Intest Res.  2015 Jan;13(1):19-26. 10.5217/ir.2015.13.1.19.

Intestinal Stricture in Crohn's Disease

• Chang CW
• Wong JM
• Tung CC
• Shih IL
• Wang HY
• Wei SC

• KMID: 1807373
• DOI: http://doi.org/10.5217/ir.2015.13.1.19

Abstract

Crohn's disease (CD) is a disease with chronic inflammation of unknown etiology involving any part of the gastrointestinal tract. The incidence and prevalence of CD are increasing recently in Asia. Half of the CD patients will have intestinal complications, such as strictures or fistulas, within 20 years after diagnosis. Twenty-five percentage of CD patients have had at least one small bowel stricture and 10% have had at least one colonic stricture and lead to significant complications. Most of these patients will require at least one surgery during their lifetime. Early diagnosis and evaluation with adequate managements for the patients can prevent disability and mortality of these patient. Here, we reviewed the current incidence of CD with stricture, the etiology of stricture, and how to diagnose and manage the stricture.

Keyword

Crohn disease; Constriction, pathologic; Intestines; Diagnosis; Disease management

MeSH Terms

Asia
Colon
Constriction, Pathologic*
Crohn Disease*
Diagnosis
Disease Management
Early Diagnosis
Fistula
Gastrointestinal Tract
Humans
Incidence
Inflammation
Intestines
Mortality
Prevalence

Figure

• 

  Fig. 1 A 33-year-old woman with CD who had active inflammation with stenosis. (A) An axial T2-weighted image and (B) an axial post-contrast T1-weighted image show abnormal wall-thickening, increased enhancement, and adjacent fat-stranding of transverse and descending colon (arrows), suggestive of active inflammation. There is intestinal stenosis with dilated proximal colon (*).

• 

  Fig. 2 A 57-year-old woman with CD who had fibrosis with stricture. (A) A coronal T2-weighted image shows an abnormal segment of the distal ileum (arrows) with wall-thickening and luminal narrowing, with relative low signal and minimal inflammatory changes, suggestive of fibrosis. There is stricture with dilated proximal intestine (*). (B) A coronal post-contrast T1-weighted image shows another involved ileal segment at the left lower abdomen (arrow), with dilated proximal intestine (*). The patient underwent an operation and fibrotic changes were confirmed.

Reference

1. Prideaux L, Kamm MA, De Cruz PP, Chan FK, Ng SC. Inflammatory bowel disease in Asia: a systematic review. J Gastroenterol Hepatol. 2012; 27:1266–1280. PMID: 22497584.

2. Silverberg MS, Satsangi J, Ahmad T, et al. Toward an integrated clinical, molecular and serological classification of inflammatory bowel disease: report of a Working Party of the 2005 Montreal World Congress of Gastroenterology. Can J Gastroenterol. 2005; 19(Suppl A):5A–36A.

3. Baumgart DC, Sandborn WJ. Crohn's disease. Lancet. 2012; 380:1590–1605. PMID: 22914295.

4. Chan G, Fefferman DS, Farrell RJ. Endoscopic assessment of inflammatory bowel disease: colonoscopy/esophagogastroduodenoscopy. Gastroenterol Clin North Am. 2012; 41:271–290. PMID: 22500517.

5. Paine E, Shen B. Endoscopic therapy in inflammatory bowel diseases (with videos). Gastrointest Endosc. 2013; 78:819–835. PMID: 24139079.

6. Burke JP, Mulsow JJ, O'Keane C, Docherty NG, Watson RW, O'Connell PR. Fibrogenesis in Crohn's disease. Am J Gastroenterol. 2007; 102:439–448. PMID: 17156147.

7. Cosnes J, Nion-Larmurier I, Beaugerie L, Afchain P, Tiret E, Gendre JP. Impact of the increasing use of immunosuppressants in Crohn's disease on the need for intestinal surgery. Gut. 2005; 54:237–241. PMID: 15647188.

8. Peyrin-Biroulet L, Loftus EV Jr, Colombel JF, Sandborn WJ. The natural history of adult Crohn's disease in population-based cohorts. Am J Gastroenterol. 2010; 105:289–297. PMID: 19861953.

9. Ben-Horin S, Chowers Y. Review article: loss of response to anti-TNF treatments in Crohn's disease. Aliment Pharmacol Ther. 2011; 33:987–995. PMID: 21366636.

10. Morita N, Toki S, Hirohashi T, et al. Incidence and prevalence of inflammatory bowel disease in Japan: nationwide epidemiological survey during the year 1991. J Gastroenterol. 1995; 30(Suppl 8):1–4. PMID: 8563866.

11. Kitahora T, Utsunomiya T, Yokota A. Epidemiological study of ulcerative colitis in Japan: incidence and familial occurrence. The Epidemiology Group of the Research Committee of Inflammatory Bowel Disease in Japan. J Gastroenterol. 1995; 30(Suppl 8):5–8. PMID: 8563890.

12. Yao T, Matsui T, Hiwatashi N. Crohn's disease in Japan: diagnostic criteria and epidemiology. Dis Colon Rectum. 2000; 43:S85–S93. PMID: 11052483.

13. Higashi A, Watanabe Y, Ozasa K, Hayashi K, Aoike A, Kawai K. Prevalence and mortality of ulcerative colitis and Crohn's disease in Japan. Gastroenterol Jpn. 1988; 23:521–526. PMID: 3215436.

14. Asakura K, Nishiwaki Y, Inoue N, Hibi T, Watanabe M, Takebayashi T. Prevalence of ulcerative colitis and Crohn's disease in Japan. J Gastroenterol. 2009; 44:659–665. PMID: 19424654.

15. Shin DH, Sinn DH, Kim YH, et al. Increasing incidence of inflammatory bowel disease among young men in Korea between 2003 and 2008. Dig Dis Sci. 2011; 56:1154–1159. PMID: 20844953.

16. Yang SK, Yun S, Kim JH, et al. Epidemiology of inflammatory bowel disease in the Songpa-Kangdong district, Seoul, Korea, 1986-2005: a KASID study. Inflamm Bowel Dis. 2008; 14:542–549. PMID: 17941073.

17. Wei SC, Lin MH, Tung CC, et al. A nationwide population-based study of the inflammatory bowel diseases between 1998 and 2008 in Taiwan. BMC Gastroenterol. 2013; 13:166. PMID: 24314308.

18. Yamamoto T, Watanabe T. Surgery for luminal Crohn's disease. World J Gastroenterol. 2014; 20:78–90. PMID: 24415860.

19. Cleynen I, Gonzalez JR, Figueroa C, et al. Genetic factors conferring an increased susceptibility to develop Crohn's disease also influence disease phenotype: results from the IBDchip European Project. Gut. 2013; 62:1556–1565. PMID: 23263249.

20. Yano Y, Matsui T, Hirai F, et al. Cancer risk in Japanese Crohn's disease patients: investigation of the standardized incidence ratio. J Gastroenterol Hepatol. 2013; 28:1300–1305. PMID: 23488881.

21. Ye BD, Yang SK, Cho YK, et al. Clinical features and long-term prognosis of Crohn's disease in Korea. Scand J Gastroenterol. 2010; 45:1178–1185. PMID: 20560811.

22. Wei SC, Ni YH, Yang HI, et al. A hospital-based study of clinical and genetic features of Crohn's disease. J Formos Med Assoc. 2011; 110:600–606. PMID: 21930071.

23. Rieder F, Fiocchi C. Mechanisms of tissue remodeling in inflammatory bowel disease. Dig Dis. 2013; 31:186–193. PMID: 24030223.

24. Rieder F, Fiocchi C. Intestinal fibrosis in inflammatory bowel disease - Current knowledge and future perspectives. J Crohns Colitis. 2008; 2:279–290. PMID: 21172225.

25. Armaka M, Apostolaki M, Jacques P, Kontoyiannis DL, Elewaut D, Kollias G. Mesenchymal cell targeting by TNF as a common pathogenic principle in chronic inflammatory joint and intestinal diseases. J Exp Med. 2008; 205:331–337. PMID: 18250193.

26. Lichtenstein GR, Olson A, Travers S, et al. Factors associated with the development of intestinal strictures or obstructions in patients with Crohn's disease. Am J Gastroenterol. 2006; 101:1030–1038. PMID: 16606351.

27. Gelbmann CM, Mestermann S, Gross V, Kollinger M, Scholmerich J, Falk W. Strictures in Crohn's disease are characterised by an accumulation of mast cells colocalised with laminin but not with fibronectin or vitronectin. Gut. 1999; 45:210–217. PMID: 10403732.

28. Graham MF. Pathogenesis of intestinal strictures in Crohn's disease-an update. Inflamm Bowel Dis. 1995; 1:220–227. PMID: 23282393.

29. Hugot JP, Laurent-Puig P, Gower-Rousseau C, et al. Mapping of a susceptibility locus for Crohn's disease on chromosome 16. Nature. 1996; 379:821–823. PMID: 8587604.

30. Hugot JP. Genetic origin of IBD. Inflamm Bowel Dis. 2004; 10(Suppl 1):S11–S15. PMID: 15168824.

31. Tung CC, Wong JM, Lee WC, et al. Combining TNFSF15 and ASCA IgA can be used as a predictor for the stenosis/perforating phenotype of Crohn's disease. J Gastroenterol Hepatol. 2014; 29:723–729. PMID: 24783249.

32. Rieder F, Zimmermann EM, Remzi FH, Sandborn WJ. Crohn's disease complicated by strictures: a systematic review. Gut. 2013; 62:1072–1084. PMID: 23626373.

33. Parente F, Maconi G, Bollani S, et al. Bowel ultrasound in assessment of Crohn's disease and detection of related small bowel strictures: a prospective comparative study versus x ray and intraoperative findings. Gut. 2002; 50:490–495. PMID: 11889068.

34. Migaleddu V, Scanu AM, Quaia E, et al. Contrast-enhanced ultrasonographic evaluation of inflammatory activity in Crohn's disease. Gastroenterology. 2009; 137:43–52. PMID: 19422826.

35. Horsthuis K, Bipat S, Bennink RJ, Stoker J. Inflammatory bowel disease diagnosed with US, MR, scintigraphy, and CT: meta-analysis of prospective studies. Radiology. 2008; 247:64–79. PMID: 18372465.

36. Kralik R, Trnovsky P, Kopáčová M. Transabdominal ultrasonography of the small bowel. Gastroenterol Res Pract. doi: 10.1155/2013/896704. Published online 19 November 2013.

37. Dietrich CF. Significance of abdominal ultrasound in inflammatory bowel disease. Dig Dis. 2009; 27:482–493. PMID: 19897964.

38. Stidham RW, Xu J, Johnson LA, et al. Ultrasound elasticity imaging for detecting intestinal fibrosis and inflammation in rats and humans with Crohn's disease. Gastroenterology. 2011; 141:819–826. PMID: 21784048.

39. Masselli G, Gualdi G. CT and MR enterography in evaluating small bowel diseases: when to use which modality? Abdom Imaging. 2013; 38:249–259. PMID: 23011551.

40. Furukawa A, Saotome T, Yamasaki M, et al. Cross-sectional imaging in Crohn disease. Radiographics. 2004; 24:689–702. PMID: 15143222.

41. Fiorino G, Bonifacio C, Malesci A, Balzarini L, Danese S. MRI in Crohn's disease--current and future clinical applications. Nat Rev Gastroenterol Hepatol. 2012; 9:23–31. PMID: 22105109.

42. Benitez JM, Meuwis MA, Reenaers C, Van Kemseke C, Meunier P, Louis E. Role of endoscopy, cross-sectional imaging and biomarkers in Crohn's disease monitoring. Gut. 2013; 62:1806–1816. PMID: 24203056.

43. Despott EJ, Gupta A, Burling D, et al. Effective dilation of small-bowel strictures by double-balloon enteroscopy in patients with symptomatic Crohn's disease (with video). Gastrointest Endosc. 2009; 70:1030–1036. PMID: 19640518.

44. Farmer RG, Hawk WA, Turnbull RB Jr. Indications for surgery in Crohn's disease: analysis of 500 cases. Gastroenterology. 1976; 71:245–250. PMID: 1084841.

45. de Buck van Overstraeten A, Wolthuis A, D'Hoore A. Surgery for Crohn's disease in the era of biologicals: a reduced need or delayed verdict? World J Gastroenterol. 2012; 18:3828–3832. PMID: 22876034.

46. Regueiro M, Schraut W, Baidoo L, et al. Infliximab prevents Crohn's disease recurrence after ileal resection. Gastroenterology. 2009; 136:441–450. PMID: 19109962.

47. de'Angelis N, Carra MC, Borrelli O, et al. Short- and long-term efficacy of endoscopic balloon dilation in Crohn's disease strictures. World J Gastroenterol. 2013; 19:2660–2667. PMID: 23674873.

48. Van Assche G, Geboes K, Rutgeerts P. Medical therapy for Crohn's disease strictures. Inflamm Bowel Dis. 2004; 10:55–60. PMID: 15058528.

49. Brooker JC, Beckett CG, Saunders BP, Benson MJ. Long-acting steroid injection after endoscopic dilation of anastomotic Crohn's strictures may improve the outcome: a retrospective case series. Endoscopy. 2003; 35:333–337. PMID: 12664391.

50. Hassan C, Zullo A, De Francesco V, et al. Systematic review: Endoscopic dilatation in Crohn's disease. Aliment Pharmacol Ther. 2007; 26:1457–1464. PMID: 17903236.

51. Hoffmann JC, Heller F, Faiss S, et al. Through the endoscope balloon dilation of ileocolonic strictures: prognostic factors, complications, and effectiveness. Int J Colorectal Dis. 2008; 23:689–696. PMID: 18338175.

52. Kwon YH, Jeon SW, Lee YK. Endoscopic management of refractory benign colorectal strictures. Clin Endosc. 2013; 46:472–475. PMID: 24143305.

53. Bonin EA, Baron TH. Update on the indications and use of colonic stents. Curr Gastroenterol Rep. 2010; 12:374–382. PMID: 20703837.

54. Lee JG, Yoo KH, Kwon CI, Ko KH, Hong SP. Angular positioning of stent increases bowel perforation after self-expandable metal stent placement for malignant colorectal obstruction. Clin Endosc. 2013; 46:384–389. PMID: 23964336.

55. Rejchrt S, Kopacova M, Brozik J, Bures J. Biodegradable stents for the treatment of benign stenoses of the small and large intestines. Endoscopy. 2011; 43:911–917. PMID: 21623562.

56. Lazarev M, Ullman T, Schraut WH, Kip KE, Saul M, Regueiro M. Small bowel resection rates in Crohn's disease and the indication for surgery over time: experience from a large tertiary care center. Inflamm Bowel Dis. 2010; 16:830–835. PMID: 19798731.

57. Casillas S, Delaney CP. Laparoscopic surgery for inflammatory bowel disease. Dig Surg. 2005; 22:135–142. PMID: 16037671.

58. Casillas S, Delaney CP, Senagore AJ, Brady K, Fazio VW. Does conversion of a laparoscopic colectomy adversely affect patient outcome? Dis Colon Rectum. 2004; 47:1680–1685. PMID: 15540299.

59. Cima RR, Wolff BG. Reoperative Crohn's surgery: tricks of the trade. Clin Colon Rectal Surg. 2007; 20:336–343. PMID: 20011431.

60. Dietz DW, Laureti S, Strong SA, et al. Safety and longterm efficacy of strictureplasty in 314 patients with obstructing small bowel Crohn's disease. J Am Coll Surg. 2001; 192:330–337. discussion 337-338. PMID: 11245375.