Classification of Strictures From Crohn’s Disease, Ulcerative Colitis, and Inflammatory Bowel Disease–Related Surgery





List of Abbreviations


CAN


Colitis-associated neoplasia


CD


Crohn’s disease


CT


Computed tomography


CTE


Computerized tomography enterography


EBD


Endoscopic balloon dilation


ES


Endoscopic stricturotomy


IBD


Inflammatory bowel disease


ICA


Ileocolonic anastomosis


ICR


Ileocolonic resection


ICV


Ileocecal valve


IPAA


Ileal pouch-anal anastomosis


IRA


Ileorectal anastomosis


ISA


Ileosigmoid anastomosis


MRE


Magnetic resonance enterography


NSAIDs


Nonsteroidal antiinflammatory drugs


TNF


Tumor necrosis factor


UC


Ulcerative colitis


US


Ultrasound




Introduction


Crohn’s disease (CD) and ulcerative colitis (UC) are the two premier forms of inflammatory bowel disease (IBD). In the Montreal Classification System, CD was divided into non-stricturing/non-penetrating (B1), stricturing (B2), and penetrating (B3), based on clinical behavior. Stricturing disease is believed to result from persistent inflammation. CD-related strictures often lead to significant morbidities such as bowel obstruction and the development of fistula and abscess. In contrast, UC is characterized by the extent of colonic involvement with categories including extensive colitis, left-sided colitis, and proctitis. Despite being a “mucosal disease,” long-term UC can also cause strictures due to cancer, muscularis mucosae hyperplasia, and submucosal fibrosis possibly related to inflammatory cells. The inflammatory component of stricture may respond to corticosteroids or anti-tumor necrosis factor (TNF) therapy. On the other hand, there has been a concern that rapid tissue healing from anti-TNF therapy may result in or promote the formation of stricture.


CD-associated primary strictures have traditionally been treated with surgery, with bowel resection, stricturoplasty, or bypass. However, surgical therapies for both CD and UC are often associated with subsequent strictures at anastomosis sites. A Belgium team of investigators reported that strictures occurred at the surgical anastomosis or neoterminal ileum in 46% of patients after surgical intervention for CD. In patients with UC who underwent ileal pouch-anal anastomosis (IPAA), anastomotic strictures have been reported as occurring in 10%–40% of patients. The purported causes of anastomotic strictures included surgery-related ischemia, bacterial stasis, and high pressures within the intestine. Anastomotic strictures tend to recur, even after surgical resection and reanastomosis, and stricturoplasty.


The disease process of IBD is complex, which is further complicated by the use of medications and surgery-altered anatomy, the strictures in IBD patients represent a wide spectrum of phenotypes. Diagnosis and classification are important for proper management and improvement of short and long outcomes.




Definition and Source of Stricture


Intestinal stricture is defined as abnormal narrowing of bowel lumen. The term of stricture has been used interchangeable with stenosis. A stricture can lead to a spectrum of narrowing, from subtle to complete obstruction. In patients with IBD, either CD or UC, stricture may result from disease process (ranging from inflammation and fibrosis to malignancy) in the mucosa, muscularis mucosae, submucosa, or muscularis propria, or combination ( intrinsic stricture ). Other extraintestinal disease process can also cause bowel stricture or obstruction ( extrinsic stricture ), such as abscess, adhesion, compression of benign or malignant mass.


In addition to the presence of narrowing of bowel, multiple other factors may determine whether the patient presents bowel-obstructive symptoms, including degree of stricture, general medical conditions, pain tolerance, and psychological conditioning and deconditioning. Therefore, stricture can be divided into symptomatic stricture and asymptomatic ones ( Table 8.1 ).



Table 8.1

Classification of Gastrointestinal Strictures in Inflammatory Bowel Disease




























































































































































































Category Description Examples
Source Intrinsic Inflammation, fibrosis, or malignancy in any layers of bowel wall Terminal ileum stricture of Crohn’s disease
Extrinsic Extraintestinal compression, pushing, and pulling Adhesion, abscess compression
Clinical presentation Symptomatic
Asymptomatic
Underlying disease and surgery Crohn’s disease Ileocecal valve stricture, anal stricture, terminal ileum strictures
Ulcerative colitis
Postsurgical Bowel resection and anastomosis Ileocolonic stricture, ileal rectal stricture
Ileal pouch Inlet and anastomosis strictures, loop ileostomy site stricture, afferent limb site strictures
Stricturoplasty Inlet and outlet strictures
Bypass Gastrojejunostomy stricture
Ileostomy/jejunostomy/colostomy Skin, stoma, and bowel stricture
Primary (disease, drug, ischemia) Disease associated
Drug associated Nonsteroidal antiinflammatory drugs (NSAID), pancreas enzyme
Secondary Anastomotic
Near suture or staple lines Pouch inlet, stricturoplasty outlet/inlet
Malignant potential Benign Ileocolonic anastomotic stricture
Malignant Adenocarcinoma, lymphoma, squamous cell cancer (in anal canal) Colon cancer from colitis-associated dysplasia
Inflammation and fibrosis component Inflammatory
Fibrotic
Mixed
Length Short <4 cm
Long ≥4 cm
Characteristic of stricture Ulcerated
Web like Concurrent NSAID use
Spindle shaped
Angulated
Symmetry Circumferentially asymmetric Some ileocecal valve stricture
Longitudinally asymmetric Ileocolonic or ileorectal anastomotic strictures
Location in nonsurgical patients Esophagus
Pylorus
Small bowel
Ileocecal valve
Colon
Rectum
Anus
Degree No stricture No stricture
Mild Passage of scope with mild resistance
Moderate Passage of scope with moderate resistance
Severe Pinhole stricture, not traversable to endoscope
Number Single
Multiple
Complexity Simple
Complex with associated conditions Fistula and/or abscess
Prestenotic luminal dilation

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Dec 30, 2019 | Posted by in GASTROENTEROLOGY | Comments Off on Classification of Strictures From Crohn’s Disease, Ulcerative Colitis, and Inflammatory Bowel Disease–Related Surgery
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