Strictures affect approximately 50% of patients with Crohn's disease during their disease course.1,2 Conventional treatments for strictures include endoscopic therapies such as balloon dilation, intralesional injection of therapeutic agents, or insertion of self-expanding stents.3 In some cases, surgery may be warranted for difficult-to-treat strictures. The IT (insulated tip) knife, which involves nonpolar electroincision, has been adopted from pancreaticobiliary endoscopy. However, IT knife stricturoplasty to treat refractory fibrostenotic strictures has been described only in a few case reports.4–6 We present a patient with Crohn's disease whose abdominal pain resolved after IT knife stricturoplasty of colorectal strictures and fecalith decompaction of a diverticulum.
A 70-year-old man with Crohn's disease presented with abdominal pain. A computed tomography scan showed diffuse wall thickening involving the rectum and rectosigmoid colon. Subsequently, a diagnostic colonoscopy (PCF model, Olympus Medical Systems, Tokyo, Japan) was performed. Video 1; watch the video at http://links.lww.com/ACGCR/A22. Intraoperatively, a nonulcerated, nontraversable rectal stricture, approximately 2 cm in diameter, was found and treated successfully with IT knife stricturoplasty in a circumferential fashion (monopolar receptacle, mode: ENDO CUT 1, Effect 2, Upmax 550 Vp, cut duration 2, cut interval 3, Coag mode off; Erbe Elektromedizin GmbH, Tübingen, Germany). At 25-cm distally, another nontraversable stricture, 5-cm in diameter, was found (Figure 1). Initially, endoscopic balloon dilation was attempted (insufflation to 19-mm), but after balloon deflation, colonoscope passage was unsuccessful (Figure 2). Subsequently, mucosal resection using IT knife stricturoplasty was attempted and, eventually, colonoscope passage was permitted (Figure 3).
After entering the transverse colon, fecalith was found to have impacted a diverticulum with a narrow mouth. Fecalith removal was unsuccessful using a Roth net, but an attempt using a basket was successful. The fecalith removal was technically difficult because of the high risk of perforation posed by the thin-walled diverticulum. The patient tolerated the procedure well, and there were no procedural complications. After stricturoplasty and fecalith removal, the patient's symptoms resolved. Hence, we believe that the strictures and fecalith-impacted diverticulum were responsible for the patient's abdominal pain.
This case illustrates that IT knife stricturoplasty is a safe and efficacious modality for the management of difficult to treat Crohn's disease-related strictures and may potentially spare patients from the need to undergo invasive procedures including surgery. Diverticular fecalith impaction, when present, may contribute to abdominal pain in patients with Crohn's disease, so fecalith retrieval and diverticular decompaction can promote symptom resolution.
Author contributions: K. Singh wrote the manuscript. K. Singh, A. Singh, and B. Shen edited the manuscript. B. Shen is the article guarantor.
Financial disclosure: None to report.
Previous presentation: This case was presented at the American College of Gastroenterology Annual Scientific Meeting, October 5-10, 2018; Philadelphia, Pennsylvania.
Informed consent was obtained for this case report.
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