Endoscopy 2014; 46(11): 956-962
DOI: 10.1055/s-0034-1390791
Original article
© Georg Thieme Verlag KG Stuttgart · New York

Factors associated with progression to surgery in Crohn’s disease patients with endoscopic stricture

Ren Mao
Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
,
Bai-li Chen
Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
,
Yao He
Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
,
Yi Cui
Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
,
Zhi-rong Zeng
Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
,
Min-hu Chen
Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
› Author Affiliations
Further Information

Publication History

submitted 31 December 2013

accepted after revision 17 June 2014

Publication Date:
17 October 2014 (online)

Background and study aims: Early intensive therapy should be considered for Crohn’s disease patients at high risk of surgery. Factors associated with the development of intestinal strictures or obstructions in Crohn’s disease were explored. The aim of our study was to identify risk factors predictive of subsequent surgery in patients with endoscopically identified stricture.

Patients and methods: In this case-control study, 86 patients with established Crohn’s disease and endoscopic strictures between 2003 and 2012 were divided into two homogeneous arms: surgery group and control group. The primary outcome was surgery. Cox regression analysis was used to evaluate risk factors associated with subsequent surgery.

Results: 33 of 86 patients (38.4 %) underwent stricture-related surgery during follow-up. The cumulative rates for surgery were 15.1 %, 19.8 %, 23.3 %, 30.2 %, and 38.4 % at 1, 3, 6, 12, and 36 months, respectively. Independent risk factors associated with subsequent surgery in Crohn’s disease patients with endoscopic strictures were: smoking (hazard ratio [HR] 5.49, 95 % confidence interval [95 %CI] 2.32 – 13.02; P = 0.000); disease duration at first detection of stricture less than 3 years (HR 3.89, 95 %CI 1.6 – 9.5; P = 0.003); presence of obstructed bowel symptoms (HR 2.68, 95 %CI, 1.24 – 5.78; P = 0.012) and Crohn’s Disease Activity Index (CDAI) > 220 (HR 2.68, 95 %CI 1.22 – 5.90; P = 0.015). For patients with 3 and 4 risk factors, the positive predictive values for subsequent surgery were 0.73 and 1.00, respectively.

Conclusion: For Crohn’s disease patients with endoscopic stricture, factors predictive of subsequent surgery were smoking, disease duration at first detection of stricture less than 3 years, presence of obstructed bowel symptoms, and CDAI > 220.

 
  • References

  • 1 Baumgart DC, Sandborn WJ. Crohn’s disease. Lancet 2012; 380: 1590-1605
  • 2 Frolkis AD, Dykeman J, Negron ME et al. Risk of surgery for inflammatory bowel diseases has decreased over time: a systematic review and meta-analysis of population-based studies. Gastroenterology 2013; 145: 996-1006
  • 3 Lakatos PL, Golovics PA, David G et al. Has there been a change in the natural history of Crohn’s disease? Surgical rates and medical management in a population-based inception cohort from Western Hungary between 1977 – 2009. Am J Gastroenterol 2012; 107: 579-588
  • 4 Ramadas AV, Gunesh S, Thomas GA et al. Natural history of Crohn’s disease in a population-based cohort from Cardiff (1986–2003): a study of changes in medical treatment and surgical resection rates. Gut 2010; 59: 1200-1206
  • 5 Peyrin-Biroulet L, Harmsen WS, Tremaine WJ et al. Surgery in a population-based cohort of Crohn’s disease from Olmsted County, Minnesota (1970–2004). Am J Gastroenterol 2012; 107: 1693-1701
  • 6 Lichtenstein GR, Olson A, Travers S et al. Factors associated with the development of intestinal strictures or obstructions in patients with Crohn’s disease. Am J Gastroenterol 2006; 101: 1030-1038
  • 7 Solberg IC, Vatn MH, Hoie O et al. Clinical course in Crohn’s disease: results of a Norwegian population-based ten-year follow-up study. Clin Gastroenterol Hepatol 2007; 5: 1430-1438
  • 8 Veloso FT, Ferreira JT, Barros L et al. Clinical outcome of Crohn’s disease: analysis according to the Vienna classification and clinical activity. Inflamm Bowel Dis 2001; 7: 306-313
  • 9 Aloi M, Viola F, D’Arcangelo G et al. Disease course and efficacy of medical therapy in stricturing paediatric Crohn’s disease. Dig Liver Dis 2013; 45: 464-468
  • 10 Moon CM, Park DI, Kim ER et al. Clinical features and predictors of clinical outcomes in Korean patients with Crohn’s disease: a Korean association for the study of intestinal diseases multicenter study. J Gastroenterol Hepatol 2014; 29: 74-82
  • 11 Swoger JM, Regueiro M. Evaluation for postoperative recurrence of Crohn disease. Gastroenterol Clin North Am 2012; 41: 303-314
  • 12 Zallot C, Peyrin-Biroulet L. Clinical risk factors for complicated disease: how reliable are they?. Dig Dis 2012; 30 (Suppl. 03) 67-72
  • 13 Satsangi J, Silverberg MS, Vermeire S et al. The Montreal classification of inflammatory bowel disease: controversies, consensus, and implications. Gut 2006; 55: 749-753
  • 14 Rieder F, Zimmermann EM, Remzi FH et al. Crohn’s disease complicated by strictures: a systematic review. Gut 2013; 62: 1072-1084
  • 15 Gustavsson A, Magnuson A, Blomberg B et al. Smoking is a risk factor for recurrence of intestinal stricture after endoscopic dilation in Crohn’s disease. Aliment Pharmacol Ther 2013; 37: 430-437
  • 16 Lakatos PL, Szamosi T, Lakatos L. Smoking in inflammatory bowel diseases: good, bad or ugly?. World J Gastroenterol 2007; 13: 6134-6139
  • 17 Lindberg E, Jarnerot G, Huitfeldt B. Smoking in Crohn’s disease: effect on localisation and clinical course. Gut 1992; 33: 779-782
  • 18 Cottone M, Rosselli M, Orlando A et al. Smoking habits and recurrence in Crohn’s disease. Gastroenterology 1994; 106: 643-648
  • 19 Mahid SS, Minor KS, Soto RE et al. Smoking and inflammatory bowel disease: a meta-analysis. Mayo Clin Proc 2006; 81: 1462-1471
  • 20 Cosnes J, Carbonnel F, Beaugerie L et al. Effects of cigarette smoking on the long-term course of Crohn’s disease. Gastroenterology 1996; 110: 424-431
  • 21 Laghi L, Costa S, Saibeni S et al. Carriage of CARD15 variants and smoking as risk factors for resective surgery in patients with Crohn’s ileal disease. Aliment Pharmacol Ther 2005; 22: 557-564
  • 22 Reese GE, Nanidis T, Borysiewicz C et al. The effect of smoking after surgery for Crohn’s disease: a meta-analysis of observational studies. Int J Colorectal Dis 2008; 23: 1213-1221
  • 23 Johnson GJ, Cosnes J, Mansfield JC. Review article: smoking cessation as primary therapy to modify the course of Crohn’s disease. Aliment Pharmacol Ther 2005; 21: 921-931
  • 24 Van Assche G, Dignass A, Panes J et al. The second European evidence-based Consensus on the diagnosis and management of Crohn’s disease: Definitions and diagnosis. J Crohns Colitis 2010; 4: 7-27
  • 25 Beaugerie L, Seksik P, Nion-Larmurier I et al. Predictors of Crohn’s disease. Gastroenterology 2006; 130: 650-656
  • 26 Smith BR, Arnott ID, Drummond HE et al. Disease location, anti-Saccharomyces cerevisiae antibody, and NOD2/CARD15 genotype influence the progression of disease behavior in Crohn’s disease. Inflamm Bowel Dis 2004; 10: 521-528
  • 27 Tang LY, Rawsthorne P, Bernstein CN. Are perineal and luminal fistulas associated in Crohn’s disease?. A population-based study. Clin Gastroenterol Hepatol 2006; 4: 1130-1134
  • 28 Thia KT, Sandborn WJ, Harmsen WS et al. Risk factors associated with progression to intestinal complications of Crohn's disease in a population-based cohort. Gastroenterology 2010; 139: 1147-1755
  • 29 Aldhous MC, Drummond HE, Anderson N et al. Does cigarette smoking influence the phenotype of Crohn’s disease? Analysis using the Montreal classification. Am J Gastroenterol 2007; 102: 577-588
  • 30 Abreu MT, Taylor KD, Lin YC et al. Mutations in NOD2 are associated with fibrostenosing disease in patients with Crohn’s disease. Gastroenterology 2002; 123: 679-688
  • 31 Newman B, Silverberg MS, Gu X et al. CARD15 and HLA DRB1 alleles influence susceptibility and disease localization in Crohn’s disease. Am J Gastroenterol 2004; 99: 306-315
  • 32 Louis E, Michel V, Hugot JP et al. Early development of stricturing or penetrating pattern in Crohn’s disease is influenced by disease location, number of flares, and smoking but not by NOD2/CARD15 genotype. Gut 2003; 52: 552-557
  • 33 Schoepfer AM, Dehlavi MA, Fournier N et al. Diagnostic delay in Crohn’s disease is associated with a complicated disease course and increased operation rate. Am J Gastroenterol 2013; 108: 1744-1753