A patient with severe Crohn's disease, an ileal stricture and proximal dilation on CTE should have...
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Transcript of A patient with severe Crohn's disease, an ileal stricture and proximal dilation on CTE should have...
![Page 1: A patient with severe Crohn's disease, an ileal stricture and proximal dilation on CTE should have medical therapy first Uma Mahadevan MD Professor of.](https://reader033.fdocuments.in/reader033/viewer/2022052223/56649cc05503460f9498619c/html5/thumbnails/1.jpg)
A patient with severe Crohn's disease, an ileal stricture and
proximal dilation on CTE should have medical therapy first
Uma Mahadevan MD
Professor of Medicine
University of California, San Francisco
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What is your goal?
• Achieve remission• Endoscopic and radiologic improvement
• Symptomatic improvement
• Avoid surgery
• Spare small bowel
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All patients are not the same
• Patient with inflammation and stricture• Naïve to biologic therapy?
• Failed prior biologic therapy?
• Response to steroids?
• How much small bowel is involved?
• How much of it is strictured?
• Prestenotic fistula
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Do we have any data?
• Does anti-TNF therapy make strictures worse?
• Does anti-TNF therapy make strictures better?
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Anti-TNF therapy does NOT cause strictures• Theoretical concern: rapid luminal healing in CD with anti-TNF increases risk of
intestinal stenosis, stricture, obstruction (SSOs).
• Treat Registry
• SSOs occurred at a significantly higher rate in patients treated with infliximab compared with other therapy
• (1.95 events/100 patient-years vs 0.99 events/100 patient-years; p < 0.001)
• Using multivariable analyses, however, infliximab therapy was not associated with SSO development.
• CD severity at the time of event onset (HR = 2.35, 95% CI 1.35-4.09)
• CD duration (HR = 1.02, 95% CI 1.00-1.04)
• Ileal disease (HR = 1.56, 95% CI 1.04-2.36)
• New corticosteroid use (HR = 2.85, 95% CI 1.23-6.57)
• ACCENT 1: no increase in SSOs on IFX maintenance vs. episodic therapy, despite higher median IFX exposure
• No increase in SSO development with rapid mucosal healing (healing at week 10)
• IFX use NOT associated with increased SSO, but with severity, duration, ileal location and new steroids
Lichtenstein Am J Gastroenterol. 2006 May;101(5):1030-8
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Does anti-TNF therapy improve
strictures?
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11 patients
• Retrospective analysis, single center experience with infliximab in CD patients with inflammatory stenoses.
• Among a total of 21 patients treated with infliximab, 11 patients had an inflammatory stenosis.
• 9 responded well, became completely asymptomatic
• Infliximab was tolerated well except for one patient who developed an intrabdominal abscess.
Holtmann Z Gastroenterol. 2003 Jan;41(1):11-7.
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6 patients
• Six patients with a documented and symptomatic small bowel stricture caused by CD refractory to corticosteroids and/or immunosuppressives, and not in need for immediate surgery.
• Single infusion of infliximab 5 mg/kg and followed up at w1, 2, 4 and 8.
• RESULTS: • Only two patients completed the 8 weeks study, with a positive response to infliximab and
improvement of inflammation confirmed by the CRP and CT scan.
• Two patients had to be operated early and the last two patients first did well but worsened after one month and were operated 35 and 42 days after infliximab, respectively.
• No surgical complications occurred in the 4 operated patients.
• In conclusion, a subset of patients with subocclusive small bowel stricturing CD may benefit from infliximab.
Louis Acta Gastroenterol Belg. 2007 Jan-Mar;70(1):15-9
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18 patients
• Retrospective study of symptomatic patients treated with infliximab after conventional treatment had failed. The short-term (week 8) and long-term results were classified according to predefined criteria as complete, partial response, or failure.
• RESULTS: • Before infliximab, 18 patients had complete obstruction or intermittent chronic abdominal pain.
• Fourteen patients were treated by corticosteroids and 13 received immunosuppressive drugs.
• At week 8, complete (10), partial response (7) and failure (1) patients
• Fourteen patients continued maintenance infliximab treatment after week 8.
• Follow up (median 18 months): 8 patients were on maintenance infliximab treatment; only eight were still on prednisone; there were five complete responses, 10 partial responses and three failures.
Pelletier Aliment Pharmacol Ther. 2009 Feb 1;29(3):279-85.
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• Historical cohort study of 226 patients with stricturing CD that had CTE or MRE
• 49% surgery within median of 1 year
Biologics Decrease Surgery Due to “Low-Risk” Strictures in Patients with CD
CTE, computed tomography enterographyMRE, magnetic resonance enterography Nepal S, Shen B et al. Presented at DDW; May 19, 2012. Abstract 271.
Biologics may reduce the risk of surgery by up to 44% in stricturing CD. HR =.44 (p=0.007)No impact of endoscopic dilation (n=50)This benefit may be more pronounced in patients with a “low-risk” (SSS=0) enterographic findings.
Development Simplified Stricture Severity (SSS) Score
Internal FistulaSmall Bowel Obstruction (SBO)
Prox. Dilation ≥ 3cmAbdominal mass/abscess
Mesenteric stranding
Su
rger
y-F
ree
%
0
100
0.0 1.0 3.5
40
60
SSS 0
47
39
No Biologics
Biologics
80
20
3.00.5 2.52.01.5
34
32
26
30
22
25
13
17
9
9
5
6
2
3
1.0 3.53.00.5 2.52.01.5
36
34
31
28
23
22
16
14
9
4
7
2
2
0
0.0
60
60
Biologics
No Biologics
p-value – 0.007
SSS 1-5
Biologics
No Biologics
p-value – 0.3
AUC = 0.7 for predicting surgery at 1 year
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Individualize your approach (i.e. common sense)
• Patient with inflammation and stricture• Naïve to biologic therapy * yes, consider therapy
• Failed biologic therapy* Go to surgery
• Response to steroids? * yes, consider therapy. Reversible component
• How much small bowel is involved? How much is strictured?• Long segment of inflammation, not all stricture * yes, consider therapy
• Short stricture * Go to surgery
• Prestenotic fistula *? vent. Surgery likely best option
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Conclusion
A patient with severe Crohn's disease, an ileal stricture and proximal dilation on CTE should have medical therapy first
• To prevent unnecessary surgery
• To minimize loss of small bowel prior to surgery
• Dilation in the setting of inflammation or a non-anastomotic stricture is unlikely to be durable