mm. The recurrence rate in the group with steroid injection was 10 and 31.3% in patients who only received dilation. The long-term success rate was 76.5% with a 10% complication rate, with no mortality .
As in other critical situations, the decision of what to do should be shared with the patient; repeat endo-scopic dilation is of course a valid and safe option and the length of the symptom-free interval will be the main parameter used to decide between conservative management and surgery.
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