How I Approach the Management of Stricturing Crohn's Disease

Crohn's-like Ileal Pouch Illness and Ileal Pouch Salvage Strategies

De novo Crohn's disease (CD) of the pouch or Crohn's-like Ileal Pouch Illness (CLIPI) is an increasingly common occurrence in an ever-growing ileal pouch population. Although currently undetermined if a subset of classic CD or a completely new entity, it primarily affects the prepouch afferent limb, pouch, and rectal cuff. Symptoms can mimic other more common disorders, such as pouchitis, and requires a thorough workup, including pouchoscopy with biopsy and often cross-sectional imaging, for the diagnosis to be made. There is an increased risk of long-term pouch failure in this population. Treatment is typically dependent upon the disease phenotype with surgical management considered in a step-up fashion. Medical management is primarily performed with "biologics," such as antitumor necrosis factor agents, although data are limited due to the lack of randomized controlled trials. Surgical management for CLIPI can include endoscopic, anorectal, and abdominal approaches to assist as "pouch-salvage strategies." The performance of advanced pouch-salvage techniques in the CLIPI population requires careful patient selection and should preferably be performed at high-volume pouch centers.

Intravenous Steroids Do Not Improve Short-Term Outcomes of Patients With Crohn's Disease Presenting With an Acute Small Bowel Obstruction

BACKGROUND

Intravenous (IV) steroids are commonly used to treat acute flares of Crohn's disease (CD). However, it is unclear if they are beneficial in the setting of uncomplicated small bowel obstruction (SBO). We sought to examine if IV steroid administration improved short-term outcomes in patients with CD hospitalized for acute, uncomplicated SBO across three New York City hospital systems.

METHODS

This retrospective study included patients ≥ 18 years old admitted between January 1, 2011, and December 31, 2019, with Crohn's disease and an admission diagnosis of uncomplicated acute SBO, defined as cases without adhesions, fistula, phlegmon, and sepsis. Primary endpoints (length of stay and frequency of surgery) were compared between patients who received IV steroids upon admission and those who did not.

RESULTS

Our analysis included 674 unique patients. Ninety-two (14%) received IV steroids, and 582 (86%) did not. IV steroid use did not result in shorter hospital stays (median days [IQR]: 3.0 (2.0-5.5) days vs 3.0 (2.0-6.0) days in the no-steroid group, P = .65) or reduce the need for surgery (4 patients (4.4%) vs 28 patients (4.8%) in the no-steroid group, P = .85). Sex, age, disease duration, concomitant biologic therapy, and NG tube placement did not independently contribute to either outcome.

CONCLUSIONS

These findings suggest that IV steroid administration for uncomplicated SBO in CD patients does not decrease hospital length of stay or need for surgery. Further research may help identify specific obstruction patterns or other therapies associated with different outcomes.

In-hospital management of inflammatory bowel disease

PURPOSE OF REVIEW

The management of hospitalized patients with inflammatory bowel disease (IBD) is complex. Despite considerable therapeutic advancements in outpatient ulcerative colitis and Crohn's disease management, the in-hospital management continues to lag with suboptimal outcomes. The purpose of this review is to provide a brief overview of our approach to managing patients hospitalized with acute severe ulcerative colitis (ASUC) and Crohn's disease-related complications, followed by a summary of emerging evidence for new management approaches.

RECENT FINDINGS

ASUC has seen the emergence of well validated prognostic models for colectomy as well as the development of novel treatment strategies such as accelerated infliximab dosing, Janus kinase inhibitor therapy, and sequential therapy, yet the rate of colectomy for steroid-refractory ASUC has not meaningfully improved. Crohn's disease has seen the development of better diagnostic tools, early Crohn's disease-related complication stratification and identification, as well as better surgical techniques, yet the rates of hospitalization and development of Crohn's disease-related complications remain high.

SUMMARY

Significant progress has been made in the in-hospital IBD management; however, both the management of ASUC and hospitalized Crohn's disease remain a challenge with suboptimal outcomes. Critical knowledge gaps still exist, and dedicated studies in hospitalized patients with IBD are needed to address them.

Diagnosis and Classification of Inflammatory Bowel Disease Strictures

Intestinal strictures are a common complication in inflammatory bowel disease (IBD). Symptoms due to intestinal strictures range from mild bloating and/or abdominal discomfort to complete bowel obstruction. Careful selection of available medical, endoscopic, or surgical therapies is critical for optimizing patient outcomes and is dependent on the effective characterization of the stricture. This article will focus on the diagnosis and classification of IBD strictures.

Prevention and Treatment of Stricturing Crohn's Disease - Perspectives and Challenges

Introduction: Fibrostenosis is a hallmark of Crohn's disease (CD), remains a challenge in today's clinical management of inflammatory bowel disease patients and represents a key event in the disease course necessitating improved preventative strategies and a multidisciplinary approach to diagnosis and management. With the advent of anti-fibrotic therapies and well-defined clinical endpoints for stricturing CD, there is promise to impact the natural history of disease.Areas covered: This review summarizes current evidence in the natural history of stricturing Crohn's disease, discusses management approaches as well as future perspectives on intestinal fibrosis.Expert opinion: Currently, there are no specific therapies to prevent progression to fibrosis or to treat it after it becomes clinically apparent. In addition to the international effort by the Stenosis Therapy and Anti-Fibrotic Research (STAR) consortium to standardize definitions and propose endpoints in the management of stricturing CD, further research to improve our understanding of mechanisms of intestinal fibrosis will help pave the way for the development of future anti-fibrotic therapies.

Strictures in Crohn's Disease: From Pathophysiology to Treatment

Despite recent advances aimed to treat transmural inflammation in Crohn's disease (CD) patients, the progression to a structuring behavior still represents an issue for clinicians. As inflammation becomes chronic and severe, the attempt to repair damaged tissue can result in an excessive production of extracellular matrix components and deposition of connective tissue, thus favoring the formation of strictures. No specific and accurate clinical predictors or diagnostic tools for intestinal fibrosis exist, and to date, no genetic or serological marker is in routine clinical use. Therefore, intestinal fibrosis is usually diagnosed when it becomes clinically evident and strictures have already occurred. Anti-fibrotic agents such as tranilast, peroxisome proliferator-activated receptor gamma agonists, rho kinase inhibitors, and especially mesenchymal stem cell therapy have provided interesting results, but most of the evidence has been derived from studies performed in vitro. Therefore, current therapy of fibrotic strictures relies mainly on endoscopic and surgical procedures. Although its long-term outcomes may be debated, endoscopic balloon dilation appears to be the safest and most effective approach to treat appropriately selected strictures. The use of endoscopic stricturotomy is currently limited by the expertise needed to perform it and by the few data available in the literature. Some good results have been achieved by the positioning of self-expandable metal stents (SEMS). However, there is no concordance regarding the type of stent to use and for how long it should be left in place. The development of new specific SEMS may lead to better outcomes and to an increased use of this alternative in CD-related strictures.

Natural history, diagnosis and treatment approach to fibrostenosing Crohn's disease

Stricturing Crohn's disease (CD) is a significant clinical problem. The presence of a stricture may be suggested by clinical symptoms. Cross-sectional imaging using computed tomography or magnetic resonance enterography is essential in diagnosing strictures as it allows further characterization and evaluation for complications such as abscess, fistulizing disease or malignancy. Managing small bowel stricturing CD should be approached in a multidisciplinary fashion. Medical therapy can be considered in strictures which are not associated with complications, with most of the data supporting anti-TNF strategies in this setting. If the disease is refractory to medical therapy, endoscopic therapy or surgery should be performed. Endoscopic balloon dilation (EBD) is an option for short, uncomplicated and straight strictures that are within reach of a colonoscope. Although EBD has good short-term outcomes, repeat dilation is often required. Surgical options mainly include resection and strictureplasty. Strictures refractory to medical therapy, not amenable or refractory to EBD, or associated with complications or malignancy should be managed surgically. However, surgery may also be considered at an earlier stage depending on disease characteristics and patient preference. Postoperative recurrence is common, highlighting the importance of careful monitoring of the patient postoperatively and optimization of medical management accordingly. There is a pressing need to develop anti-fibrotics for the treatment of stricturing CD. This requires the development of standardized diagnostic criteria, patient-reported outcome measures and validation of endpoints in fibrostenotic CD. The STAR consortium is pioneering this effort in order to allow development and testing of anti-fibrotics in future clinical trials.