Long-Acting Steroid Injection after Endoscopic Dilation of Anastomotic Crohn’s Strictures May Improve the Outcome: A Retrospective Case Series

Background and Study Aims: Endoscopic balloon dilation of Crohn’s strictures is widely practised, but may not result in long-term symptomatic benefit, leading to the need for repeat dilation or surgery. It is hypothesized that long-acting steroid injection into strictures after dilation may decrease the need for further stricture dilation and improve the outcome in symptomatic patients.
Patients and Methods: Patients with Crohn’s disease who have had balloon dilation and triamcinolone injection performed for symptomatic anastomotic strictures were identified from endoscopy records. Case notes were reviewed to determine outcomes.
Results: Fourteen patients underwent a total of 26 dilations, with triamcinolone injected (median dose 20 mg, 10 - 40 mg) in 20 of the procedures. Seven patients (50 %) had sustained remission after a single dilation and steroid injection, with a median follow-up period of 16.4 months (range 13.2 - 22.0 months). Four patients (28.5 %) required more than one dilation (median three dilations, range two to four) to control their symptoms, with a median follow-up period of 27.8 months (range 14 - 32.8 months). Endoscopic management failed in three patients (21.4 %), who were referred for surgery. There were no complications due to dilation or triamcinolone injection.
Conclusions: Triamcinolone injection into the stricture after dilation is safe, easy to perform, and may be a useful adjunct in the management of anastomotic Crohn’s strictures. These data will require further support through a randomized and controlled trial.

References

• 1 Rutgeerts P, Geboes K, Vantrappen G. et al . Natural history of recurrent Crohn’s disease at the ileocolonic anastomosis after curative surgery.  Gut. 1984;  25 665-672
• 2 Lochs H, Mayer W, Fleig W. et al . Prophylaxis of postoperative relapse in Crohn’s disease with mesalamine: European Cooperative Crohn’s Disease Study VI.  Gastroenterology. 2000;  118 264-273
• 3 Rutgeerts P, Hiele M, Geboes K. et al . Controlled trial of metronidazole treatment for prevention of Crohn’s recurrence after ileal resection.  Gastroenterology. 1995;  108 1617-1621
• 4 Breysem Y, Janssens J F, Coremans G. et al . Endoscopic balloon dilatation of colonic and ileo-colonic Crohn’s strictures: long-term results.  Gastrointest Endosc. 1992;  38 142-147
• 5 Couckuyt H, Gevers A M, Coremans G. et al . Efficacy and safety of hydrostatic balloon dilatation of ileocolonic Crohn’s strictures: a prospective long-term analysis.  Gut. 1995;  36 577-580
• 6 Blomberg B, Rolny P, Jarnerot G. Endoscopic treatment of anastomotic strictures in Crohn’s disease.  Endoscopy. 1991;  23 195-198
• 7 Brooker J C, Thomas-Gibson S, Shah S G. et al . Endoscopic dilatation of Crohn’s strictures: long-term outcomes in 85 consecutive patients [abstract].  Gastrointest Endosc. 2000;  51 98
• 8 Griffith B H. The treatment of keloid with triamcinolone acetonide.  Plast Reconstr Surg. 1966;  38 202-208
• 9 Ketchum L D, Smith J, Robinson D W, Masters F W. Treatment of hypertrophic scar, keloid and scar contracture by triamcinolone acetonide.  Plast Reconstr Surg. 1966;  38 209-218
• 10 Kirsch M, Blue M, Desai R K, Sivak M V. Intralesional steroid injections for peptic esophageal strictures.  Gastrointest Endosc. 1991;  37 180-182
• 11 Kochhar R, Ray J D, Sriram P V. et al . Intralesional steroids augment the effects of endoscopic dilation in corrosive esophageal strictures.  Gastrointest Endosc. 1999;  49 509-513
• 12 Nelson R D, Hernandez A J, Goldstein H M, Saca A. Treatment of irradiation oesophagitis: value of hydrocortisone injection.  Am J Gastroenterol. 1979;  71 17-23
• 13 Holder T M, Ashcraft K W, Leape L. The treatment of patients with oesophageal strictures by local steroid injections.  J Paediatr Surg. 1969;  4 646-653
• 14 Ashcraft K W, Holder T M. The experimental treatment of oesophageal strictures by intralesional steroid injections.  J Thorac Cardiovasc Surg. 1969;  58 685-693
• 15 Ketchum L D, Robinson D W, Masters F W. The degradation of mature collagen: a laboratory study.  Plast Reconstr Surg. 1967;  40 89-91
• 16 Ramboer C, Verhamme M, Dhondt E. et al . Endoscopic treatment of stenosis in recurrent Crohn’s disease with balloon dilation combined with local corticosteroid injection.  Gastrointest Endosc. 1995;  42 252-255
• 17 Lavy A. Triamcinolone improves outcome in Crohn’s disease strictures.  Dis Colon Rectum. 1997;  40 184-186