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Review
. 2013 Jul;62(7):1072-84.
doi: 10.1136/gutjnl-2012-304353. Epub 2013 Apr 26.

Crohn's disease complicated by strictures: a systematic review

Florian Rieder  1 , Ellen M Zimmermann, Feza H Remzi, William J Sandborn
Affiliations
Review

Crohn's disease complicated by strictures: a systematic review

Florian Rieder et al. Gut. 2013 Jul.

Abstract

The occurrence of strictures as a complication of Crohn's disease is a significant clinical problem. No specific antifibrotic therapies are available. This systematic review comprehensively addresses the pathogenesis, epidemiology, prediction, diagnosis and therapy of this disease complication. We also provide specific recommendations for clinical practice and summarise areas that require future investigation.

Keywords: Crohn's colitis; Fibrogenesis; Fibrosis; IBD Clinical.

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Conflict of interest statement

Competing interests FR is receiving consulting fees from GA Generic Assays GmbH, Germany. EMZ is receiving research grants from UCB Pharmaceuticals and Abbott Laboratories. FHR has no disclosures to report. WJS has received consulting fees from Abbott, ActoGeniX NV, AGI Therapeutics Inc, Alba Therapeutics Corp, Albireo, Alfa Wasserman, Amgen, AM-Pharma BV, Anaphore, Astellas, Athersys Inc, Atlantic Healthcare Ltd, Aptalis, BioBalance Corp, Boehringer-Ingelheim, Bristol-Myers Squibb, Celgene, Celek Pharmaceuticals, Cellerix SL, Cerimon Pharmaceuticals, ChemoCentryx, CoMentis, Cosmo Technologies, Coronado Biosciences, Cytokine Pharmasciences, Eagle Pharmaceuticals, EnGene Inc, Eli Lilly, Enteromedics, Exagen Diagnostics Inc, Ferring Pharmaceuticals, Flexio Therapeutics Inc, Funxional Therapeutics Ltd, Genzyme Corp, Gilead Sciences, Given Imaging, GlaxoSmithKline, Human Genome Sciences, Ironwood Pharmaceuticals, KaloBios Pharmaceuticals, Lexicon Pharmaceuticals, Lycera Corp, Meda Pharmaceuticals, Merck Research Laboratories, Merck Serono, Millennium Pharmaceuticals, Nisshin Kyorin Pharmaceuticals, Novo Nordisk, NPS Pharmaceuticals, Optimer Pharmaceuticals, Orexigen Therapeutics Inc, PDL Biopharma, Pfizer, Procter and Gamble, Prometheus Laboratories, ProtAb Ltd, Purgenesis Technologies Inc, Relypsa Inc, Roche, Salient Pharmaceuticals, Salix Pharmaceuticals, Santarus, Schering Plough, Shire Pharmaceuticals, Sigmoid Pharma Ltd, Sirtris Pharmaceuticals, SLA Pharma UK Ltd, Targacept, Teva Pharmaceuticals, Therakos, Tilliotts Pharma AG, TxCell SA, UCB Pharma, Viamet Pharmaceuticals, Vascular Biogenics Ltd, Warner Chilcott UK Ltd and Wyeth; research grants from Abbott, Bristol-Myers Squibb, Genentech, GlaxoSmithKline, Janssen, Millennium Pharmaceuticals, Novartis, Pfizer, Procter and Gamble, Shire Pharmaceuticals and UCB Pharma; payments for lectures/speakers bureaux from Abbott, Bristol-Myers Squibb and Janssen; and holds stock/stock options in Enteromedics.

Figures

Figure 1
Figure 1
Interplay between tissue damage of the intestinal bowel wall, caused by recruited and activated leukocytes and tissue repair, exerted by intestinal mesenchymal cells. Chronic, severe inflammation and tissue damage leads to excessive repair and untimately intestinal fibrosis. ECM, extracellular matrix; MMP, matrix metalloproteinase; ROS, reactive oxygen species.
Figure 2
Figure 2
Reduction of transmural oedema significantly affects the luminal cross-sectional area (adapted from Yaffe et al).
Figure 3
Figure 3
Through-the-scope endoscopic pneumatic balloon dilation of an anastomotic ileocecal stricture.
Figure 4
Figure 4
Manual examination for evaluation of tissue thickening and definition of the resection margin: the index finger opposes the thumb at the mesenteric–intestinal border.
Figure 5
Figure 5
Surgical techniques for stricturoplasty. (A–C) Heineke–Mikulicz-like procedure; (D–F) intermediate procedure (eg, Finney procedure); (G–I) enteroenterostomies (eg, isoperistaltic side-to-side strictureplasty by Michelassi).
Figure 6
Figure 6
Suggested approach to stricture therapy. *If endoscopically reachable, technically feasible and indicated. #Indications for stricturoplasty include: presence of multiple strictures over extensive length of bowel, previous significant small bowel resection (>100 cm), short bowel syndrome, strictures without phlegmon or septic fistula, duodenal strictures and anastomotic strictures. Contraindications include: associated abscess or phlegmon, perforation with diffuse peritonitis, suspicion of carcinoma in the stricture or poor nutritional status. Stricturoplasty can be performed safely in active disease. §Need to rule out malignancy. ED, endoscopic dilation.
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