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Aboelezz AF, Othman MO. Endoscopic Management of Colonic Obstruction. Gastrointest Endosc Clin N Am 2024; 34:141-153. [PMID: 37973225 DOI: 10.1016/j.giec.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Large bowel obstruction is a serious event that occurs in approximately 25% of all intestinal obstructions. It is attributed to either benign, malignant, functional (pseudo-obstruction), or mechanical conditions. Benign etiologies of colonic obstructions include colon volvulus, anastomotic strictures, radiation injury, ischemia, inflammatory processes such as Crohn's disease, diverticulitis, bezoars, and intussusception.
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Affiliation(s)
- Ahmad F Aboelezz
- Department of Internal Medicine, Gastroenterology and Hepatology Section, Faculty of Medicine, Tanta University, El Bahr Street, Tanta Qism 2, Tanta 1, Gharbia Governorate 31111, Egypt
| | - Mohamed O Othman
- Department of Internal Medicine, Gastroenterology and Hepatology Section, Baylor College of Medicine, Gastroenterology Section at Baylor St Luke's Medical Center, 7200 Cambridge Street. Suite 8A, Houston, TX 77030, USA.
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2
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Dashnyam U, Nagayama M, Yano T, Sakamoto H, Mieno M, Owada J, Oguro K, Khurelbaatar T, Sunada K, Lefor AK, Yamamoto H. Maintenance of complete mucosal healing is associated with avoiding restenosis after endoscopic balloon dilation of Crohn's disease-related small intestinal strictures. DEN OPEN 2023; 3:e239. [PMID: 37082738 PMCID: PMC10111114 DOI: 10.1002/deo2.239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 03/17/2023] [Accepted: 04/03/2023] [Indexed: 04/22/2023]
Abstract
Background Endoscopic balloon dilation (EBD) is an effective, minimally invasive treatment for Crohn's disease (CD) related intestinal strictures. However, restenosis frequently occurs and requires repetitive EBD or surgical resection. Since previous studies could not evaluate restenosis based on stricture diameter, factors affecting restenosis after EBD were unclear. This study aimed to identify these factors by precisely measuring the diameter of small intestinal strictures in patients with CD. Methods This single-center retrospective study enrolled patients with CD with de novo small intestinal strictures who underwent two double-balloon enteroscopy sessions (EBD and follow-up) between January 2016 and October 2021. Clinical and endoscopic data were obtained from electronic medical records. A calibrated small-caliber-tip transparent hood was used to precisely measure stricture diameters. Multivariate analysis was performed to identify factors associated with restenosis. Results Forty-eight patients (37 male) were analyzed. The total number of strictures detected decreased from 162 to 143. The mean diameter of all strictures and the narrowest stricture in each patient increased significantly from 8.6 to 9.8 mm and from 7.6 to 8.7 mm, respectively. Thirty-two (67%) patients developed endoscopic restenosis. Multivariate analysis showed that the presence of ulcers at the follow-up session was a risk factor for restenosis (odds ratio 9.4, p = 0.01). Patients with complete mucosal healing at both sessions (n = 21) showed significant improvement in the narrowest stricture (+1.7 mm, p = 0.001). Conclusions Maintenance of complete mucosal healing is significantly associated with avoiding restenosis after EBD in CD-related small intestinal strictures.
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Affiliation(s)
- Ulzii Dashnyam
- Department of MedicineDivision of GastroenterologyJichi Medical UniversityTochigiJapan
- Department of PediatricsMongolian National University of Medical SciencesUlaanbaatarMongolia
| | - Manabu Nagayama
- Department of MedicineDivision of GastroenterologyJichi Medical UniversityTochigiJapan
| | - Tomonori Yano
- Department of MedicineDivision of GastroenterologyJichi Medical UniversityTochigiJapan
| | - Hirotsugu Sakamoto
- Department of MedicineDivision of GastroenterologyJichi Medical UniversityTochigiJapan
| | - Makiko Mieno
- Department of Medical InformaticsCenter for InformationJichi Medical UniversityTochigiJapan
| | - Jun Owada
- Department of MedicineDivision of GastroenterologyJichi Medical UniversityTochigiJapan
| | - Kunihiko Oguro
- Department of MedicineDivision of GastroenterologyJichi Medical UniversityTochigiJapan
| | - Tsevelnorov Khurelbaatar
- Department of MedicineDivision of GastroenterologyJichi Medical UniversityTochigiJapan
- Endoscopy Center, Mongolian Japan HospitalMongolian National University of Medical SciencesMongoliaUlaanbaatar
| | - Keijiro Sunada
- Department of MedicineDivision of GastroenterologyJichi Medical UniversityTochigiJapan
| | | | - Hironori Yamamoto
- Department of MedicineDivision of GastroenterologyJichi Medical UniversityTochigiJapan
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3
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Hong SM, Baek DH. A Review of Colonoscopy in Intestinal Diseases. Diagnostics (Basel) 2023; 13:diagnostics13071262. [PMID: 37046479 PMCID: PMC10093393 DOI: 10.3390/diagnostics13071262] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 03/25/2023] [Accepted: 03/26/2023] [Indexed: 03/30/2023] Open
Abstract
Since the development of the fiberoptic colonoscope in the late 1960s, colonoscopy has been a useful tool to diagnose and treat various intestinal diseases. This article reviews the clinical use of colonoscopy for various intestinal diseases based on present and future perspectives. Intestinal diseases include infectious diseases, inflammatory bowel disease (IBD), neoplasms, functional bowel disorders, and others. In cases of infectious diseases, colonoscopy is helpful in making the differential diagnosis, revealing endoscopic gross findings, and obtaining the specimens for pathology. Additionally, colonoscopy provides clues for distinguishing between infectious disease and IBD, and aids in the post-treatment monitoring of IBD. Colonoscopy is essential for the diagnosis of neoplasms that are diagnosed through only pathological confirmation. At present, malignant tumors are commonly being treated using endoscopy because of the advancement of endoscopic resection procedures. Moreover, the characteristics of tumors can be described in more detail by image-enhanced endoscopy and magnifying endoscopy. Colonoscopy can be helpful for the endoscopic decompression of colonic volvulus in large bowel obstruction, balloon dilatation as a treatment for benign stricture, and colon stenting as a treatment for malignant obstruction. In the diagnosis of functional bowel disorder, colonoscopy is used to investigate other organic causes of the symptom.
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Ismail MS, Charabaty A. Management of Crohn's stricture: medical, endoscopic and surgical therapies. Frontline Gastroenterol 2022; 13:524-530. [PMID: 36250181 PMCID: PMC9555137 DOI: 10.1136/flgastro-2021-101827] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 01/21/2022] [Indexed: 02/04/2023] Open
Abstract
Patients with Crohn's disease are at high risk of presenting with or developing a bowel stricture during the course of their disease. The available therapeutic options to manage a symptomatic Crohn's stricture include medical therapy (mainly biologics), surgical resection and endoscopic interventions. The choice of therapeutic modality depends on the clinical presentation of the stricture, the nature of the stricture (inflammatory vs fibrotic, primary vs anastomotic) and its anatomical characteristics on endoscopy and imaging (length, number, location of strictures and severity of obstruction). The aim herein is to provide an overview of the comprehensive assessment of a Crohn's stricture and to review the indications of the different therapeutic modalities, their success rates and their limitations to help clinicians properly evaluate and manage Crohn's strictures.
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Affiliation(s)
- Mohamed Saleh Ismail
- Gastroenterology and Hepatology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Aline Charabaty
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Sibley Memorial Hospital, Washington, District of Columbia, USA
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5
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Bettenworth D, Lopez R, Hindryckx P, Levesque BG, Rieder F. Heterogeneity in endoscopic treatment of Crohn's disease-associated strictures: An international inflammatory bowel disease specialist survey. J Gastroenterol 2016; 51:939-48. [PMID: 26831355 DOI: 10.1007/s00535-016-1172-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 01/17/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Crohn's disease (CD) is frequently complicated by intestinal strictures, which are commonly treated by endoscopic balloon dilation (EBD). However, available data on this area of treatment is limited. The aim of this study was to depict the heterogeneity of endoscopic management of CD-associated strictures among international CD specialists to identify common treatment standards. METHODS IBD experts of the International Organization for the Study of Inflammatory Bowel Disease (IOIBD), the European Crohn's and Colitis Organization (ECCO), and from the Prospective Value In IBD trials (PROVIT) completed a web-based questionnaire to evaluate their endoscopic experience, practice setting, and number of EBDs performed annually. Additionally, two case scenarios and technical practice parameters were investigated. RESULTS A total of 126 subjects from 15 countries completed the survey. The maximal length of dilated stricture was 4.5 ± 1.7 cm. The most commonly used maximal balloon size was graded as 15-18 mm. While 87.2 % of the participants favored EBD for anastomotic strictures, only 58.6 % did so in the case of naïve strictures. Only 35.7 % of physicians dilated actively inflamed strictures. Interventional endoscopists were more likely to dilate only clinically symptomatic strictures (p = 0.046). Surgeons favored surgical treatment of de novo ileocecal strictures compared to gastroenterologists (p = 0.026), reported a shorter stricture length being amendable by EBD (p = 0.045), and more frequently used concomitant therapies (p = 0.001). Operator experience increased the likelihood of EBD use in actively inflamed strictures (p = 0.002), maximum length of stricture, and maximum balloon size (p = 0.001). CONCLUSIONS EBD is a widely used treatment approach for stricturing CD. Individual approaches differ significantly based on background of the operator, experience level, and practice setting.
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Affiliation(s)
- Dominik Bettenworth
- Department of Medicine B, University Hospital of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany.
| | - Rocio Lopez
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Pieter Hindryckx
- Department of Gastroenterology, Ghent University Hospital, Ghent, Belgium
| | - Barrett G Levesque
- Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - Florian Rieder
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
- Department of Pathobiology, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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6
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Gecse KB, Sebastian S, Hertogh GD, Yassin NA, Kotze PG, Reinisch W, Spinelli A, Koutroubakis IE, Katsanos KH, Hart A, van den Brink GR, Rogler G, Bemelman WA. Results of the Fifth Scientific Workshop of the ECCO [II]: Clinical Aspects of Perianal Fistulising Crohn's Disease-the Unmet Needs. J Crohns Colitis 2016; 10:758-65. [PMID: 26826183 DOI: 10.1093/ecco-jcc/jjw039] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Accepted: 01/26/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS Perianal fistulas affect up to one-third of Crohn's patients during the course of their disease. Despite the considerable disease burden, current treatment options remain unsatisfactory. The Fifth Scientific Workshop [SWS5] of the European Crohn's and Colitis Organisation [ECCO] focused on the pathophysiology and clinical impact of fistulas in the disease course of patients with Crohn's disease [CD]. METHODS The ECCO SWS5 Working Group on clinical aspects of perianal fistulising Crohn's disease [pCD] consisted of 13 participants, gastroenterologists, colorectal surgeons, and a histopathologist, with expertise in the field of inflammatory bowel diseases. A systematic review of literature was performed. RESULTS Four main areas of interest were identified: natural history of pCD, morphological description of fistula tracts, outcome measures [including clinical and patient-reported outcome measures, as well as magnetic resonance imaging] and randomised controlled trials on pCD. CONCLUSIONS The treatment of perianal fistulising Crohn's disease remains a multidisciplinary challenge. To optimise management, a reliable classification and proper trial endpoints are needed. This could lead to standardised diagnosis, treatment, and follow-up of Crohn's perianal fistulas and the execution of well-designed trials that provide clear answers. The prevalence and the natural history of pCD need further evaluation.
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Affiliation(s)
- Krisztina B Gecse
- First Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Shaji Sebastian
- Inflammatory Bowel Disease Unit, Hull & East Yorkshire NHS Trust, Hull, UK
| | - Gert de Hertogh
- Department of Pathology, University of Leuven, Leuven, Belgium
| | - Nuha A Yassin
- Department of Colorectal Surgery, St Mark's Hospital and Academic Institute, London, UK
| | - Paulo G Kotze
- Colorectal Surgery Unit, Catholic University of Paraná, Curitiba, PR, Brazil
| | - Walter Reinisch
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Antonino Spinelli
- Colorectal Surgery Unit, Humanitas Research Hospital, Humanitas University, Milan, Italy
| | | | - Konstantinos H Katsanos
- Division of Gastroenterology, Department of Medicine, School of Health Sciences, Ioannina, Greece
| | - Ailsa Hart
- Inflammatory Bowel Disease Unit, St Mark's Hospital, London, UK
| | - Gijs R van den Brink
- Department of Gastroenterology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Gerhard Rogler
- Division of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - Willem A Bemelman
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Ooi CJ, Makharia GK, Hilmi I, Gibson PR, Fock KM, Ahuja V, Ling KL, Lim WC, Thia KT, Wei SC, Leung WK, Koh PK, Gearry RB, Goh KL, Ouyang Q, Sollano J, Manatsathit S, de Silva HJ, Rerknimitr R, Pisespongsa P, Abu Hassan MR, Sung J, Hibi T, Boey CCM, Moran N, Leong RWL. Asia-Pacific consensus statements on Crohn's disease. Part 2: Management. J Gastroenterol Hepatol 2016; 31:56-68. [PMID: 25819311 DOI: 10.1111/jgh.12958] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/11/2015] [Indexed: 02/05/2023]
Abstract
The Asia Pacific Working Group on Inflammatory Bowel Disease was established in Cebu, Philippines, at the Asia Pacific Digestive Week conference in 2006 under the auspices of the Asian Pacific Association of Gastroenterology (APAGE) with the goal of developing best management practices, coordinating research and raising awareness of IBD in the region. The consensus group previously published recommendations for the diagnosis and management of ulcerative colitis (UC) with specific relevance to the Asia-Pacific region. The present consensus statements were developed following a similar process to address the epidemiology, diagnosis and management of Crohn's disease (CD). The goals of these statements are to pool the pertinent literature specifically highlighting relevant data and conditions in the Asia-Pacific region relating to the economy, health systems, background infectious diseases, differential diagnoses and treatment availability. It does not intend to be all-comprehensive and future revisions are likely to be required in this ever-changing field.
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Affiliation(s)
- Choon Jin Ooi
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Govind K Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Ida Hilmi
- Division of Gastroenterology and Hepatology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Peter R Gibson
- Monash University Department of Medicine, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Kwong Ming Fock
- Department of Gastroenterology, Changi General Hospital, Singapore
| | - Vineet Ahuja
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Khoon Lin Ling
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Wee Chian Lim
- Department of Gastroenterology, Tan Tock Seng Hospital, Singapore
| | - Kelvin T Thia
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Shu-chen Wei
- Department of Internal Medicine, National Taiwan University, Taipei, Taiwan
| | | | - Poh Koon Koh
- Department of Colorectal Surgery, Singapore General Hospital, Singapore
| | - Richard B Gearry
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Khean Lee Goh
- Division of Gastroenterology and Hepatology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Qin Ouyang
- Division of Gastroenterology, Department of Internal Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Jose Sollano
- Department of Medicine, University of Santo Tomas, Manila, Philippines
| | - Sathaporn Manatsathit
- Department of Medicine, Division of Gastroenterology, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - H Janaka de Silva
- Department of Medicine, Faculty of Medicine, University of Kelaniya, Colombo, Sri Lanka
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
| | - Pises Pisespongsa
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | | | - Joseph Sung
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong
| | | | | | - Neil Moran
- Gastroenterology and Liver Services, Concord Hospital, Sydney, New South Wales, Australia
| | - Rupert W L Leong
- Gastroenterology and Liver Services, Concord Hospital, Sydney, New South Wales, Australia
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8
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Li Y, Stocchi L, Shen B, Liu X, Remzi FH. Salvage surgery after failure of endoscopic balloon dilatation versus surgery first for ileocolonic anastomotic stricture due to recurrent Crohn's disease. Br J Surg 2015; 102:1418-25; discussion 1425. [PMID: 26313750 DOI: 10.1002/bjs.9906] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 06/03/2015] [Accepted: 06/23/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Both surgical resection and endoscopic balloon dilatation are treatment options for ileocolonic anastomotic stricture caused by recurrent Crohn's disease unresponsive to medications. Perioperative outcomes of salvage surgery owing to failed endoscopic balloon dilatation in comparison with performing surgery first for the same indication are unclear. METHODS An analysis of a prospectively maintained Crohn's disease database was carried out to compare perioperative outcomes of patients who had surgery for failure of endoscopic balloon dilatation with outcomes in patients who underwent resection first for ileocolonic anastomotic stricture caused by recurrent Crohn's disease between 1997 and 2013. RESULTS Of 194 patients, 114 (58·8 per cent) underwent surgery without previous endoscopic balloon dilatation. The remaining 80 patients had salvage surgery after one or more endoscopic balloon dilatations during a median treatment span of 14·5 months. Patients in the salvage surgery group had a significantly shorter length of anastomotic stricture (P < 0·001). Salvage surgery was associated with increased rates of stoma formation (P = 0·030), overall surgical-site infection (SSI) (P = 0·025) and organ/space SSI (P = 0·030). In multivariable analysis, preoperative endoscopic balloon dilatation was independently associated with both postoperative SSI (odds ratio 3·16, 95 per cent c.i. 1·01 to 9·84; P = 0·048) and stoma diversion (odds ratio 3·33, 1·14 to 9·78; P = 0·028). CONCLUSION Salvage surgery after failure of endoscopic balloon dilatation is associated with increased adverse outcomes in comparison with surgery first. This should be discussed with patients being considered for endoscopic balloon dilatation for ileocolonic anastomotic stricture due to recurrent Crohn's disease.
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Affiliation(s)
- Y Li
- Departments of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - L Stocchi
- Departments of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - B Shen
- Departments of Gastroenterology/Hepatology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - X Liu
- Departments of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - F H Remzi
- Departments of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Gasparetto M, Angriman I, Guariso G. The multidisciplinary health care team in the management of stenosis in Crohn's disease. J Multidiscip Healthc 2015; 8:167-79. [PMID: 25878504 PMCID: PMC4388000 DOI: 10.2147/jmdh.s38729] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background Stricture formation is a common complication of Crohn’s disease (CD), occurring in approximately one-third of all patients with this condition. Our aim was to summarize the available epidemiology data on strictures in patients with CD, to outline the principal evidence on diagnostic imaging, and to provide an overview of the current knowledge on treatment strategies, including surgical and endoscopic options. Overall, the unifying theme of this narrative review is the multidisciplinary approach in the clinical management of patients with stricturing CD. Methods A Medline search was performed, using “Inflammatory Bowel Disease”, “stricture”, “Crohn’s Disease”, “Ulcerative Colitis”, “endoscopic balloon dilatation” and “strictureplasty” as keywords. A selection of clinical cohort studies and systematic reviews were reviewed. Results Strictures in CD are described as either inflammatory or fibrotic. They can occur de novo, at sites of bowel anastomosis or in the ileal pouch. CD-related strictures generally show a poor response to medical therapies, and surgical bowel resection or surgical strictureplasty are often required. Over the last three decades, the potential role of endoscopic balloon dilatation has grown in importance, and nowadays this technique is a valid option, complementary to surgery. Conclusion Patients with stricturing CD require complex clinical management, which benefits from a multidisciplinary approach: gastroenterologists, pediatricians, radiologists, surgeons, specialist nurses, and dieticians are among the health care providers involved in supporting these patients throughout diagnosis, prevention of complications, and treatment.
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Affiliation(s)
- Marco Gasparetto
- Department of Women and Children's Health, Paediatric Gastroenterology Unit, Padua University Hospital, Padova, Italy
| | - Imerio Angriman
- Department of Surgery, Gastroenterology and Oncology, Padua University, Padova, Italy
| | - Graziella Guariso
- Department of Women and Children's Health, Paediatric Gastroenterology Unit, Padua University Hospital, Padova, Italy
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Paine E, Shen B. Endoscopic therapy in inflammatory bowel diseases (with videos). Gastrointest Endosc 2013; 78:819-835. [PMID: 24139079 DOI: 10.1016/j.gie.2013.08.023] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Accepted: 08/15/2013] [Indexed: 02/08/2023]
Abstract
Endoscopic therapies are important modalities in the treatment of IBD, adjunct to medical and surgical approaches. These therapeutic techniques are particularly useful in the management of IBD-associated or IBD surgery–associated strictures, fistulas, and sinuses and colitis-associated neoplasia. Although the main focus of endoscopic therapies in IBD has been on balloon stricture dilation and ablation of adenoma-like lesions, new endoscopic approaches are emerging, including needle-knife stricturotomy, needle-knife sinusotomy, endoscopic stent placement, and fistula tract injection. Risk management of endoscopy-associated adverse events is also evolving. The application of endoscopic techniques in novel ways in the treatment of IBD is just beginning and will likely expand rapidly in the near future.
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Affiliation(s)
- Elizabeth Paine
- Division of Digestive Diseases, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Bo Shen
- Department of Gastroenterology/Hepatology, the Cleveland Clinic Foundation, Cleveland, Ohio, USA.
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11
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Pittet V, Froehlich F, Maillard MH, Mottet C, Gonvers JJ, Felley C, Vader JP, Burnand B, Michetti P, Schoepfer A. When do we dare to stop biological or immunomodulatory therapy for Crohn's disease? Results of a multidisciplinary European expert panel. J Crohns Colitis 2013; 7:820-6. [PMID: 23664620 DOI: 10.1016/j.crohns.2013.04.013] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 04/15/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND Safety and economic issues have increasingly raised concerns about the long term use of immunomodulators or biologics as maintenance therapies for Crohn's disease (CD). Despite emerging evidence suggesting that stopping therapy might be an option for low risk patients, criteria identifying target groups for this strategy are missing, and there is a lack of recommendations regarding this question. METHODS Multidisciplinary European expert panel (EPACT-II Update) rated the appropriateness of stopping therapy in CD patients in remission. We used the RAND/UCLA Appropriateness Method, and included the following variables: presence of clinical and/or endoscopic remission, CRP level, fecal calprotectin level, prior surgery for CD, and duration of remission (1, 2 or 4 years). RESULTS Before considering withdrawing therapy, the prerequisites of a C-reactive protein (CRP) and fecal calprotectin measurement were rated as "appropriate" by the panellists, whereas a radiological evaluation was considered as being of "uncertain" appropriateness. Ileo-colonoscopy was considered appropriate 1 year after surgery or after 4 years in the absence of prior surgery. Stopping azathioprine, 6-mercaptopurine or methotrexate mono-therapy was judged appropriate after 4 years of clinical remission. Withdrawing anti-TNF mono-therapy was judged appropriate after 2 years in case of clinical and endoscopic remission, and after 4 years of clinical remission. In case of combined therapy, anti-TNF withdrawal, while continuing the immunomodulator, was considered appropriate after two years of clinical remission. CONCLUSION A multidisciplinary European expert panel proposed for the first time treatment stopping rules for patients in clinical and/or endoscopic remission, with normal CRP and fecal calprotectin levels.
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Affiliation(s)
- Valerie Pittet
- Healthcare Evaluation Unit, Institute of Social & Preventive Medicine (IUMSP), Lausanne University Hospital, Lausanne, Switzerland.
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12
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Wu XR, Mukewar S, Kiran RP, Remzi FH, Shen B. Surgical stricturoplasty in the treatment of ileal pouch strictures. J Gastrointest Surg 2013; 17:1452-61. [PMID: 23690206 DOI: 10.1007/s11605-013-2216-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Accepted: 04/22/2013] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The objective of this study was to evaluate the efficacy of stricturoplasty and endoscopic balloon dilatation in the treatment for ileal pouch strictures. METHOD Consecutive inflammatory bowel disease patients with pouch strictures seen at our Pouch Center from 2002 to 2012 were studied. The efficacy and safety of stricturoplasty (vs. endoscopic balloon dilation) were evaluated with both univariate and multivariate analyses. RESULTS A total of 167 patients met the inclusion criteria, including 16 (9.6 %) with surgical stricturoplasty and 151 (90.4 %) with endoscopic balloon dilation. Ninety-four patients (56.3 %) were male, with a mean age at the diagnosis of pouch stricture of 41.6 ± 13.2 years. Fifty-one patients (30.5 %) had multiple pouch strictures, while 100 (59.9 %) patients had strictures at the pouch inlet. The mean length of pouch strictures was 1.2 ± 0.6 cm. No difference was found between the stricturoplasty and endoscopic dilation groups in clinicopathological variables, except for the degree of strictures (p = 0.019). After a mean follow-up of 4.1 ± 2.6 years, pouch stricture recurred in 92 patients (55.1 %) and 21 (12.6 %) patients developed pouch failure. The time interval between the procedure and pouch stricture recurrence or pouch failure was longer in the stricturoplasty group than that in the endoscopic dilation group (p < 0.001). Patients in the two groups had similar overall pouch survival rates and stricture-free survival rates. In the multivariate analysis, stricturoplasty vs. endoscopic dilation was not significantly associated with either overall pouch survival or stricture-free survival. There was no difference in the procedure-associated complication rates between the two groups. CONCLUSION Surgical stricturoplasty and endoscopic dilation treatment are complimentary techniques for pouch strictures. Repeated endoscopic dilatations are often required, while surgical stricturoplasty appeared to yield a longer time interval to stricture recurrence or pouch failure.
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Affiliation(s)
- Xian-rui Wu
- Department of Colorectal Surgery, The Cleveland Clinic Foundation, Cleveland, OH, USA
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Chiodini RJ, Dowd SE, Davis B, Galandiuk S, Chamberlin WM, Kuenstner JT, McCallum RW, Zhang J. Crohn's disease may be differentiated into 2 distinct biotypes based on the detection of bacterial genomic sequences and virulence genes within submucosal tissues. J Clin Gastroenterol 2013; 47:612-20. [PMID: 23426447 DOI: 10.1097/mcg.0b013e31827b4f94] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To determine whether bacterial pathogens can be detected within the diseased submucosal tissues of patients with Crohn's disease by molecular techniques independent of cultural methods. DESIGN We designed a quantitative polymerase chain reaction to detect 32 virulence genes and transposons within submucosal tissues of patients with Crohn's disease and controls and compared the microbiome of the submucosa with mucosal bacterial populations. RESULTS Within submucosal tissues, the bacterial invasion/adherence genes eaeA and invA were detected in 43% of patients (P=0.01 and 0.008 vs. mucosa and controls, respectively) and the Mycobacterium-specific IS900 and 251F genes detected in 50% of patients (P=0.03 vs. mucosa and controls). These findings were mutually exclusive: invasion/adhesion genes and Mycobacterium-associated transposons were not detected in the same patient. Metagenomic sequencing and quantitative polymerase chain reaction results confirmed effective separation of the submucosal and mucosal microbiome and the existence of a submucosal bacterial population within diseased tissues. CONCLUSIONS This study is the first to examine the microbial populations of submucosal tissues during intestinal disease and provide evidence of a distinct submucosal microbiome and biotypes within Crohn's disease. These data suggests that Crohn's disease may not be a single disease, but a spectrum that can be divided into distinct biotypes based on the presence of invasion/adherence genes or Mycobacterium-associated transposons. If corroborated by larger population studies, these findings could revolutionize the diagnosis, management, and treatment of Crohn's disease by the identification of patient biotypes and the application of targeted chemotherapeutic treatments that go beyond supportive in nature.
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Affiliation(s)
- Rodrick J Chiodini
- Division of Gastroenterology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX 79905, USA.
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14
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Abstract
The occurrence of strictures as a complication of Crohn's disease is a significant clinical problem. No specific antifibrotic therapies are available. This systematic review comprehensively addresses the pathogenesis, epidemiology, prediction, diagnosis and therapy of this disease complication. We also provide specific recommendations for clinical practice and summarise areas that require future investigation.
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Affiliation(s)
- Florian Rieder
- Department of Pathobiology, Lerner Research Institute, NC22, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
| | - Ellen M Zimmermann
- Division of Gastroenterology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Feza H Remzi
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - William J Sandborn
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
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15
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Abstract
Stricture formation is a common complication of Crohn’s disease, occurring in approximately one third of all patients with this condition. While the traditional management of such strictures has been largely surgical, there have been case series going back three decades highlighting the potential role of endoscopic balloon dilation in this clinical setting. This review article summarizes the stricture pathogenesis, focusing on known clinical and genetic risk factors. It then highlights the endoscopic balloon dilation research to date, with particular emphasis on three large recent case series. It concludes by describing the literature consensus regarding specific methodology and presenting avenues for future investigations.
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Affiliation(s)
- Raluca Vrabie
- Raluca Vrabie, Gerald L Irwin, David Friedel, Winthrop University Hospital, 259 First Street, Mineola, NY 11501, United States
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16
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Gustavsson A, Magnuson A, Blomberg B, Andersson M, Halfvarson J, Tysk C. Endoscopic dilation is an efficacious and safe treatment of intestinal strictures in Crohn's disease. Aliment Pharmacol Ther 2012; 36:151-8. [PMID: 22612326 DOI: 10.1111/j.1365-2036.2012.05146.x] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2012] [Revised: 03/21/2012] [Accepted: 05/02/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND Bowel strictures are a major cause of morbidity, hospitalisation and surgery in Crohn's disease. AIM We report short- and long-term efficacy and safety of endoscopic balloon dilation of strictures due to Crohn's disease. METHODS Retrospective study of patients who underwent endoscopic balloon dilation between 1987 and 2009. RESULTS We performed 776 dilations, of which 621 (80%) were on anastomotic strictures, in 178 patients (94 women) with Crohn's disease. At first dilation, median (IQR) age of patients was 45 (37-56) years and disease duration 16 (8-22) years. Technical success rate was 689/776 (89%). A subset of 75 patients from the primary catchment area, with >5-year follow-up, underwent a total of 246 dilations. At 1-year follow-up, 60/75 (80%) patients had undergone no further intervention or one additional dilation only. At 3 and 5 years, corresponding figures were 43/75 (57%) and 39/75 (52%). Cumulative proportions of patients undergoing surgery at 1, 3 and 5 years were 13%, 28% and 36%. Complication rate per procedure for all 178 patients was 41/776 (5.3%), bowel perforation (n = 11, 1.4%), major bleeding requiring blood transfusion (n = 8, 1.0%), minor bleeding (n = 10, 1.3%) and abdominal pain or fever (n = 12, 1.5%). Ten patients underwent surgery due to complications (perforation n = 8, bleeding n = 2). There was no procedure-related mortality. CONCLUSIONS Endoscopic balloon dilation is an efficacious and safe alternative to surgical resection of intestinal strictures in Crohn's disease. At 5-year follow-up, 52% of patients required no further or one additional dilation only, whereas 36% had undergone surgical resection. Complication frequency was low.
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Affiliation(s)
- A Gustavsson
- Department of Medicine, Division of Gastroenterology, Örebro University Hospital, Sweden
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17
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Whelan JF, Ivatury RR. Enterocutaneous fistulas: an overview. Eur J Trauma Emerg Surg 2011; 37:251-8. [PMID: 26815107 DOI: 10.1007/s00068-011-0097-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Accepted: 02/26/2011] [Indexed: 11/29/2022]
Abstract
Enterocutaneous fistulas remain a difficult management problem. The basis of management centers on the prevention and treatment of sepsis, control of fistula effluent, and fluid and nutritional support. Early surgery should be limited to abscess drainage and proximal defunctioning stoma formation. Definitive procedures for a persistent fistula are indicated in the late postoperative period, with resection of the fistula segment and reanastomosis of healthy bowel. Even more complex are the enteroatmospheric fistulas in the open abdomen. These enteric fistulas require the highest level of multidisciplinary approach for optimal outcomes.
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Affiliation(s)
- J F Whelan
- Department of Surgery, Virginia Commonwealth University, 1200 East Broad Street W15E, Richmond, VA, 23298, USA
| | - R R Ivatury
- Department of Surgery, Virginia Commonwealth University, 1200 East Broad Street W15E, Richmond, VA, 23298, USA.
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18
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Juillerat P, Pittet V, Mottet C, Felley C, Gonvers JJ, Vader JP, Burnand B, Froehlich F, Wolters FL, Stockbrügger RW, Michetti P. Appropriateness of early management of newly diagnosed Crohn's disease in a European population-based cohort. Scand J Gastroenterol 2010; 45:1449-56. [PMID: 20653489 DOI: 10.3109/00365521.2010.505660] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The European Panel on the Appropriateness of Crohn's disease Therapy (EPACT) has developed appropriateness criteria. We have applied these criteria retrospectively to the population-based inception cohort of Crohn's disease (CD) patients of the European Collaborative Study Group on Inflammatory Bowel Disease (EC-IBD). MATERIAL AND METHODS A total of 426 diagnosed CD patients from 13 European centers were enrolled at the time of diagnosis (first flare, naive patients). We used the EPACT definitions to identify 247 patients with active luminal CD. We then assessed the appropriateness of the initial drug prescription according to the EPACT criteria. RESULTS Among the cohort patients 163 suffered from mild-to-moderate CD and 84 from severe CD. Among the mild-to-moderate disease group, 96 patients (59%) received an appropriate treatment, whereas for 66 patients (40%) the treatment was uncertain and in one case (1%) inappropriate. Among the severe disease group, 86% were treated medically and 14% required surgery. 59 (70%) were appropriately treated, whereas for one patient (1%) the procedure was considered uncertain and for 24 patients (29%) inappropriate. CONCLUSION Initial treatment was appropriate in the majority of cases for non-complicated luminal CD. Inappropriate or uncertain treatment was given in a significant minority of patients, with an increased potential risk of adverse events.
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Affiliation(s)
- Pascal Juillerat
- Department of Gastroenterology & Hepatology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland.
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19
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Juillerat P, Pittet V, Vader JP, Burnand B, Gonvers JJ, de Saussure P, Mottet C, Seibold F, Rogler G, Sagmeister M, Felley C, Michetti P, Froehlich F. Infliximab for Crohn's disease in the Swiss IBD Cohort Study: clinical management and appropriateness. Eur J Gastroenterol Hepatol 2010; 22:1352-7. [PMID: 20964261 DOI: 10.1097/meg.0b013e32833eaa8a] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Antitumor necrosis factor a agents have significantly improved the management of Crohn's disease (CD), but not all patients benefit from this therapy. We used data from the Swiss Inflammatory Bowel Disease Cohort Study and predefined appropriateness criteria to examine the appropriateness of use of infliximab (IFX) in CD patients. METHODS EPACT II (European Panel on the Appropriateness of CD Therapy, 2007; www.epact.ch) appropriateness criteria have been developed using a formal explicit panel process combining evidence from the published literature and expert opinion. Questionnaires relating to EPACT II criteria were used at enrollment and follow-up of all Swiss Inflammatory Bowel Disease Cohort Study patients. A step-by-step analysis of all possible indications for IFX therapy in a given patient allowed identification of the most appropriate indication and final classification in a single appropriateness category (appropriate, uncertain, inappropriate). RESULTS Eight hundred and twenty-one CD patients were prospectively enrolled between November 2006 and March 2009. IFX was administered to 146 patients (18%) at enrollment and was most frequently used for complex fistulizing disease and for the maintenance of remission induced by biological therapy. IFX therapy was considered appropriate in 44%, uncertain in 44%, and inappropriate in 10% of patients. CONCLUSION In this cohort, 9 out of 10 indications for IFX therapy were clinically generally acceptable (appropriate or uncertain) according to EPACT II criteria. Uncertain indications resulted mainly from the current more liberal use of IFX in clinical practice as compared with the EPACT II criteria.
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Affiliation(s)
- Pascal Juillerat
- Department of Gastroenterology and Hepatology, Institute of Social and Preventive Medicine, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland.
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20
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Pittet V, Juillerat P, Michetti P, Vader JP, Burnand B, Rogler G, Beglinger C, Seibold F, Mottet C, Felley C, Gonvers JJ, Froehlich F. Appropriateness of therapy for fistulizing Crohn's disease: findings from a national inflammatory bowel disease cohort. Aliment Pharmacol Ther 2010; 32:1007-16. [PMID: 20937046 DOI: 10.1111/j.1365-2036.2010.04434.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND About 30-50% of patients with Crohn's disease (CD) develop fistulae, implying significant disease burden and complicated clinical management. AIM To assess appropriate use of therapy for fistulizing CD patients enrolled in the Swiss Inflammatory Bowel Disease Cohort using criteria developed by the European Panel on the Appropriateness of Crohn's disease Therapy. METHODS Specific questionnaires were used to gather information on disease and its management. We assessed appropriateness of therapy at enrolment for adult CD patients with one or several fistulae. RESULTS Two hundred and eighty-eight CD patients had fistulizing disease, of which 80% had complex fistulae and 32% currently had active draining fistulae. Mean age (s.d.) at diagnosis was 27 years (11), 51% males. Of the patients, 78% were judged as having globally an appropriate therapy, which was more often given for complex fistulae (87%) than for simple fistulae (67%). Antibiotics, azathioprine/MP, methotrexate and conservative surgery were almost always appropriate. Anti-tumor necrosis factor α was considered globally appropriate (91%), although most often with an uncertain indication. The 5ASA compounds, steroids and aggressive surgery were most often inappropriate (84%, 58% and 86% respectively). CONCLUSIONS Formal appropriateness criteria for CD therapy were applied to a national cohort of IBD patients. For more than three-quarters of the patients with fistulizing CD, therapy was globally appropriate.
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Affiliation(s)
- V Pittet
- Institute of Social & Preventive Medicine, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Switzerland.
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Dubois RW. On the second European Panel on the Appropriateness of Crohn's disease Therapy (EPACT-II). J Crohns Colitis 2009; 3:223-4. [PMID: 21172279 DOI: 10.1016/j.crohns.2009.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2009] [Accepted: 09/04/2009] [Indexed: 02/08/2023]
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