Florian Rieder, MD, on Stricture Management in Crohn Disease

Many individuals with Crohn disease (CD) develop intestinal obstruction due to strictures throughout the course of their disease. Anti-inflammatory medications, endoscopic therapy and surgical procedures are the only treatment options available for individuals with CD and stricture.

While advances have been made in the development of treatment methods to target pathways to control chronic inflammation, no antifibrotic medications are available for the management of strictures in CD.

Gastroenterology Consultant spoke with Florian Rieder, MD, a staff member in the Department of Gastroenterology, Hepatology & Nutrition at Cleveland Clinic, about how the management of strictures in CD has changed over time, what challenges remain, and the need for antifibrotic therapies.

Gastroenterology Consultant: How are strictures in CD typically managed?

Florian Rieder: If an individual arrives at the hospital with clinical symptoms of obstruction such as abdominal cramping, vomiting, or constipation, the individual should undergo bowel ultrasonography, computed tomography (CT) enterography or magnetic resonance (MR) enterography. These imaging techniques detect the presence of obstruction. Once obstruction is established, it is crucial to determine if inflammation is present in the stricture or not. If we see signs of inflammation signified by either contrast enhancements or edema on the cross-sectional imaging, increased C-reactive protein level, or by elevated fecal calprotectin, we would initiate anti-inflammatory therapy. The type of anti-inflammatory therapy depends on which medication the individual is already receiving at the time of arrival at the hospital. Anti-inflammatory options include corticosteroids and biologics, and whatever anti-inflammatory medication the patient is on, it needs to be optimized.

If a patient responds to the anti-inflammatory medication and is doing fine, then we would initiate maintenance therapy for that patient with that medication. If the optimization of anti-inflammatory therapy does not work, fails to improve symptoms, or the symptoms return quickly, then the next steps would be to look at the location of the stricture, its length, and determine if there are any other features around it.

We need to check for abscesses, internal penetrating disease, or malignancy to determine further steps. If at onset there is no sign of inflammation, the clinician may go directly to the next step without administering anti-inflammatory therapy. The reason why we do that is because there are other therapeutic options. One is endoscopic balloon dilation, which can be done if the strictures are less than 5 centimeters, are in reach of endoscopy, and if they are not angulated. If an individual has strictures longer than 5 centimeters, then there are 2 surgical options: resection or strictureplasty.

GASTRO CON: How has management changed over time?

FR: When we initially started managing strictures, there was a much higher rate of surgical intervention, meaning resection. Over the years, surgical techniques have evolved to bowel-preserving surgery, so-called strictureplasty. The recovery after surgery is much shorter than it used to be, and there is an emergence of endoscopic techniques to dilate the stricture and treat the patient without the need for surgical intervention. Parallel to that, anti-inflammatory therapy has greatly improved.

GASTRO CON: What are the biggest challenges specialists face in the management of strictures?

FR: We do not have any specific antifibrotic medications for the management of strictures. The biggest challenge in the field is that we do not have clinical trial endpoints that allow testing of antifibrotic agents in CD. There are many antifibrotic medications available in other organs, and we have many mechanisms that may be important for strictures in CD, but they have not been tested in clinical trials. Only anti-inflammatory medications are available for use among individuals with stricture. Another challenge is that we cannot predict which individuals will have multiple strictures over time. It is very important to be able to predict this if we want to develop preventive strategies and treat obstruction over the course of the disease. There is a large body of work being done to develop biomarkers to help us stratify patients and predict which ones will have multiple strictures.

GASTRO CON: What are 3 key takeaways for specialists about strictures in CD?

FR: First, obtaining cross-sectional imaging, via ultrasonography, CT enterography or MR enterography. Prior to any medical or endoscopic intervention, it is crucial to determine the right treatment approach. A second point to remember is medical therapy is a valid option for strictures in CD. Endoscopic balloon dilation should be considered among individuals with strictures less than 5 centimeters that do not have internal abscesses, penetrating trauma, or any signs of malignancy. Lastly, it is important to note that colonic strictures are a very different phenotype compared with small-bowel strictures. Colonic strictures carry a higher risk of malignancy, and patients with colonic strictures should undergo a completely different treatment approach with a far lower threshold for surgical intervention.