2169 Endoscopic Stricturotomy via Argon Plasma Coagulation With Balloon Dilation for Refractory Colonic Stricture Secondary to Crohn’s Disease

INTRODUCTION: Stricture is a significant complication in patients with Crohn’s disease (CD). Up to 80 % of patients will require at least one surgery for stricture, fistula, or abscess during their lifetime. The current treatment modalities are surgery, endoscopic balloon dilation (EBD), or endoscopic stricturotomy (ES) via a needle-knife or electrosurgical knife. We report a combined endoscopic stricturotomy via argon plasma coagulation (APC) with balloon dilation in a patient with refractory benign colonic stricture due to Crohn disease. CASE DESCRIPTION/METHODS: A 56-year old man with a twenty-seven-year history of Crohn’s disease presented to the clinic with chronic right-sided abdominal pain. He has two to three bowel movements a day. He is a non-smoker, denied alcohol, or illicit drug use. He had prior use of anti-TNF inhibitor with secondary loss of response. Current medication included azathioprine, esomeprazole, and ustekinumab injection every eight weeks. Vital signs were normal. The abdomen was soft, non-tender, no organomegaly, normal bowel sounds, and normal rectal exam. Labs revealed hemoglobin 14.2 g/dl, leukocyte count 7k/mm3, platelets 393k/mm3, urea nitrogen 13 mg/dl, creatinine 1.0 mg/dl, CRP 0.9, mg/dl and fecal calprotectin 59 ug/g. Magnetic resonance enterography (MRE) was performed and revealed severe short segment stricture of the mid ascending colon (Figure 1). He underwent a colonoscopy, and it showed a benign-appearing, severe non-traversed stricture measuring 3 cm in length x 1.1 cm in inner diameter in the ascending colon (Figure 2). Coagulation for tissue destruction and stricturotomy using pulsed argon plasma at 1.5 liters/minute and 40 watts was accomplished, followed by balloon dilator up to 15 mm with significant improvement in the luminal narrowing (Figure 3). The site was traversed, and the cecum was inspected. The patient was seen in the clinic two months later, and he was doing well, and his abdominal pain was resolved. DISCUSSION: Surgery is still considered to be the standard therapy in patients with a colonic stricture. Endoscopic stricturotomy has emerged as a promising modality to avoid or minimize the need for surgery. Up to our knowledge, using the APC mediated ES has not been reported. So, we report the successful use of this technique combined with balloon dilation in a patient with severe CD- associated benign stricture. The clinician should be aware of such procedure as an effective treatment modality in refractory benign colonic stricture.