Endoscopic management of intestinal strictures in Crohn’s disease: Current status and future perspectives

Abstract

Crohn’s disease (CD) is a chronic inflammatory disorder frequently complicated by intestinal strictures, which may lead to obstructive symptoms and repeated surgical interventions. With advances in therapeutic endoscopy, endoscopic management has emerged as an effective bowel-sparing alternative in selected patients. A multidisciplinary approach, involving gastroenterologists, gastrointestinal surgeons, and radiologists, is essential for optimal patient selection and procedural planning. This review article summarizes the current evidence on the endoscopic management of CD-related strictures, focusing on pathophysiology, patient selection, endoscopic balloon dilation, stricturotomy, stenting, outcomes, complications, and comparison with surgical approaches. Emerging techniques and future directions are also discussed. Endoscopic therapy, when applied to appropriately selected strictures, can achieve durable symptom relief and delay or avoid surgery in a significant proportion of patients.

Key Words: Crohn’s disease; Intestinal strictures; Endoscopic balloon dilation; Endoscopic stricturotomy; Self-expanding metallic stents; Therapeutic endoscopy; Surgery

Core Tip: Crohn’s disease is a chronic inflammatory disorder frequently complicated by intestinal strictures, leading to obstructive symptoms and repeated surgical interventions. In the era of therapeutic endoscopy, endoscopic management has emerged as an effective bowel-sparing alternative in selected patients. A multidisciplinary approach, involving gastroenterologists, gastrointestinal surgeons, and radiologists, is essential for optimal patient selection and procedural planning. We have summarized the current evidence focusing on pathophysiology, patient selection, endoscopic balloon dilation, stricturotomy, stenting, outcomes, complications, and comparison with surgical approaches. In selected patients, endoscopic therapy can achieve durable symptom relief and delay or avoid surgery in a significant proportion of patients.

INTRODUCTION

Crohn’s disease (CD) is a chronic transmural inflammatory disorder of the gastrointestinal (GI) tract that frequently progresses to fibrostenotic complications. Intestinal strictures represent one of the most common and debilitating complications of CD, occurring in up to 30%-50% of patients within 10-20 years of diagnosis and contributing significantly to obstructive symptoms, malnutrition, repeated hospitalizations, and high surgical rates[1]. In the Indian subcontinent, stricturing phenotype at presentation is particularly frequent (often > 40% of cases), reflecting delayed diagnosis, genetic predisposition (e.g., NOD2 variants are less common but environmental factors are prominent), and a more aggressive disease course compared to Western cohorts[2]. Although any part of the GI tract can develop fibrostenotic complications, the most common site is the terminal ileum and ileocecal valve[3]. Endoscopic therapies have emerged as important bowel-preserving strategies that can delay or avoid surgery in carefully selected patients. Over the past two decades, techniques including endoscopic balloon dilation (EBD), endoscopic stricturotomy (ESt), endoscopic strictureplasty (ESTx), and selective stenting have expanded the therapeutic armamentarium. However, optimal patient selection, technique selection, and integration with medical and surgical approaches remain challenging. This review provides a comprehensive, evidence-based update on the endoscopic management of CD-associated intestinal strictures. It covers epidemiology, pathogenesis, stricture characterization, pre-procedural considerations, established endoscopic modalities (EBD, ESt, stenting), emerging techniques, comparative outcomes with surgery, along with future directions.

SEARCH STRATEGY

This narrative review was conducted through comprehensive literature searches in PubMed and Google Scholar from January 2000 to May 2026. Search items included “Crohn’s disease”, “inflammatory bowel disease”, “intestinal stricture”, “fibrostenotic”, “endoscopic balloon dilation”, “EBD”, “endoscopic stricturotomy”, “stricturotomy”, “EST”, “endoscopic strictureplasty”, “ESTx”, “self-expanding metal stent”, “SEMS”, “LAMS”, “intralesional steroid”, and “surgery”. Major international guidelines [European Crohn’s and Colitis Organization (ECCO) 2024, American College of Gastroenterology (ACG) 2025, Indian Society of Gastroenterology 2015] and consensus statements [Global Interventional Inflammatory Bowel Disease (GIIBD) group], systematic reviews, meta-analyses, randomized controlled trials, and high-quality cohort studies were prioritized. Reference lists of included articles and key review papers were manually searched for additional relevant publications. Only English-language articles were included. Emphasis was given to studies published in the last 10 years, landmark trials (CREOLE, STRIDENT, ProtDilat, BEST-CD), and recent systematic reviews (2023-2026). Relevant studies were selected through a structured review process based on title relevance, methodological quality, clinical significance, and applicability to the scope of this review.

EPIDEMIOLOGY AND NATURAL HISTORY OF CD WITH SPECIAL FOCUS ON STRICTURING PHENOTYPE

CD was formally described in 1932 by Crohn et al[4] as “regional ileitis”, a condition frequently progressing to stenosis and fistulae. Although the disease likely existed for centuries, its incidence has risen globally, particularly in newly industrialised regions, highlighting the role of environmental factors in genetically susceptible individuals[5].

CD is heterogeneous. The Montreal classification[6] categorizes it by: Age at diagnosis: A1 (< 17 years), A2 (17-40 years), A3 (> 40 years). Location: L1 (ileal), L2 (colonic), L3 (ileocolonic), L4 (upper GI, modifier). Behaviour: B1 (non-stricturing, non-penetrating/inflammatory), B2 (stricturing), B3 (penetrating/fistulizing); perianal disease as "p" modifier.

Disease location in CD remains relatively stable over time (e.g., ileal disease usually remains ileal-dominant), whereas disease behaviour is dynamic and progressive. In a landmark hospital-based cohort, Louis et al[7] showed that while only ~26% of patients had stricturing or penetrating disease at diagnosis, this proportion rose significantly, with nearly 46% showing a change in behaviour over 10 years. Approximately 20%-30% progressed from inflammatory (B1) to complicated (B2/B3) phenotype within the first 5 years[7]. Population-based studies report somewhat slower progression, likely reflecting inclusion of milder cases[8-11]. Key predictors of behavioural progression include young age at diagnosis, ileal disease location, perianal involvement, smoking, and need for steroids at initial flare[12,13].

Population-based cohorts indicate that 56%-81% of patients present with inflammatory behaviour, 5%-24% with stricturing, and 4%-23% with penetrating phenotypes[14]. The cumulative probability of progression from inflammatory to stricturing/penetrating disease reaches approximately 20% within the first year after diagnosis[15]. While surgery was historically the main definitive treatment, the introduction of biologics and small molecules has reduced surgical rates. Earlier studies reported cumulative surgery risks of 33.3% at 5 years and 46.6% at 10 years[16], compared with contemporary rates of ~18% and 26%, respectively[17]. The 10-year risk of repeat resection has similarly declined from ~35% to closer to 30% in the biologic era[18]. Despite improved inflammatory control and reduced operative rates, the incidence of intestinal strictures has not declined proportionately, indicating a dissociation between chronic inflammation and fibrosis.

Compared with Western cohorts, Indian patients with CD exhibit a more aggressive fibrostenotic phenotype, with higher rates of stricturing disease at diagnosis, greater cumulative stricture burden, and increased surgical and reoperation rates, attributed to delayed diagnosis, small-bowel predominance, and frequent overlap with intestinal tuberculosis (Table 1)[7,16,17,19-22]. Although stricturing and penetrating complications are common in CD and tend to increase over time, the transition from inflammatory to complicated (late) disease is neither uniform nor linear[23]. While some patients already manifest stricturing or penetrating disease at diagnosis, others may remain free of complications even after decades of disease duration. This marked heterogeneity underscores the complex and individualized natural history of CD, influenced by disease location, inflammatory burden, genetic susceptibility, environmental exposure, and host-specific factors.

Table 1 Comparative epidemiology of stricturing Crohn’s disease: Global vs Indian data[7,16,17,19-22].

Region/study	Stricturing at diagnosis	10-year cumulative stricture risk	Surgery risk (10 years)	Key notes
Western cohorts	15%-25%	30%-50%	40%-55% (pre-biologic); lower in the biologic era (~26%-40%)	Lower stricturing phenotype at disease onset
Indian cohorts	35%-49%	Often > 50%	High (often > 30%-40%); high reoperation rates	Higher stricturing phenotype at onset, intestinal tuberculosis mimicry common, delayed diagnosis, small bowel predominant

PATHOGENESIS OF STRICTURES IN CD

Stricturing CD develops as a result of an aberrant wound-healing response to chronic transmural inflammation[24]. Persistent mucosal injury disrupts the epithelial barrier, allowing microbial antigens to trigger both innate and adaptive immune responses, thereby activating T helper 1 cell (Th1), Th2, and particularly Th17 pathways[25]. In the initial acute phase, there is a predominance of Th1 cells, which release interleukin-1β (IL-1β), interferon-γ, and tumor necrosis factor alpha (TNF-α). This drives robust inflammation and tissue damage while also contributing to early fibrosis by upregulating mesenchymal cell production of collagen, fibronectin, and matrix metalloproteinase-1 (MMP-1)[26]. As inflammation becomes chronic, the immune response shifts to involve a larger contribution from Th2 and Th17 cell subtypes, which are particularly important in the progression of intestinal fibrosis[25,27]. Th2 cells release IL-4 and IL-13, which promote macrophage differentiation into the M2 subtype. These M2 macrophages are key profibrotic effectors[1], secreting multiple mediators including platelet-derived growth factor, fibroblast growth factor, insulin-like growth factor, and transforming growth factor-β1 (TGF-β1). Among these, TGF-β1 is recognized as the most potent driver of intestinal fibrosis, as it powerfully regulates mesenchymal cell proliferation, activation, and extracellular matrix (ECM) production. Th17 cells further amplify fibrosis through the secretion of IL-17 and IL-21[25,28] (Figure 1).

Figure 1 Schematic illustration of the multifactorial pathogenesis of fibrostenotic Crohn’s disease, highlighting immune, mesenchymal, microbial, and mesenteric fat contributions leading to extracellular matrix deposition. Th: T lymphocyte helper cells; IL: Interleukin; IFN-γ: Interferon gamma; TNF-α: Tumor necrosis factor alpha; Wnt: Wingless/Integrated signaling pathway; mTOR: Mammalian target of rapamycin; EMT: Epithelial to mesenchymal transition; EndoMT: Endothelial to mesenchymal transition; ECM: Extracellular matrix; AIEC: Adherent-invasive Escherichia coli; MMP-1: Matrix metalloproteinase 1; TIMP: Tissue inhibitors of metalloproteinase; miR: MicroRNA.

This cytokine milieu promotes the expansion and activation of mesenchymal cells, including fibroblasts, myofibroblasts, and smooth muscle cells, resulting in excessive ECM deposition, smooth muscle hyperplasia, and progressive bowel wall thickening. Epithelial-to-mesenchymal transition and endothelial-to-mesenchymal transition further increase the pool of fibrogenic cells[29]. Over time, an imbalance between MMPs and their inhibitors leads to reduced ECM degradation and irreversible scar formation[1,25,29] (Figure 1).

Genetic factors play a significant role, with NOD2/CARD15 mutations being strongly associated with the fibrostenotic phenotype, particularly in ileal disease[30]. Epigenetic modifications, including DNA methylation and alterations in microRNAs (such as reduced miR-29), also contribute to sustained fibroblast activation and collagen production[31]. Recent studies have highlighted the importance of gut microbiota dysbiosis, with adherent-invasive Escherichia coli promoting macrophage-to-fibroblast transition and fibrosis[32,33]. Additionally, mesenteric “creeping fat” actively participates by secreting profibrotic mediators and interacting with the underlying bowel wall[34,35]. Single-cell transcriptomic analyses have revealed substantial heterogeneity among intestinal fibroblasts and specific profibrotic subpopulations, along with key pathways such as Wnt/β-catenin, mammalian target of rapamycin, and amphiregulin signalling from Th17 cells[36,37]. This complex, multifactorial pathogenesis integrates immune dysregulation, mesenchymal remodelling, genetic predisposition, microbial influences, and mesenteric fat signalling, ultimately leading to progressive luminal narrowing and obstructive complications in CD (Figure 1).

STRICTURE DEFINITION AND CLINICAL PRESENTATION OF STRICTURING CD

A CD stricture is defined as a persistent narrowing of the intestinal lumen resulting from transmural inflammation, fibrosis, smooth muscle hypertrophy, or a combination of these processes, leading to impaired passage of luminal contents. Strictures may occur anywhere along the GI tract but most commonly involve the terminal ileum and ileocolonic region[3]. Approximately 25% of CD patients have at least one small intestinal stricture, whereas colonic strictures occur in at least 10% of patients[38]. Morphologically, a stricture is characterized by luminal narrowing with associated bowel wall thickening and often pre-stenotic dilatation on cross-sectional imaging. A small-bowel CD stricture is defined radiologically by the presence of at least two of the following three features: Bowel wall thickening (≥ 25% increase in wall thickness compared with adjacent normal bowel or wall thickness > 3 mm in an adequately distended bowel), localized luminal narrowing (> 50% reduction in luminal diameter relative to an adjacent non-affected bowel loop), and pre-stenotic dilatation (proximal bowel diameter ≥ 3 cm)[39]. Although pre-stenotic dilatation has traditionally been defined using a threshold of ≥ 3 cm, more recent diagnostic recommendations and imaging studies have proposed a lower cutoff of ≥ 2.5 cm to improve identification of early or evolving strictures and facilitate earlier therapeutic intervention before overt obstructive complications develop[40]. Endoscopically, a clinically significant stricture is commonly defined as a narrowing that prevents the non-resistant passage of a standard adult colonoscope without prior dilation[39]. CD strictures are biologically heterogeneous: Purely inflammatory (reversible with medical therapy), mixed, or predominantly fibrotic (irreversible, requiring mechanical intervention). Most strictures encountered in clinical practice contain varying degrees of both inflammatory and fibrotic components[1,29].

Clinically, strictures may manifest with symptoms of intermittent or persistent bowel obstruction, including crampy abdominal pain, postprandial bloating, nausea, vomiting, abdominal distension, and altered bowel habits. Systemic features of active inflammation, such as fever, fatigue, or elevated inflammatory markers, may coexist when there is a significant inflammatory component. Still, many longstanding strictures are predominantly fibrotic with minimal systemic symptoms. The clinical presentation varies considerably depending on the location (most commonly the terminal ileum), length, degree of narrowing, and presence of associated complications such as fistulae or pre-stenotic dilatation.

CLASSIFICATION OF CD STRICTURES

Given the marked heterogeneity in location, length, inflammatory burden, fibrosis, and associated complications, appropriate characterization and categorization of CD-associated strictures are essential for selecting optimal therapeutic strategies, including medical therapy, endoscopic intervention, or surgery (Table 2)[41].

Table 2 Categorization of Crohn’s disease strictures.

Category	Subtypes	Examples/clinical relevance
Source/etiology	Intrinsic	Intrinsic: Most CD strictures (inflammation/fibrosis), anastomotic/postoperative strictures, malignant CD strictures. Extrinsic: Adhesions, compression by abscess/phlegmon
	Extrinsic
Clinical presentation	Symptomatic	Guides the urgency of intervention
	Asymptomatic
Underlying disease/process	Primary (CD related)	Important for management strategy
	Secondary [post-surgical (including stoma site stricture)]
Malignant potential	Benign	Critical to rule out before endoscopic therapy, especially in long-standing colonic disease
	Malignant
Inflammation vs fibrosis	Inflammatory	Influences response to medical vs endoscopic therapy
	Fibrotic
	Mixed
Length	Short (< 4-5 cm)	Short → better for endoscopic therapy (EBD/ESt)
	Long (≥ 4-5 cm)
Number	Single	Multiple → higher complexity
	Multiple
Severity/degree	Mild	Mild/moderate-allows passage of scope with mild/moderate resistance, respectively. Severe- pinhole stricture, not traversable to scope
	Moderate
	Severe
Morphology/stricture characteristics	Web/ulcerated/spindle-shaped/angulated, symmetrical/asymmetrical	Influences technical feasibility and risk of perforation during intervention
Complexity	Simple	Complex strictures are typically long, angulated, multiple, associated with fistulae, abscess, deep ulcerations, or marked pre-stenotic dilatation
	Complex
Location	Esophagus, pylorus, small bowel, IC valve, colon, rectum, anus	Determines endoscopic approach and feasibility

CD: Crohn’s disease; EBD: Endoscopic balloon dilation; ESt: Endoscopic stricturotomy; IC: Ileo-caecal.

DIAGNOSTIC TOOLS AND PHENOTYPE STRATIFICATION

Accurate differentiation between predominantly inflammatory, mixed, and fibrotic strictures (Table 3)[25] in CD is critical for therapeutic decision-making, as inflammatory strictures may respond to medical therapy while fibrotic strictures often require endoscopic or surgical intervention. Cross-sectional imaging remains the cornerstone for non-invasive stricture detection, characterization, and phenotype stratification. A stricture is generally defined by bowel wall thickening (> 3 mm), luminal narrowing (> 50%), and upstream dilation (≥ 2.5-3 cm) on cross-sectional imaging[39,40]. Multimodal assessment integrating clinical features, biomarkers, endoscopy, and imaging is recommended.

Table 3 Differentiating inflammatory vs fibrotic strictures[25].

	Inflammatory strictures	Fibrotic strictures	Notes/limitations
Symptoms	More acute/subacute flares; diarrhea; systemic signs; better medical response	Chronic progressive obstructive symptoms; poor medical response	Overlap is common; symptoms poorly correlate with the degree of fibrosis. Asymptomatic strictures are possible
Endoscopy	Ulcers, friability, erythema, edema; soft to touch	Pale, rigid, featureless narrowing; minimal ulcers; firm to touch	Endoscopy limited to accessible segments and mucosa only (misses submucosal/transmural fibrosis). Combination with imaging improves accuracy
Histology	Neutrophils, crypt abscesses, edema, and lymphoid aggregates	Dense collagen, smooth muscle hypertrophy, minimal inflammation	Transmural process - patchy; biopsies are superficial and underestimate fibrosis; scoring systems exist but are heterogeneous
Biomarkers	High CRP, ESR, fecal calprotectin	Often normal/low CRP/ESR/fecal calprotectin despite symptoms	No highly specific validated biomarker for fibrosis
Intestinal US (+/- elastography)	Wall thickening (> 3 mm), hypoechoic (loss of stratification), hypervascularity (high color Doppler/Limberg score), mesenteric fat stranding/lymph nodes. Lower stiffness. CEUS: Early hyperenhancement	Preserved stratification or hyperechoic, reduced vascularity. Higher stiffness on shear-wave elastography (e.g., higher kPa values)	Promising multiparametric approach (B-mode + Doppler + elastography + CEUS). Good for the terminal ileum; no radiation
CTE	Wall thickening + stratified/layered mucosal hyperenhancement, comb sign (mesenteric hypervascularity), fat stranding, lymphadenopathy, edema	Homogeneous or minimal enhancement, fatty submucosal infiltration, less mesenteric inflammation, prominent pre-stenotic dilation. Thickened wall with “featureless” appearance	Radiation exposure (avoid in young/repeat imaging). High accuracy for strictures but moderate for differentiation alone
MRE (preferred)	T2-hyperintense mural edema, stratified early hyperenhancement, DWI restriction (low ADC), comb sign, nodular luminal thickening	T2-hypointense/iso (low edema), homogeneous/delayed enhancement, less DWI restriction in pure fibrosis, pre-stenotic dilation, smooth luminal thickening, elevated magnetization transfer ratio	Best non-invasive test for characterization (sensitivity/specificity high for fibrosis)

CRP: C-reactive protein; ESR: Erythrocyte sedimentation rate; CEUS: Contrast-enhanced ultrasound; US: Ultrasound; CTE: Computed tomography enterography; MRE: Magnetic resonance enterography; ADC: Apparent diffusion coefficient; DWI: Diffusion-weighted imaging.

Intestinal ultrasound (IUS) has emerged as a valuable, radiation-free, point-of-care tool, particularly for terminal ileal disease (pooled sensitivity 79%, pooled specificity 92%)[42]. B-mode IUS assesses wall thickness, stratification (loss suggests inflammation), and hypervascularity (high color Doppler/Limberg score)[43]. Contrast-enhanced ultrasound (CEUS) involves intravenous administration of microbubble contrast such as SonoVue, and small intestine contrast ultrasound involves small bowel distension with ingestion of an isosmolar contrast agent such as polyethylene glycol[44]. CEUS highlights early hyperenhancement in inflammatory strictures. Shear-wave elastography (SWE) quantifies stiffness, with higher values (e.g., elevated kPa) correlating with fibrosis and muscular hypertrophy[45]. Studies demonstrate moderate-to-good accuracy for fibrosis detection, with point SWE often superior[45,46]; IUS is particularly useful for serial monitoring and has shown high specificity for small bowel stenosis when multiple parameters are combined[47,48].

Computed tomography enterography (CTE) and magnetic resonance enterography (MRE) provide comprehensive transmural and extramural assessment. CTE offers excellent sensitivity (85%) and specificity (100%) for stricture detection with stratified mucosal hyperenhancement, comb sign, and fat stranding favouring inflammation, while homogeneous or minimal delayed enhancement and prominent pre-stenotic dilation suggest fibrosis[25,49]. Dual-energy CTE adds value through iodine density mapping (mg/mL) and normalized iodine values, which correlate better with active inflammation than conventional enhancement patterns, improving sensitivity and phenotype differentiation[29,50,51].

MRE is the preferred modality for repeated imaging, particularly in younger patients, due to the lack of ionizing radiation (sensitivity 92%, specificity 90%)[49]. Inflammatory features include T2-hyperintense mural edema, early stratified (layered) enhancement, diffusion-weighted imaging restriction (low apparent diffusion coefficient), and ulcers/comb sign. Fibrotic features show T2 iso- to hypointensity, homogeneous or delayed enhancement, and higher stiffness[25]. Magnetization transfer (MT) magnetic resonance imaging is a promising advanced sequence: The MT ratio or normalized MT ratio increases with collagen/ECM content and shows a strong correlation with histologic fibrosis (independent of inflammation in several studies), with good sensitivity/specificity for moderate-to-severe fibrosis[52,53]. Advanced techniques such as texture analysis, radiomics, and 68Ga-FAPI PET/MR show promise in quantifying fibrosis more precisely[1].

Composite scores aid standardization and prognostication. The magnetic resonance index of activity (MaRIA)[54] and simplified MaRIA[55] primarily assess inflammatory activity (wall thickness, edema, ulceration, enhancement) but help contextualize strictures. The Lémann Index quantifies cumulative structural bowel damage across the entire GI tract, incorporating stricturing, penetrating lesions, and prior surgery, making it valuable for long-term damage assessment and disease modification trials[56,57].

Ileocolonoscopy or balloon-assisted enteroscopy (BAE) confirms luminal narrowing but underestimates transmural fibrosis. Video capsule endoscopy requires patency capsule pre-testing to avoid retention.

Biomarkers and recent advances aid risk stratification but are not yet sufficiently specific for real-time phenotype differentiation. Elevated C-reactive protein (CRP), erythrocyte sedimentation rate, and fecal calprotectin indicate inflammation, while serologic antimicrobial antibodies (e.g., anti-flagellin) and certain proteomic markers (MMP-1, insulin-like growth factor binding protein 2) correlate with complicated stricturing behaviour[1,58]. Novel approaches such as 68Ga-FAPI PET (fibroblast activation protein) and artificial intelligence (AI)-assisted radiomics show promise for more precise fibrosis quantification[59,60].

MEDICAL THERAPY

Purely or predominantly inflammatory strictures respond to advanced therapies. The landmark CREOLE study (multicentre prospective cohort, n = 97) demonstrated that adalimumab achieved treatment success (no steroids, no dilation/surgery) in 64% at week 24 and 46% at median 3.8-year follow-up in symptomatic small-bowel strictures[61]. The STRIDENT trial (open-label RCT, n = 77) was the first to randomize patients with symptomatic strictures to intensive (high-dose adalimumab + thiopurine with escalation) vs standard adalimumab monotherapy; both arms improved symptoms and stricture morphology on imaging, confirming that even fibrostenotic strictures with an inflammatory component are drug-responsive, with intensive therapy showing numerical superiority[62] (Table 4).

Table 4 Pivotal medical therapy trials in Crohn’s disease strictures.

Trial	Design	n	Intervention	Primary success	Long-term
CREOLE (2018)	Prospective cohort	97	ADA	64% at week 24	29% prolonged success at 4 years; 51% surgery-free
STRIDENT (2021)	RCT (intensive vs standard)	77	Intensive ADA + thiopurine	Symptom improvement 79% (vs 64%) at 12 months	< 33% surgery at 4.5 years
Post-hoc biologics	Pooled	> 500	Anti-TNF, UST, VDZ	> 60% endoscopic response at 1 year	Reduced surgery

ADA: Adalimumab; RCT: Randomized controlled trial; TNF: Tumor necrosis factor; UST: Ustekinumab; VDZ: Vedolizumab.

Post-hoc analyses of pivotal trials (infliximab, ustekinumab) confirm endoscopic improvement in > 60% of patients with non-passable strictures at 1 year[63]. ACG 2025 guidelines recommend advanced therapies (anti-TNF, ustekinumab, or vedolizumab) for symptomatic strictures with active inflammation and also endorse early biologics in high-risk stricturing phenotypes[64] (Table 4).

ENDOSCOPIC TREATMENT MODALITIES

Endoscopic therapy may serve either as a bridge to surgery or as a definitive primary treatment modality, particularly in patients with high operative risk, limited bowel reserve, multiple prior resections, or those who prefer to defer or avoid surgical intervention. Figure 2 provides an overview of the various endoscopic treatment modalities for CD-associated strictures and highlights their comparative characteristics, indications, advantages, and limitations.

Figure 2 Overview of endoscopic treatment modalities for Crohn’s disease strictures, including indications, technical aspects, advantages, and limitations of endoscopic balloon dilation, endoscopic stricturotomy, and stenting. CD: Crohn’s disease; EBD: Endoscopic balloon dilation; ESt: Endoscopic stricturotomy; RCT: Randomized controlled trial.

PRE-PROCEDURE CONSIDERATIONS

Pre-procedural considerations are primarily based on the consensus recommendations of the GIIBD group[41]. Comprehensive stricture characterization using cross-sectional imaging and endoscopy is mandatory to assess length (ideally ≤ 5 cm), inflammatory vs fibrotic component, number, angulation, and associated complications such as fistula, abscess, or pre-stenotic dilatation, as these factors strongly influence technical success and risk of perforation[65]. Adequate bowel preparation with split-dose polyethylene glycol is recommended for most cases, although a low-residue diet with cautious preparation is preferred in patients with obstructive symptoms[66]. Conscious sedation is usually sufficient for straightforward procedures, while monitored anaesthesia care or general anaesthesia is preferred for complex, prolonged, or deep small-bowel interventions. Fluoroscopic guidance should be routinely utilized in technically demanding cases, and carbon dioxide insufflation is recommended to enhance safety and patient comfort[67]. Routine antibiotic prophylaxis is not required, but may be considered in high-risk patients. Background immunosuppression can generally be continued, with optimization of medical therapy advised for predominantly inflammatory strictures[41]. Management of antithrombotic agents should follow current ASGE/ESGE guidelines, recognising ESt as a higher bleeding-risk procedure[68,69].

EBD

Patient selection

CD-associated strictures suitable for EBD are typically short (≤ 5 cm), predominantly fibrotic or mixed inflammatory-fibrotic lesions, and accessible endoscopically. Both de novo and anastomotic strictures may be treated. EBD is most commonly used for ileocolonic and colonic strictures, although small-bowel strictures may also be managed using enteroscopy-assisted techniques. Deep ulceration within the stricture is generally considered a contraindication because of increased perforation risk, whereas superficial ulceration alone is not an absolute contraindication. The presence of adjacent fistulae or abscesses is usually regarded as unsuitable for EBD due to the risk of tract disruption, perforation, or sepsis[41,70]. Because colorectal strictures in CD may harbour occult malignancy, careful endoscopic assessment and tissue sampling are mandatory before intervention. The reported prevalence of CD-associated neoplasia ranges from approximately 1.2% to 6.4%[71,72]. Accordingly, the GIIBD group consensus recommends biopsy of both primary and anastomotic strictures before endoscopic treatment, especially in longstanding colonic disease or when the endoscopic appearance is atypical or suspicious[41].

Procedure technique

EBD is the most established endoscopic therapy for CD-associated strictures. The technique most commonly employs controlled radial expansion through-the-scope balloons, which exert radial force uniformly across the entire stricture length. These balloons permit graded dilation through sequential inflation steps using a single catheter. These balloons are available in multiple diameters and may be advanced either with or without guidewire assistance depending on the stricture anatomy and procedural complexity. During the procedure, the colonoscope is advanced to the site of narrowing to directly assess the stricture morphology, length, degree of luminal compromise, ulceration, and traversability. Whenever feasible, visualization of the bowel proximal to the stricture should be attempted to evaluate upstream inflammation, additional strictures, fistulous openings, or significant pre-stenotic dilatation. Tight strictures may sometimes be traversed using a pediatric colonoscope or upper GI endoscope. In particularly narrow or angulated strictures preventing the passage of the entire scope, the balloon catheter is typically advanced across the stenosis over a guidewire under fluoroscopic guidance. Dilation under direct endoscopic visualization is generally preferred whenever possible because it allows more precise assessment and may reduce procedural complications. Retrograde dilation is preferred to antegrade dilation if the stricture is initially traversable. During inflation, direct through-the-balloon visualization is useful to identify controlled mucosal tearing, which is considered an expected therapeutic endpoint. Following dilation, the treated segment should be carefully re-examined to assess the degree of tearing, evaluate the proximal bowel, and exclude bleeding or perforation[41].

Graded dilation to 18-20 mm is generally recommended for ileocolonic and colonic strictures, while smaller balloon diameters are typically used for small-bowel and upper GI strictures[25,41]. Dilation to at least 15 mm significantly reduces future surgical risk, whereas diameters of 16-18 mm are associated with longer symptom-free intervals[73]. Although the ideal inflation duration has not been formally studied, inflation for approximately 1-3 minutes is commonly practiced[41]. Repeat dilation is frequently required and should not be considered treatment failure. Instead, a conservative strategy employing serial dilations over time is often preferred to aggressive single-session dilation, particularly in complex or recurrent disease. The choice of balloon diameter during repeat sessions is usually guided by prior dilation size, procedural response, and the interval to symptom recurrence or reintervention[25,41].

Outcome/results

EBD, first described in 1984 for an anastomotic rectal stricture, is now an established bowel-preserving therapy for CD-associated strictures[70]. It demonstrates high technical success rates (74%-100%), moderate-to-high clinical success rates (55%-90%) defined as improvement in obstructive symptoms, along with low complication rates of approximately 3%-10%[74]. Enteroscopy-guided dilation for small-bowel strictures has shown similarly favourable outcomes, with pooled technical success, short-term clinical success, and major complication rates of 94.9%, 82.3%, and 5.3%, respectively[75]. The principal limitation of EBD is stricture recurrence, resulting in a substantial need for repeat intervention. During long-term follow-up, nearly half of patients develop recurrent obstructive symptoms, while 50%-65% require further intervention, including repeat dilation or surgery[74]. In enteroscopy-assisted series, approximately 38.8% of patients required re-dilatation and 27.4% ultimately underwent surgery[75]. Importantly, the need for repeat EBD should not be regarded as treatment failure, but rather as part of a bowel-conserving strategy aimed at delaying or avoiding intestinal resection.

Comparison with other modalities

Although randomized controlled trials comparing EBD with surgery are lacking, comparative studies suggest that primary surgery provides superior long-term surgery-free survival and lower recurrence rates. In a large comparative study of patients with primary ileocolonic CD strictures, upfront ileocolonic resection was associated with significantly longer surgery-free survival compared with EBD (11.1 years vs 5.4 years, P < 0.001), although EBD successfully delayed the need for surgery by several years in many patients[76]. Similarly, in patients with ileocolonic anastomotic (ICA) strictures, surgery was associated with a lower risk of subsequent surgery, while EBD delayed the need for reoperation by an average of 6.45 years[77]. However, surgery was associated with significantly higher initial morbidity (major adverse events 32.2% vs 4.7% with EBD, P < 0.0001) and loss of bowel length, making EBD an attractive first-line bowel-sparing option in appropriately selected patients with short, accessible strictures[76]. Compared with newer endoscopic techniques such as ESt/ESTx, EBD remains more widely available, technically simpler, and supported by the largest body of evidence. However, ESt/ESTx may provide greater and more durable luminal expansion in selected short fibrotic or anastomotic strictures, particularly when EBD fails or recurrence is frequent. Unlike EBD, which applies radial force uniformly across the stenosis, ESt involves targeted incision of the fibrotic tissue, potentially reducing recurrent recoil but at the cost of greater bleeding risk and higher technical complexity[25].

Predictors of efficacy

Several factors have been associated with poorer outcomes and increased likelihood of surgery after EBD, including longer stricture length, marked pre-stenotic dilatation, active inflammation, multiple strictures, prior intestinal resections, and shorter interval between disease diagnosis and dilation[70,77]. Longer strictures are associated with significantly lower success rates and a greater likelihood of subsequent surgery, with surgical risk increasing by approximately 8% for every additional centimetre of stricture length[78]. Predictive models have been developed to stratify long-term risk. One nomogram for ICA strictures incorporated disease duration, interval from surgery, symptomatic disease, and pre-stenotic dilatation to estimate 5-year surgery-free survival after EBD; EBD could delay surgery in ICA strictures by more than 6 years[79]. Another validated model, the BACARDI score (B3 stricturing disease, anti-TNF exposure, NOD2/CARD15 mutation, pre-stenotic dilatation, and CRP > 11 mg/L), predicts the likelihood of surgical requirement in stricturing ileal disease. Scores of 4-6 suggest limited benefit from continued medical or endoscopic therapy and favour early surgical management[80].

Complications

EBD is generally safe, with overall complication rates ranging from approximately 3%-10%[74]. Major complications include perforation, bleeding, and post-procedural pain. Deep ulceration, long or angulated strictures, and adjacent fistulae or abscesses significantly increase the risk. Immediate recognition and appropriate rescue therapy (endoscopic or surgical) are essential if complications arise during or after the procedure. Selected meta-analyses evaluating the outcomes of EBD in CD strictures are summarized in Table 5[75,81,82].

Table 5 Selected meta-analyses of endoscopic balloon dilation in Crohn’s disease strictures.

Ref.	Patients/procedures	Technical success	Clinical success	Surgery-free (long-term)	Major complications
Bettenworth et al[75], 2020 (BAE)	463 patients/1189 procedures	94.9%	82.3%	72.5% (surgery rate 27.5%)	5.4%
Navaneethan et al[82], 2016 (BAE)	1163 patients	89%	~70%	73% (surgery rates 18% vs 29% for anastomotic vs primary strictures)	~4%
Moond et al[81], 2024 (BAE)	1570 patients	87.7%	69.8%	74.7% (surgery rate 25.3%)	5.5%

BAE: Balloon assisted enteroscopy.

EST

Patient selection

CD-associated strictures suitable for ESt are typically short (≤ 3 cm), fibrotic, and accessible lesions[25,70]. Both primary and anastomotic strictures, as well as strictures refractory to EBD, may be treated. ESt is especially useful in strictures with dense fibrosis where simple radial stretching with balloon dilation may provide inadequate or short-lived luminal expansion. Patients with complex, long, angulated, or deeply ulcerated strictures, or those with associated abscesses, require careful evaluation, as these conditions may increase the risk of perforation or sepsis[41].

Procedure technique

ESt uses electrocautery (thermal energy) to incise fibrotic stricture tissue, thereby enlarging the bowel lumen. Unlike EBD, which relies on radial mechanical stretching, ESt achieves luminal expansion through controlled cutting of the fibrotic ring, potentially resulting in more durable patency. Initially, it was explored using laser vaporization of the obstructing tissue combined with linear incisions to increase luminal diameter[83]. Currently, electroincision is typically performed using needle knives or insulated-tip electrosurgical knives with endoscopic retrograde cholangiopancreatography electrosurgical settings, most commonly the endocut mode[41]. After careful endoscopic assessment of the stricture morphology, the fibrotic segment is progressively incised under direct visualization until adequate luminal widening is achieved. Electroincision may be performed in radial, circumferential, or horizontal orientations depending on stricture morphology and operator preference. The incision depth is carefully controlled to avoid transmural injury. In some cases, adjunctive balloon dilation may be performed after incision to further optimize luminal expansion[25]. Because of the technical complexity and risk profile, ESt should be performed by experienced therapeutic endoscopists in high-volume centres.

Outcome/results

Over the past decade, ESt has emerged as an important therapeutic option for CD-associated strictures, particularly fibrotic and anastomotic lesions. Reported technical success ranges from 88%-100%, clinical success ranges from 50%-96%, while surgery rate after ESt ranges from 0%-18.2%[84]. Compared with EBD, ESt provides targeted incision of fibrotic tissue rather than uniform radial stretching. This precision results in greater and more durable luminal expansion, especially in dense fibrotic or anastomotic strictures.

Comparison with other modalities

Comparative studies suggest potentially favourable clinical outcomes with ESt compared with EBD in selected patients. In a key retrospective case-control study by Lan and Shen[85], ESt achieved 100% technical success vs 89.5% for EBD in anastomotic strictures. Symptomatic and endoscopic improvement rates were higher with ESt, and subsequent surgery was required in only 9.5% of ESt patients compared to 33.5% with EBD (P = 0.03). ESt carried a lower perforation risk (0% vs 1.1%) but higher bleeding requiring transfusion (8.8% vs 0%). Systematic reviews and meta-analyses support these findings. A meta-analysis by Jaber et al[86] showed pooled technical success of 96.4% and clinical success of 62%, with ESt demonstrating higher clinical success [odds ratio (OR) = 3.59] than EBD, similar technical success, lower perforation (due to precision in ESt vs uniform mechanical force used in EBD), and higher bleeding.

ESt also compares favourably to surgery. Retrospective comparisons of ESt vs ileocolonic resection for anastomotic or primary ileal strictures showed comparable stricture-related surgery-free survival but significantly lower major adverse events with ESt (10.2% vs 31.9%, P = 0.003)[87,88]. Propensity-matched data further indicate that endoscopic approaches (including ESt) achieve similar symptom-free and re-operation rates to surgery while avoiding resection in the majority of suitable cases[89].

Predictors of efficacy

ESt appears most effective in short (≤ 3 cm), fibrotic, and anastomotic strictures. In contrast, long-segment disease, severe angulation, active deep ulceration, associated fistulae or abscesses, and extensive inflammatory activity may reduce efficacy and increase procedural risk. Operator expertise is an important determinant of outcome because ESt requires precise electrosurgical incision depth and orientation[25,41,70].

Complications

The major complications of ESt include bleeding, perforation, and post-procedural pain or ulceration. Among these, delayed bleeding is the most important adverse event and usually results from exposure of a visible vessel within the post-electrocautery ulcer bed[41]. Reported bleeding rates range up to approximately 11.8%, and some cases may require blood transfusion or endoscopic hemostatic therapy[84]. Perforation rates are generally low, usually below 2%, and appear lower than those reported with EBD in comparative studies[84]. This may relate to the precision of controlled electrocautery incision compared with the diffuse radial mechanical force generated during balloon dilation. Because ESt involves advanced electrosurgical dissection within a diseased bowel segment, the procedure should be undertaken only in centres with expertise in therapeutic endoscopy and the capability to manage potential adverse events promptly. Table 6 summarizes selected key studies evaluating the efficacy and safety of endoscopic stricturotomy in CD strictures.

Table 6 Selected key evidence studies of endoscopic stricturotomy in Crohn’s disease strictures.

Ref.	Design	Patients/comparison	Key outcomes for ESt	Complications (ESt)
Lan and Shen[85], 2018	Retrospective case-control (anastomotic CD strictures)	21 ESt vs 164 EBD	Technical success 100%; surgery 9.5% (vs 33.5% with EBD)	Bleeding 8.8%; perforation 0%
Abreu et al[84], 2026	Systematic review	1040 IBD patients (470 CD)	Technical success 88%-100%; clinical success 50%-96%; re-intervention rates [endoscopic (18.2%-66.6%) or surgical (0%-18.2%)]	Bleeding 11.8%; perforation < 2%
Jaber et al[86], 2024	Meta-analysis	287 patients (640 procedures)	Technical success 96.4%; clinical success 62%; re-intervention rates [endoscopic (44.2%) or surgical (16.4%)]	Bleeding 10.5%; perforation 3.5%
Lan et al[87], 2019	Retrospective (anastomotic CD strictures)	35 ESt vs 147 ICR	Surgery-free survival comparable (surgery rates 11.3% vs 10.2%)	Major adverse events 10.2% (vs 31.9%)
Lan et al[88], 2020	Retrospective (primary distal ileal strictures)	13 ESt vs 32 ICR	Technical success 100%; comparable surgery-free survival (surgery rates 15.4% vs 18.8%)	Lower complications 6.9% (vs 25%)

ESt: Endoscopic stricturotomy; CD: Crohn’s disease; EBD: Endoscopic balloon dilation; IBD: Inflammatory bowel disease; ICR: Ileo-colonic resection.

ENDOSCOPIC STENTING

Patient selection

Endoscopic stent placement can be considered for selected CD strictures, particularly fibrotic ones that are refractory to EBD or technically difficult to manage with dilation alone due to increased length or complexity. Stenting is most commonly considered for anastomotic or colonic strictures where repeated EBD has failed or when surgery is undesirable or needs to be delayed. It is generally regarded as a selective second-line or bridge-to-surgery option rather than routine first-line therapy. Patient selection should be individualized after thorough cross-sectional imaging to assess stricture length, geometry, and associated complications[25,90].

Procedure technique

Endoscopic stent placement aims to achieve sustained luminal patency by deploying a self-expanding stent across the stenotic segment. Initially, a small-caliber endoscope is advanced to and, when feasible, across the stricture to assess its length and geometry. Gentle preliminary dilation to 12-14 mm may occasionally be necessary to facilitate passage of the scope. A guidewire is then passed through the stenotic segment, and the stent deployed over the guidewire under endoscopic guidance, with the endoscope positioned distal to the lesion. However, because of the frequent complexity of colonic strictures, colonic angulations, and the presence of stool, fluoroscopic guidance is commonly employed. Combined endoscopic and fluoroscopic placement obviates the need for passage of the endoscope across the stricture. A biliary catheter is advanced across the stricture over a stiff guidewire, and water-soluble dye is injected to delineate the geometry and length of the stricture. The stent is then placed under combined endoscopic and fluoroscopic guidance. The selected stent should typically exceed the stricture length by approximately 4 cm to ensure adequate coverage and reduce migration risk. Although no stents are specifically designed for CD, fully covered self-expanding metal stents (FCSEMS), partially covered self-expanding metal stents (SEMS), and biodegradable stents have all been evaluated. Covered SEMS are generally preferred because they permit subsequent removal, usually after about 4 weeks. Biodegradable stents gradually dissolve over several months, although clinical evidence remains limited[41,90].

Outcome/results

SEMS provide immediate luminal patency by exerting continuous radial expansile force. Systematic reviews and meta-analyses have demonstrated high technical success but only moderate overall efficacy of stenting. A 2023 systematic review and meta-analysis by Chandan et al[91] reported pooled technical and clinical success rates of approximately 93% and 61%, respectively, with repeat stenting required in about 11% of patients. Another review by Scotti et al[92] (2023) noted technical success of 95% and short-term efficacy of 100%, but long-term efficacy of only 56% (improving to 76% with scheduled retrieval of partially covered SEMS). Overall, 27% of patients eventually required surgery.

Comparison with other modalities

Compared with EBD, SEMS provide continuous radial expansile force rather than transient mechanical stretching, and have been investigated as an alternative to EBD, particularly in refractory or longer lesions. However, available evidence suggests higher complication rates compared with EBD, mainly related to stent migration. The landmark ProtDilat trial directly compared FCSEMS with EBD in Crohn’s-related strictures[93]. In this multicentre randomized study by Loras et al[93], EBD demonstrated superior outcomes with 80% of patients remaining free from new therapeutic intervention at 1 year compared to 51% in the FCSEMS group (OR = 3.9, P = 0.006). Severe adverse events were infrequent and comparable between groups, including perforation rates of approximately 3% in each arm. This trial established EBD as more effective than FCSEMS for most CD strictures[93]. Compared with surgery, stenting offers a minimally invasive bowel-preserving alternative and may function as a bridge to delayed elective surgery in selected high-risk patients. However, because of moderate long-term efficacy and frequent stent-related complications, stenting has not replaced surgery or EBD as standard therapy.

Predictors of efficacy

Stenting tends to perform better in short to intermediate length (≤ 10 cm) fibrotic strictures, particularly those without extreme angulation or active severe inflammation. Long-term efficacy improves with scheduled stent retrieval (particularly with partially covered SEMS)[92]. Factors associated with poorer outcomes include severe angulation, active inflammation, penetrating disease, long strictures, and inability to achieve stable stent positioning. Stent migration remains the major limitation contributing substantially to treatment failure and repeat intervention[94]. Further data are needed to define the stricture characteristics better and patient factors that predict sustained benefit from stenting.

Complications

The principal complications of endoscopic stenting include stent migration (up to 40%), perforation (approximately 3% in the ProtDilat trial), pain, bleeding, obstruction, and recurrent stenosis[93,94]. Among these, migration is the most frequent adverse event and represents the major limitation of SEMS therapy in CD. Major complications occurred in up to 27% of cases in a systematic review[92]. Covered stents, while removable, may have higher migration rates than uncovered devices. Biodegradable stents avoid the need for retrieval but currently lack robust evidence supporting routine use[25,90]. Given the moderate long-term efficacy and substantial complication profile, endoscopic stenting should currently be reserved for carefully selected patients managed in centres with expertise in advanced therapeutic endoscopy. Table 7 summarizes selected key studies evaluating the efficacy and safety of colonic stenting in CD strictures.

Table 7 Selected key evidence studies of colonic stenting in Crohn’s disease strictures.

Ref.	Design	Patients/stent type	Key outcomes	Complications/surgery
Loras et al[93], 2022 (ProtDilat)	Multicentre RCT	FCSEMS vs EBD (maximum 2 sessions) (n = 80)	51% intervention-free at 1 year (vs 80% EBD)	Low severe AEs (~3% perforation)
Chandan et al[91], 2023	Systematic review & meta-analysis	163 patients (SEMS-fully/partially covered or biodegradable)	Technical 93%; clinical 61%	Migration common (44%); 11% repeat stenting
Scotti et al[92], 2023	Systematic review	173 patients	Technical success 95%; clinical success 100% for successfully placed stents; long-term efficacy 56%	Major complications 11%; surgery ~20%
Giri et al[94], 2022	Meta-analysis	170 patients	Technical success 98.2%; clinical success 71.3%	Stent migration 32%; post-procedural pain 20%; surgery rates 8.6%

RCT: Randomized controlled trial; FCSEMS: Fully covered self-expanding metal stents; EBD: Endoscopic balloon dilation; AEs: Adverse events; SEMS: Self-expanding metal stents.

INVESTIGATIONAL AND EMERGING ENDOSCOPIC MODALITIES

Beyond established endoscopic therapies such as EBD, ESt, and SEMS, several emerging modalities have been investigated for CD-associated strictures (Table 8).

Table 8 Selected key evidence studies on emerging/investigational endoscopic modalities for Crohn’s disease strictures.

Modality	Ref.	Design	Patients/key details	Main outcomes	Complications	Notes/limitations
ESTx	Abreu et al[84], 2026	Systematic review	15 studies, 470 CD patients	Technical success 91.7%-100%; clinical success 71.4%-91%	Bleeding 5.2%-8.8%; perforation 0%-3.4%	Promising for short, fibrotic, anastomotic or EBD-refractory strictures
Intralesional corticosteroid injection	Di Nardo et al[95], 2010	RCT (pediatric)	29 pediatric CD patients	Reduced re-dilation and surgery vs placebo	No significant increase	Positive in children; conflicting adult data
Intralesional corticosteroid injection	East et al[96], 2007	RCT (adult)	13 adult patients (anastomotic CD stricture)	No benefit (trend toward worse outcome)	Similar to placebo	Small sample; no biologics used
Intralesional anti-TNF injection	Hendel et al[97], 2014	Prospective case series	6 CD patients (small bowel strictures)	Technical success; reduction in mSES-CD score	No adverse events	Larger RCTs needed
LAMS	Kankotia et al[99], 2024	Retrospective case series (LAMS vs EBD)	Benign lower GI strictures (including CD)	Technical success 100%; clinical success ~82% at > 6 months	No adverse events vs 17% with EBD	Equal efficacy vs EBD; trend towards fewer procedures with LAMS
LAMS	Yuksel et al[100], 2024	Case report	Combined ESt + LAMS	Technical success and short-term relief	None	Hybrid approach promising
LAMS	Manski and Schlachterman[101], 2023	Case report	Duodenal CD strictures	Technical success and short-term relief	None	Limited data; selective use in high operative risk patients
Image-guided hybrid technique	Pal et al[104], 2025	Case report (with IUS)	Hybrid ESt + EBD guided by intestinal US	Successful symptom relief	None	Precision approach; emerging
Biodegradable stents	Karstensen et al[102], 2016	Case series	6 CD cases	Technical success 83%, clinical success 20%	Migration, mucosal overgrowth, stent collapse	Highly investigational
Biodegradable stents	Rejchrt et al[103], 2011	Case series	11 CD patients	Technical success > 90%; rapid symptom relief but high early stent migration rates 28%	None	Highly investigational

ESTx: Endoscopic strictureplasty; CD: Crohn’s disease; EBD: Endoscopic balloon dilation; RCT: Randomized controlled trial; TNF: Tumor necrosis factor; mSES-CD: Modified Simple Endoscopic Score for Crohn’s Disease; LAMS: Lumen apposing metal stent; GI: Gastrointestinal; ESt: Endoscopic stricturotomy; IUS: Intestinal ultrasound.

ESTx involves controlled electroincision of the stricture (similar in principle to surgical Heineke-Mikulicz) followed by clip closure of the incised edges to maintain luminal patency. A 2026 systematic review by Abreu et al[84] (15 studies, 470 CD patients) reported high technical success (91.7%-100%) and clinical success (71.4%-91%), with bleeding rates of 5.2%-8.8% and perforation 0%-3.4%. ESTx appears promising, particularly for short, fibrotic strictures, anastomotic strictures, or strictures refractory to prior EBD.

The role of adjunctive intralesional injections remains controversial. Two small randomized controlled trials evaluating long-acting corticosteroid injection (triamcinolone) after EBD yielded conflicting results: One paediatric study showed reduced re-dilation and surgery[95], while an adult trial suggested no benefit or even a trend toward worse outcomes[96]. A 2024 review concluded that the true benefit remains uncertain and routine use is not currently recommended[90]. Limited case series have explored intralesional anti-TNF agents (e.g., infliximab), reporting feasibility and potential efficacy, but high-quality data are lacking[97,98].

Lumen-apposing metal stents (LAMS), originally developed for pancreatic fluid collections, have been repurposed for short refractory or anastomotic CD strictures. Small case series and reports (2023-2025) have demonstrated technical feasibility and short-to-medium term efficacy, often as a bridge to further therapy or surgery, with potentially lower migration than conventional SEMS due to their anchoring flanges[99-101]. Hybrid approaches combining ESt with LAMS placement have also shown promise in selected cases[100].

Other investigational techniques include biodegradable stents[91,102,103] and image-guided hybrid procedures[104]. These remain experimental with very limited published data. High-quality randomized controlled trials are urgently needed to establish the safety, efficacy, and long-term outcomes of these novel approaches. At present, their use should be reserved for high-volume interventional inflammatory bowel disease (IBD) centres within a multidisciplinary framework, with the overarching goal of bowel preservation and individualized therapy selection.

OUTCOME MEASURES

Both short-term and long-term efficacy and safety outcomes should be considered and assessed when evaluating endoscopic therapy for CD-associated strictures. Technical success after EBD is defined as successful passage of an adult colonoscope across a previously non-traversable stricture after intervention without major immediate complications. Clinical success refers to improvement or resolution of obstructive symptoms following treatment[75,105].

Long-term efficacy is commonly evaluated using endoscopic intervention-free survival and surgery-free survival, which remain the most widely reported outcome measures in studies of endoscopic therapy for Crohn’s strictures. Additional outcomes include need for stricture-related hospitalization or emergency visits. Long-term success is often defined as avoidance of surgery for at least 1 year following endoscopic treatment[75,105].

QUALITY OF EVIDENCE AND METHODOLOGICAL LIMITATIONS OF AVAILABLE STUDIES

The majority of evidence supporting endoscopic management of CD strictures derives from retrospective studies, case series, and a limited number of prospective observational studies and small randomized trials. High-quality, multicentre randomized controlled trials remain scarce.

Important limitations include: (1) Selection bias: Patients selected for endoscopic therapy often have shorter, accessible, and technically favourable strictures, limiting generalizability to all stricturing phenotypes; (2) Retrospective design: Most comparative studies are retrospective and subject to confounding by indication, treatment allocation bias, and variable follow-up duration; (3) Heterogeneity: Significant heterogeneity exists across studies with respect to stricture characteristics (location, length, inflammatory vs fibrotic phenotype), prior surgical history, concomitant medical therapy, and disease severity. This makes direct comparison between studies difficult; (4) Non-uniform outcome definitions: Definitions of technical success, clinical success, recurrence, and long-term efficacy vary substantially across studies, making comparison between studies difficult; and (5) Centre and operator effects: Outcomes are heavily influenced by endoscopist expertise and studies performed predominantly in specialized high-volume IBD centres, reducing reproducibility in routine practice.

Future research should prioritize adequately powered multicentre RCTs with standardized outcome definitions and longer follow-up. Despite these limitations, the cumulative evidence supports endoscopic approaches as valuable bowel-preserving options in carefully selected patients.

POST-PROCEDURE MONITORING AND CARE

Careful post-procedure observation is essential for early recognition of complications. Patients are generally monitored for at least 2-4 hours after uncomplicated procedures, with longer observation recommended following complex interventions or BAE-assisted therapy. Monitoring should focus on abdominal pain, fever, tachycardia, bleeding, or signs of perforation. Dietary intake is usually advanced gradually from clear liquids as tolerated, although temporary bowel rest may be required after extensive dilation or stricturotomy. Imaging with abdominal radiography or computed tomography should be selectively performed when perforation is clinically suspected. Long-term follow-up typically includes clinical reassessment and repeat endoscopic or radiologic evaluation within 3-6 months, particularly in symptomatic patients, as restenosis and repeat intervention are common. Continuation or escalation of disease-modifying medical therapy following endoscopic intervention remains crucial for altering the natural history of fibrostenotic CD and improving surgery-free outcomes[41,90].

COMPLICATIONS AND MANAGEMENT

Endoscopic interventions for CD-associated intestinal strictures are generally safe when performed by experienced operators in high-volume centres; however, they carry recognized risks of adverse events that must be discussed during informed consent. The overall safety profile is favourable compared to surgery, with major complication rates typically ranging from 2%-6% depending on the modality, stricture characteristics, and operator expertise[41]. Perforation remains the most serious complication, occurring in 1%-3% of EBD, with higher risk in inflamed, angulated, long strictures (> 5 cm; risk increases ~8% per additional cm), high balloon inflation pressures/diameters (> 20-25 mm), and multiple strictures[74,75,81,82]. Immediate intraprocedural recognition is critical. Small, contained perforations may be managed endoscopically with through-the-scope clips, over-the-scope clips (OTSC), or stents, combined with CO₂ insufflation (preferred over air), broad-spectrum antibiotics, bowel rest, and close monitoring. Larger or free perforations, or patients with clinical deterioration (peritonitis, sepsis), require urgent surgical consultation and intervention (e.g., resection, diversion, or repair)[106]. Conservative management with antibiotics and percutaneous drainage (if abscess forms) is appropriate in selected stable patients. ESt is associated with a comparatively lower perforation rate but higher clinically significant bleeding (8%-11.8%)[84-86]. Most cases are self-limited or manageable endoscopically with clips, coagulation (e.g., hemostatic forceps or argon plasma), epinephrine injection, or topical hemostatic agents. Transfusion and angiographic embolization are rarely needed[41]. Patients on antithrombotics require careful periprocedural management as per ASGE/ESGE guidelines[68,69]. Stent migration is the major limitation of SEMS, reported in up to 40% of cases with fully covered designs[90,91]. Scheduled retrieval (typically at 4 weeks) reduces long-term complications[92]. Endoscopic or fluoroscopic retrieval is usually feasible. Other adverse events include post-procedural pain (common, usually self-limited), transient ileus, infection/sepsis (rare), and sedation-related issues. Stricture recurrence represents the major long-term challenge, with 40%-65% of patients requiring re-intervention after EBD and 25%-30% eventually needing surgery over extended follow-up[74,75,81,82]. Early recognition of complications, timely conservative or endoscopic management, and ready access to surgical backup are essential for achieving optimal outcomes.

MANAGEMENT OF CD STRICTURES IN THE PRESENCE OF A CONCOMITANT FISTULA AT THE SAME SITE

The coexistence of a stricture and fistula at the same anatomic site represents one of the most challenging phenotypes in CD. Fistulas in CD develop due to transmural inflammation, which leads to deep ulceration that penetrates through the bowel wall, creating an abnormal communication with adjacent bowel loops, skin, or organs. High intraluminal pressure proximal to a stricture can contribute to perforation, fistula formation, or abscess development upstream of the stricture in some cases[107]. In one large registry analysis of complicated CD, stricturing-only was ~29%, penetrating-only ~11%, and combined stricturing + penetrating (B2B3) ~17%[108]. This overlap significantly increases procedural complexity and risk, often shifting the therapeutic balance towards a multidisciplinary approach integrating optimized medical therapy, selective endoscopic intervention, and surgery. According to the GIIBD group consensus, the presence of an associated fistula or abscess is generally considered a relative or absolute contraindication for EBD[41]. Radial force generated during balloon inflation: Can theoretically disrupt the fistula tract, leading to free perforation, abscess formation, or worsening sepsis. Large case series and systematic reviews have historically excluded patients with concurrent fistula from EBD cohorts for this reason. When attempted in highly selected cases (e.g., as a bridge to definitive therapy or in patients unfit for surgery), graded dilation with smaller balloons under fluoroscopic guidance and close post-procedure monitoring is mandatory[109]. Evidence from cohorts that included fistulizing disease shows higher rates of adverse events and surgery. For instance, the presence of a fistula was an independent predictor of need for surgical intervention after EBD (hazard ratio = 5.50, 95% confidence interval: 2.16-14.0)[110]. ESt offers a more precise, controlled alternative in this setting. Using needle-knife or insulated-tip knife electroincision, the fibrotic stricture can be selectively opened in a targeted direction (e.g., away from the fistula orifice, if feasible). Limited data from expert centers suggest ESt may be safer than EBD in complex stricture-fistula phenotypes because it avoids uniform radial pressure[74]. Endoscopic stenting can be considered selectively for refractory strictures with fistula as a bridge to surgery or longer-term palliation[107,111].

Integrated fistula management is essential. When a stricture and fistula coexist, initial control of sepsis (intravenous antibiotics, abscess drainage via endoscopy, radiology, or surgery) followed by endoscopic stricture therapy (preferably Est) plus fistula interventions (endoscopic fistulotomy[107,112], OTSC closure[74,113-115], or fistula plug/glue injection (perineal fistulas)[74,107]) may be pursued in a stepwise multidisciplinary fashion. Endoscopic therapy for fistula and abscess has expanded significantly and can complement stricture management[74,116]. Surgical intervention remains the preferred definitive approach for most patients with combined stricture-fistula disease, especially when the stricture is long (> 5 cm), angulated, multiple, or associated with a complex fistula/abscess/phlegmon. Laparoscopic resection with fistula takedown or bowel-preserving strictureplasty (when feasible) offers durable results[107]. Endoscopic therapy in this context is best viewed as a bridge to optimize timing of surgery, reduce inflammation, or preserve bowel length in patients with short bowel risk or multiple prior operations.

SURGERY

Despite advances in endoscopic therapy, surgery continues to play an important role in the management of CD strictures. It is the preferred approach for patients with refractory obstructive symptoms, perforation, or complex strictures as well as for those with suspicion of malignancy. Laparoscopic ileocolic resection remains the standard for limited terminal ileal disease[117], offering reduced morbidity compared to open surgery. Bowel-preserving strictureplasty is strongly recommended in patients with multiple strictures or those with prior extensive resections to minimise the risk of short-bowel syndrome. Heineke-Mikulicz strictureplasty is typically performed for short (< 10 cm) strictures, while Finney or Michelassi techniques are used for longer or multiple lesions[25]. Meta-analyses have shown comparable overall morbidity between strictureplasty and resection, although strictureplasty alone is associated with a modestly higher recurrence rate (OR = 1.36-1.61)[118,119]. Long-term data nevertheless support its safety and efficacy. The ECCO 2024 guidelines explicitly recommend strictureplasty as a valid alternative to resection in small-bowel CD[120].

In current practice, short (≤ 5 cm), easily accessible strictures (esophagus, stomach, duodenum, terminal ileum, and colorectum) without penetrating complications are preferentially managed endoscopically, whereas complex, long, multiple, or angulated strictures with high inflammatory burden or penetrating disease are better served by surgical intervention[70]. The cumulative 10-year surgery risk in CD remains 40%-55%, although this has decreased to approximately 30% in the biologic era, with reoperation rates after index resection around 30%-35%[16-18]. A multidisciplinary, individualized approach integrating endoscopic and surgical options remains essential for optimal bowel preservation and long-term outcomes.

MANAGEMENT ALGORITHM AND POSITIONING OF ENDOSCOPIC THERAPIES FOR STRICTURES IN CD

EBD remains the first-line endoscopic therapy for most suitable CD strictures due to its wide availability, technical simplicity, and acceptable safety profile. In contrast, ESt/ESTx offers controlled, precise tissue cutting, resulting in greater and more durable luminal expansion, particularly in short fibrotic or anastomotic strictures. The strongest contemporary comparative evidence now comes from the randomized controlled BEST-CD trial (NCT05521867), which compared EBD vs ESt for short (< 3 cm) CD strictures[121]. In this study, technical success was similar between EBD and ESt (90.5% vs 95%), but ESt demonstrated significantly lower re-intervention rates (15% vs 42.9%, P = 0.05) and lower subsequent surgery rates (5% vs 28.6%, P = 0.045), with comparable adverse-event profiles between groups. Bleeding events were slightly more frequent after ESt but were manageable endoscopically, and no patient required transfusion. A 2026 experimental randomized animal study also confirmed greater and more durable luminal enlargement with EST compared to EBD[122]. While these results are promising, larger multicentre confirmatory trials are needed to establish the optimal role of ESt relative to EBD across diverse patient populations. Therefore, EBD is generally preferred for simple, short (3-5 cm), non-angulated strictures, whereas ESt may be considered preferentially in experienced centres for short (≤ 3 cm) fibrotic, refractory or recurrent anastomotic lesions. Hybrid approaches (ESt + EBD) are increasingly being used in complex cases[104,123]. SEMS are usually reserved as second-line or bridge-to-surgery options for refractory or longer strictures because of higher migration rates and inferior long-term efficacy. Long (> 5 cm), multiple, angulated, severely inflamed, or penetrating strictures associated with fistulae, abscesses, or marked pre-stenotic dilatation are generally better managed surgically (Figure 3).

Figure 3 Proposed multidisciplinary management algorithm for Crohn’s disease-associated intestinal strictures integrating medical, endoscopic, and surgical options based on stricture characteristics and patient factors. CD: Crohn’s disease; MRE: Magnetic resonance enterography; CTE: Computed tomography enterography; IUS: Intestinal ultrasonography; Rx: Treatment; TNF: Tumor necrosis factor; UST: Ustekinumab; VDZ: Vedolizumab; EBD: Endoscopic balloon dilation; CRE TTS: Controlled radial expansion through-the-scope; ESt: Endoscopic stricturotomy; FCSEMS: Fully covered self-expandable metal stents; ESTx: Endoscopic strictureplasty; LAMS: Lumen apposing metal stents; MDT: Multidisciplinary team.

FUTURE DIRECTIONS

The field of endoscopic management of CD strictures is evolving rapidly, with several promising developments on the horizon. Well-designed randomized controlled trials are still needed, including further studies beyond the recent BEST-CD trial comparing EBD vs ESt[121], evaluation of hybrid techniques, and studies assessing the optimal integration of endoscopic therapy with newer biologics and small molecules. The development of effective anti-fibrotic therapies targeting key pathways such as TGF-β signalling, IL-36, and fibroblast activation represents a major paradigm shift, with the potential to prevent or reverse intestinal fibrosis rather than merely treating its mechanical consequences[124]. Technological innovations are also expected to enhance outcomes. These include AI-assisted stricture characterization and procedural planning[125], real-time functional assessment tools such as EndoFLIP[126,127], advanced imaging modalities including radiomics and 68Ga-FAPI PET/MR for better differentiation of inflammatory vs fibrotic components[128], and next-generation stents or drug-eluting devices tailored for IBD[129,130]. Improved navigation systems for deep small-bowel strictures and image-guided hybrid procedures will further expand the safety and applicability of endoscopic interventions.

CONCLUSION

Endoscopic therapy has become a cornerstone in the multidisciplinary, bowel-preserving management of CD-associated intestinal strictures. EBD remains the first-line modality for short, accessible strictures, while ESt offers potentially greater luminal gain and lower surgery rates in selected fibrotic and anastomotic lesions. SEMS serve as a selective bridge in refractory cases, and emerging techniques such as ESTx and image-guided hybrid procedures show promise. Careful pre-procedural phenotypic characterization using cross-sectional imaging (particularly MRE and IUS) and multidisciplinary discussion are critical for optimal outcomes. While endoscopic approaches can significantly delay or prevent surgery in appropriately selected patients, complex, long, multiple, angulated, or penetrating strictures continue to require surgical intervention. Strictureplasty remains a valuable bowel-preserving surgical option in patients with extensive disease. Future progress depends on well-designed randomized trials, development of effective anti-fibrotic agents, refinement of precision imaging and endoscopic techniques, and cost-effectiveness studies, especially in high-burden regions like India. Ultimately, an individualized, phenotype-driven, multimodal strategy integrating optimised medical therapy, advanced endoscopy, and judicious surgery offers the best chance of minimising intestinal damage and improving long-term quality of life in patients with stricturing CD.