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The management of colorectal stricture complicating inflammatory bowel disease [IBD] remains a challenging condition. Stricture raises concern about neoplastic complications, which cannot be fully ruled out by negative endoscopic biopsies. Also, impassable strictures restrict the endoscopic monitoring of upstream disease activity and dysplasia. Surgery remains the ‘gold standard’ treatment for colonic strictures but is associated with high morbidity. Over the past few decades, our therapeutic arsenal for IBD has been reinforced by biologics and therapeutic endoscopy. Few studies have focused on colonic strictures, and so current therapeutic strategies are based on a low level of evidence and applied by analogy with the treatment of ileal strictures. With a view to facilitating the decision making process in clinical practice, we reviewed the literature on the epidemiology, natural history, and management of colonic strictures in IBD.

Background The approved maintenance regimens for ustekinumab in Crohn’s disease [CD] are 90 mg every 8 or 12 weeks. Some patients will respond partially to ustekinumab or will experience a secondary loss of response. It remains poorly known if these patients may benefit from shortening the interval between injections. Methods All patients with active CD, as defined by Harvey–Bradshaw score ≥ 4 and one objective sign of inflammation [C-reactive protein > 5 mg/L and/or faecal calprotectin > 250 µg/g and/or radiological and/or endoscopic evidence of disease activity] who required ustekinumab dose escalation to 90 mg every 4 weeks for loss of response or incomplete response to ustekinumab 90 mg every 8 weeks were included in this retrospective multicentre cohort study. Results One hundred patients, with a median age of 35 years [interquartile range, 28–49] and median disease duration of 12 [7–20] years were included. Dose intensification was performed after a median of 5.0 [2.8–9.0] months of ustekinumab treatment and was associated with corticosteroids and immunosuppressants in respectively 29% and 27% of cases. Short-term clinical response and clinical remission were observed in respectively 61% and 31% after a median of 2.4 [1.3–3.0] months. After a median follow-up of 8.2 [5.6–12.4] months, 61% of patients were still treated with ustekinumab, and 26% were in steroid-free clinical remission. Among the 39 patients with colonoscopy during follow-up, 14 achieved endoscopic remission [no ulcers]. At the end of follow-up, 27% of patients were hospitalized, and 19% underwent intestinal resection surgery. Adverse events were reported in 12% of patients, including five serious adverse events. Conclusion In this multicentre study, two-thirds of patients recaptured response following treatment intensification with ustekinumab 90 mg every 4 weeks.

Background Crohn’s disease (CD) has a significant impact on health status and quality of life, by affecting physical and emotional well-being and by impairment of social and functional abilities. In the era of treat to target concept, endoscopic healing has emerged to be the goal to achieve to prevent intestinal damage and disability. It is not clear what level of endoscopic healing is associated with CD disability. We, therefore, aimed to compare disability associated to complete endoscopic healing or partial endoscopic healing in patients with CD. Methods We conducted a multicentric prospective study, between September 2019 and November 2020, in one University Hospital, one general hospital and one private practice center including consecutive patients with CD in clinical remission and either complete mucosal healing (CDEIS =0) or partial mucosal healing (CDEIS > 0 and ≤ 4). The 10-item self-questionnaire IBD-disk was used to assess disability. Moderate-to-severe disability was defined as an overall IBD-disk score ≥ 40. Results A total of 82 patients were included. Forty-four (53%) were women, the median age and disease duration were respectively 35.3 years (Interquartile range (IQR 28.6–45.2) and 8.0 years (IQR, 3.0–17.0). The median overall IBD-disk score was 26.5 (IQR, 9 -45.0) and 30 (36.6%) had moderate-to-severe disability. Complete endoscopic healing was observed in 48 patients (57.3%). Median IBD-Disk score was respectively 24 (IQR, 9.0–40.5) and 34 (IQR, 9.5–51.5) for patients with complete and partial endoscopic healing (p=0.068). Respectively, 13/48 (27%) and 17/34 (50%) of patients with complete and partial endoscopic healing had moderate-to-severe disability (p=0.039). In multivariate analysis, partial mucosal healing (OR=3.04, CI95% [1.11, 8.94], p=0.03), female gender (OR=3.93, CI95% [1.43, 11.94], p=0.008) and smoking (OR= CI95% 5.88 [1.72, 25.0] p=0.039) were significantly associated with moderate-to-severe disability. Among the IBD-disk subscores, defecation score (median, IQR) (0.0 [0.0–3.0] vs 4.0 [0.0–7.5], p=0.028) and energy score (4.0 [0.0–6.0] vs 6.0 [2.5–8.0], p=0.023) were significantly lower in complete endoscopic healing. Conclusion One-third of patient with endoscopic healing reported moderate-to-severe disability. Complete endoscopic healing (CDEIS = 0) was associated with lower disability than partial endoscopic healing (CDEIS > 0 and ≤ 4) in CD. Deeper endoscopic healing may be needed to reduce the risk of disability in CD.

Background The management of enterocutaneous fistulas (ECF) in Crohn’s disease (CD) patients is complex and requires a multidisciplinary approach. Despite the advent of anti-TNF, the majority of patients still need surgical management. The aim of this study was to report the feasibility of endoscopic treatment of ECF in CD patient. Methods We prospectively identified CD patients with an ECF who failed to conventional medical therapies. Demographic and clinical data were collected retrospectively. Under general anaesthesia, a colonoscopy was performed to identify the fistula. At the discretion of the operator, an Ovesco® clip under or hemostatic clip were placed on the top of the fistula, with radiological opacification control. Technical success was defined by the clip placement on the EFC. The clinical success was defined by the closure of the fistula (defined by the absence of emission of stool or gas by the cutaneous orifice). Results Eight patients (female, 75 %, median age 45 years (interquartile range (IQR), 33–51)) were identified. Regarding the EFC, they evolved from a median of 3 months (IQR, 1.75–5.5) before the endoscopic management. The fistulas were localised on the ileocolonic anastomosis for 7 patients, and on the stomach in one. Two patients had an endoscopic activity, as defined by the presence of ulcer(s). Seven patients were treated with an OVESCO clip and one with Boston® resolution 360 hemostatic clips. Thirteen endoscopic procedures were performed, with a median number of 1 procedure/patient (IQR, 1–2). Technical success was observed in 100% of cases. Clinical success at 3 months was observed in 75% of cases (6/8 patients). After a median follow-up of 8 months (IQR, 5–12), 2/6 patients in clinical success underwent a new procedure due to EFC recurrence at respectively 4 and 7 months due to a clip migration. Among the 2 failures, one patient underwent a second colonoscopy with a new Ovesco® placement and the other was treated with fibrin glue. In both cases the procedure was ineffective. No complication related to the clip insertion was observed. Conclusion This demonstrates |, for the first time, the feasibility and short-term effectiveness of endoscopic clips for the treatment of EFC in CD patients. New prospective studies should confirm these results.