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Kurdistan GEH Board Journal Club

Dr.Mohamed Al-Shekhani.

IBD:Complications

IBD-RELATED STRICTURES

IBD-RELATED FISTULA&sinuses

Abcesses

COLITIS-ASSOCIATED NEOPLASIA

Bezoars in ileal pouch reservoir

Surgical anastomotic strictures

IBD:Classifications

Nonstricturing/nonpenetrating (B1) Stricturing (B2)Penetrating (B3)

Extensive colitis Left-sided colitis ProctitisStricture: cancer,muscularis mucosa hyperplasia,inflamm submucosal fibrosis

Lympho ColitisCollagenoius Colitis

IBD:

CD:Montreal classification

UC:Classification

Microscopic

colitis

IBD Strictures:

Inflam strictures

MechanicalFibrotic

strictures

Anti– TNF, biologics, or steroids.

Endoscopic or surgery

Med if inflamm

Endoscopic Surgery

Management:

CD/UC strictures trt

IBD Strictures : Endoscopy or surgery

For stricturesat the surgical anastomosis, colon, or small bowel no > 4-7 cm in length.

EndoscopyTTS balloon

dilation Surgery

int resection with anastomosisor stricturoplasty

IBD Strictures : Endoscopy or surgery

CHOICE Depends on

EndoscopyTTS balloon

dilation Surgery

Disease course Characteristics of strictures, Concurrent IBD-associated adverse events ( abscesses), Medical comorbiditieslocal expertise.

IBD : Surgery complications

At the surgical anastomosis or neoterminalileum

Septic:

Between the ileal pouchBody & anal transitional zone after restorative proctocolectomy for UC

Surgery complications: recurrence

FistulasLeakAbscesses

Anastomotic strictures:

IBD strictures: Diagnosis

Recommended before diagnostic/therapeutic endoscopy to provide the “ roadmap” (eg, location, number& length of strictures).

Main advantage is the ability to obtain biopsies for histologic assessment &deliver therapy at the time of the diagnosis.

CTE,MRE,TAUS,SICUS,EUS,SI follow Though,GGE.

Abd& pelvic imaging :

Endoscopy:

Abd/pelvic imagings:

CTE:

Noninvasive, available, easy to perform, IV contrast Excessive ionizing radiation.

Active CD: fat stranding,mucosal hyperenhancement, vasa recta engorgement,transmural infl ammation, lymphadenopathy, abscessor fitula.

Fibrostenotic disease on CTE definedBy presence of narrowing of the intestinal lumen without active infl ammation

Advantages/Disadvantages:

MRE:

A low intensity onT1 &T2 sequences is characteristic of chronic fibroticstrictures,

A high intensity on fat-suppressed T2 imagesis a feature of infl ammatory edematous strictures.

For assess of small / large bowel CD with particular utilityFor distinguishing between fi brostenotic& active disease.

Advantages/Disadvantages:

TAUS,SI CEU:

used to detect small bowel strictures in CD

High sensitivity/specificity

Operator-dependent

Advantages/Disadvantages:

Gastrograffin enema (GGE):

Used for distal colonic stricturesor fistulas, for ileal pouch-anal anastomosis (IPAA)adverse events including strictures& anastomotic leaks,for abnormalities at the neoterminal ileum in patientswith stomas.

Useful in the detection of the number/length of strictures& their conditions.

Sens 100% in diagnosing pouch-anal anastomotic strictures when ananastomotic 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.

Advantages/Disadvantages:

IBD strictures:endoscopic trts&Complication

TTS BD

Perforation: cliping,OTC,surgery

NK Endoscopic stricturotomy

Bleeding: most can be controlled by endoscopic hemostasis

Stenting

Endoscopic trts:

Endoscopic balloon dilation therapy

TYPE TTS

Indications

IBD-related benign small bowel, ileocolonic, or colonic strictures. symptomatic strictures <4 -5 cm withoutassociated fistulas abscesses, or malignancy. facilitate completion of dysplasia surveillance in non-traversable strictures.

Endoscopic stricturotomy

TYPE Needle-knife

Indications

Ileocolonic ileal pouch strictures.More effective than TTS balloon dilation in refractory IBD-related benign strictures,with acceptable adverse events as bleeding and perforation.

Endoscopic stent placement

TYPE SEMS ? Bidegradable

Migration prv

Migration reduced by endoscopic suturing.

IBD complications:others

sinuses Anastomotic leaks

Bezoars in ileal pouch reservoir

Endo dilation of strictures & removal of bezoars

Endotrts: NK, Stents,

1

2

3

5

4Endoinj: fibrin glue

Endoinj: stem cells

Med trts:No good long-term results

Endoscopic injections:Doxycycline+acetylctstein

Endoinj: 50% glucose or honey

CD:Fistla treaTments

CD-Fistulas: treatments

Colitis-associated neoplasia:

COLITIS-ASSOCIATED NEOPLASIA.

DALM: raised lesion with associated

dysplasia

Adenoma-like lesion resembling sporadic adenoma without adjacent flat dysplasia

Non– adenoma-like lesion is typically an ulcerated, broadbased,irregular lesion.

diagnosis of all dysplasia needs to be confirmed by at least 2 expert GI pathologists.

PolypectomyColonoscopy repeated

in 6/12

ColectomyMay be removed by

EMR or ESD

Patients with multifocal flat low-grade dysplasia, repetitive low-grade dysplasia, or high-grade

dysplasia should be referred for total colectomy.

Endoscopic procedures-associated adverseevents & management:

Perforation trts:Endoscopic clip; usual or OTC, FC SEMS. Endoscopic therapy in IBD patients should be performed by specialized endoscopists, with proper surgical backup.

Perforation:> In non-IBD Patients BZ of the inflammation & immunne modulators use.

Complications:

1

Perfo

ration

s

Bleed

ing2

Bleeding:Managed by endoscopic clips. 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.

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 IBD-associated 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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