Intest Res.  2016 Jul;14(3):285-288. 10.5217/ir.2016.14.3.285.

High grade anorectal stricture complicating Crohn's disease: endoscopic treatment using insulated-tip knife

• Chon HK
• Shin IS
• Kim SW
• Lee ST

• KMID: 2354972
• DOI: http://doi.org/10.5217/ir.2016.14.3.285

Abstract

Endoscopic treatments have emerged as an alternative to surgery, in the treatment of benign colorectal stricture. Unlike endoscopic balloon dilatation, there is limited data on endoscopic electrocautery incision therapy for benign colorectal stricture, especially with regards to safety and long-term patency. We present a case of a 29-year-old female with Crohn's disease who had difficulty in defecation and passing thin stools. A pelvic magnetic resonance imaging scan, gastrograffin enema, and sigmoidoscopy showed a high-grade anorectal stricture. An endoscopic insulated-tip knife incision was successfully performed to resolve the problem. From our experience, we suggest that endoscopic insulated-tip knife treatment may be a feasible and effective modality for patients with short-segment, very rigid, fibrotic anorectal stricture.

Keyword

Crohn diseases; Anorectal stricture; Endoscopic insulated-tip knife

MeSH Terms

Adult
Constriction, Pathologic*
Crohn Disease*
Defecation
Diatrizoate Meglumine
Dilatation
Electrocoagulation
Enema
Female
Humans
Magnetic Resonance Imaging
Sigmoidoscopy
Diatrizoate Meglumine

Figure

• 

  Fig. 1 Pelvic MRI finding. Axial (A) and coronal (B) T2-weighted MR image demonstrated circumferential and short segment stricture of anorectal area (arrow in A and B).

• 

  Fig. 2 Gastrograffin enema finding. It showed high-grade anorectal stricture, a segment about 1.4 cm in size.

• 

  Fig. 3 Endoscopic findings of anorectal stricture (A) Initial sigmoidoscopy, showing a luminal stricture with fibrotic tissue and exudate except for two tiny holes (1-mm [black arrow] and 5-mm [white arrow]) (B, C) The fibrotic tissue near the 1 mm hole was removed via hot biopsy and widened to about 1 cm. (D) Endoscopic electrocautery incision using an insulated-tip knife through the widened hole was carried out between the 1-cm and 5-mm hole (E) Stricture area was widened (F) Follow-up sigmoidoscopy after 1 year.

Reference

1. Brochard C, Siproudhis L, Wallenhorst T, et al. Anorectal stricture in 102 patients with Crohn's disease: natural history in the era of biologics. Aliment Pharmacol Ther. 2014; 40:796–803. PMID: 25109493.

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

3. Krieger BR, Steinhagen RM. Perianal Crohn's disease - A surgical perspective. Semin Colon Rectal Surg. 2012; 23:125–129.

4. Keighley MR, Allan RN. Current status and influence of operation on perianal Crohn's disease. Int J Colorectal Dis. 1986; 1:104–107. PMID: 3611935.

5. 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.

6. Thienpont C, D'Hoore A, Vermeire S, et al. Long-term outcome of endoscopic dilatation in patients with Crohn's disease is not affected by disease activity or medical therapy. Gut. 2010; 59:320–324. PMID: 19840991.

7. Kerkhof M, Dewint P, Koch AD, van der Woude CJ. Endoscopic needle-knife treatment of refractory ileo-ascending anastomotic stricture. Endoscopy. 2013; 45(Suppl 2):E57–E58. PMID: 23526517.

8. DiSario JA, Pedersen PJ, Bichiş-Canoutas C, Alder SC, Fang JC. Incision of recurrent distal esophageal (Schatzki) ring after dilation. Gastrointest Endosc. 2002; 56:244–248. PMID: 12145604.

9. Brandimarte G, Tursi A. Endoscopic treatment of benign anastomotic esophageal stenosis with electrocautery. Endoscopy. 2002; 34:399–401. PMID: 11972272.

10. Brandimarte G, Tursi A, Gasbarrini G. Endoscopic treatment of benign anastomotic colorectal stenosis with electrocautery. Endoscopy. 2000; 32:461–463. PMID: 10863912.

11. Hagiwara A, Togawa T, Yamasaki J, Shirasu M, Sakakura C, Yamagishi H. Endoscopic incision and balloon dilatation for cicatricial anastomotic strictures. Hepatogastroenterology. 1999; 46:997–999. PMID: 10370654.

12. Ibarguen-Secchia E. Endoscopic pyloromyotomy for congenital pyloric stenosis. Gastrointest Endosc. 2005; 61:598–600. PMID: 15812419.

13. Baron TH. Snares, knives, and scissors. Tech Gastrointest Endosc. 2006; 8:22–27.

14. Hyun JJ, Chun HJ, Keum B, et al. Weblike stenosis due to gastroesophageal reflux disease, treated with an insulation-tipped diathermic knife-2 (IT-2). Endoscopy. 2010; 42(Suppl 2):E110. PMID: 20306396.

15. Lee SS, Hwang ST, Jang NG, et al. A case of congenital duodenal web causing duodenal stenosis in a down syndrome child: endoscopic resection with an insulated-tip knife. Gut Liver. 2011; 5:105–109. PMID: 21461083.

16. Koh KH, Kim SJ, Park S, et al. Two cases of central airway obstruction treated with an insulation-tipped diathermic knife-2. Korean J Med. 2014; 86:755–760.