Tauseef Ali, MD, on Penetrating and Stricturing Crohn's Disease
Dr Ali recaps his presentation from the AIBD Dallas regional meeting on the treatment of penetrating and stricturing Crohn's disease.
Tauseef Ali, MD, is Clinical Assistant Professor of Medicine at the University of Oklahoma and medical executive director of Saints Digestive Institute and director of IBD clinical and research program at SSM Health Saint Anthony Hospital in Oklahoma City, Oklahoma.
Hi, I'm Dr. Tauseef Ali. I'm a director of SSM Health St. Anthony Hospital, Crohn's and Colitis Center in Oklahoma City, Oklahoma. This year I was given a daunting task of giving a presentation on stricturing and fistulizing Crohn's disease during AIBD regionals held in Dallas in June, 2025.
As we all know, Crohn's disease is a progressive disease and it carries some complications, including stricturing disease and a fistulizing disease that can happen in about 10 to 20% of the patients. So I covered some important clinical aspects of managing these two complications. So let's start with the stricturing disease. We know that about 10 to 20% of the patients with Crohn's disease can actually present with stricturing disease at the time of diagnosis. We also know that Crohn's disease is a progressive disease and it can lead to stricture formation in about half of the patient over the course of their illness. So it's very important to recognize and diagnose stricture in Crohn's disease. Symptoms alone or a plain abdominal film and physical examination does not aid in the diagnosis of stricture. What we have learned that cross-sectional imaging such as CT enterography, MR enterography, intestinal ultrasound, as well as endoscopy, where you see the narrowing in the intestine that is not passable through the adult colonoscope, helps us to establish the diagnosis of a stricture. In Crohn's disease, the stricture could be inflammatory as well as fibrotic stricture. Sometimes it is very difficult to differentiate between the inflammatory and fibrotic stricture. On imaging, it's easy to see the inflammation. It's very hard to confirm the fibrotic component of the stricture. When you see inflammation in the stricture, you initially start with medical therapy. I reviewed data of not only anti-TNF therapies, but also some other advanced therapies such as interleukin 23 inhibitors, anti-integrin therapies, as well as JAK inhibitors and their role in the strictures of Crohn's disease.
One important highlight of my presentation was recognizing the risk of malignancy in colonic stricture and be very careful about that. We know that our goal of managing stricture is to open it up so that patients have less symptoms or no symptoms and their symptoms improve and the obstruction is relieved. In colonic stricture, one of in the important goal is to open up that stricture so you can look upstream and ensure there is no malignancy. The risk of malignancy always needs to be kept in mind in the stricturing Crohn's disease when it involves the large intestine. If medical therapy is not helping or there is no inflammation, balloon dilation is also available to help improve the obstruction in these strictures. And if there is phlegmon, abscess, there's a sharp angulation where you cannot use balloon dilation. Surgery can also play an important role in relieving the obstruction. I also reviewed the data of stent placement, and in fact, there were more patients who actually got relieved with balloon dilation and have better outcomes as compared to patients who stent for the relief of the stricture.
My next segment was on perianal fistula, another very debilitating condition in patients suffering from Crohn's disease. Still infliximab or the anti-TNF therapy holds the MVP position when it comes to the treatment of perianal disease or perianal fistulas. There is a role of antibiotics, short-term duration, good response when combined with anti-TNF therapy.
I also reviewed the latest classification of perianal fistula, how it is divided into low and high fistulas as compared to our very previous definitions of very complex categories of different perianal fistulas. So a clinically relevant definition where low fistulas can be managed with medical therapy; if there is proctitis involved, the risk of surgery becomes very high. So you really need to aggressively treat proctitis. And if it is a complex fistula, a fistula that is associated with pain, a fistula that is associated with abscess or a fistula that is associated with multiple external openings, these fistulas have better outcomes when you combine surgical and medical therapies together. An exam under anesthesia with placement of setons when it is required or indicated along with aggressive medical therapy, yield better outcome.
In short, whether it's a stricturing disease or fistulizing disease, early correct diagnosis, multidisciplinary approach leads to better outcome for your patients.
