Serial intralesional injections of infliximab in small bowel Crohn's strictures are feasible and might lower inflammation

Abstract

Background: Crohn's disease can cause strictures throughout the gastrointestinal tract. Endoscopic balloon dilatation is a well-established treatment, but recurrence is seen in up to three out of four cases. Infliximab is playing an increasingly important role in the modern systemic treatment of severe Crohn's disease. Combining the anti-inflammatory effects of infliximab with the proven effect of endoscopic balloon dilatation could possibly improve outcome. In small studies, intralesional injections in perianal fistulas have been effective and endoscopic injection therapy in colonic strictures is feasible.

Objective: We wanted to assess whether serial intralesional injection of infliximab in small bowel strictures is feasible and reduces local inflammation.

Methods: We included six patients with Crohn's disease and inflammatory small bowel strictures. They were treated with endoscopic serial balloon dilatation. Subsequent to each dilatation, 40 mg infliximab was injected submucosally. A modified simplified endoscopic score for Crohn's disease was used for the involved area before the initial treatment and at the final follow-up after six months. Complications and development of symptoms were registered.

Results: Balloon dilatation and serial injection of infliximab were accomplished in five out of six patients. One patient completed the serial balloon dilatations and follow-up but received only one infliximab injection. The modified simplified endoscopic score for Crohn's disease decreased in all patients. There were no adverse events registered and all patients described themselves as feeling well.

Conclusions: Combining balloon dilatation of strictures with serial intralesional injection of infliximab in Crohn's disease of the small bowel is feasible and seems successful in reducing inflammation.

Keywords: Crohn’s disease; Double balloon enteroscopy; Endoscopic balloon dilatation; infliximab.

Figure 1.

(a) Inflamed Crohn stricture located an ileocolic anastomosis. (b) Endoscopic submucosal injection of 10 mg of infliximab.

Figure 2.

Endoscopic balloon dilatation of a small bowel Crohn stricture.

Figure 3.

Modified simplified endoscopic score for Crohn’s disease before and after treatment. Size of ulcers (orange), extent of ulcerated surface (green), and proportion with other lesions (blue) are depicted.