Stenosis is one of the most common complications in patients with Crohn's disease (CD), causing morbidity and possible repeated surgeries. It is crucial to find alternative conservative measures to avoid or delay surgery in CD patients with stenosis. Currently, endoscopic balloon dilation (EBD) is the endoscopic treatment of choice.1,2 Stents can be used in benign diseases due to their technological evolution and their effectiveness in malignant stenosis. Information regarding the efficacy and safety of stents in the treatment of strictures in CD is limited, and most of the stents used are tubular self-expandable metal stents. Few recent cases using lumen apposing metal stents (LAMS) have been reported.3,4 Only in one of them was a LAMS used to treat a duodenal stenosis, but in performing a bypass and not placing the stent at the site of the stenosis.5 We present a case of duodenal stenosis successfully treated with LAMS, and to our knowledge this is the first case of CD duodenal stenosis treated with this type of stent reported in the literature.
A 25-year-old man with a recent diagnosis of ileal CD and treated with infliximab and azathioprine presented symptoms of upper gastro-intestinal obstruction (vomiting, epigastralgia, and weight loss) of one year's duration. Upper endoscopy revealed a short stenosis (1cm) with significant inflammation in the duodenal bulb and an important bulbar pre-stenotic dilation that prevented passing of the gastroscope (Fig. 1a). After ruling out a peptic origin and malignancy (taking multiple biopsies, without presence of Helicobater Pylori and after intensive treatment with proton-pump inhibitors), an intensification of medical treatment was carried out (infliximab 10mg/kg every 8 weeks), and endoscopic treatment with EBD was initially performed without clinical success (two session of EBD achieving a maximum balloon diameter of 15mm). After 4 months from the intensification of the medical treatment and with a predominantly fibrotic stenosis, it was decided to place a stent. Due to the characteristics of the stenosis, a LAMS (Hot AXIOS™ Boston Scientific; 20mm×10mm) was chosen. Using a therapeutic gastroscope, a long guidewire (jagwire, Boston Scientific; 0.035in.) was passed with endoscopic and fluoroscopic control. Then the stent was passed over the guidewire and was correctly deployed and placed, with the help of endoscopic and fluoroscopic control (Fig. 1b–d). After the procedure the patient suffered important abdominal pain controlled with conventional analgesia, and the stent was removed 4.5 months later without complications (Fig. 1e). The patient has remained asymptomatic for 5 months after the stent removal, with upper endoscopy showing no inflammation or stenosis (Fig. 1f). The use of a LAMS may be an option in short upper gastrointestinal stenosis in CD patients.
(A) Endoscopic image of duodenal stenosis. (B) Fluoroscopic image of stent deployment. (C and D) Endoscopic images of the stent successfully deployed and placed in duodenal stenosis. (E) Endoscopic image immediately after stent removal. (F) Endoscopic image of the previous site of duodenal stenosis 5 months after stent removal, without inflammation or stenosis.
CL. Received a speaking fee from Boston Scientific and consulting fees from Fujifilm.
Other authors declare that they have no competing interests.
