Detection and Treatment of Stricturing Crohn's Disease

Dr Rieder reviews his talk on the detection and treatment of stricturing Crohn's disease, including medical therapy, endoscopy, and surgery, which he presented at the Advances in Inflammatory Bowel Diseases regional meeting.

Florian Rieder, MD, is vice chair and cosection director for inflammatory bowel diseases in the Division of Gastroenterology, Hepatology, and Nutrition at Cleveland Clinic in Cleveland, Ohio.

TRANSCRIPT:

Welcome to this recap from the AIBD Regionals. My name is Florian Rieder. I'm the vice chair and cosection director for inflammatory bowel diseases at the section of Gastroenterology, Hepatology, and Nutrition at the Cleveland Clinic. I'm going to talk today about stricturing Crohn's disease and the key highlights of my presentation at the AIBD Regionals.

I'm interested in this topic, because stricturing Crohn's disease is a significant clinical problem. It affects more than half of patients with Crohn's disease throughout their lifetime, and really, currently, there is no medical therapy as a long-term option. The current available therapies are mechanical balloon dilation and surgical resection. So one may wonder, is prevention the best antistricture therapy? To prevent strictures from occurring, you would need to have solid and accurate biomarkers that tell you early on if a patient will progress to stricturing Crohn's disease or not.

While we have a wealth of evidence in this space, including the risk, pediatric risk inception cohort, the tested microbial antibodies, genetic factors, and other gene expression profiles in mucosal biopsies, no marker exists that is accurate enough for clinical practice to stratify patients early on. So we're not good in predicting stricturing Crohn's disease specifically, but we are very good in detecting it in the current cross-sectional imaging techniques that we have at our disposal. Ultrasound, CT, and MR have a very high accuracy for detecting stenosis.

The other way to detect stenosis is by endoscopy, and luminal narrowing, impassable with a colonoscope, is a factor that found entry into the 2 validated scoring systems for endoscopy in Crohn's disease, the SES-CD and the CDEIS. What we are not good at is to distinguish the degree of fibrosis in a stricture from the degree of inflammation, which is important for decision making. Because if the inflammation portion is very high, we may treat with an anti-inflammatory, and if the fibrosis portion is high, we may send the patient for mechanical therapy. So conventional techniques, even MRI, have a large overlap between features that delineate fibrosis and features that delineate inflammation.

So how do we treat stricturing Crohn's disease in 2023? The decision to treat is to see, is this stenosis inflammatory, or has it a low inflammatory component? Does the patient have symptoms? Are there any associated conditions, such as phlegmon, penetrating disease, abscess, dysplasia, or malignancy, any contraindications for medical therapy, or any contraindications for endoscopic therapy? In medical therapy, in most instances, it's the first step to treat symptomatic stricturing disease, and corticosteroids are quite successful in this setting, even though the data supporting it is restricted to retrospective observational cohort studies.

Data on azathioprine that was compared in a randomized controlled fashion with mesalazine in patients with obstruction after initial supportive care and was found to be superior to mesalazine in patients with stricturing Crohn's disease. The biologics are now available in the CREOLE trial as well as the STRIDENT trial who tested anti-TNF in Crohn's disease. Patients with strictures have shown promising results in temporizing these patients from a perspective of reducing the symptom burden. There's no data yet on novel biologics or small molecules and this field is emerging. So watch out for publications at the Digestive Disease week in 2023. But we just completed a global consensus among stakeholders around the world to talk about medical therapy of stricturing disease, when we'll publish the results on how experts use anti-inflammatories in this scenario.

The second option is endoscopic therapy or endoscopic balloon dilation. And this is a very good short-term option. In 90% of the cases when you attempt to dilate, you're able to dilate; clinical efficacy is 80%, which shows symptom improvement, which indicates symptom improvement in 80% of the patients and less than 3% of the patients have complications, which includes bleeding, perforation, or need for hospitalization. Looking at long-term results after 1 year, about half of the patients need redilation and about 30% of the patients and need surgical intervention. Stent placement has been evaluated but has been widely abandoned for reasons of complications such as stent migration and the use of stents in patients with stricturing Crohn's disease has been further discouraged by recent randomized controlled trial comparing endoscopic dilation with the balloon compared to intestinal stent placement where balloon dilation was in fact superior to intestinal stent placement.

Upper GI strictures can be dilated as well and ultimately the decision between endoscopic dilation or surgery depends on is this a short stenosis long interval to previous surgery or dilation on the intermittent obstructive symptoms. Then you favor endoscopic dilation. if the dilation is technically difficult, if there are long or multiple strictures, the presence of abscess, fistula, or phlegmon. In this case, you favor a strictureplasty or resection.

Colonic stricture is in a completely different category because of the higher risk for malignancy and risk factors for malignancy. In colon colonic strictures are disease duration, location proximal to the splenic flexure or symptomatic large bowel obstruction. So the threshold to resect these patients is lower compared to small bowel strictures.

Novel antifibrotic therapies are on the horizon and the work that we are doing with a global consortium called the Stenosis Therapy and Antifibrosis Research Consortium have devised Clinical Trial Protocol and a pathway collaboration with the FDA to develop novel antifibrotics. So stay tuned in this area. There's a lot of movement and we hope we will have several trials started in the year of 2023. So thank you very much for your attention. Thank you for listening to the recap of AIBD regionals on stricturing Crohn's disease, and I hope to see you next time. Thank you very much.