Endoscopic treatment approaches for inflammatory bowel diseases: old friends and new weapons

Inflammatory bowel diseases (IBD), comprising Crohn's disease (CD) and ulcerative colitis (UC), are chronic inflammatory conditions affecting the gastrointestinal tract. These diseases can lead to various complications, including strictures, fistulas, and abscesses, significantly impacting patients' quality of life. Endoscopy plays a crucial role in diagnosing IBD, assessing disease activity, and monitoring treatment response. In recent years, advances in operative endoscopy have introduced novel strategies for managing IBD-related complications, particularly strictures and dysplastic lesions. This review summarizes the current endoscopic treatment approaches for IBD, highlighting their advantages and disadvantages.

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 gut integrity and increases the risk of colorectal cancer (CRC). Fibrotic strictures in CD and UC pose significant challenges for clinicians and often require surgical intervention. However, modern medical therapies have improved the natural history of IBD, particularly when initiated early.

Endoscopic Treatment Approaches

1. Strictures in IBD

Strictures in IBD are complex and can result from a combination of fibrosis and inflammation. The management of these strictures requires a tailored approach considering factors such as etiology, number, degree, shape, length, location, and associated conditions. Cross-sectional imaging modalities like ultrasound, CT, and MRI are valuable tools for diagnosing strictures and differentiating between fibrotic and 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 primarily required for fibrotic strictures.

a. Endoscopic Balloon Dilation (EBD)

EBD is an effective technique for treating CD-related strictures, particularly those localized in the small bowel, ileocolonic, or colonic regions. EBD is best suited for accessible, short, and anastomotic strictures, with through-the-scope balloon catheters preferred due to their safety and ease of use. The dilation process involves inserting a balloon catheter through the stricture and inflating it under X-ray guidance, with the endoscopist determining the appropriate dilation diameter. Retrograde dilation is used for passable strictures, while anterograde dilation with wire-guided balloons is employed for non-passable strictures.

EBD offers short-term symptomatic improvement in the majority of patients, with a significant proportion avoiding surgery for extended periods. However, symptomatic recurrence is common, and the optimal technical details of EBD, such as balloon size and duration of insufflation, remain undefined.

2. Management of Dysplastic Lesions

Dysplastic lesions in IBD patients, which may precede CRC, can be managed endoscopically. Techniques like endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) offer minimally invasive options for resecting dysplastic tissue. 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

Advantages:

• Minimally invasive, reducing surgery-related morbidity and mortality.
• Preserves bowel anatomy and function.
• Repeatable and can be performed as needed.
• Can be used to assess disease activity and progression.

Disadvantages:

• Technical challenges, particularly with complex strictures and dysplastic lesions.
• Risk of complications, including bleeding, perforation, and recurrence.
• Limited long-term data on efficacy and durability of endoscopic treatments.

Conclusions

Endoscopic treatment approaches have emerged as important tools in the management of IBD-related strictures and dysplastic lesions. While 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 involving gastroenterologists, radiologists, and colorectal surgeons, ensuring a patient-tailored approach that balances risks and benefits.

Reference:

Alberto Barchi, Sarah Bencardino, Ernesto Fasulo, Ferdinando D’Amico, Alessandra Zilli, Gionata Fiorino, Tommaso Lorenzo Parigi, Endoscopic Treatment Approaches for Inflammatory Bowel Diseases: Old Friends and New Weapons, Journal of Translational Gastroenterology, doi: 10.14218/JTG.2023.00096.