List of Abbreviations
The American Society for Gastrointestinal Endoscopy
Computed tomography enterography
Endoscopic submucosal dissection
Examination under anesthesia
Inflammatory bowel disease
Ileal pouch-anal anastomosis
Monitored anesthesia care
Magnetic resonance enterography
Nonsteroidal antiinflammatory drug
Primary sclerosing cholangitis
Tumor necrosis factor
Dr. Bo Shen is supported by the Ed and Joey Story Endowed Chair.
In the past decade, endoscopic therapy has emerged as a valid alternative in the treatment of inflammatory bowel disease (IBD) to medical and surgical therapy, as it is more effective than medical therapy and less invasive than surgical surgery for IBD-associated stricture and maybe Crohn’s disease (CD)–related fistula. Endoscopic therapy has served as a bridging treatment modality between the medical and surgical therapy. Endoscopic therapy in IBD should be performed in experienced hands with main goals to avoid or space out the need for surgery. In this chapter, we discuss the preparation of endoscopic management for CD or ulcerative colitis-associated complications based on current literature and our vast experiences in a tertiary Interventional Inflammatory Bowel Disease (IBD) Unit at the Cleveland Clinic Foundation.
Screening for Candidate Patients
Not all patients with IBD-associated strictures, fistula, or surgical anastomotic leaks are eligible for endoscopic therapy. Therapeutic endoscopy should be avoided or postponed in patients with one of the following conditions: (1) malnutrition or severe comorbidities and being poor candidate for rescuing surgical intervention in case of endoscopy complications; (2) emergency setting; (3) concurrent use of immunosuppressive agents, such as corticosteroids and antitumor necrosis factor (TNF); (4) pregnancy; and (5) bleeding disorders or concurrent use of anticoagulations.
Routine history and physical examination should be performed before the procedure. Female patients at reproductive age may be screened for pregnancy.
Routine laboratory testing is useful for evaluating the risk of scheduled procedures, and for assisting in the selection of the appropriate endoscopic techniques. The American Society for Gastrointestinal Endoscopy (ASGE) recommended that preprocedural testing, such as complete blood counts, basic metabolic panel, coagulation tests, and electrocardiography, should be done selectively in indicated patients based on the medical history, physical examination, and procedure risk factors.
Defibrillator must be turned off during endoscopic electroincision and electrocauterization. The patient will need to be continuously monitored with a portable defibrillator.
Pre- and Post- Procedure Imaging
Preprocedural computed tomography enterography (CTE), magnetic resonance enterography (MRE), small bowel series, barium enema, and water-soluble contrasted gastrografin enema are imperative in the diagnosis and roadmap of IBD-related complications. For detailed information please see Chapter 7 . For CD-related stricture, CTE is the most commonly used modality since it is sensitive to identify the stricture, readily available and easy to perform. CTE imaging can delineate the location, number, length, and concurrent conditions (e.g., fistula and abscess) of strictures. However, CTE cannot differentiate inflammatory strictures from fibrostenotic ones. MRE may be more useful in this setting. Barium enema and GGE are commonly used in the assessment of CD-related complications of the large bowel and ileal pouch-anal anastomosis (IPAA). GGE via stoma can be performed in patients with colostomy or ileostomy. MRE with fistula protocol is more accurate than CT for the diagnosis of CD-related fistula, with reported accuracy ranging from 76% to 100%.
The surgical intervention is a common practice in the management of patients with CD and to a less degree in those with UC. CD-related surgeries include resection of bowel and anastomosis, stricturoplasty, bypass (for duodenum CD), fistulotomy, and abscess drainage. The bowel anatomy of CD or UC patients is often altered by those surgeries, especially by stricturoplasty and bypass surgery. The endoscopist needs to know the altered bowel anatomy in those patients, by a careful review of previous endoscopy report, operative report, and imaging of abdomen and pelvis.
Procedure-associated complications can occur. The endoscopist should have a lower threshold to send for abdominal imaging in patients suspected of bowel perforation. Ideally, the imaging center is close to the endoscopy suite.
In most cases, the therapeutic endoscopic intervention for IBD is done in an outpatient setting. The patient needs to be closely monitored for symptoms and signs of excessive bleeding or perforation after the procedure in the recovery room for at least 30 min. The patient will be asked to remain in town for 24 h in case of any delayed-onset complications.
Fluoroscopy may be needed when performing endoscopic stricture therapy. The use of fluoroscopy allows for the delineation of the to-be-treated stricture and the orientation of the entire balloon catheter. However, the use of fluoroscopy exposes the patient, the endoscopist and the endoscopy nurses to excessive ionizing radiation. Therefore, endoscopic therapy for IBD is routinely performed without fluoroscopic guidance in our center even in the treatment of tight and/or angulated strictures.
Air insufflation is imperative for keeping the intestinal lumen under constant visualization. However, the patients may experience discomfort if too much air is insufflated, especially in patients with a history of long-segment bowel resection or stricturoplasty. To reduce patient’s postprocedure bloating, the use of carbon dioxide insufflation rather than room air, is recommended due to its quicker absorption. The use of carbon dioxide insufflation during the procedure may facilitate a quicker recovery. Patients with chronic lung diseases, however, should avoid the use of carbon dioxide.
Endoscopic procedure may be performed in operative room, that is, examination under anesthesia (EUA). EUA is particularly useful in the detection of fistula in the distal bowel or perianal area. We here advocate that EUA with a combined medical/endoscopic and surgical teams in the operating room for CD or pouch patients with complex strictures, fistulae, and perianal disorders, which is now routinely performed at the Cleveland Clinic.