Kurdistan Board weekly Journal club: IBD endoscopic therapies.

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Kurdistan GEH Board Journal Club
Dr.Mohamed Al-Shekhani.

2. IBD:Complications
IBD-RELATED STRICTURES
IBD-RELATED FISTULA&sinuses
Abcesses
COLITIS-ASSOCIATED NEOPLASIA
Bezoars in ileal pouch reservoir
Surgical anastomotic strictures

3. IBD:Classifications
CD:
Montreal
classification
IBD:
UC:
Classification
Microscopic
colitis
Nonstricturing/nonpenetrating (B1)
Stricturing (B2)
Penetrating (B3)
Extensive colitis
Left-sided colitis
Proctitis
Stricture: cancer,muscularis mucosa
hyperplasia,inflamm submucosal fibrosis
Lympho Colitis
Collagenoius Colitis

7. IBD Strictures:
Management:
Inflam
strictures
Mechanical
Fibrotic
strictures
Endoscopic or surgery
Med if
inflamm
Anti– TNF, biologics, or steroids.
CD/UC strictures trt
Endoscopic
Surgery

8. IBD Strictures : Endoscopy or surgery
Endoscopy
TTS balloon
dilation
For strictures
at the surgical
anastomosis,
colon, or small
bowel no > 4-7
cm in length.
int resection
with
anastomosis
or
stricturoplasty
Surgery

9. IBD Strictures : Endoscopy or surgery
CHOICE Depends
on
Endoscopy
TTS balloon
dilation
Disease course
Characteristics of strictures,
Concurrent IBD-associated
adverse events ( abscesses),
Medical comorbidities
local expertise.
Surgery

10. IBD : Surgery complications
Surgery complications: recurrence
Leak
Abscesses
Septic:
Anastomotic
strictures:
At the surgical
anastomosis or
neoterminal
ileum
Fistulas
Between the ileal pouch
Body & anal transitional zone
after restorative
proctocolectomy for UC

11. IBD strictures: Diagnosis
Abd& pelvic imaging :
Recommended before diagnostic/therapeutic endoscopy to
provide the “ roadmap” (eg, location, number& length of
strictures).
Endoscopy:
Main advantage is the ability to obtain biopsies for histologic
assessment &deliver therapy at the time of the diagnosis.
Abd/pelvic imagings:
CTE,MRE,TAUS,SICUS,EUS,SI follow Though,GGE.

12. CTE:
Advantages/Disadvantages:
Noninvasive,
available, easy
to perform,
IV contrast
Excessive
ionizing
radiation.
Active CD: fat
stranding,
mucosal
hyperenhancem
ent, vasa recta
engorgement,
transmural infl
ammation,
lymphadenopath
y, abscess
or fitula.
Fibrostenotic
disease on
CTE defined
By presence
of narrowing
of the
intestinal
lumen without
active infl
ammation

13. MRE:
Advantages/Disadvantages:
A low intensity
on
T1 &T2
sequences is
characteristic of
chronic fibrotic
strictures,
A high intensity
on fatsuppressed T2
images
is a feature of
infl ammatory
edematous
strictures.
For assess of
small / large
bowel CD with
particular
utility
For
distinguishing
between fi
brostenotic&
active disease.

14. TAUS,SI CEU:
Advantages/Disadvantages:
used to detect
small bowel
strictures in CD
High
sensitivity/specif
icity
Operatordependent

15. Gastrograffin enema (GGE):
Advantages/Disadvantages:
Used for distal
colonic strictures
or fistulas, for ileal
pouch-anal
anastomosis (IPAA)
adverse events
including strictures&
anastomotic
leaks,for
abnormalities at the
neoterminal ileum in
patients
with stomas.
Useful in the
detection of the
number/length
of strictures&
their conditions.
Sens 100% in
diagnosing pouchanal anastomotic
strictures when an
anastomotic
diameter >8 mm is
used for Diagnosis.
Sens80%,spec 95%
for inlet/distal SI
strictures with a
spec 93% for outlet
strictures in patients
with IPAA.

16. IBD strictures:endoscopic trts&Complication
Endoscopic trts:
TTS BD
NK Endoscopic
stricturotomy
Perforation:
cliping,OTC,surgery
Bleeding: most
can be
controlled by
endoscopic
hemostasis
Stenting

17. Endoscopic balloon dilation therapy
TTS
TYPE
Indications
IBD-related benign small bowel, ileocolonic, or
colonic strictures.
symptomatic strictures <4 -5 cm without
associated fistulas abscesses, or malignancy.
facilitate completion of dysplasia surveillance in
non-traversable strictures.

21. Endoscopic stricturotomy
TYPE
Indications
Needle-knife
Ileocolonic
ileal pouch strictures.
More effective than TTS balloon dilation in
refractory IBD-related benign strictures,with
acceptable adverse events as bleeding and
perforation.

23. Endoscopic stent placement
TYPE
SEMS ? Bidegradable
Migration reduced by endoscopic suturing.
Migration prv

27. IBD complications:others
sinuses
Endotrts: NK, Stents,
Anastomotic
leaks
Bezoars in
ileal pouch
reservoir
Endo dilation of strictures &
removal of bezoars

28. CD-Fistulas: treatments
Med trts:
No good longterm results
1
Endoinj: fibrin
glue
4
2
Endoscopic
injections:
Doxycycline+ac
etylctstein
Endoinj: 50%
glucose or
honey
Endoinj: stem
cells
5
CD:Fistla treaTments
3

29. Colitis-associated neoplasia:
DALM: raised lesion
with associated
dysplasia
Polypectomy
Colonoscopy repeated
in 6/12
Adenomalike lesion
resembling
sporadic
adenoma
without
adjacent flat
dysplasia
COLITISASSOCIATED
NEOPLASIA.
Patients with multifocal flat lowgrade dysplasia, repetitive lowgrade dysplasia, or high-grade
dysplasia should be referred for total
colectomy.
Non–
adenomaColectomy
like lesion is May be removed by
typically an
EMR or ESD
ulcerated,
broadbased,
irregular
lesion.
diagnosis of all dysplasia needs to be confirmed by at least 2
expert GI pathologists.

31. Endoscopic procedures-associated adverse
events & management:
Perforation:
> In non-IBD Patients BZ of the
inflammation & immunne modulators use.
Complications:
Bleeding
Perforations
1
Perforation trts:
Endoscopic clip; usual or OTC, FC SEMS.
Endoscopic therapy in IBD patients should be
performed by specialized endoscopists, with
proper surgical backup.
Bleeding:
Managed by endoscopic clips.
2
ASGE guidelines: endoscopic dilation is with a
higher risk of bleeding, hold clopidogrel or
ticlopidine 7 -10 days before endoscopy
&warfarin before the procedure with bridging
therapy in patients at high risk of
thromboembolic events.

35. IBD complications: Endotherapies
 Endoscopic trts are important modalities in the trt of
IBD, adjunct to medical& surgical approaches.
 They are particularly useful in the management of IBDassociated or IBD surgery– associated strictures,
fistulas, &sinuses &colitis-associated neoplasia.
 The main focus is on balloon stricture dilation& ablation
of adenoma-like lesions
 New endoscopic approaches are emerging, include
needle-knife stricturotomy, needle-knife sinusotomy,
endoscopic stent placement& fistula tract injection.
 Risk management of endoscopy-associated adverse
events is also evolving.
 These novel treatments just beginning& will likely
expand rapidly in the near future.

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