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

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

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.

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.

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.

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.

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.

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.

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.