Partha Pal

By Partha Pal, D. Nageshwar Reddy and Zaheer Nabi

The evaluation of small bowel in inflammatory bowel disease (IBD) is mainly performed in cases with newly diagnosed or suspected Crohn’s disease (CD). The available modalities for small bowel evaluation include radiological imaging (barium meal follow through, magnetic resonance enteroclysis, computed tomography enteroclysis) and small bowel endoscopy also known as enteroscopy. The main advantage of small bowel endoscopy over radiological imaging is that it allows for obtaining biopsy specimen required for histological confirmation of the diagnosis. Various endoscopic modalities for endoscopic evaluation of small bowel include push enteroscopy and device assisted enteroscopy (DAE). Push enteroscopy allows only limited evaluation of proximal small bowel. Therefore, DAE is generally preferred over push enteroscopy for small bowel evaluation. DAE includes single balloon enteroscopy, double balloon enteroscopy, and spiral enteroscopy. The available literature suggests that there is no significant difference in the diagnostic yield among the available DAE devices. Therefore, the choice of DAE is largely dependent on the availability as well as local expertise. More recently, motorised spiral enteroscopy has been introduced. The main advantage of this novel DAE is ease of use with the possibility of evaluating the entire small bowel via per-oral route. However, the data regarding the use of motorised spiral enteroscopy is limited and comparative trials are required in future.

Part of the book: Endoscopy in Small Bowel Diseases

By Partha Pal, Rupa Banerjee, Mohan Ramchandani, Zaheer Nabi, Duvvuru Nageshwar Reddy and Manu Tandan

Interventional inflammatory bowel disease (IIBD) is going to play a major role in complex IBD including ulcerative-colitis associated neoplasia (UCAN) and postoperative complications after ileal pouch-anal anastomosis (IPAA) in ulcerative colitis (UC). We performed a literature search in PubMed using keywords such as “UCAN” and “endoscopic management of pouch complications,” After screening 1221 citations, finally, 91 relevant citations were identified for the systematic review. Endoscopic recognition of dysplasia should be done by high-definition white light endoscopy (HD-WLE) or dye-based/virtual chromoendoscopy (CE) especially in known dysplasia or primary sclerosing cholangitis (PSC). Endoscopically visible lesions without deep submucosal invasion can be resected endoscopically with endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), or using full-thickness resection device (FTRD). Image-enhanced endoscopy (IEE) and IIBD have an emerging role in screening, diagnosis, and management of colitis-associated neoplasia in UC and can avoid colectomy. IIBD can manage a significant proportion of post-IPAA complications. Pouch strictures can be treated with endoscopic balloon dilation (EBD) or stricturotomy, whereas acute and chronic anastomotic leak or sinuses can be managed with through the scope (TTS)/over the scope clips (OTSC) and endoscopic fistulotomy/sinusotomy.

Part of the book: Ulcerative Colitis

By Partha Pal

Part of the book: Crohn’s Disease

By Partha Pal, Rupa Banerjee, Mohan Ramchandani, Rajendra Patel, Zaheer Nabi, Swathi Kanaganti, Rajesh Gupta, Manu Tandan and Duvvuru Nageshwar Reddy

Fistulas and abscesses in Crohn’s disease (CD) are mechanical complications of long term disease and can indicate an aggressive disease course. Usually chronic inflammation leads to stricture which leads to high intra-luminal pressure with resultant fistula and abscess upstream to stricture. Exceptions to that may include perianal fistulizing CD which may even precede luminal CD. Hence, management of fistula and abscesses entails management of associated strictures without which these are bound to recur. These mechanical complications (stricture/fistula/abscess) usually occur after initial 4–5 years of disease. Traditionally the management of these complications include surgical therapy. However, surgical therapy can be associated with substantial morbidity specially in these patients on immunosuppressive medications and post-operative recurrence is not uncommon. Interventional radiological procedures to drain intra-abdominal/pelvic abscess can be helpful provided that there are no intervening bowel loops. Hence, there is an unmet need of relatively less invasive endoscopic therapies for treatment of CD related fistulas and abscesses. In this chapter, we shall discuss the role of endoscopic therapy in CD related fistula and abscess.

Part of the book: Crohn’s Disease