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Endoscopy in Crohn s Disease Peter Darwin, MD Director of

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Endoscopy in Crohn s Disease Peter Darwin, MD Director of Gastrointestinal Endoscopy University of Maryland Hospital Division of Gastroenterology – PowerPoint PPT presentation

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Title: Endoscopy in Crohn s Disease Peter Darwin, MD Director of


1
Endoscopy in Crohns Disease
Peter Darwin, MD Director of
Gastrointestinal Endoscopy University of
Maryland Hospital Division of
Gastroenterology
2
Outline
  • Case histories
  • Diagnosis
  • Assessment of response
  • Dysplasia and surveillance
  • Bleeding
  • Stricture management
  • Emerging technology

3
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?

4
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 ?

5
Diagnosis
  • Asymmetric patchy inflammation
  • Skip lesions
  • Rectal sparring
  • Ulcerations
  • Biopsy
  • Erosions and normal mucosa
  • Granulomas in 15 to 35 of specimens

6
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7
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

8
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9
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

10
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
11
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

12
Hemorrhage in Crohns
  • No data to support cautery or injection therapy
  • Surgical intervention
  • Consider tattooing of the site

13
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.
14
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
15
Clinical Course
16
Balloon Dilation of Strictures
17
Descending Colon Stricture
18
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

19
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

20
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21
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

22
Injection of Corticosteroids
  • Post dilation
  • Sclerotherapy needle
  • Triamcinolone 40 mg/ml 1 cc in 4 quadrants at
    site of maximal inflammation/stenosis

23
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24
Intestinal Stents
  • Limited data
  • Migration is common
  • Coated metal enteral stents / plastic stents may
    be of benefit

25
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.
26
Inlet and Outlet Strictures
27
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)
28
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
29
Pouch Disease Activity Index
30
Strictures Scores
31
Cleveland Global Quality of Life Scores
32
Emerging Technology
  • Double balloon enteroscopy
  • Endoscopic ultrasound
  • Optical coherence tomography
  • Magnification chromoendoscopy

33
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34
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35
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36
Takayuki Matsumoto, Tomohiko Moriyama, et. al.
Gastrointest Endosc 200562 392-8
37

38
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39
Optical Coherence Tomography
  • Based on low-coherence
  • interferometry
  • High resolution imaging
  • Uses light (not sound)
  • Resolution 10X greater than EUS
  • No acoustic coupling

40
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.
41
Colonic Pit Pattern
Huang Q, Norio F, et. al. Gastrointest Endosc
2004 60520-6.
42
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43
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 ?
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