Jakob Hendel

Serial intralesional injections of infliximab in small bowel Crohn’s strictures are feasible and might lower inflammation

Background Crohn’s disease can cause strictures throughout the gastrointestinal tract. Endoscopic balloon dilatation is a well-established treatment, but recurrence is seen in up to three out of four cases. Infliximab is playing an increasingly important role in the modern systemic treatment of severe Crohn’s disease. Combining the anti-inflammatory effects of infliximab with the proven effect of endoscopic balloon dilatation could possibly improve outcome. In small studies, intralesional injections in perianal fistulas have been effective and endoscopic injection therapy in colonic strictures is feasible. Objective We wanted to assess whether serial intralesional injection of infliximab in small bowel strictures is feasible and reduces local inflammation. Methods We included six patients with Crohn’s disease and inflammatory small bowel strictures. They were treated with endoscopic serial balloon dilatation. Subsequent to each dilatation, 40 mg infliximab was injected submucosally. A modified simplified endoscopic score for Crohn’s disease was used for the involved area before the initial treatment and at the final follow-up after six months. Complications and development of symptoms were registered. Results Balloon dilatation and serial injection of infliximab were accomplished in five out of six patients. One patient completed the serial balloon dilatations and follow-up but received only one infliximab injection. The modified simplified endoscopic score for Crohn’s disease decreased in all patients. There were no adverse events registered and all patients described themselves as feeling well. Conclusions Combining balloon dilatation of strictures with serial intralesional injection of infliximab in Crohn’s disease of the small bowel is feasible and seems successful in reducing inflammation.

Confocal laser endomicroscopy: a novel method for prediction of relapse in Crohn's disease.

BACKGROUND AND STUDY AIMS Confocal laser endomicroscopy (CLE) has been shown to predict relapse in ulcerative colitis in remission, but little is currently known about its role in Crohns disease. The aim of this study was to identify reproducible CLE features in patients with Crohns disease and to examine whether these are risk factors for relapse. PATIENTS AND METHODS This was a single-center prospective feasibility study of CLE imaging in patients with Crohns disease. CLE imaging was performed in the terminal ileum and four colorectal sites, and was correlated with histopathology and macroscopic appearance. Clinical relapse, defined as the need for treatment escalation or surgical intervention, was recorded during follow-up. RESULTS The study included 50 patients: 39 with Crohns disease (20 in remission), and 11 controls. Ileal fluorescein leakage and microerosions were significantly more frequent in patients with endoscopically active Crohns disease compared with patients with inactive Crohns disease and controls (P = 0.005 and (P = 0.006, respectively). The same applied to colorectal fluorescein leakage and vascular alterations ((P = 0.043 and (P = 0.034, respectively). During a 12-month follow-up period, ileal fluorescein leakage and microerosions were significant risk factors for relapse in the subgroup of patients in remission (log rank (P = 0.009 and (P = 0.007, respectively) as well as in the entire group of patients with Crohns disease (log rank (P = 0.006 and (P = 0.01, respectively). Inter- and intraobserver reproducibility was almost perfect (κ > 0.80) or substantial (κ > 0.60) for the majority of CLE parameters. CONCLUSIONS CLE can identify reproducible microscopic changes in the terminal ileum that are risk factors for relapse in patients with otherwise inactive Crohns disease. TRIAL REGISTRATION ClinicalTrials.gov (NCT01738529).

Biodegradable stents for the treatment of bowel strictures in Crohn's disease: technical results and challenges

Background and study aims: In patients with Crohn’s disease, the idea of biodegradable stents for treatment of bowel strictures with limited effect of endoscopic balloon dilation is tempting and initial results have been promising. The aim of this study was to evaluate the technical and clinical success of biodegradable stents for treatment of inflamed Crohn’s strictures refractory to endoscopic balloon dilatation. Patients and methods: Consecutive patients treated with biodegradable stents due to Crohn’s disease and inflamed bowel strictures refractory to endoscopic balloon dilatation were included. Technical and clinical success were evaluated. Results: Six patients were included in the study. Technical success was obtained in five patients (83 %). Clinical success was limited to one patient (20 %); failure was observed due to mucosal overgrowth (n = 2), stent migration (n = 1), and stent collapse (n = 1). Conclusions: In Crohn’s disease, it is technically feasible to treat bowel strictures with biodegradable stents. However, we have stopped using biodegradable stents due to lack of clinical success and side effects such as mucosal overgrowth and stent collapse.