Thomas Borody, MD, PhD, FRACP, FACG
Centre for Digestive Diseases
Five Dock, New South Wales, Australia
Gaurav Agrawal, MBBS, MRCP1, Rhys Collyer2, Annabel Clancy, BND, PhD, APD3, Anoja W. Gunaratne, PhD, MSc, BAMS3, Stephan Lampe, BSc, BCom2, Thomas Borody, MD, PhD, DSc, FRACP4
1CDD, Sydney, New South Wales, Australia; 2Centre for Digestive Diseases, Sydney, New South Wales, Australia; 3Centre for Digestive Diseases, Five Dock, New South Wales, Australia; 4Center for Digestive Diseases, Five Dock, New South Wales, Australia
Introduction: Approximately one third of patients with Crohn’s disease (CD) will develop strictures within 10 years of diagnosis, commonly in the terminal ileum and ileocecal valve (ICV). Strictures often lead to abdominal pain, obstruction and are a risk factor for developing internal fistulae and cancer. Current treatment involves endoscopic balloon dilatation or strictureplasty. However, this may result in postoperative complications or recurrence. Recent evidence suggests that Mycobacterium avium ssp paratuberculosis may be a causative agent of CD and anti-mycobacterial antibiotic therapy (AMAT) has been shown to induce remission significantly better than placebo. The effects of AMAT on strictures has not been reported.
Aim: To report the outcomes of AMAT in patients with CD and an ileal stricture/s.
Methods: This is a single centre retrospective (January 1995-December 2018) case review of patients diagnosed with CD, who had ileal stricture on colonoscopy and were treated with AMAT which comprised a combination of clarithromycin, rifabutin, and clofazimine, some with added ethambutol, ciprofloxacin, metronidazole or tinidazole. Symptoms, colonoscopy reports, biochemistry and concurrent medications were reviewed and recorded at pre-treatment and 6, 12, 18 and >24 months on treatment.
Results: Forty-three patients (24 male, 16-56yrs) with an average age of 31yrs, and 5yrs (0-27yrs) after diagnosis were included. At pre-treatment, 17 patients had stricturing of the ICV, 25 had stricturing of the ileum and one had stricturing in both the ileum and ICV. Of the patients who had follow up colonoscopy data (N=32), after >24 months of AMAT, 22/32 patients (69%) had complete resolution and 2/32 patients had partial resolution of their strictures. Interestingly, after resolution of stricture on AMAT one patient ceased treatment. At 36 month follow up post cessation of AMAT the patient’s ileocecal stricture had returned. Further treatment with AMAT resulted in resolution of the stricture.
Discussion: AMAT for CD is effective in opening Crohn’s strictures avoiding the need for repeated dilatations or surgery. These observations suggest that stricturing in CD may be mediated by mycobacterial infection, as reported in tuberculosis strictures. To our knowledge, CD strictures have not previously been reported to open using medical therapy. Further prospective documentation is required to better define this positive effect of AMAT, including rate of resolution.
Citation: Gaurav Agrawal, MBBS, MRCP; Rhys Collyer; Annabel Clancy, BND, PhD, APD; Anoja W. Gunaratne, PhD, MSc, BAMS; Stephan Lampe, BSc, BCom; Thomas Borody, MD, PhD, DSc, FRACP. P2328 - CROHN’S STRICTURES OPEN WITH ANTI-MYCOBACTERIAL ANTIBIOTIC THERAPY (AMAT): A RETROSPECTIVE REVIEW. Program No. P2328. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.