Stricture is a common complication of inflammatory bowel disease (IBD), including Crohn disease (CD) and ulcerative colitis.

Strictures may result from the chronic process of inflammation and tissue repair of underlying disease, as well as tissue healing of inflammation from medical therapy, the concurrent use of nonsteroidal anti-inflammatory drugs, or surgery-associated ischemia.

Strictures in IBD can be classified as follows: (1) primary (ie, disease associated) versus secondary (eg, anastomotic), based on etiology (Figs. 6-1 and 6-2); (2) short (<4 cm) versus long (≥4 cm), based on the length; (3) inflammatory versus fibrostenotic versus mixed; and benign versus malignant, based on histology; (4) mild versus moderate versus severe, based on the degree; (5) various locations, such as ileocolonic anastomosis (Fig. 6-2) and strictureplasty site (Fig. 6-3); and (6) associated conditions (eg, fistula, abscess, malignancy).

Endoscopic balloon dilation (EBD) has evolved into a main treatment modality of IBD and non-IBD-associated strictures.

EBD can have associated complications, including bowel perforation and excessive bleeding.

IBD patients on systemic corticosteroids have a higher risk for procedure-associated bowel perforation. EBD procedure should be avoided or postponed for those patients.

A high-quality bowel preparation is important for safe and successful EBD.

Preprocedural abdominal imaging should be obtained and carefully reviewed, which will help provide a road-map for the endoscopic intervention.

It is important to review any previous operative notes (since a number of patients have had some form of surgery in the past) and endoscopy notes prior to the current endoscopy procedure.

Surgical backup should be readily available, if a perforation occurs.

EBD can be performed in an outpatient setting with or without fluoroscopic guidance.

EBD can be performed with patients utilizing conscious sedation alone in most cases.

EBD can be performed via adult colonoscope, pediatric colonoscope, or gastroscope, depending on the degree and location of stricture.

Patients are placed in the left lateral decubitus position. This provides access to the perineum and avoids potential respiratory issues with the prone position.

During the index endoscopy, any strictures should be biopsied to rule out malignancy.

The endoscopist should make an attempt to traverse encountered stricture, even when encountering some resistance. Ultrathin endoscopes may be used to traverse the stricture and observe the bowel segment proximal to the stricture.

The passage of scope through the stricture will allow for observation of the bowel anatomy at the proximal side of the stricture and the characterization of length, nature, and degree of the stricture.

EBD can be performed in a retrograde (ie, passage of scope through stricture, introduction of the balloon, then pulling scope back, followed by insufflation of balloon) or an antegrade manner. Retrograde EBD is preferred to antegrade EBD.

For strictures that are not traversable, antegrade EBD may be performed. A wire exchange technique is recommended during antegrade EBD to reduce the risk of bowel perforation.

The wire should be pushed out from the tip of the balloon during insufflation to reduce barotrauma from the tip of a forward-slipped balloon.

For the treatment of an IBD-associated stricture, the targeted balloon size is set from 15 to 20 mm, depending on the location, degree, length, and shape of the stricture.

There are two commonly used balloons, 5.5 and 8.0 cm, in length. The short balloon is equipped with a guidewire.

The duration of balloon insufflation is around 5 seconds.

A second look of stricture and bowel segment proximal to the stricture after EBD is often performed to observe efficacy of the treatment, to ensure no excessive bleeding or perforation, and/or to perform a rescuing procedure (such as clipping of bleeding vessel or perforation) as needed. In addition, passage of the endoscope through dilated stricture has been used to measure “technical success” of EBD.

The role of intralesional injection of long acting corticosteroids after EBD in keeping the lumen patent and avoidance of restricturing is controversial.

Patients are observed in the endoscopy recovery suite for at least 30 minutes. An excessive pain, bloating, or unstable vital sign should immediately trigger further evaluation, such as plain abdominal series to rule out a perforation.