Intest Res.  2017 Apr;15(2):166-173. 10.5217/ir.2017.15.2.166.

Current status of endoscopic balloon dilation for Crohn's disease

• Hirai F

• KMID: 2425157
• DOI: http://doi.org/10.5217/ir.2017.15.2.166

Abstract

The therapeutic target in Crohn's disease (CD) has been raised to the achievement of mucosal healing. Although effective treatments that target cytokines and other molecules has been widely used for CD, intestinal strictures are still a major cause of surgery. Endoscopic balloon dilation (EBD) is known to be an effective and safe intervention for intestinal strictures in CD. Since frequent intestinal resection often results in short bowel syndrome and can decrease the quality of life, EBD can help avoid surgery. EBD with a conventional colonoscope for Crohn's strictures of the colon and ileo-colonic anastomosis has established efficacy and safety. In addition, EBD using balloon-assisted enteroscopy has recently been applied for small bowel Crohn's strictures. Although the evidence is not strong, EBD may become an alternative to surgery in small bowel strictures in CD. EBD and other new methods such as self-expanding stent implantation for Crohn's strictures may be useful and safe; however, it is important to address several issues regarding these interventions and to establish a protocol for combined therapies.

Keyword

Endoscopic balloon dilation; Crohn disease; Colorectal stricture; Ileo-colonic anastomotic stricture; Small bowel stricture

MeSH Terms

Colon
Colonoscopes
Constriction, Pathologic
Crohn Disease*
Cytokines
Quality of Life
Short Bowel Syndrome
Stents
Cytokines

Figure

• 

  Fig. 1 (A) Double-contrast small bowel enterography showed multiple intestinal strictures (arrows) in the ileum. (B) Endoscopic findings of the most severe small bowel stricture. (C) Endoscopic findings during inflation of through-the-scope balloon catheter. Endoscopic balloon dilation (EBD) could be performed for all small bowel strictures. (D) Small bowel stricture markedly improved after EBD. Although two additional EBD sessions were needed, clinical efficacy (defined as no stenotic symptoms and no need for surgery) has been maintained for 5 years after the initial EBD.

Reference

1. Harper PH, Fazio VW, Lavery IC, et al. The long-term outcome in Crohn's disease. Dis Colon Rectum. 1987; 30:174–179. PMID: 3829859.

2. Munkholm P, Langholz E, Davidsen M, Binder V. Disease activity courses in a regional cohort of Crohn's disease patients. Scand J Gastroenterol. 1995; 30:699–706. PMID: 7481535.

3. Rungoe C, Langholz E, Andersson M, et al. Changes in medical treatment and surgery rates in inflammatory bowel disease: a nationwide cohort study 1979-2011. Gut. 2014; 63:1607–1616. PMID: 24056767.

4. Bernell O, Lapidus A, Hellers G. Risk factors for surgery and postoperative recurrence in Crohn's disease. Ann Surg. 2000; 231:38–45. PMID: 10636100.

5. Hellers G. Crohn's disease in Stockholm county 1955-1974: a study of epidemiology, results of surgical treatment and long-term prognosis. Acta Chir Scand Suppl. 1979; 490:1–84. PMID: 293116.

6. Poggioli G, Pierangeli F, Laureti S, Ugolini F. Review article: indication and type of surgery in Crohn's disease. Aliment Pharmacol Ther. 2002; 16(Suppl 4):59–64.

7. Matsui T, Hatakeyama S, Ikeda K, Yao T, Takenaka K, Sakurai T. Long-term outcome of endoscopic balloon dilation in obstructive gastroduodenal Crohn's disease. Endoscopy. 1997; 29:640–645. PMID: 9360875.

8. Blomberg B, Rolny P, Järnerot G. Endoscopic treatment of anastomotic strictures in Crohn's disease. Endoscopy. 1991; 23:195–198. PMID: 1915133.

9. Couckuyt H, Gevers AM, Coremans G, Hiele M, Rutgeerts P. Efficacy and safety of hydrostatic balloon dilatation of ileocolonic Crohn's strictures: a prospective longterm analysis. Gut. 1995; 36:577–580. PMID: 7737567.

10. Matsui T, Ikeda K, Tsuda S, et al. Long-term outcome of endoscopic balloon dilation in obstructive gastrointestinal Crohn's disease: a prospective long-term study. Diagn Ther Endosc. 2000; 6:67–75. PMID: 18493528.

11. Sabaté JM, Villarejo J, Bouhnik Y, et al. Hydrostatic balloon dilatation of Crohn's strictures. Aliment Pharmacol Ther. 2003; 18:409–413. PMID: 12940926.

12. Thomas-Gibson S, Brooker JC, Hayward CM, Shah SG, Williams CB, Saunders BP. Colonoscopic balloon dilation of Crohn's strictures: a review of long-term outcomes. Eur J Gastroenterol Hepatol. 2003; 15:485–488. PMID: 12702904.

13. Morini S, Hassan C, Lorenzetti R, et al. Long-term outcome of endoscopic pneumatic dilatation in Crohn's disease. Dig Liver Dis. 2003; 35:893–897. PMID: 14703886.

14. Singh VV, Draganov P, Valentine J. Efficacy and safety of endoscopic balloon dilation of symptomatic upper and lower gastrointestinal Crohn's disease strictures. J Clin Gastroenterol. 2005; 39:284–290. PMID: 15758621.

15. Nomura E, Takagi S, Kikuchi T, et al. Efficacy and safety of endoscopic balloon dilation for Crohn's strictures. Dis Colon Rectum. 2006; 49(10 Suppl):S59–S67. PMID: 17106817.

16. Ferlitsch A, Reinisch W, Püspök A, et al. Safety and efficacy of endoscopic balloon dilation for treatment of Crohn's disease strictures. Endoscopy. 2006; 38:483–487. PMID: 16767583.

17. 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.

18. Mueller T, Rieder B, Bechtner G, Pfeiffer A. The response of Crohn's strictures to endoscopic balloon dilation. Aliment Pharmacol Ther. 2010; 31:634–639. PMID: 20047581.

19. Scimeca D, Mocciaro F, Cottone M, et al. Efficacy and safety of endoscopic balloon dilation of symptomatic intestinal Crohn's disease strictures. Dig Liver Dis. 2011; 43:121–125. PMID: 20561831.

20. Gustavsson A, Magnuson A, Blomberg B, Andersson M, Halfvarson J, Tysk C. Endoscopic dilation is an efficacious and safe treatment of intestinal strictures in Crohn's disease. Aliment Pharmacol Ther. 2012; 36:151–158. PMID: 22612326.

21. Nanda K, Courtney W, Keegan D, et al. Prolonged avoidance of repeat surgery with endoscopic balloon dilatation of anastomotic strictures in Crohn's disease. J Crohns Colitis. 2013; 7:474–480. PMID: 22898397.

22. Endo K, Takahashi S, Shiga H, Kakuta Y, Kinouchi Y, Shimosegawa T. Short and long-term outcomes of endoscopic balloon dilatation for Crohn's disease strictures. World J Gastroenterol. 2013; 19:86–91. PMID: 23326167.

23. Bhalme M, Sarkar S, Lal S, Bodger K, Baker R, Willert RP. Endoscopic balloon dilatation of Crohn's disease strictures: results from a large United Kingdom series. Inflamm Bowel Dis. 2014; 20:265–270. PMID: 24374876.

24. Atreja A, Aggarwal A, Dwivedi S, et al. Safety and efficacy of endoscopic dilation for primary and anastomotic Crohn's disease strictures. J Crohns Colitis. 2014; 8:392–400. PMID: 24189349.

25. Yamamoto H, Kita H, Sunada K, et al. Clinical outcomes of double-balloon endoscopy for the diagnosis and treatment of small-intestinal diseases. Clin Gastroenterol Hepatol. 2004; 2:1010–1016. PMID: 15551254.

26. Yamamoto H, Yano T, Ohmiya N, et al. Double-balloon endoscopy is safe and effective for the diagnosis and treatment of small-bowel disorders: prospective multicenter study carried out by expert and non-expert endoscopists in Japan. Dig Endosc. 2015; 27:331–337. PMID: 25180488.

27. Fukumoto A, Tanaka S, Yamamoto H, et al. Diagnosis and treatment of small-bowel stricture by double balloon endoscopy. Gastrointest Endosc. 2007; 66(3 Suppl):S108–S112. PMID: 17709019.

28. Pohl J, May A, Nachbar L, Ell C. Diagnostic and therapeutic yield of push-and-pull enteroscopy for symptomatic small bowel Crohn's disease strictures. Eur J Gastroenterol Hepatol. 2007; 19:529–534. PMID: 17556897.

29. Ohmiya N, Arakawa D, Nakamura M, et al. Small-bowel obstruction: diagnostic comparison between double-balloon endoscopy and fluoroscopic enteroclysis, and the outcome of enteroscopic treatment. Gastrointest Endosc. 2009; 69:84–93. PMID: 19111689.

30. 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.

31. Hirai F, Beppu T, Sou S, Seki T, Yao K, Matsui T. Endoscopic balloon dilatation using double-balloon endoscopy is a useful and safe treatment for small intestinal strictures in Crohn's disease. Dig Endosc. 2010; 22:200–204. PMID: 20642609.

32. Gill RS, Kaffes AJ. Small bowel stricture characterization and outcomes of dilatation by double-balloon enteroscopy: a single-centre experience. Therap Adv Gastroenterol. 2014; 7:108–114.

33. Hirai F, Beppu T, Takatsu N, et al. Long-term outcome of endoscopic balloon dilation for small bowel strictures in patients with Crohn's disease. Dig Endosc. 2014; 26:545–551. PMID: 24528293.

34. Sunada K, Shinozaki S, Nagayama M, et al. Long-term outcomes in patients with small intestinal strictures secondary to Crohn's disease after double-balloon endoscopy-assisted balloon dilation. Inflamm Bowel Dis. 2016; 22:380–386. PMID: 26535767.

35. Morar PS, Faiz O, Warusavitarne J, et al. Systematic review with meta-analysis: endoscopic balloon dilatation for Crohn's disease strictures. Aliment Pharmacol Ther. 2015; 42:1137–1148. PMID: 26358739.

36. 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.

37. Gustavsson A, Magnuson A, Blomberg B, Andersson M, Halfvarson J, Tysk C. Smoking is a risk factor for recurrence of intestinal stricture after endoscopic dilation in Crohn's disease. Aliment Pharmacol Ther. 2013; 37:430–437. PMID: 23205619.

38. 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.

39. Di Nardo G, Oliva S, Passariello M, et al. Intralesional steroid injection after endoscopic balloon dilation in pediatric Crohn's disease with stricture: a prospective, randomized, double-blind, controlled trial. Gastrointest Endosc. 2010; 72:1201–1208. PMID: 20951986.

40. East JE, Brooker JC, Rutter MD, Saunders BP. A pilot study of intrastricture steroid versus placebo injection after balloon dilatation of Crohn's strictures. Clin Gastroenterol Hepatol. 2007; 5:1065–1069. PMID: 17627903.

41. Hirai F, Beppu T, Nishimura T, et al. Carbon dioxide insufflation compared with air insufflation in double-balloon enteroscopy: a prospective, randomized, double-blind trial. Gastrointest Endosc. 2011; 73:743–749. PMID: 21237455.

42. Wang WL, Wu ZH, Sun Q, et al. Meta-analysis: the use of carbon dioxide insufflation vs. room air insufflation for gastrointestinal endoscopy. Aliment Pharmacol Ther. 2012; 35:1145–1154. PMID: 22452652.

43. Lenz P, Meister T, Manno M, et al. CO2 insufflation during single-balloon enteroscopy: a multicenter randomized controlled trial. Endoscopy. 2014; 46:53–58. PMID: 24353124.

44. Hirai F, Matsui T, Yao K, Sou S, Seki T. Efficacy of carbon dioxide insufflation in endoscopic balloon dilation therapy by using double balloon endoscopy. Gastrointest Endosc. 2007; 66(3 Suppl):S26–S29. PMID: 17709025.

45. Cosnes J, Cattan S, Blain A, et al. Long-term evolution of disease behavior of Crohn's disease. Inflamm Bowel Dis. 2002; 8:244–250. PMID: 12131607.

46. Sato Y, Matsui T, Yano Y, et al. Long-term course of Crohn's disease in Japan: incidence of complications, cumulative rate of initial surgery, and risk factors at diagnosis for initial surgery. J Gastroenterol Hepatol. 2015; 30:1713–1719. PMID: 26094852.

47. Hirai F. Efficacy of endoscopic balloon dilation for small bowel strictures in patients with Crohn's disease. In : Proceedings of the 4th Annual Meeting of Asian Organization for Crohn's & Colitis; 2016 July 7-9; Kyoto, Japan.

48. Greener T, Shapiro R, Klang E, et al. Clinical outcomes of surgery versus endoscopic balloon dilation for stricturing Crohn's disease. Dis Colon Rectum. 2015; 58:1151–1157. PMID: 26544812.

49. Yamamoto T, Keighley MR. Long-term results of strictureplasty for ileocolonic anastomotic recurrence in Crohn's disease. J Gastrointest Surg. 1999; 3:555–560. PMID: 10482715.

50. Sampietro GM, Cristaldi M, Maconi G, et al. A prospective, longitudinal study of nonconventional strictureplasty in Crohn's disease. J Am Coll Surg. 2004; 199:8–20. PMID: 15217622.

51. Futami K, Arima S. Role of strictureplasty in surgical treatment of Crohn's disease. J Gastroenterol. 2005; 40(Suppl 16):35–39. PMID: 15902962.

52. Yamamoto T, Fazio VW, Tekkis PP. Safety and efficacy of strictureplasty for Crohn's disease: a systematic review and meta-analysis. Dis Colon Rectum. 2007; 50:1968–1986. PMID: 17762967.

53. Attar A, Maunoury V, Vahedi K, et al. Safety and efficacy of extractible self-expandable metal stents in the treatment of Crohn's disease intestinal strictures: a prospective pilot study. Inflamm Bowel Dis. 2012; 18:1849–1854. PMID: 22161935.

54. Loras C, Pérez-Roldan F, Gornals JB, et al. Endoscopic treatment with self-expanding metal stents for Crohn's disease strictures. Aliment Pharmacol Ther. 2012; 36:833–839. PMID: 22966851.

55. 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.

56. Shen B, Lian L, Kiran RP, et al. Efficacy and safety of endoscopic treatment of ileal pouch strictures. Inflamm Bowel Dis. 2011; 17:2527–2535. PMID: 21351202.