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