Inflammatory bowel diseases (IBD), which include Crohn’s disease (CD) and ulcerative colitis (UC), are chronic inflammatory conditions that affect the gastrointestinal tract. These diseases can lead to various complications, including strictures, fistulas, and abscesses, which have a significant impact on patients’ quality of life. Endoscopy plays a crucial role in the diagnosis of IBD, assessment of disease activity, and monitoring of response to treatment. In recent years, advances in operative endoscopy have introduced new strategies for the management of IBD-related complications, particularly strictures and dysplastic lesions. This review summarizes current approaches to endoscopic treatment of IBD, highlighting their advantages and disadvantages.
Chronic inflammatory bowel diseases and their complications
CD and UC are characterized by inflammation of the gastrointestinal tract, which can lead to irreversible structural damage. CD often presents with strictures, while UC affects intestinal integrity and increases the risk of colorectal cancer (CRC). Fibrous strictures in CD and UC pose significant challenges to clinicians and often require surgical intervention. However, modern medical therapies have improved the natural history of IBD, especially when initiated early.
Endoscopic treatment approaches
1. Strictures in IBD
IBD strictures are complex and may result from a combination of fibrosis and inflammation. Management of these strictures requires a personalized approach considering factors such as etiology, number, degree, shape, length, location, and associated conditions. Cross-sectional imaging modalities such as ultrasound, CT, and MRI are valuable tools to diagnose strictures and differentiate fibrotic from inflammatory strictures. Anti-inflammatory medical therapy can reduce wall edema and intestinal wall thickness, while mechanical therapies, including endoscopic balloon dilation (EBD) and surgery, are mainly required for fibrotic strictures.
a. Endoscopic balloon dilation (EBD)
Endoscopic dilatation is an effective technique for treating CD-related strictures, particularly those located in the small bowel, ileocecal, or colonic regions. Endoscopic dilatation is particularly suitable for accessible, short, and anastomotic strictures, with balloon catheters being preferred due to their safety and ease of use. The dilatation process involves inserting a balloon catheter through the stricture and inflating it under radiographic guidance, with the endoscopist determining the appropriate dilatation diameter. Retrograde dilatation is used for passable strictures, while antegrade dilatation with wire-guided balloons is used for non-passable strictures.
Vaginal insufflation provides short-term symptomatic improvement in the majority of patients, with a significant proportion avoiding surgery for prolonged periods. However, symptomatic recurrence is common and the optimal technical details of vaginal insufflation, such as balloon size and duration of insufflation, remain undefined.
2. Management of dysplastic lesions
Dysplastic lesions in patients with IBD, which may precede colorectal cancer, can be treated endoscopically. Techniques such as endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) offer minimally invasive options for resection of dysplastic tissues. These techniques require expertise and careful patient selection, as they can be technically challenging and associated with complications. Nevertheless, they represent important tools in the management of dysplastic lesions in IBD.
Advantages and disadvantages of endoscopic approaches
Benefits:
- Minimally invasive, reducing surgery-related morbidity and mortality.
- Preserves intestinal anatomy and function.
- Repeatable and can be performed as needed.
- Can be used to assess disease activity and progression.
Disadvantages:
- Technical challenges, especially in cases of complex stenoses and dysplastic lesions.
- Risk of complications, including bleeding, perforation and recurrence.
- Limited long-term data on the efficacy and durability of endoscopic treatments.
Conclusions
Endoscopic treatment approaches have become important tools in the management of IBD-related strictures and dysplastic lesions. Although these techniques offer minimally invasive options, they also require expertise and careful patient selection. Future research is needed to refine technical details, optimize treatment strategies, and improve long-term outcomes. Endoscopic management of IBD should be approached by a multidisciplinary team including gastroenterologists, radiologists, and colorectal surgeons, ensuring a personalized approach for the patient that balances risks and benefits.
