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Git j club IBD endotrts.


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Kurdistan Board weekly Journal club: IBD endoscopic therapies.

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Git j club IBD endotrts.

  1. 1. LOGO Kurdistan GEH Board Journal Club Dr.Mohamed Al-Shekhani.
  2. 2. IBD:Complications IBD-RELATED STRICTURES IBD-RELATED FISTULA&sinuses Abcesses COLITIS-ASSOCIATED NEOPLASIA Bezoars in ileal pouch reservoir Surgical anastomotic strictures
  3. 3. IBD:Classifications CD: Montreal classification IBD: UC: Classification Microscopic colitis Nonstricturing/nonpenetrating (B1) Stricturing (B2) Penetrating (B3) Extensive colitis Left-sided colitis Proctitis Stricture: cancer,muscularis mucosa hyperplasia,inflamm submucosal fibrosis Lympho Colitis Collagenoius Colitis
  4. 4. IBD Strictures: Management: Inflam strictures Mechanical Fibrotic strictures Endoscopic or surgery Med if inflamm Anti– TNF, biologics, or steroids. CD/UC strictures trt Endoscopic Surgery
  5. 5. IBD Strictures : Endoscopy or surgery Endoscopy TTS balloon dilation For strictures at the surgical anastomosis, colon, or small bowel no > 4-7 cm in length. int resection with anastomosis or stricturoplasty Surgery
  6. 6. IBD Strictures : Endoscopy or surgery CHOICE Depends on Endoscopy TTS balloon dilation Disease course Characteristics of strictures, Concurrent IBD-associated adverse events ( abscesses), Medical comorbidities local expertise. Surgery
  7. 7. IBD : Surgery complications Surgery complications: recurrence Leak Abscesses Septic: Anastomotic strictures: At the surgical anastomosis or neoterminal ileum Fistulas Between the ileal pouch Body & anal transitional zone after restorative proctocolectomy for UC
  8. 8. IBD strictures: Diagnosis Abd& pelvic imaging : Recommended before diagnostic/therapeutic endoscopy to provide the “ roadmap” (eg, location, number& length of strictures). Endoscopy: Main advantage is the ability to obtain biopsies for histologic assessment &deliver therapy at the time of the diagnosis. Abd/pelvic imagings: CTE,MRE,TAUS,SICUS,EUS,SI follow Though,GGE.
  9. 9. CTE: Advantages/Disadvantages: Noninvasive, available, easy to perform, IV contrast Excessive ionizing radiation. Active CD: fat stranding, mucosal hyperenhancem ent, vasa recta engorgement, transmural infl ammation, lymphadenopath y, abscess or fitula. Fibrostenotic disease on CTE defined By presence of narrowing of the intestinal lumen without active infl ammation
  10. 10. MRE: Advantages/Disadvantages: A low intensity on T1 &T2 sequences is characteristic of chronic fibrotic strictures, A high intensity on fatsuppressed T2 images is a feature of infl ammatory edematous strictures. For assess of small / large bowel CD with particular utility For distinguishing between fi brostenotic& active disease.
  11. 11. TAUS,SI CEU: Advantages/Disadvantages: used to detect small bowel strictures in CD High sensitivity/specif icity Operatordependent
  12. 12. Gastrograffin enema (GGE): Advantages/Disadvantages: Used for distal colonic strictures or fistulas, for ileal pouch-anal anastomosis (IPAA) adverse events including strictures& anastomotic leaks,for abnormalities at the neoterminal ileum in patients with stomas. Useful in the detection of the number/length of strictures& their conditions. Sens 100% in diagnosing pouchanal anastomotic strictures when an anastomotic diameter >8 mm is used for Diagnosis. Sens80%,spec 95% for inlet/distal SI strictures with a spec 93% for outlet strictures in patients with IPAA.
  13. 13. IBD strictures:endoscopic trts&Complication Endoscopic trts: TTS BD NK Endoscopic stricturotomy Perforation: cliping,OTC,surgery Bleeding: most can be controlled by endoscopic hemostasis Stenting
  14. 14. Endoscopic balloon dilation therapy TTS TYPE Indications IBD-related benign small bowel, ileocolonic, or colonic strictures. symptomatic strictures <4 -5 cm without associated fistulas abscesses, or malignancy. facilitate completion of dysplasia surveillance in non-traversable strictures.
  15. 15. Endoscopic stricturotomy TYPE Indications Needle-knife Ileocolonic ileal pouch strictures. More effective than TTS balloon dilation in refractory IBD-related benign strictures,with acceptable adverse events as bleeding and perforation.
  16. 16. Endoscopic stent placement TYPE SEMS ? Bidegradable Migration reduced by endoscopic suturing. Migration prv
  17. 17. IBD complications:others sinuses Endotrts: NK, Stents, Anastomotic leaks Bezoars in ileal pouch reservoir Endo dilation of strictures & removal of bezoars
  18. 18. CD-Fistulas: treatments Med trts: No good longterm results 1 Endoinj: fibrin glue 4 2 Endoscopic injections: Doxycycline+ac etylctstein Endoinj: 50% glucose or honey Endoinj: stem cells 5 CD:Fistla treaTments 3
  19. 19. Colitis-associated neoplasia: DALM: raised lesion with associated dysplasia Polypectomy Colonoscopy repeated in 6/12 Adenomalike lesion resembling sporadic adenoma without adjacent flat dysplasia COLITISASSOCIATED NEOPLASIA. Patients with multifocal flat lowgrade dysplasia, repetitive lowgrade dysplasia, or high-grade dysplasia should be referred for total colectomy. Non– adenomaColectomy like lesion is May be removed by typically an EMR or ESD ulcerated, broadbased, irregular lesion. diagnosis of all dysplasia needs to be confirmed by at least 2 expert GI pathologists.
  20. 20. Endoscopic procedures-associated adverse events & management: Perforation: > In non-IBD Patients BZ of the inflammation & immunne modulators use. Complications: Bleeding Perforations 1 Perforation trts: Endoscopic clip; usual or OTC, FC SEMS. Endoscopic therapy in IBD patients should be performed by specialized endoscopists, with proper surgical backup. Bleeding: Managed by endoscopic clips. 2 ASGE guidelines: endoscopic dilation is with a higher risk of bleeding, hold clopidogrel or ticlopidine 7 -10 days before endoscopy &warfarin before the procedure with bridging therapy in patients at high risk of thromboembolic events.
  21. 21. IBD complications: Endotherapies  Endoscopic trts are important modalities in the trt of IBD, adjunct to medical& surgical approaches.  They are particularly useful in the management of IBDassociated or IBD surgery– associated strictures, fistulas, &sinuses &colitis-associated neoplasia.  The main focus is on balloon stricture dilation& ablation of adenoma-like lesions  New endoscopic approaches are emerging, include needle-knife stricturotomy, needle-knife sinusotomy, endoscopic stent placement& fistula tract injection.  Risk management of endoscopy-associated adverse events is also evolving.  These novel treatments just beginning& will likely expand rapidly in the near future.
  22. 22. LOGO