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Kurdistan Board weekly Journal club: IBD endoscopic therapies.
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Kurdistan GEH Board Journal Club
Dr.Mohamed Al-Shekhani.
IBD:Complications
IBD-RELATED STRICTURES
IBD-RELATED FISTULA&sinuses
Abcesses
COLITIS-ASSOCIATED NEOPLASIA
Bezoars in ileal pouch reservoir
Surgical anastomotic strictures
IBD:Classifications
Nonstricturing/nonpenetrating (B1) Stricturing (B2)Penetrating (B3)
Extensive colitis Left-sided colitis ProctitisStricture: cancer,muscularis mucosa hyperplasia,inflamm submucosal fibrosis
Lympho ColitisCollagenoius Colitis
IBD:
CD:Montreal classification
UC:Classification
Microscopic
colitis
IBD Strictures:
Inflam strictures
MechanicalFibrotic
strictures
Anti– TNF, biologics, or steroids.
Endoscopic or surgery
Med if inflamm
Endoscopic Surgery
Management:
CD/UC strictures trt
IBD Strictures : Endoscopy or surgery
For stricturesat the surgical anastomosis, colon, or small bowel no > 4-7 cm in length.
EndoscopyTTS balloon
dilation Surgery
int resection with anastomosisor stricturoplasty
IBD Strictures : Endoscopy or surgery
CHOICE Depends on
EndoscopyTTS balloon
dilation Surgery
Disease course Characteristics of strictures, Concurrent IBD-associated adverse events ( abscesses), Medical comorbiditieslocal expertise.
IBD : Surgery complications
At the surgical anastomosis or neoterminalileum
Septic:
Between the ileal pouchBody & anal transitional zone after restorative proctocolectomy for UC
Surgery complications: recurrence
FistulasLeakAbscesses
Anastomotic strictures:
IBD strictures: Diagnosis
Recommended before diagnostic/therapeutic endoscopy to provide the “ roadmap” (eg, location, number& length of strictures).
Main advantage is the ability to obtain biopsies for histologic assessment &deliver therapy at the time of the diagnosis.
CTE,MRE,TAUS,SICUS,EUS,SI follow Though,GGE.
Abd& pelvic imaging :
Endoscopy:
Abd/pelvic imagings:
CTE:
Noninvasive, available, easy to perform, IV contrast Excessive ionizing radiation.
Active CD: fat stranding,mucosal hyperenhancement, vasa recta engorgement,transmural infl ammation, lymphadenopathy, abscessor fitula.
Fibrostenotic disease on CTE definedBy presence of narrowing of the intestinal lumen without active infl ammation
Advantages/Disadvantages:
MRE:
A low intensity onT1 &T2 sequences is characteristic of chronic fibroticstrictures,
A high intensity on fat-suppressed T2 imagesis a feature of infl ammatory edematous strictures.
For assess of small / large bowel CD with particular utilityFor distinguishing between fi brostenotic& active disease.
Advantages/Disadvantages:
TAUS,SI CEU:
used to detect small bowel strictures in CD
High sensitivity/specificity
Operator-dependent
Advantages/Disadvantages:
Gastrograffin enema (GGE):
Used for distal colonic stricturesor fistulas, for ileal pouch-anal anastomosis (IPAA)adverse events including strictures& anastomotic leaks,for abnormalities at the neoterminal ileum in patientswith stomas.
Useful in the detection of the number/length of strictures& their conditions.
Sens 100% in diagnosing pouch-anal anastomotic strictures when ananastomotic diameter >8 mm is used for Diagnosis. Sens80%,spec 95% for inlet/distal SI strictures with a spec 93% for outlet strictures in patients with IPAA.
Advantages/Disadvantages:
IBD strictures:endoscopic trts&Complication
TTS BD
Perforation: cliping,OTC,surgery
NK Endoscopic stricturotomy
Bleeding: most can be controlled by endoscopic hemostasis
Stenting
Endoscopic trts:
Endoscopic balloon dilation therapy
TYPE TTS
Indications
IBD-related benign small bowel, ileocolonic, or colonic strictures. symptomatic strictures <4 -5 cm withoutassociated fistulas abscesses, or malignancy. facilitate completion of dysplasia surveillance in non-traversable strictures.
Endoscopic stricturotomy
TYPE Needle-knife
Indications
Ileocolonic ileal pouch strictures.More effective than TTS balloon dilation in refractory IBD-related benign strictures,with acceptable adverse events as bleeding and perforation.
Endoscopic stent placement
TYPE SEMS ? Bidegradable
Migration prv
Migration reduced by endoscopic suturing.
IBD complications:others
sinuses Anastomotic leaks
Bezoars in ileal pouch reservoir
Endo dilation of strictures & removal of bezoars
Endotrts: NK, Stents,
1
2
3
5
4Endoinj: fibrin glue
Endoinj: stem cells
Med trts:No good long-term results
Endoscopic injections:Doxycycline+acetylctstein
Endoinj: 50% glucose or honey
CD:Fistla treaTments
CD-Fistulas: treatments
Colitis-associated neoplasia:
COLITIS-ASSOCIATED NEOPLASIA.
DALM: raised lesion with associated
dysplasia
Adenoma-like lesion resembling sporadic adenoma without adjacent flat dysplasia
Non– adenoma-like lesion is typically an ulcerated, broadbased,irregular lesion.
diagnosis of all dysplasia needs to be confirmed by at least 2 expert GI pathologists.
PolypectomyColonoscopy repeated
in 6/12
ColectomyMay be removed by
EMR or ESD
Patients with multifocal flat low-grade dysplasia, repetitive low-grade dysplasia, or high-grade
dysplasia should be referred for total colectomy.
Endoscopic procedures-associated adverseevents & management:
Perforation trts:Endoscopic clip; usual or OTC, FC SEMS. Endoscopic therapy in IBD patients should be performed by specialized endoscopists, with proper surgical backup.
Perforation:> In non-IBD Patients BZ of the inflammation & immunne modulators use.
Complications:
1
Perfo
ration
s
Bleed
ing2
Bleeding:Managed by endoscopic clips. ASGE guidelines: endoscopic dilation is with a higher risk of bleeding, hold clopidogrel or ticlopidine 7 -10 days before endoscopy &warfarin before the procedure with bridging therapy in patients at high risk of thromboembolic events.
IBD complications: Endotherapies Endoscopic trts are important modalities in the
trt of IBD, adjunct to medical& surgical approaches.
They are particularly useful in the management of IBD-associated or IBD surgery– associated strictures, fistulas, &sinuses &colitis-associated neoplasia.
The main focus is on balloon stricture dilation& ablation of adenoma-like lesions
New endoscopic approaches are emerging, include needle-knife stricturotomy, needle-knife sinusotomy, endoscopic stent placement& fistula tract injection.
Risk management of endoscopy-associated adverse events is also evolving.
These novel treatments just beginning& will likely expand rapidly in the near future.
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