Dr Cross reviews his presentation at the ACG Postgraduate Course on the diagnosis and management of fibrostenotic strictures in Crohn's disease, including options for medical, endoscopic, and surgical treatment.

Raymond Cross, MD, is Medical Director of The Center for Inflammatory Bowel and Colorectal Diseases at The Melissa L. Posner Institute for Digestive Health and Liver Disease at Mercy Medical Center​, in Baltimore, Maryland​.

Managing Fibrostenotic Strictures in Crohn’s Disease

• Crohn’s disease strictures usually contain both inflammation and fibrosis. Imaging typically shows wall thickening, luminal narrowing, and prestenotic dilation; endoscopically, passage of a colonoscope is difficult or impossible.
• Advanced therapy may benefit patients with shorter symptom duration and strictures, no substantial prestenotic dilation, and no associated fistula or abscess. Cross reported short-term response exceeding 80% at 6 months in patients with favorable features.
• Balloon dilation has approximately 90% technical success, 70% symptom improvement, and 3% complications. Cross advised early colorectal surgery involvement after one advanced therapy fails; surgery is also an upfront option.

Hello everyone. I'm Raymond Cross from Mercy Medical Center in Baltimore. And at ACG, I was part of a symposium entitled When Crohn's Gets Complicated, and my specific talk was on fibrostenotic complications of Crohn's. So when you're talking about fibrostenotic complications or strictures, the first thing you want to do is define what a stricture is. On imaging, typically a stricture is going to be a thickened wall with a decreased luminal diameter with prestenotic dilation. Endoscopically, we define a stricture as the inability to pass a colonoscope through the stricture, or at least difficulty without having significant resistance.

When I was in training, we thought that there were two types of strictures. There's purely inflammatory strictures or swelling, and then there were fibrostenotic or scar strictures. So we know now that most strictures are a mix of both inflammation and fibrosis. So the question clinically is when you see a patient with a stricturing complication, how can you determine whether medical therapy may benefit?

And there's a number of different studies that have looked at that, but in general, decreased duration of symptom onset, shorter strictures, strictures without significant prestenotic dilation, and strictures that don't have an associated penetrating complication like a fistula or abscess, have a good probability of short-term success. So it can be over 80% at 6 months for those patients to respond to therapy. Now, we don't know what the best therapy for stricturing disease is, but just in general, most of the studies have been with anti -TNF. So if you have a patient that has good prognostic criteria, certainly trying one of our advanced therapies is very reasonable.

We also talk about, can you manage these strictures endoscopically? So I talk about balloon dilation. Success rate for balloon dilation is approximately 90% and complication rates are about 3% typically bleeding and rarely perforation. As far as clinical effectiveness, it's probably somewhere in the 70% range to decrease symptoms. In the long term, though, with endoscopic dilation, there's the rule of thirds. A third of people will progress to surgery within 5 years. A third of people to dilation will work one time and has a durable response. And another third of patients need repeated dilations.

When you're talking about dilations, does size matter? It definitely matters. So typically getting that balloon to 15, ideally to 18 millimeters, is crucial and the outcomes are better if you can get a stricture dilated. I think one of the key messages of my talk is that in a patient who has a stricture that looks like it's amenable to treatment, trying a advanced therapy is reasonable, but cycling through multiple advanced therapies to try to get the stricture to open is not really a good strategy and really involving a colorectal surgeon early, particularly after the first therapy is failed.

And additionally, you can offer a patient surgical approach upfront, and I think that's a very reasonable thing to do, is to do a surgical reset and then do monitoring for recurrence.

Lastly, we’ve come up with an algorithm that basically summarizes what I said, that talks about is this person an appropriate candidate for a trial of medical therapy? If yes, reassess in a treat to target approach. If they do well, continue with ongoing monitoring. If they don't do well, is it a short stricture within reach and scope you can consider balloon dilation. Is it above the reach of the scope? That's going to be a surgery, either a resection or strictureplasty. And then if none of those are really an option, they're going to go straight away to surgery. So hopefully you've learned a little synopsis of my lecture from ACG. Thank you for your attention.