Crohn's Disease Complicated by Strictures
Crohn's Disease Complicated by Strictures
Important new insights into the pathogenesis, epidemiology and diagnosis of intestinal stricture formation are beginning to emerge.
Our inability to determine which patients develop critical strictures and which will have rapid disease progression remains a significant knowledge gap. Furthermore, detailed information on the ability of modern biological therapies to alter the natural history of CD remains a fundamental question in our field. The pathogenesis of intestinal fibrosis is more complicated than previously thought and the answer to preventing fibrogenesis is more complex than simply the early treatment of inflammation.
In the area of therapeutic intervention controlled trials are needed to help guide the optimal treatment approach. The lack of unified definitions for intestinal strictures and thus the lack of available trial endpoints for the prevention of stricture formation poses a problem. Pathologists, endoscopists and radiologists all use their own group or centre-specific scoring systems, making comparisons of different studies difficult to impossible, and none of these scores has been validated.
Significant promise exists in new or refined imaging modalities and in the extension of our current disease activity indices to include information about strictures and fibrosis. Longitudinal studies are necessary in patients with already present strictures. It remains unclear if existing strictures have the ability to regress (either spontaneously or with medical therapy) or if fibrosis is a one-way process. A validated biomarker to monitor disease progression would allow study of medications to treat fibrosis specifically and would enable controlled trials to address many unanswered questions such as the optimal management of asymptomatic strictures. A biomarker would help us better determine the role and timing of endoscopic and surgical therapies as well as the impact of novel strategies such as manipulation of stress pathways and the microbiome.
The future of CD care is in the understanding and anticipation of disease progression and designing strategies to impact the natural history of the disease for better long-term patient outcomes.
Unanswered Questions
Important new insights into the pathogenesis, epidemiology and diagnosis of intestinal stricture formation are beginning to emerge.
Our inability to determine which patients develop critical strictures and which will have rapid disease progression remains a significant knowledge gap. Furthermore, detailed information on the ability of modern biological therapies to alter the natural history of CD remains a fundamental question in our field. The pathogenesis of intestinal fibrosis is more complicated than previously thought and the answer to preventing fibrogenesis is more complex than simply the early treatment of inflammation.
In the area of therapeutic intervention controlled trials are needed to help guide the optimal treatment approach. The lack of unified definitions for intestinal strictures and thus the lack of available trial endpoints for the prevention of stricture formation poses a problem. Pathologists, endoscopists and radiologists all use their own group or centre-specific scoring systems, making comparisons of different studies difficult to impossible, and none of these scores has been validated.
Significant promise exists in new or refined imaging modalities and in the extension of our current disease activity indices to include information about strictures and fibrosis. Longitudinal studies are necessary in patients with already present strictures. It remains unclear if existing strictures have the ability to regress (either spontaneously or with medical therapy) or if fibrosis is a one-way process. A validated biomarker to monitor disease progression would allow study of medications to treat fibrosis specifically and would enable controlled trials to address many unanswered questions such as the optimal management of asymptomatic strictures. A biomarker would help us better determine the role and timing of endoscopic and surgical therapies as well as the impact of novel strategies such as manipulation of stress pathways and the microbiome.
The future of CD care is in the understanding and anticipation of disease progression and designing strategies to impact the natural history of the disease for better long-term patient outcomes.
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