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Inflammatory bowel diseases
Fibrostenotic strictures in Crohn’s disease
Jun Hwan Yoo, Stefan Holubar, Florian Rieder
Intest Res 2020;18(4):379-401.   Published online April 10, 2020
DOI: https://doi.org/10.5217/ir.2019.09148
AbstractAbstract PDFPubReaderePub
The use of biologic agents including anti-tumor necrosis factor monoclonal antibodies followed by anti-integrins and anti-interleukins has drastically changed the treatment paradigm of Crohn’s disease (CD) by improving clinical symptoms and mucosal healing. However, up to 70% of CD patients still eventually undergo surgery mainly due to fibrostenotic strictures. There are no specific anti-fibrotic drugs yet. This review comprehensively addresses the mechanism, prediction, diagnosis and treatment of the fibrostenotic strictures in CD. We also introduce promising anti-fibrotic agents which may be available in the near future and summarize challenges in developing novel therapies to treat fibrostenotic strictures in CD.

Citations

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Original Articles
Miscellaneous
Clinical profile and outcomes of opioid abuse gastroenteropathy: an underdiagnosed disease entity
Ramit Mahajan, Yogesh Gupta, Arshdeep Singh, Pulkit Dhiman, Vandana Midha, Chandan Kakkar, Vikram Narang, Varun Mehta, Kavita Saggar, Ajit Sood
Intest Res 2020;18(2):238-244.   Published online February 25, 2020
DOI: https://doi.org/10.5217/ir.2019.00104
AbstractAbstract PDFPubReaderePub
Background/Aims
Opioid-induced bowel dysfunction includes nausea, vomiting, constipation and abdominal distension. We describe patients presenting with gastrointestinal (GI) ulcers and ulcerated strictures secondary to opioid abuse, an entity not well described in literature.
Methods
This retrospective observational study included patients with opioid abuse gastroenteropathy presenting to Dayanand Medical College and Hospital, Ludhiana, India between January 2013 and December 2018. Opioid abuse gastroenteropathy was defined as gastric or small bowel ulcers and ulcerated strictures in patients abusing opioids, where all other possible etiologies of GI ulcers/strictures were excluded. Clinical, biochemical, endoscopic, radiological and histological parameters as well as response to treatment were assessed.
Results
During the study period, 20 patients (mean age, 38.5±14.2 years; 100% males) were diagnosed to have opioid induced GI ulcers and/or ulcerated strictures. The mean duration of opioid consumption was 6.2±3.4 years. The mean duration of symptoms at presentation was 222.1±392.3 days. Thirteen patients (65%) had gastroduodenal involvement, 6 (30%) had a jejunoileal disease and 1 (5%) had an ileocecal stricture. Two patients (10%) presented with upper GI bleeding, 11 (55%) had features of gastric outlet obstruction and 7 (35%) presented with small bowel obstruction. Abdominal pain and iron deficiency anemia were the most common presentations. Only 1 patient (5%) responded to proton pump inhibitors, 3 (15%) had a lasting response to endoscopic balloon dilatation, while all other (80%) required surgical intervention.
Conclusions
Opioid abuse gastroenteropathy presents as ulcers and ulcerated strictures which respond poorly to medical management and endoscopic balloon dilatation. A majority of these cases need surgical intervention.

Citations

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    Chen Li, Jindong Chu, Xiaodong Jia, Haibin Su
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    Mohsen Masoodi, Mohammad Sabzikarian, Nikta Masoodi, Saeed Farhadi, Gholam Reza Rezamand, Seidamir Pasha Tabaeian, Atefeh Talebi, Farimah Fayyaz
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    Mithu Bhowmick, Vishal Sharma
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Predictive factors for malignancy in undiagnosed isolated small bowel strictures
Ujjwal Sonika, Sujeet Saha, Saurabh Kedia, Nihar Ranjan Dash, Sujoy Pal, Prasenjit Das, Vineet Ahuja, Peush Sahni
Intest Res 2017;15(4):518-523.   Published online October 23, 2017
DOI: https://doi.org/10.5217/ir.2017.15.4.518
AbstractAbstract PDFPubReaderePub
<b>Background/Aims</b><br/>

Patients with small bowel strictures have varied etiologies, including malignancy. Little data are available on the demographic profiles and etiologies of small bowel strictures in patients who undergo surgery because of intestinal obstruction but do not have a definitive pre-operative diagnosis.

Methods

Retrospective data were analyzed for all patients operated between January 2000 and October 2014 for small bowel strictures without mass lesions and a definite diagnosis after imaging and endoscopic examinations. Demographic parameters, imaging, endoscopic, and histological data were extracted from the medical records. Univariate and multivariate analyses were conducted to identify factors that could differentiate between intestinal tuberculosis (ITB) and Crohn's disease (CD) and between malignant and benign strictures.

Results

Of the 7,425 reviewed medical records, 89 met the inclusion criteria. The most common site of strictures was the proximal small intestine (41.5%). The most common histological diagnoses in patients with small bowel strictures were ITB (26.9%), CD (23.5%), non-specific strictures (20.2%), malignancy (15.5%), ischemia (10.1%), and other complications (3.4%). Patients with malignant strictures were older than patients with benign etiologies (47.6±15.9 years vs. 37.4±16.4 years, P=0.03) and age >50 years had a specificity for malignant etiology of 80%. Only 7.1% of the patients with malignant strictures had more than 1 stricture and 64% had proximally located strictures. Diarrhea was the only factor that predicted the diagnosis of CD 6.5 (95% confidence interval, 1.10–38.25; P=0.038) compared with the diagnosis of ITB.

Conclusions

Malignancy was the cause of small bowel strictures in approximately 16% patients, especially among older patients with a single stricture in the proximal location. Empirical therapy should be avoided and the threshold for surgical resection is low in these patients.

Citations

Citations to this article as recorded by  
  • Cryptogenic multifocal ulcerous stenosing enteritis: A ray of light on the umbra of the dark continent
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Review
Current status of endoscopic balloon dilation for Crohn's disease
Fumihito Hirai
Intest Res 2017;15(2):166-173.   Published online April 27, 2017
DOI: https://doi.org/10.5217/ir.2017.15.2.166
AbstractAbstract PDFPubReaderePub

The therapeutic target in Crohn's disease (CD) has been raised to the achievement of mucosal healing. Although effective treatments that target cytokines and other molecules has been widely used for CD, intestinal strictures are still a major cause of surgery. Endoscopic balloon dilation (EBD) is known to be an effective and safe intervention for intestinal strictures in CD. Since frequent intestinal resection often results in short bowel syndrome and can decrease the quality of life, EBD can help avoid surgery. EBD with a conventional colonoscope for Crohn's strictures of the colon and ileo-colonic anastomosis has established efficacy and safety. In addition, EBD using balloon-assisted enteroscopy has recently been applied for small bowel Crohn's strictures. Although the evidence is not strong, EBD may become an alternative to surgery in small bowel strictures in CD. EBD and other new methods such as self-expanding stent implantation for Crohn's strictures may be useful and safe; however, it is important to address several issues regarding these interventions and to establish a protocol for combined therapies.

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Case Report
High grade anorectal stricture complicating Crohn's disease: endoscopic treatment using insulated-tip knife
Hyung Ku Chon, Ik Sang Shin, Sang Wook Kim, Soo Teik Lee
Intest Res 2016;14(3):285-288.   Published online June 27, 2016
DOI: https://doi.org/10.5217/ir.2016.14.3.285
AbstractAbstract PDFPubReaderePub

Endoscopic treatments have emerged as an alternative to surgery, in the treatment of benign colorectal stricture. Unlike endoscopic balloon dilatation, there is limited data on endoscopic electrocautery incision therapy for benign colorectal stricture, especially with regards to safety and long-term patency. We present a case of a 29-year-old female with Crohn's disease who had difficulty in defecation and passing thin stools. A pelvic magnetic resonance imaging scan, gastrograffin enema, and sigmoidoscopy showed a high-grade anorectal stricture. An endoscopic insulated-tip knife incision was successfully performed to resolve the problem. From our experience, we suggest that endoscopic insulated-tip knife treatment may be a feasible and effective modality for patients with short-segment, very rigid, fibrotic anorectal stricture.

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