What is a stricture?

3 Medical Therapies to Treat Strictures in Crohn’s Disease

Anyone who has Crohn’s disease knows that the symptoms of the disease are no picnic. Abdominal cramps, diarrhea, constipation, and other symptoms can make life unpleasant to say the least. Worrying about more serious complications of Crohn’s disease, such as strictures, is yet another challenge that patients may face.

A stricture is a narrowing of a section of the intestine that causes problems by slowing or blocking the movement of food through the area. Strictures, which are caused by recurrent inflammation, can lead to hospitalization and also to surgery to correct them.

Symptoms of strictures include abdominal pain, cramping, and bloating. In serious cases, strictures can progress to the point of causing a complete intestinal obstruction, which may result in nausea, vomiting, abdominal distention, and severe abdominal pain.

It is possible for strictures to occur anywhere along the gastrointestinal tract, but they are most often found in the last part of the small intestine and in the colon. “Between 70 and 90 percent of people with Crohn’s disease will require surgery after 5 to 10 years,” says Anita K. Gregory, MD, director of the colorectal program at St. Joseph Hospital in Orange, California, and a member of the medical advisory committee for the Orange County chapter of the Crohn’s & Colitis Foundation of America. “Of those requiring surgery, 50 percent are due to strictures.”

Ways to Treat Strictures

The treatment of strictures can be difficult, and the risk for recurrence after treatment is relatively high. New lesions may be seen as soon as one year after surgery, with 20 to 44 percent of patients who have undergone surgery needing a second surgical procedure.

There are three different options available to treat strictures, says Bo Shen, MD, a gastroenterologist in the Cleveland Clinic’s Digestive Disease Institute in Ohio. These are:

  • Medical therapy with steroids and an anti-inflammatory agent
  • Endoscopic surgery (balloon dilation or needle knife therapy to open up the stricture)
  • Bowel resection and anastomosis or strictureplasty

Though surgery is the most effective treatment, followed by endoscopy and then medical therapy, the degree of invasiveness and complications also follow in that order, according to Dr. Shen.

“Strictureplasty evolved as a surgical procedure designed to preserve intestinal length,” says Dr. Gregory. “It is appropriate for diffuse multiple strictures, patients with previous resections of more than 100 centimeters of small intestine, and those with short bowel syndrome.”

Endoscopic balloon dilation is technically successful in 75 to 90 percent of cases, according to Gregory. And she says there is a risk for significant complications such as major bleeding or perforation in three percent of patients. An article published in January 2016 in the United European Gastroenterology Journal found that the procedure is safe and effective as a first line of treatment for people with Crohn’s. Of the 46 patients with Crohn’s who received balloon dilation, the research reports that 83 percent were satisfied with the outcome.

While living with Crohn’s complications can be very difficult, it is likely that periods of disease flares when symptoms are worse will be followed by times of remission when these symptoms are less noticeable or maybe even nonexistent. And while perhaps not permanent or perfect, treatment options that can make life a little bit easier certainly do exist.

Colon Stricture

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Medically reviewed by Drugs.com. Last updated on Sep 24, 2019.

  • Care Notes

What is a colon stricture?

A colon stricture is the narrowing of the large intestine. A stricture slows or prevents waste from passing through your large intestine. Colon strictures can become life-threatening if they are not treated.

What causes colon strictures?

  • Chronic inflammation and scars from inflammatory bowel disease, such as Crohn disease
  • Your colon looping around itself (volvulus)
  • Adhesions in your abdomen
  • Hernias
  • Tumors inside or outside of your colon

What are the symptoms of colon strictures?

You may not have any symptoms. The following are the most common symptoms:

  • Constipation
  • Pain or cramps in your abdomen
  • Bloated or distended abdomen
  • Nausea and vomiting

How are colon strictures diagnosed?

Your healthcare provider may see a stricture on an abdominal x-ray or CT scan.

How are colon strictures treated?

  • Balloon dilation may be done. A scope with a light and camera is placed into your colon. A balloon is placed over a guidewire and inflated in the narrow area. Healthcare providers inflate the balloon several times for short periods. The inflated balloon pushes against the narrow wall and opens it.
  • A stent may need to be placed to open the stricture. A stent is a metal coil. The stent will be left in place to keep the stricture open.
  • Surgery may be needed if balloon dilation does not work. It may also be needed if your healthcare provider is not able to reach the stricture with a scope. There are 2 types of surgery:
    • A resection is used to remove the part of the intestine that has the stricture. Then, the remaining 2 ends or 2 sides are sewn together.
    • A stricturoplasty may be needed if you have had a large part of your intestine removed. It may also be needed if there many areas with strictures in your intestine.

How can I prevent colon strictures?

You may not be able to prevent strictures if you have certain chronic conditions, such as Crohn disease. The following may help to prevent colon strictures:

  • Eat a variety of healthy foods. Choose foods that are low in fat. Eat more fruits and vegetables.
  • Do not smoke. Nicotine can damage blood vessels and make it more difficult to manage your colon stricture. Smoking also increases your risk for colorectal cancer. Do not use e-cigarettes or smokeless tobacco in place of cigarettes or to help you quit. They still contain nicotine. Ask your healthcare provider for information if you currently smoke and need help quitting.
  • Do not lift heavy items. This will help prevent hernias that can cause part of your intestine to go through your abdominal wall.

When should I seek immediate care?

  • You have a fever.
  • You have nausea and vomiting, and severe, worsening abdominal pain.
  • You have severe abdominal swelling.
  • You cannot have a bowel movement or pass gas.

When should I contact my healthcare provider?

  • You have abdominal cramps that come and go.
  • You have diarrhea but feel like your bowels are still full.
  • You have questions or concerns about your condition or care.

Care Agreement

You have the right to help plan your care. Learn about your health condition and how it may be treated. Discuss treatment options with your healthcare providers to decide what care you want to receive. You always have the right to refuse treatment. The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.

© Copyright IBM Corporation 2019 Information is for End User’s use only and may not be sold, redistributed or otherwise used for commercial purposes. All illustrations and images included in CareNotes® are the copyrighted property of A.D.A.M., Inc. or IBM Watson Health

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  • Intestinal Obstruction

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  • Bowel Obstruction
  • Ileus
  • Melanosis Coli

Small Intestine Atresia and Stenosis

Condition Description

The digestive tract is a very long, coiling tube that starts at the mouth and ends at the anus. The main parts of the digestive tract are the mouth, the esophagus, the stomach, the small intestine, the colon and the anus. The small intestine is responsible for most of the digestion and the absorption of the nutrients from the food that is eaten. The small intestine has three segments. The first segment, the duodenum, is connected to the stomach. The second segment is the jejunum and the final segment, the ileum, connects to the colon, also known as the large intestine.

Small intestine atresia (SIA) means that there is a complete blockage or interruption somewhere in the course of the small intestine. Small intestine stenosis (SIS) means that there is a narrowing of the passage within the small intestine. Both of these conditions either completely block or significantly impede the passage of food through the digestive tract. Either situation makes it very difficult or impossible to digest food, absorb nutrients and eliminate waste through the large intestine. An interruption, blockage or narrowing of the small intestine may occur anywhere along its length.

Most of the time, SIA is not believed to be familial. In the instances where a recurrence has been reported within a family, the pattern of inheritance suggests autosomal recessive inheritance.

Prevalence

Few studies have investigated the prevalence (how often the condition occurs) of small intestine atresia or stenosis. Of those that have, the prevalence of an atresia or stenosis has been reported to be from 1.3 to 2.9 per 10,000 live births. In the published medical literature, there is quite a bit of variation in the estimated prevalence rates. Recently, a large population-based study using information from several European birth defects registries estimated the prevalence of any type of SIA to be 1.6 per 10,000 live births; duodenal atresia at 0.9 per 10,000 live births; and jejuno-ileal atresia at 0.7 per 10,000 live births. Males and females are affected in equal numbers.

Common Associated Conditions

According to the large, European population-based study, 20.6% of any type of small intestine atresia or stenosis was associated with a chromosomal disorder. Of the individuals with SIA of any type who were single babies (not part of a twin, triplet or other multiple pregnancy), about a quarter (26.7%) had another major birth defect in addition to the SIA. Additional body systems that were observed to be affected included cardiac, craniofacial, digestive (in addition to the SIA), and urinary systems, and limbs.

Short-Term Treatment and Outcomes

In the short term, the first order of business involves surgery to open up or reconnect the small intestine so the digestive tract can process, absorb nutrients, and allow the passage of food. Following surgery, the digestive tract has to be allowed to heal and be slowly trained to process and move food along its passage. This process may take many days or even weeks. If other birth defects are present, these may need to be repaired at this time, also.

Long-term Treatment and Outcomes

Long-term treatment and outcome depend on several factors. In some cases, the small intestine is greatly shortened and this is likely to result in a digestive tract that doesn’t work well to digest and absorb nutrients. This is called short bowel syndrome and it may make recovery more complicated and make recovery take longer. Recently, a surgical procedure called serial transverse enteroplasty (STEP) procedure has been developed that works to lengthen the short intestine.

In the case of SIA in a baby with a chromosomal or other genetic condition, other issues may be present and, based on what other problems are either known or suspected, an individualized treatment plan will need to be developed and carried out. If another body system is involved, there may or may not need to be interventions to repair this body system at or close to the same time that the small intestine is repaired.

Common Complications

Complications can occur after surgery as the intestine and incisions heal. If a fever develops that is higher than 101 Fahrenheit or if the incision begins to look red and swollen or infected, it may signal that an infection is developing. If vomiting continues or the baby is not starting to eat normally, this needs to be evaluated by the baby’s care team. Lastly, if it seems as if the baby is not urinating as much or as often as usual, it may be that he is not absorbing enough water and is becoming dehydrated. This will be evident if she is not wetting her diapers as often as usual.

Potential Effects on Children’s Development

If the SIA is an isolated finding (there are no other medical issues and it is not a feature of a syndrome or more complex condition) it is very possible that the baby’s development will not be greatly impacted. There is a likelihood that developmental delay or intellectual disability could be a part of a spectrum of features (e.g. a syndrome). If there is reason to suspect that the baby has a chromosomal or genetic condition or other body systems are affected, then development may also be affected. In any case, following up with care providers and screening the baby for developmental milestones can often rule out these concerns. If there are developmental delays, identifying and characterizing them as early as possible may help to guide interventions that will help assure the best outcomes possible.

Condition Specific Organizations

  • Duodenal Atresia or Stenosis
  • Jejunal Atresia
  • What is intestinal atresia?
  • Intestinal atresia and stenosis in Children.
  • About Small Bowel Atresia
  • Association of Gastrointestinal Motility Disorders, Inc.

Additional information and resources for families are available.

PMC

Results

There were 14 males and 6 females in this study with an average age of 32 years (range 16 to 60 years). There was a delay of 1 year, on an average, in seeking a gastroenterologist’s advice (range 2 to 30 months).

Table 1 shows mode of presentation and clinical features in these cases. Eleven (55%) patients presented with history suggestive of subacute intestinal obstruction. Diarrhoea was the mode of presentation in 7 (35%). Two patients did not have any bowel symptoms at the onset. These 2 patients presented with respiratory symptoms and were being treated for pulmonary tuberculosis. Weight loss, hepatomegaly and signs of nutritional deficiencies were the common clinical features. Abdominal lumps and respiratory findings were not common.

TABLE 1

Mode of presentation and clinical profile of benign colonic strictures (n=20)

Parameters No Percentage
Mode of presentation
  Subacute intestinal obstruction 11 55
  Diarrhoea 7 35
    Small bowel 4
    Large bowel 3
  Respiratory symptoms 2 10
Clinical Profile
  Weight loss > 2 kg 20 100
  Pallor 12 60
  Glossitis 6 30
  Oedema feet 4 20
  Hepatomegaly 14 70
  Lump right iliac fossa 5 25
  Respiratory findings 4 20
  Perianal abscess 2 10
  Perianal fistulae 1 5
  Polyarthritis 2 10
  Pyoderma gangrenosum 1 5

Table 2 gives barium enema findings. It was performed in 18 patients. In 1 patient stricture was detected on barium meal follow-through examination and subsequently confirmed by colonoscopy. In another patient the stricture was detected during surgery for acute intestinal obstruction. The latter patient had miliary tuberculosis and was being treated with anti-tubercular drugs. In 3 patients barium enema gave impression of malignancy. However on biopsy the lesions were found to be benign. Two patients had 2 strictures each. Associated features of ulcerative colitis were seen in 3 cases. In 2 patients strictures were smooth without any associated findings. Thirteen showed associated features of nodularity and ulceration. Long strictures were seen in 7 patients. The longest stricture involved the entire ascending colon till the mid-transverse colon.

TABLE 2

Barium enema findings in 18 cases of benign colonic strictures

Features No Percentage
Single stricture 13 72.2
Associated pan-colitis 3 16.6
Associated nodularity and ulcerations 14 77.7
Long stricture 8 44.4
Site of stricture
Descending colon 4 20.0
Transverse colon 7 35.0
Ascending colon 6 30.0
Sigmoid colon 1 5.0
Rectum and rectosigmoid 1 5.0
Ascending colon upto mid transverse colon 1 5.0

Barium meal follow-through examination was done in 7 subjects. Associated small gut involvement (of the ileum mainly) was seen in 5 cases. In most patients barium enema preceded barium meal examination. However, in 2 cases barium meal follow-through was the first investigation to demonstrate colonic stricture. Chest radiography was done in all patients. In 14 it was normal. Miliary tuberculosis was seen in 1 patient. In 2 cases there were healed tubercular lesions and in 3 patients active lesions were seen. Mantoux test was done in 8 patients. It was positive (more than 10 mm induration) in 5 who were subsequently diagnosed as having tubercular strictures.

Colonoscopy was performed in 13 patients. It could not be performed in the others due to various reasons – 3 patients underwent emergency laparotomy for acute intestinal obstruction, 2 had associated pulmonary tuberculosis thus making the diagnosis obvious. One patient had severe rectal involvement and 1 patient was unwilling for colonoscopy. In the patient with severe rectal involvement the biopsy was taken through a sigmoidoscope. In all patients who underwent colonoscopy multiple biopsies were taken from the lesions. Nine cases showed ulceration, hyperaemia and nodularity at the site of stricture. Three patients showed features of ulcerative colitis. In 1 case stricture was the only finding without any associated lesion.

Table 3 shows histopathological findings of biopsy specimen. Ulcerative colitis was readily diagnosed on histopathological examination. Specific findings of tuberculosis i.e., caseating granulomas with AFB was seen only in 1 case. One patient showed typical findings of ischaemic colitis. In 4 patients demonstration of caseating granulomas without AFB was taken as evidence of tubercular infection. A diagnostic dilemma occurred in as many as 10 patients in whom non-caseating granulomas and non-specific inflammatory cells were found.

TABLE 3

Histopathological findings in 20 patients with benign colonic strictures

Nature of specimen Findings No
Colonoscopic biopsy (n=13) Ulcerative colitis 3
Caseating granuloma
  with AFB 1
  without AFB 2
Non-caseating granuloma 2
Infiltration with chronic inflammatory cells 4
Normal 1
Sigmoidoscopic biopsy (n=1) Non-caseating granuloma 1
Surgical biopsy (n=7)* Caseating granuloma 2
Non-caseating granuloma 2
Ischaemic colitis 1
Non-specific inflammation I
Biopsy not taken 1

*includes one patient who already had undergone colonoscopic biopsy.

Table 4 gives final aetiological diagnosis in 20 cases of benign colonic strictures. Definitive diagnosis based on histopathology could be made in 9 (45%) cases. In the others the final diagnosis was arrived at by considering clinical profile, chest radiographic findings, Mantoux test, barium meal follow-through, as well as response to therapy and long-term follow-up. Overall, tuberculosis was by far the commonest cause detected in 13 (65%) patients. In 2 cases no aetiological cause could be established even on detailed investigations. Diagnosis of Crohn’s disease was made on demonstration of caseating granulomas on biopsy, perianal fistulae, skip lesions and failure to respond to anti-tubercular therapy over a long period. None of our patients had colonoscopic or histopathological findings of solitary ulcer of the colon and rectum.

TABLE 4

Aetiological diagnosis in 20 cases of benign colonic strictures

Diagnosis No Percentage
Tuberculosis 13 65
Ulcerative colitis 3 15
Ischaemic colitis 1 5
Crohn’s disease 1 5
No cause established 2 10

As far as treatment was concerned, 2 of 3 patients of ulcerative colitis responded to specific therapy with sulphasalazine and steroids. The third patient did not respond and was advised surgical treatment which he refused and was lost to follow-up. The patient with Crohn’s disease was given 2 years therapy for tuberculosis. In fact all patients were initially started on antitubercular therapy. The therapy was modified subsequently based on change in diagnosis.

Seven (35%) patients required surgical intervention. Emergency surgery was required for acute intestinal obstruction in 2 and ileal perforation in one. Resection and anastomosis was the procedure of choice performed in 5 patients. Closure of perforation was done in 1 patient. The patient with ischaemic colitis had 2 strictures. Stricturoplasty was done for both the strictures. Biopsies were taken from all patients except from the patient with ileal perforation.

Neil Barker, Peterborough

I was diagnosed with stage two bowel cancer in July 2003 when I was 41 years old. There is no such thing as ‘never too young’ with bowel cancer.

I already had crohn’s disease which was diagnosed in 1993. The symptoms are very similar to bowel cancer, and over the years experienced flare ups with blood in poo, weight loss, extreme fatigue and blockages that cause extreme discomfort.

I just thought it was the IBD getting worse. I mentioned this when attending a routine appointment with my Gastroentrology team at my local hospital who said I was due a colonoscopy. I knew there was an increased risk of me being diagnosed with bowel cancer due to crohn’s, but the hospital was monitoring me so I felt in good hands. The colonoscopy revealed a colon stricture which the camera couldn’t get past and a subsequent CT scan showed a tumour.

I was diagnosed with bowel cancer and had surgery to have my colon, rectum and anus removed, which has left me with a permanent ileostomy. I then had six months of chemo punctuated by having a brain tumour identified and successfully removed, luckily this was not connected to bowel cancer.

It might sound strange, but I actually felt much better after my bowel cancer diagnosis. Whilst crohn’s is incurable, since my operation to remove my bowel and rectum, my symptoms were less severe. I guess every cloud and all that!

But then in 2010 bowel cancer struck my family again. My father was diagnosed with the disease and died a month later. He was 74 and had very few symptoms.

So when in 2016 I heard about Lynch syndrome from my sister in the States, I immediately mentioned this to my GP who thought it worth looking into given my family history. An appointment was arranged with the genetics team at Addenbrookes. They took my family history and tested a sample from my tumour. A few months later the test results came back negative. It was a huge relief.

Strictureplasty

Chronic inflammation in the intestines can cause the walls of your digestive tract to thicken or form scar tissue. This can narrow a section of intestine, called a stricture, which may lead to an intestinal blockage. A strictureplasty is a surgical procedure to repair a stricture by widening the narrowed area without removing any portion of your intestine.

It is important to repair strictures because the narrowing of your intestine could lead to a blockage that prevents stool from passing through the body. When strictures are caused by disease inflammation, initial treatment may typically include medication to help improve the narrowing of the intestines. Surgery may also be a necessary option. Strictureplasty and small bowel resection are two surgical procedures to repair a stricture.

Symptoms of a stricture

  • Nausea

  • Vomiting

  • Severe cramping

  • Constipation

What You Should Know About Strictureplasty

Any surgery is concerning, but learning about the procedure can lessen your concerns and give you information to discuss with your healthcare team.

  • Strictureplasty is a generally safe procedure. It is most effective in the lower sections of the small intestine, called the ileum and the jejunum.

  • Strictureplasty is less effective in the upper section of the small intestine, called the duodenum.

  • Strictureplasty avoids the need to remove a section of your small intestine. It is preferred when possible, because removing portions of your small intestine cause sometimes cause other complications, including a condition called short bowel syndrome (SBS) which occurs when large sections of the small intestine are removed due to surgery (or various surgeries) and the body is unable to absorb adequate amounts of nutrients and water.

During the procedure

  • Your surgeon will make cuts lengthwise along the narrowed areas of your intestine, then sew up the intestine crosswise.

  • This type of incision and repair shortens and widens the affected part of your bowel, allowing food to pass through.

  • Your surgeon may repair several strictures during the same surgery.

Ask Your Doctor

  • How is the stricture diagnosed?

  • What preparations will I need to make before my strictureplasty?

  • What are the potential complications from surgery?

  • What kind of restrictions will I have after my surgery?

  • How long will it take me to recover from my strictureplasty?

  • How will the surgery affect my diet and bowel movements?

Understanding what causes strictures

Identifying the key processes that cause scarring in the gut.

2014

Our research is currently focused on the therapeutic potential of altering the genetic signalling pathway to prevent fibrosis in Crohn’s disease

What the research is looking at:

Gut inflammation in Crohn’s Disease can result in the development of scar tissue – this is called fibrosis. Fibrosis involves a type of cell called a fibroplast multiplying and producing a protein called collagen. This collagen builds up to form strictures (narrowings) in the small intestine. Blockages caused by these strictures are a very common reason for surgery in Crohn’s Disease.

As yet, there is no medical therapy available to reverse fibrosis. However, researchers have already identified a particular chain of molecules called MicroRNAs (miRNAs) that may be linked with fibrosis. It is thought that these particular miRNAs may have an impact on a genetic pathway within the cell called ‘Wnt’. A genetic pathway is the chain of processes leading from a gene to creation of proteins or other molecules. It is already known that activation of the Wnt pathway is a common feature in a number of other diseases, including cancer and fibrosis of other organs. The researchers want to find out the role of this pathway in Crohn’s Disease, and whether modulating (altering) it may be a way of preventing or delaying fibrosis in Crohn’s Disease

Conclusions: The researchers were able to confirm their hypotheses. Firstly, they were able to show that the miRNAs are increased during fibrosis. Secondly, they were able to show that blocking the Wnt pathway in cells from the intestine could prevent fibrosis. These results suggest that blocking the miRNAs and the Wnt pathway (either alone or in combination) could be a novel treatment approach for reducing strictures in Crohn’s Disease.

What do researchers think this could this mean for people with IBD?

If researchers are able to identify the chain of genetic and molecular processes that lead to fibrosis, then particular treatments and drug combinations could be used to inhibit those processes. This could reduce the formation of strictures and the associated need for surgery in patients with Crohn’s Disease.

Who’s leading the research: Prof Andrew Silver, Dr James Lindsay, Barts and the London School of Medicine

Our funding: £73,134 over 12 months

Official title of the application: “Inhibition of Wnt signalling using small molecule inhibitors and C14MC antagomiRs as a novel combination therapy for fibrostenosing disease in Crohn’s disease.”

Tags: Genetics / Strictures

Experience with Balloon Dilatation in Crohn’s and Non-Crohn’s Benign Small-Bowel Strictures: Is There a Difference?

Abstract

Background/Aim. Endoscopic balloon dilation (EBD) has been effective for small-bowel strictures in patients with Crohn’s disease (CD). However, its efficacy and indication for small-bowel strictures in non-CD patients have not been established. This study evaluated the clinical efficacy and safety of EBD for small-bowel strictures in non-CD patients compared with CD patients. Methods. Ninety-eight consecutive patients (mean age, 53 years; average observation period, 45 months) with small-bowel strictures diagnosed by double-balloon endoscopy were retrospectively evaluated at Hiroshima University Hospital from August 2003 to April 2017. The average number of procedures, short-term and long-term EBD success rates, and safety profiles between the non-CD and CD groups were examined. Results. Surgery was selected as the initial treatment in 44 cases (45%) (non-CD group, 27 (61%); CD group, 17 (39%)) as EBD is not indicated. Fourteen non-CD patients had strictures due to malignant tumors, while 13 patients had benign strictures. Twenty-three patients (non-CD, 12; CD, 11) underwent EBD. Forty-three EBD procedures were performed for 17 stricture sites (average: 2.5 procedures/site) in non-CD patients and 41 EBD procedures for 18 stricture sites (average: 2.3 procedures/site) in CD patients. The short-term success rate was 100% (23/23), whereas the long-term success rate was 92% (11/12) in non-CD patients and 82% (9/11) in CD patients. No significant differences in the surgery-free rate occurred between both groups. Furthermore, one adverse event, bleeding after EBD, was encountered in the non-CD group (8%, 1/12). Conclusion. EBD for small-bowel strictures demonstrated good clinical outcomes in non-CD patients.

1. Introduction

Recently, small-bowel diseases such as ulcerations, angiodysplasias, tumors, and strictures can be diagnosed by balloon endoscopy and capsule endoscopy (CE). Particularly, double-balloon endoscopy (DBE) and single-balloon endoscopy have been widely used for the diagnosis and endoscopic treatment of small-bowel diseases. In 2001, Yamamoto et al. first described DBE as a new method to visualize the entire small-bowel. Besides direct observation, DBE allows for histological diagnosis by forceps biopsy and interventional treatment including hemostasis, polypectomy, endoscopic mucosal resection, and balloon dilation. Therefore, DBE has become a key modality for evaluating small-bowel diseases, with a greater diagnostic yield than conventional modalities such as fluoroscopic enteroclysis. Recently, there have been several reports regarding the diagnostic and therapeutic roles of DBE .

Small-bowel strictures are often caused by chronic inflammatory diseases such as Crohn’s disease (CD). In CD patients, the risk of surgery 10 years after a diagnosis of intestinal stricture was 38–55% in a population-based cohort study . Moreover, recurrent strictures often develop after surgical resection. The rate of reoperation was 31.4% and 61.2% in patients who underwent initial surgery within 5 and 10 years, respectively . CD patients with repeated small-bowel surgical resections for strictures are at risk of developing short bowel syndrome. Therefore, an alternative therapeutic approach has been applied to avoid the need for small-bowel resection.

Endoscopic balloon dilation (EBD) has recently been effective in treating small-bowel strictures caused by CD . However, only few reports have evaluated the long-term outcomes of EBD using DBE for small-bowel strictures due to CD .

The causes of small-bowel strictures in non-CD patients are diverse, including neoplasms, nonsteroidal anti-inflammatory drug- (NSAID-) induced ulcerations, intestinal tuberculosis, enteritis, and postsurgical strictures. Although the utility of EBD in CD has been reported, there are few reports on the efficacy and safety of EBD for small-bowel strictures caused by non-CD conditions, such as strictures caused by NSAID-induced ulcerations . Currently, the diagnostic and therapeutic strategies for small-bowel strictures in non-CD conditions have not been standardized.

This study thus is aimed at evaluating the efficacy and safety of EBD for small-bowel strictures in non-CD patients compared with CD patients.

2. Material and Methods

2.1. Patients

We retrospectively examined 98 consecutive patients (mean age, 53 years; average observation period, 45 months) with small-bowel strictures, who were among 1,318 patients who underwent DBE from August 2003 to April 2017 at Hiroshima University Hospital. Regardless of the presence of abdominal symptoms from gastrointestinal obstruction, a small-bowel stricture was defined as a lesion wherein an endoscope could not pass through. We excluded the cases that we could not observe for more than 1 year in this study. We performed EBD for small-bowel strictures in 23 patients (non-CD group, 12 patients; CD group, 11 patients). Hence, a total of 23 patients were evaluated in this study.

This study was conducted in accordance with the Declaration of Helsinki and was approved by the Institutional Review Board of the Hiroshima University Hospital (approval number: E-1142, Institutional Review Board registration date: March 23, 2018). All patients were informed of the risks and benefits of EBD and provided written informed consent prior to the procedure. None of the patients refused to undergo EBD for small-bowel strictures during the study period.

2.2. Methods

The indications for EBD were as follows: (1) small-bowel strictures causing obstructive symptoms or proximal extension from the stricture site as shown by diagnostic imaging (fluoroscopic examination or computed tomography), (2) benign strictures wherein an endoscope could not pass through, (3) stricture , and (4) strictures without a fistula, abscess, deep ulceration, severe adhesion, or curvature .

Our management for small-bowel strictures was as follows. In cases of small-bowel stricture due to malignant tumor, we selected surgical resection or bypass considered by general condition. In cases of benign small-bowel stricture, we selected EBD as the first choice when the above adaptation was satisfied. We selected surgery if patients did not satisfy the EBD indication. In asymptomatic cases of benign small-bowel strictures, we selected medical treatment or follow-up.

The patients underwent overnight fasting in preparation for EBD. In principle, we selected the antegrade approach for the procedure. EBD was carried out using a DBE (EN-450 T5, EN-580 T5; Fujifilm Medical Co., Tokyo, Japan) and an 8–18 mm through-the-scope (TTS) balloon catheter (CRE™; Boston Scientific Co., Natick, MA, USA) measuring 7.5 Fr and 5.5 cm in length. The size of the balloon was determined according to the size of the stricture site. The balloon was positioned across the stricture and filled with diluted Gastrografin and was inflated to a pressure of 1–8 atm for 30 s. Dilation was performed by monitoring the pressure of the inflated balloon using a dilator under X-ray guidance. The maximum dilation diameter and balloon pressure were confirmed by fluoroscopy and determined at the discretion of the operating endoscopists. After dilation, we performed a small-bowel follow-through using Gastrografin to confirm leakage outside the intestinal tract (Figure 1).

(a)
(b)
(c)
(d)
(e)
(f)
(a)
(b)
(c)
(d)
(e)
(f) Figure 1 The endoscopic balloon dilation procedure. (a) Endoscopic imaging of a stricture due to scar after chemotherapy for malignant lymphoma. (b) Balloon dilation. (c) After dilation. (d) Endoscopic imaging of stricture after 5 times of dilation. (e) Contrast study of the stricture during dilation. (f) Contrast study of the stricture after dilation.

We evaluated the average number of procedures, short-term and long-term EBD success rates, and safety profiles between the non-CD and CD groups. Complications were defined as perforation and active bleeding requiring surgery or blood transfusion after EBD. Short-term EBD success was defined as the disappearance of abdominal symptoms due to gastrointestinal obstruction and long-term EBD success as having no surgery for >1 year. Oral-side intestinal extension was defined as existence of a clear stricture of the small-bowel toward the oral side by computed tomography or transabdominal ultrasonographic examination. Meanwhile, endpoint of EBD was defined as successfully passing the endoscope through the stricture site. In our hospital, EBD was performed repeatedly when an endoscope could not pass through the stricture site. Redilation was performed when abdominal symptoms recur due to gastrointestinal obstruction.

2.3. Statistical Analyses

The chi-squared test or Fisher’s exact test was used for comparison of frequencies. The Kaplan-Meier method and log-rank test were used for analyzing the cumulative surgery-free rate. A value of <0.05 was regarded as statistically significant. The software program JMP Pro 13 (SAS, Cary, NC, USA) was used for the statistical analyses.

3. Results

3.1. Cohort Details

Figure 2 shows the details of initial treatment in this study. We selected surgery as the initial treatment in 44 cases (non-CD group, 27 cases; CD group, 17 cases) and performed EBD as the initial treatment in 23 cases (non-CD group, 12 cases; CD group, 11 cases). Table 1 shows the clinical characteristics of all cases. Non-CD patients were significantly older than CD patients. The CD group had a higher proportion of males. Moreover, the CD group had a significantly higher proportion of multiple strictures. Although the CD group tended to have more stricture sites, there was no significant difference between both groups. The CD group had a significantly higher number of stricture sites located in the distal small-bowel, while the non-CD group had significantly more sites in the proximal small-bowel. In the cases of medical treatment in the non-CD group, their etiologies were intestinal tuberculosis. No case required additional surgery among the follow-up cases. The primary diseases of all cases and all surgery cases in the non-CD group are shown in Tables 2 and 3, respectively. The non-CD surgery cases included 14 cases of small-bowel strictures due to malignant tumors. Among them, 11 cases were malignant strictures due to primary small-bowel cancer.

Figure 2 Initial treatment for small-bowel strictures. Surgery was selected as the initial treatment in 27 cases of the non-CD group (47%) and 17 cases of the CD group (41%). In total, surgery was selected as the initial treatment in 44 cases (45%). In the surgery cases of the non-CD group, 14 patients (52%) had strictures due to malignant tumor. EBD was performed in 23 cases (23%) overall as the initial treatment. Twelve cases (21%) and 11 cases (27%) had EBD performed as the initial treatment in the non-CD and CD groups, respectively EBD: endoscopic balloon dilation. Table 1 Clinical characteristics of all cases.

Primary disease Non-CD group, (%)
Malignant stenosis 16 (28)
 Primary small-bowel cancer 12 (21)
 Peritoneal dissemination from other organs 1 (2)
 ML 2 (4)
 Gastrointestinal stromal tumor 1 (2)
Benign stenosis 41 (72)
 Intestinal tuberculosis 13 (23)
 Ischemic enteritis 7 (12)
 Ulceration of unknown origin 7 (12)
 Radiation enteritis 3 (5)
 NSAID-induced ulceration 3 (5)
 Adhesion ileus 3 (5)
 Scars after chemotherapy for ML 2 (4)
 Others 3 (5)
NSAID: nonsteroidal anti-inflammatory drug; ML: malignant lymphoma.

Table 2 Primary diseases of the small-bowel strictures in the non-Crohn’s disease group.

Primary disease Non-CD group, (%)
Malignant stenosis 14 (52)
 Primary small-bowel cancer 11 (41)
 Peritoneal dissemination from other organs 1 (4)
 Malignant lymphoma 1 (4)
 Gastrointestinal stromal tumor 1 (4)
Benign stenosis 13 (48)
 Ischemic enteritis 4 (15)
 Radiation enteritis 3 (11)
 Adhesion ileus 3 (11)
 Intestinal tuberculosis 1 (4)
 Anastomotic ulceration 1 (4)
 CEAS 1 (4)
CEAS: Chronic enteropathy associated with SLCO2A1.

Table 3 Primary diseases of surgery cases in the non-Crohn’s disease group.

3.2. Technical Details

We performed EBD for 12 cases of small-bowel strictures in the non-CD group. The primary diseases of these EBD cases are shown in Table 4. These EBD cases included three cases of intestinal tuberculosis, three cases of NSAID-induced ulceration, two cases of a complete response after chemotherapy for malignant lymphoma, two cases of ischemic enteritis, and two other cases. In the CD group, one patient underwent EBD after surgery due to recurrence of stricture. We performed EBD for a total of 11 cases of small-bowel strictures in the CD group.

Table 4 Primary diseases of cases that underwent endoscopic balloon dilation (EBD) in the non-Crohn’s disease group.

3.3. Outcomes and Complications

All EBD procedures were performed successfully in both CD and non-CD groups. All 23 patients had confirmed disappearance of abdominal symptoms after EBD. Thus, the short-term success rate was 100% in both groups. Five patients underwent surgery during the observation period: two patients in the non-CD group (17%, 2/12) and three patients in the CD group (27%, 3/11). In the additional surgery cases in the non-CD group, the etiologies of small-bowel strictures were intestinal tuberculosis and circumferential small-bowel ulceration due to intraperitoneal band. The cases received repeated EBD, but their symptoms did not improve. Therefore, we selected surgery. The reasons for surgery were as follows: recurrent abdominal symptoms resistant to medical treatment or EBD (non-CD group, two cases; CD group, one case) and remaining strictures that could not be approached by DBE (CD group, two cases). Two patients (1 from each group) underwent surgery >1 year after initial EBD. The long-term success rate was 92% (11/12) and 82% (9/11) in the non-CD and CD groups, respectively. As shown in Figure 3, no significant differences in the surgery-free rate occurred between both groups.

Figure 3 The cumulative surgery-free rate. The cumulative surgery-free rate of EBD cases after 1 year and 2 years from the initial EBD in the non-CD and CD groups was 92% (11/12) and 83% (10/12) and 82% (9/11) and 73% (8/11), respectively. There were no significant differences in the surgical-free rate between the non-CD and CD groups.

Bleeding occurred in only one case in the non-CD group (8%) after EBD for stenosis, due to scar after ML chemotherapy. In this case, EBD was performed repeatedly because of recurrent symptoms of abdominal obstruction. After four EBD procedures, the patient had a melena and progression of anemia. Although the patient required blood transfusion, the bleeding was stopped by conservative treatment including fasting and infusion of hemostatic drugs. No complications were found in the CD group.

Table 5 shows a comparison of clinical outcomes of EBD between both groups. In summary, the average number of times that EBD was performed was 2.5 (43 EBD procedures for 17 stricture sites) in the non-CD group and 2.3 (41 EBD procedures for 18 stricture sites) in the CD group. There were no significant differences in the number of procedures, short-term success rate, long-term success rate, surgery avoidance rate in the observation period, and complications between both groups.

Table 5 Outcomes of endoscopic balloon dilation between the non-Crohn’s disease (CD) group and CD groups.

4. Discussion

This study investigated the therapeutic management of small-bowel strictures with EBD in both non-CD and CD patients. With the development of the endoscope, we can easily observe the small-bowel using DBE. DBE can be used for histological diagnosis by forceps biopsy and for endoscopic treatment of small-bowel disease . In clinical practice, the etiology of a small-bowel stricture can be diagnosed by enteroscopy and histology. Moreover, surgery should be the curative or palliative treatment for malignant stricture. Based on our findings, EBD showed good clinical outcomes for small-bowel strictures in the non-CD group regardless of etiology; thus, EBD may be considered for benign strictures in a non-CD patient regardless of etiology.

Recently, a few cohort studies reported that EBD can be an alternative treatment to surgery for small-bowel strictures in CD . Hirai et al. performed the largest cohort study on short-term and long-term clinical outcomes of EBD for small-bowel strictures in CD. They reported a short-term success rate of 80% and a cumulative surgery-free rate of 79% at 2 years and 73% at 3 years. EBD using DBE was unsuccessful in 13 of 65 cases (20%): the endoscope could not be inserted up to the stricture site in 8 cases and the guidewire or balloon could not be maintained at the correct position of the stricture in 5 cases. They also reported that successful EBD cases showed significantly higher surgery-free rates than unsuccessful cases using the Kaplan-Meier method. In a systematic review of 13 published articles, Baars et al. reported on the efficacy and safety of EBD for small-bowel strictures in both CD and non-CD cases. In their study, the average follow-up time was 31.8 months per patient and the complication rate was 4.8% per patient. During the follow-up period, EBD (defined as nonsurgical treatment) was performed in 80% of patients. Meanwhile, in our study, we revealed the efficacy and safety of EBD for benign small-bowel strictures in non-CD patients.

To our knowledge, there are only few cohort studies or case reports on the efficacy and safety of EBD for strictures in non-CD patients . Furthermore, the clinical outcome of small-bowel strictures in non-CD patients based on long-term observation remains unclear. We considered that the first treatment of choice for malignant stenosis is surgery, including resection or bypass for palliative treatment. Indeed, we selected surgical treatment for malignant small-bowel strictures at 88% (14/16). The remaining two cases were unable to endure an operation because of poor general conditions. Recently, endoscopic metallic stent placement has been performed as palliative treatment for malignant stenosis . For benign strictures, however, the treatment has not been standardized and there is currently no consensus on whether surgical or medical treatment is more appropriate. This could be attributed to the diverse etiology of small-bowel strictures, including NSAID-induced ulceration, intestinal tuberculosis, ischemic enteritis, and idiopathic causes.

A few cases of EBD for small-bowel strictures due to NSAID-induced ulceration, one of the representative conditions causing gastrointestinal strictures in non-CD patients, have been reported . Small-bowel injury due to NSAIDs was reported as “diaphragm disease” . Diaphragm disease is characterized by a pinhole lumen of 2–3 mm in diameter and a thin diaphragm. The risk of perforation with EBD for diaphragm disease could be low . Intestinal tuberculosis may occur with gastrointestinal obstruction. The gastrointestinal obstruction may also be exacerbated during antituberculosis treatment due to healing by cicatrization . It was reported that about 20–40% of patients with abdominal tuberculosis presented with an acute abdomen and required surgical management . The experience of EBD in patients with ileal tuberculosis is limited to a few case reports . Ischemic enteritis can result in complete healing, chronic enteritis, or stricture . In patients with strictures due to ischemic enteritis, there was only one case series by Nishimura et al. . Moreover, the mean length of the stenosis tends to be longer than that seen in cases of CD . Hayashi et al. performed EBD in seven cases due to ischemic enteritis, and three cases eventually underwent surgery. Small-bowel ML may also result in gastrointestinal complications such as perforation, bleeding, and ileus. The frequency of perforation, bleeding, and ileus is 7–17% , 4–38% , and 6–18% , respectively. ML is known to develop not only before treatment but also after the treatment. While stricture formation might be considered a predictable complication of primary small-bowel ML, it has not been identified in the previous studies . There were some case reports on EBD for small-bowel strictures occurring after or during chemotherapy for primary small-bowel ML . Cho et al. reported a case of perforation after EBD for an intestinal stricture due to ML.

Our study revealed that the observation period was significantly longer in the CD group. CD patients are required long-term follow-up because of repetition of relapse and remission. On the other hand, it is rare to repeat relapse by eliminating the causes in non-CD cases of benign small-bowel strictures, such as NSAID-induced ulceration. There are many benign strictures, and their clinical backgrounds seem to have difference in the observation period in this study.

This study has some limitations. First, it is a single-center retrospective study. The retrospective design could have resulted in recruitment bias. Second, the number of participants was relatively small. Hence, further large prospective cohort studies will help evaluate the key predictors of long-term EBD success. Third, small-bowel strictures were caused by several etiologies. Although we examined various etiologies of small-bowel strictures in the non-CD group, the list remains limited. Lastly, the procedures were not performed according to a defined study protocol. Balloon diameter, interval between dilations, length of follow-up, or technical approach may vary even between patients analyzed in the same study. Therefore, large cohort studies that evaluate the long-term results of EBD according to each etiology and follow a defined endoscopic approach are necessary.

5. Conclusions

EBD is a safe and effective treatment for small-bowel strictures in both non-CD and CD patients. In cases of benign small-bowel strictures, EBD was an effective treatment regardless of the etiology. However, it is necessary to prospectively observe a larger number of patients for a longer period to confirm these results more precisely.

Data Availability

The data used to support the findings of this study are available from the corresponding author on reasonable request.

Disclosure

The research was presented as an abstract at the American national conference “DDW” in June 2018.

Conflicts of Interest

The authors have no conflict of interests to declare.

Acknowledgments

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The study was supported by departmental resources only.

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