Endoscopy in Crohn s Disease Peter Darwin, MD Director of

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Endoscopy in Crohns Disease
Peter Darwin, MD Director of
Gastrointestinal Endoscopy University of
Maryland Hospital Division of
Gastroenterology
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Outline

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

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Case 1

• The patient is a 28 year old man with isolated
  iliocolonic Crohns 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?

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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 ?

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Diagnosis

• Asymmetric patchy inflammation
• Skip lesions
• Rectal sparring
• Ulcerations
• Biopsy
• Erosions and normal mucosa
• Granulomas in 15 to 35 of specimens

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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

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Dysplasia and Surveillance

• Extensive colitis gt 8 years
• Accuracy in predicting dysplasia correlates with
  of biopsies
• Annual colonoscopy with multiple biopsy specimens
• 4 circumferential each 10 cm

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Approach to Polypoid Lesions
Adenoma like DALM
Outside colitis
Within colitis
Polypectomy/biopsy
No dysplasia No carcinoma
Indeterminate
Flat dysplasia carcinoma
Non-IBD adenoma
Polypectomy Regular surveillance
Polypectomy Increased surveillance
Colectomy
Chawla A, Lichtenstein G. Gastrointest Endoscopy
Clin N Am 12 (2002) 525-534
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Hemorrhage in Crohns

• 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

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Hemorrhage in Crohns

• No data to support cautery or injection therapy
• Surgical intervention
• Consider tattooing of the site

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Acute Major GI hemorrhage in IBD

• 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
199949153-7.
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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
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Clinical Course
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Balloon Dilation of Strictures
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Descending Colon Stricture
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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

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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

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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

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Injection of Corticosteroids

• Post dilation
• Sclerotherapy needle
• Triamcinolone 40 mg/ml 1 cc in 4 quadrants at
  site of maximal inflammation/stenosis

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Intestinal Stents

• Limited data
• Migration is common
• Coated metal enteral stents / plastic stents may
  be of benefit

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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
2004992340-47.
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Inlet and Outlet Strictures
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Clinical Presentation
n ()
Diarrhea Abdominal pain Perianal
pain Bloating Nausea or vomiting Bleeding Daily
use of antidiarrheal agents Fistulas Weight loss
18 (94) 19 (100) 15 (79) 9 (47) 3 (16) 4
(21) 8 (42) 6 (32) 5 (26)
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Types of Strictures
Number Inlet Outlet of cases
strictures strictures
11 14 6 5
0 5 3
0 3 19
14 14
Crohns disease of the pouch Cuffitis Pouchitis
Total
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Pouch Disease Activity Index
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Strictures Scores
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Cleveland Global Quality of Life Scores
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Emerging Technology

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

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Takayuki Matsumoto, Tomohiko Moriyama, et. al.
Gastrointest Endosc 200562 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

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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
2002124880-8.
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Colonic Pit Pattern
Huang Q, Norio F, et. al. Gastrointest Endosc
2004 60520-6.
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Case 1

• The patient is a 28 year old man with isolated
  iliocolonic Crohns 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?

44
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 ?