Fibro-stenosing disease is the primary reason for surgery in 20% of Crohn's patients. Post-operative recurrence rates can be seen in >50% of patients. The presence of NOD mutations has been associated with fibro-stenosing disease in adult cohorts but the same hasn't been noted in children. Endoscopy offers a minimally invasive option for management of these cases and there is no long-term safety and efficacy data in pediatric patients. The possible cost-saving implications of this strategy also need to be taken into account.
Six patients in our clinical practice developed fibro-stenosing disease in areas amenable to endoscopic examination. Of these, 5 proceeded to endoscopic dilatation, after a thorough discussion with the family about the risks and benefits of endoscopic management and one was sent to surgical resection due to long segment length.
Five subjects underwent 9 serial hydrostatic balloon dilatations. 4 had simple strictures while 1 patient had a complex stricture (4 strictures) in the ileum which was unknown until the time of endoscopy. NOD genetic analysis was performed in 4 patients and 2 were found to have a mutant allele present. EUS examination of all the stricture tracks was performed prior to dilatations to rule out external compression, mural fluid collections or other pathology. All patients were kept on parenteral nutrition and/or low residue diet while they underwent therapy. Triamcinolone 40 mg was injected into the strictures prior to dilatation.
Average post-op follow up for all patients is 438 days and no complications directly related to the procedures have been reported. One patient done under propofol sedation developed aspiration pneumonia. One patient was sent to surgery after 1 dilatation due to poor compliance with therapy and underwent a hemicolectomy. All patients reported symptomatic improvement after dilatation. Endoscopic management is a viable and safe option in the treatment of Crohn's associated fibro-stenosing disease in children (see Table 1).