Endoscopy in Crohn’s Disease

Peter Darwin, MD

Director of Gastrointestinal Endoscopy

University of Maryland Hospital

Division of Gastroenterology

Outline

• Case histories• Diagnosis• Assessment of response• Dysplasia and surveillance• Bleeding• Stricture management• Emerging technology

Case 1

• The patient is a 28 year old man with isolated iliocolonic Crohn’s disease resected 8 years prior.

• Was without symptoms but has developed intermittent abdominal distension, bloating and emesis requiring admission.

• SBFT shows a 1 cm tight anastamotic stenosis• Is attempt at endoscopic management appropriate?

Case 2

• 19 year old student presents with several months of vague epigastic discomfort, night sweats and weight loss.

• Evaluation shows a microcytic anemia and thrombocytosis.

• Abdominal CT shows a thickened mid-ileum without lymphadenopathy. Attempts to intubate the TI during colonoscopy were unsuccessful.

• Is tissue needed prior to treatment ?

Diagnosis

• Asymmetric patchy inflammation• Skip lesions• Rectal sparring• Ulcerations• Biopsy

– Erosions and normal mucosa– Granulomas in 15 to 35% of specimens

Assessment of Response

• Endoscopic monitoring may have a role with biologic agents

• Subgroup of the ACCENT-1 trial– Mucosal healing with infliximab, time to

relapse is significantly prolonged• 9 with endoscopic healing remained in remission for

a median of 20 weeks• 4 clinical remission only, relapse after a median of 4

weeks

Dysplasia and Surveillance

• Extensive colitis > 8 years• Accuracy in predicting dysplasia correlates

with # of biopsies• Annual colonoscopy with multiple biopsy

specimens– 4 circumferential each 10 cm

Approach to Polypoid LesionsAdenoma like DALM

Outside colitis Within colitis

Polypectomy/biopsy

Non-IBDadenoma

PolypectomyRegular surveillance

No dysplasiaNo carcinoma

Indeterminate Flat dysplasiacarcinoma

PolypectomyIncreased surveillance

Colectomy

Chawla A, Lichtenstein G. Gastrointest Endoscopy Clin N Am 12 (2002) 525-534

Hemorrhage in Crohn’s

• Acute major hemorrhage is uncommon• Bleeding can occur in any segment• Massive hemorrhage is usually from an

ulcer eroding into a vessel• Resuscitation• Endoscopy vs tagged RBC scan to localize

a bleeding segment• Avoid embolization if possible

Hemorrhage in Crohn’s

• No data to support cautery or injection therapy

• Surgical intervention• Consider tattooing of the site

• Database review from 1989 to 1996– 1739 patients / 31 (1.8%) due to IBD– 3 with UC and 28 with CD / 1 UGI source– None hematemesis– GI hemorrhage in 0.1% UC and 1.2% CD

• Diagnostic evaluation– Source found by colonoscopy in 25 patients (25%) and

EGD in 2 patients

Pardi D, Loftus E, et al. Gastrointest Endosc 1999;49:153-7.

Acute Major GI hemorrhage in IBD

Endoscopic Therapy for Patients with CD and Focal Sites of

hemorrhage

Patient Site Stigmata Endoscopic Rx Medical Rx

1 Duodenum clot Injection Corticosteroids ranitidine

2 Jejunum oozing ulcer Injection Corticosteroids ranitidine

3 Colon clot Injection with Corticosteroids coagulation metronidazole

Clinical Course

Balloon Dilation of Strictures

Descending Colon Stricture

Colonic Strictures

• No randomized clinical trials• Consider nonsurgical management if:

– Endoscopically accessible– Multiple prior resections– Shorter strictures (less than 5 cm)– Steroid injection if significant inflammation

Malignant Potential

• Increased incidence of colonic and small bowel carcinoma

• Higher risk with longer duration of disease• Stricture biopsy required• Utilize thin caliper scopes to evaluate

proximal to the stenosis

Balloon Dilation of Strictures

• High success rate for anastamotic strictures• Used for colonic and duodenal stenosis• TTS balloons 15 to 18 mm for 1 minute• Fluoroscopy only if needed• Successful if scope passed post• Medical treatment• Complications

Injection of Corticosteroids

• Post dilation• Sclerotherapy needle• Triamcinolone 40 mg/ml – 1 cc in 4

quadrants at site of maximal inflammation/stenosis

Intestinal Stents

• Limited data • Migration is common• Coated metal enteral stents / plastic stents

may be of benefit

Endoscopic Balloon Dilation of Ileal Pouch Strictures

• Aim: evaluate outpatient ileal pouch stricture dilation

• Methods: Nonfluroscopy, nonsedated dilation with 11-18 mm TTS balloons in 19 consecutive patients

Shen B, Fazio V, Remzi F, et al. Am J Gastro 2004;99:2340-47.

Inlet and Outlet Strictures

Clinical Presentation

n (%)

DiarrheaAbdominal painPerianal painBloatingNausea or vomitingBleedingDaily use of antidiarrheal agentsFistulasWeight loss

18 (94%)19 (100%)15 (79%)9 (47%)3 (16%)4 (21%)8 (42%)6 (32%)5 (26%)

Types of Strictures

Number Inlet Outletof cases strictures strictures

Crohn’s disease of the pouch

Cuffitis

Pouchitis

Total

11 14 6

5 0 5

3 0 3

19 14 14

Pouch Disease Activity Index

Strictures Scores

Cleveland Global Quality of Life Scores

Emerging Technology

• Double balloon enteroscopy• Endoscopic ultrasound• Optical coherence tomography• Magnification chromoendoscopy

Takayuki Matsumoto, Tomohiko Moriyama, et. al. Gastrointest Endosc 2005;62 :392-8

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Optical Coherence Tomography

•Based on low-coherence

interferometry•High resolution imaging•Uses light (not sound)•Resolution 10X greater than EUS•No acoustic coupling

Magnification Chromoendoscopy

• Utilizes magnifying endoscopes with tissue stains to better characterize the mucosa

• May improve efficacy of surveillance colonoscopy– 165 patients with UC randomized to

conventional screening vs CE. – Targeted biopsies– Identified more areas of dysplasia

Kiesslich R, Fritch J, et. al. Gastro 2002;124:880-8.

Colonic Pit Pattern

Huang Q, Norio F, et. al. Gastrointest Endosc 2004; 60:520-6.

Case 1

• The patient is a 28 year old man with isolated iliocolonic Crohn’s disease resected 8 years prior.

• Was without symptoms but has developed intermittent abdominal distension, bloating and emesis requiring admission.

• SBFT shows a 1 cm tight anastamotic stenosis• Is attempt at endoscopic management appropriate?

Case 2

• 19 year old student presents with several months of vague epigastic discomfort, night sweats and weight loss.

• Evaluation shows a microcytic anemia and thrombocytosis.

• Abdominal CT shows a thickened mid-ileum without lymphadenopathy. Attempts to intubate the TI during colonoscopy were unsuccessful.

• Is tissue needed prior to treatment ?