Endoscopy in Crohn’s Disease   Peter Darwin, MD Director of Gastrointestinal Endoscopy University of Maryland Hospital Div...
Outline <ul><li>Case histories </li></ul><ul><li>Diagnosis </li></ul><ul><li>Assessment of response </li></ul><ul><li>Dysp...
Case 1 <ul><li>The patient is a 28 year old man with isolated iliocolonic Crohn’s disease resected 8 years prior. </li></u...
Case 2 <ul><li>19 year old student presents with several months of vague epigastic discomfort, night sweats and weight los...
Diagnosis <ul><li>Asymmetric patchy inflammation </li></ul><ul><li>Skip lesions </li></ul><ul><li>Rectal sparring </li></u...
 
Assessment of Response <ul><li>Endoscopic monitoring may have a role with biologic agents </li></ul><ul><li>Subgroup  of t...
 
Dysplasia and Surveillance <ul><li>Extensive colitis > 8 years </li></ul><ul><li>Accuracy in predicting dysplasia correlat...
Approach to Polypoid Lesions Adenoma like DALM Outside colitis Within colitis Polypectomy/biopsy Non-IBD adenoma Polypecto...
Hemorrhage in Crohn’s <ul><li>Acute major hemorrhage is uncommon </li></ul><ul><li>Bleeding can occur in any segment </li>...
Hemorrhage in Crohn’s <ul><li>No data to support cautery or injection therapy </li></ul><ul><li>Surgical intervention </li...
<ul><li>Database review from 1989 to 1996 </li></ul><ul><ul><li>1739 patients / 31 (1.8%) due to IBD </li></ul></ul><ul><u...
Endoscopic Therapy for Patients with CD and Focal Sites of hemorrhage Patient  Site  Stigmata  Endoscopic Rx  Medical Rx 1...
Clinical Course
Balloon Dilation of Strictures
Descending Colon Stricture
Colonic Strictures <ul><li>No randomized clinical trials </li></ul><ul><li>Consider nonsurgical management if: </li></ul><...
Malignant Potential <ul><li>Increased incidence of colonic and small bowel carcinoma </li></ul><ul><li>Higher risk with lo...
 
Balloon Dilation of Strictures <ul><li>High success rate for anastamotic strictures </li></ul><ul><li>Used for colonic and...
Injection of Corticosteroids <ul><li>Post dilation </li></ul><ul><li>Sclerotherapy needle </li></ul><ul><li>Triamcinolone ...
 
Intestinal Stents <ul><li>Limited data  </li></ul><ul><li>Migration is common </li></ul><ul><li>Coated metal enteral stent...
Endoscopic Balloon Dilation of Ileal Pouch Strictures <ul><li>Aim: evaluate outpatient ileal pouch stricture dilation </li...
Inlet and Outlet Strictures
Clinical Presentation n (%) Diarrhea Abdominal pain Perianal pain Bloating Nausea or vomiting Bleeding Daily use of antidi...
Types of Strictures Number  Inlet  Outlet of cases  strictures  strictures Crohn’s disease of the pouch Cuffitis Pouchitis...
Pouch Disease Activity Index
Strictures Scores
Cleveland Global Quality of Life Scores
Emerging Technology <ul><li>Double balloon enteroscopy </li></ul><ul><li>Endoscopic ultrasound </li></ul><ul><li>Optical c...
 
 
 
Takayuki Matsumoto, Tomohiko Moriyama, et. al.  Gastrointest Endosc 2005;62 :392-8
`
 
Optical Coherence Tomography <ul><li>Based on low-coherence  </li></ul><ul><li>interferometry </li></ul><ul><li>High resol...
Magnification Chromoendoscopy <ul><li>Utilizes magnifying endoscopes with tissue stains to better characterize the mucosa ...
Colonic Pit Pattern Huang Q, Norio F, et. al. Gastrointest Endosc 2004; 60:520-6.
 
Case 1 <ul><li>The patient is a 28 year old man with isolated iliocolonic Crohn’s disease resected 8 years prior. </li></u...
Case 2 <ul><li>19 year old student presents with several months of vague epigastic discomfort, night sweats and weight los...
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Pancreatic Cancer: The Use of Endosonography

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Pancreatic Cancer: The Use of Endosonography

  1. 1. Endoscopy in Crohn’s Disease Peter Darwin, MD Director of Gastrointestinal Endoscopy University of Maryland Hospital Division of Gastroenterology
  2. 2. Outline <ul><li>Case histories </li></ul><ul><li>Diagnosis </li></ul><ul><li>Assessment of response </li></ul><ul><li>Dysplasia and surveillance </li></ul><ul><li>Bleeding </li></ul><ul><li>Stricture management </li></ul><ul><li>Emerging technology </li></ul>
  3. 3. Case 1 <ul><li>The patient is a 28 year old man with isolated iliocolonic Crohn’s disease resected 8 years prior. </li></ul><ul><li>Was without symptoms but has developed intermittent abdominal distension, bloating and emesis requiring admission. </li></ul><ul><li>SBFT shows a 1 cm tight anastamotic stenosis </li></ul><ul><li>Is attempt at endoscopic management appropriate? </li></ul>
  4. 4. Case 2 <ul><li>19 year old student presents with several months of vague epigastic discomfort, night sweats and weight loss. </li></ul><ul><li>Evaluation shows a microcytic anemia and thrombocytosis. </li></ul><ul><li>Abdominal CT shows a thickened mid-ileum without lymphadenopathy. Attempts to intubate the TI during colonoscopy were unsuccessful. </li></ul><ul><li>Is tissue needed prior to treatment ? </li></ul>
  5. 5. Diagnosis <ul><li>Asymmetric patchy inflammation </li></ul><ul><li>Skip lesions </li></ul><ul><li>Rectal sparring </li></ul><ul><li>Ulcerations </li></ul><ul><li>Biopsy </li></ul><ul><ul><li>Erosions and normal mucosa </li></ul></ul><ul><ul><li>Granulomas in 15 to 35% of specimens </li></ul></ul>
  6. 7. Assessment of Response <ul><li>Endoscopic monitoring may have a role with biologic agents </li></ul><ul><li>Subgroup of the ACCENT-1 trial </li></ul><ul><ul><li>Mucosal healing with infliximab, time to relapse is significantly prolonged </li></ul></ul><ul><ul><ul><li>9 with endoscopic healing remained in remission for a median of 20 weeks </li></ul></ul></ul><ul><ul><ul><li>4 clinical remission only, relapse after a median of 4 weeks </li></ul></ul></ul>
  7. 9. Dysplasia and Surveillance <ul><li>Extensive colitis > 8 years </li></ul><ul><li>Accuracy in predicting dysplasia correlates with # of biopsies </li></ul><ul><li>Annual colonoscopy with multiple biopsy specimens </li></ul><ul><ul><li>4 circumferential each 10 cm </li></ul></ul>
  8. 10. Approach to Polypoid Lesions Adenoma like DALM Outside colitis Within colitis Polypectomy/biopsy Non-IBD adenoma Polypectomy Regular surveillance No dysplasia No carcinoma Indeterminate Flat dysplasia carcinoma Polypectomy Increased surveillance Colectomy Chawla A, Lichtenstein G. Gastrointest Endoscopy Clin N Am 12 (2002) 525-534
  9. 11. Hemorrhage in Crohn’s <ul><li>Acute major hemorrhage is uncommon </li></ul><ul><li>Bleeding can occur in any segment </li></ul><ul><li>Massive hemorrhage is usually from an ulcer eroding into a vessel </li></ul><ul><li>Resuscitation </li></ul><ul><li>Endoscopy vs tagged RBC scan to localize a bleeding segment </li></ul><ul><li>Avoid embolization if possible </li></ul>
  10. 12. Hemorrhage in Crohn’s <ul><li>No data to support cautery or injection therapy </li></ul><ul><li>Surgical intervention </li></ul><ul><li>Consider tattooing of the site </li></ul>
  11. 13. <ul><li>Database review from 1989 to 1996 </li></ul><ul><ul><li>1739 patients / 31 (1.8%) due to IBD </li></ul></ul><ul><ul><li>3 with UC and 28 with CD / 1 UGI source </li></ul></ul><ul><ul><li>None hematemesis </li></ul></ul><ul><ul><li>GI hemorrhage in 0.1% UC and 1.2% CD </li></ul></ul><ul><li>Diagnostic evaluation </li></ul><ul><ul><li>Source found by colonoscopy in 25 patients (25%) and EGD in 2 patients </li></ul></ul>Pardi D, Loftus E, et al. Gastrointest Endosc 1999;49:153-7. Acute Major GI hemorrhage in IBD
  12. 14. Endoscopic Therapy for Patients with CD and Focal Sites of hemorrhage Patient Site Stigmata Endoscopic Rx Medical Rx 1 Duodenum clot Injection Corticosteroids ranitidine 2 Jejunum oozing ulcer Injection Corticosteroids ranitidine 3 Colon clot Injection with Corticosteroids coagulation metronidazole
  13. 15. Clinical Course
  14. 16. Balloon Dilation of Strictures
  15. 17. Descending Colon Stricture
  16. 18. Colonic Strictures <ul><li>No randomized clinical trials </li></ul><ul><li>Consider nonsurgical management if: </li></ul><ul><ul><li>Endoscopically accessible </li></ul></ul><ul><ul><li>Multiple prior resections </li></ul></ul><ul><ul><li>Shorter strictures (less than 5 cm) </li></ul></ul><ul><ul><li>Steroid injection if significant inflammation </li></ul></ul>
  17. 19. Malignant Potential <ul><li>Increased incidence of colonic and small bowel carcinoma </li></ul><ul><li>Higher risk with longer duration of disease </li></ul><ul><li>Stricture biopsy required </li></ul><ul><li>Utilize thin caliper scopes to evaluate proximal to the stenosis </li></ul>
  18. 21. Balloon Dilation of Strictures <ul><li>High success rate for anastamotic strictures </li></ul><ul><li>Used for colonic and duodenal stenosis </li></ul><ul><li>TTS balloons 15 to 18 mm for 1 minute </li></ul><ul><li>Fluoroscopy only if needed </li></ul><ul><li>Successful if scope passed post </li></ul><ul><li>Medical treatment </li></ul><ul><li>Complications </li></ul>
  19. 22. Injection of Corticosteroids <ul><li>Post dilation </li></ul><ul><li>Sclerotherapy needle </li></ul><ul><li>Triamcinolone 40 mg/ml – 1 cc in 4 quadrants at site of maximal inflammation/stenosis </li></ul>
  20. 24. Intestinal Stents <ul><li>Limited data </li></ul><ul><li>Migration is common </li></ul><ul><li>Coated metal enteral stents / plastic stents may be of benefit </li></ul>
  21. 25. Endoscopic Balloon Dilation of Ileal Pouch Strictures <ul><li>Aim: evaluate outpatient ileal pouch stricture dilation </li></ul><ul><li>Methods: Nonfluroscopy, nonsedated dilation with 11-18 mm TTS balloons in 19 consecutive patients </li></ul>Shen B, Fazio V, Remzi F, et al. Am J Gastro 2004;99:2340-47.
  22. 26. Inlet and Outlet Strictures
  23. 27. Clinical Presentation n (%) Diarrhea Abdominal pain Perianal pain Bloating Nausea or vomiting Bleeding Daily use of antidiarrheal agents Fistulas Weight loss 18 (94%) 19 (100%) 15 (79%) 9 (47%) 3 (16%) 4 (21%) 8 (42%) 6 (32%) 5 (26%)
  24. 28. Types of Strictures Number Inlet Outlet of cases strictures strictures Crohn’s disease of the pouch Cuffitis Pouchitis Total 11 14 6 5 0 5 3 0 3 19 14 14
  25. 29. Pouch Disease Activity Index
  26. 30. Strictures Scores
  27. 31. Cleveland Global Quality of Life Scores
  28. 32. Emerging Technology <ul><li>Double balloon enteroscopy </li></ul><ul><li>Endoscopic ultrasound </li></ul><ul><li>Optical coherence tomography </li></ul><ul><li>Magnification chromoendoscopy </li></ul>
  29. 36. Takayuki Matsumoto, Tomohiko Moriyama, et. al. Gastrointest Endosc 2005;62 :392-8
  30. 37. `
  31. 39. Optical Coherence Tomography <ul><li>Based on low-coherence </li></ul><ul><li>interferometry </li></ul><ul><li>High resolution imaging </li></ul><ul><li>Uses light (not sound) </li></ul><ul><li>Resolution 10X greater than EUS </li></ul><ul><li>No acoustic coupling </li></ul>
  32. 40. Magnification Chromoendoscopy <ul><li>Utilizes magnifying endoscopes with tissue stains to better characterize the mucosa </li></ul><ul><li>May improve efficacy of surveillance colonoscopy </li></ul><ul><ul><li>165 patients with UC randomized to conventional screening vs CE. </li></ul></ul><ul><ul><li>Targeted biopsies </li></ul></ul><ul><ul><li>Identified more areas of dysplasia </li></ul></ul>Kiesslich R, Fritch J, et. al. Gastro 2002;124:880-8.
  33. 41. Colonic Pit Pattern Huang Q, Norio F, et. al. Gastrointest Endosc 2004; 60:520-6.
  34. 43. Case 1 <ul><li>The patient is a 28 year old man with isolated iliocolonic Crohn’s disease resected 8 years prior. </li></ul><ul><li>Was without symptoms but has developed intermittent abdominal distension, bloating and emesis requiring admission. </li></ul><ul><li>SBFT shows a 1 cm tight anastamotic stenosis </li></ul><ul><li>Is attempt at endoscopic management appropriate? </li></ul>
  35. 44. Case 2 <ul><li>19 year old student presents with several months of vague epigastic discomfort, night sweats and weight loss. </li></ul><ul><li>Evaluation shows a microcytic anemia and thrombocytosis. </li></ul><ul><li>Abdominal CT shows a thickened mid-ileum without lymphadenopathy. Attempts to intubate the TI during colonoscopy were unsuccessful. </li></ul><ul><li>Is tissue needed prior to treatment ? </li></ul>

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