Naina, the question is, just from me, when you do the deep small bowel structure, use a balloon enteroscopy, balloon enteroscopy, you want to do the antigrade fashion or retrograde fashion? Which one is easier? Thanks, Bo. You know, it depends on the location of the structure. In general, antigrade is easier, only because retrograde, if they have a significant structure, the prep is always harder for these patients. And when there's a lot of stool in the colon, the enteroscopy gets quite hard. But if they're distal ileal structures, then a colonoscopy, a retrograde approach is quite easy. So what's the maximum number you would do in the deep small bowel structure? For example, it's like three or four, if there's some people have the multiple of them, some of the people with it, really, for the coronaries, actually, quite often, they have the multiple, like three or four or five. And what's the maximum number you would do, or there's no maximum number? No maximum number, as long as they're in a short segment. So if they're spread throughout the ileum, and I don't think I'm going to get to the proximal ones, really, then I probably wouldn't do it. But I would still try, because these patients will have significant morbidity from requiring a long segment resection. So especially if the cross-sectional imaging shows no active inflammation, then we will give them a chance at seeing how far we can get and dilate the structures as we come upon them. Wonderful. And then Mike also had another question, actually, from the audience. I wonder, it's like, I think that Ode himself would do this occasionally, do the stent. Is there any rule for fully covered, self-expandable, metallic stent, the rule for the treatment of the structure? I welcome every panelist to answer the question, but Ode, go first. Do you do the stent for the people with the structure? Yeah, I mean, it depends, actually. If it's a, the patient has no other option, patient has got a risk of short ball if you have surgeries, or has an issue with recurrent ball obstructions, or does not want repeated procedures again and again, usually my usual approach is endostopic stricturotomy, not stent as a first option. But if that also fails, then if the short structure, I would prefer like a lumen-expanding stent, lumen-opposing metal stent, like axial stent, if the short structure, that'd be better. But a fully covered, self-expanding metal stent is probably riskier because of high risk of migration. So I always worry about putting a fully expanded stent in a patient with Crohn's, but if there's a last resort and a patient want to avoid surgery, I may put those. But again, I will usually remove them within two weeks at the max, I don't place them longer than usually within a week if I can, I don't even leave two weeks just to avoid the risk of migration. And I'm trying to put a clip there after I put a stent in, just to prevent the risk of migration, but the risk is still there. It's still there. You have the clip. So actually, I wonder if Dr. Bernstein is still available. And there's a question, is there any transmittal healing rate with various biologic agent in structural small bowel Crohn's disease, transmittal healing? That's an easy one because the short answer is we don't know. You know, I think as we've heard from David today, and as we've heard from other speakers who were pointing out the discrepancy between endoscopy and cross-sectional imaging, the only way to know is really by serial cross-sectional imaging. And you know, it's unfortunate that David's not alive because, you know, one of the problems we all struggle with, with cross-sectional imaging is, you know, as the bowel is peristalsing, there's thickened segments that aren't really inflamed segments. You know, how many times a bow have we all chased thickening on a CT or MRI and we don't find anything endoscopically? It's not because there is transmittal disease, it's because it's really normal. So when there is bonafide inflammatory disease that you can see cross-sectionally as part of the stricture, the only way you're going to know is by following it up with more cross-sectional imaging. At least for me, which is why MRE has become my favorite option over CTE, because I want to do serial cross-sectional imaging and there's no radiation with MR. So this will be leading to another question for Dr. Bernstein and others. So I have a patient, 78 years old, has an endoscopically associated bowel perforation and emergency surgery now has the iliorectal anastomosis stricture. So anastomosis at around 15 centimeters, the length is about 1.5 centimeters. So I tried the balloon dilatation, I tried the IT knife therapy, and the stricture closed again. Is there any rule for using any agent, systemic steroid, local steroid, or systemic biologic agent for Crohn's disease associated anastomotic stricture? Any rule? So I'll take a shot at this and then I'll be happy to hear what anybody else has to say. One thing that's interesting about this clinical scenario, Bo, is that when there's an iliorectal anastomosis at 15 centimeters, you know, often with Crohn's disease, when we go in and find a stricture, our knee-jerk reaction is to dilate it to get as good a look as we can. But you know, sometimes we're making things worse when the anastomosis is so low. The stricture may actually be limiting the diarrhea the patient is having. So you want to ask yourself, you know, why are you doing this? Now if they're having obstructive symptoms, then you're going to need to do it. But just a reminder, especially for low strictures, don't dilate it if the patient is doing reasonably well just because it happens to be a stricture. Hopefully you can biopsy enough. And I have always had a tendency to go, you know, we've got balloons that go anywhere from 8 to 20 millimeters. I like to go as high as I can. But especially in low strictures, you know, if I feel I have to dilate it to get through so I can make sure there's not a malignancy to make sure that I'm seeing the other side, I may not want to go fully dilated because part of that stricture may be helping continence. Now there's no data that's hard data that's going to tell us which biologic therapy may prevent stricture recurrence once we dilate it, which is the scenario we're struggling with. So the drug that I would probably try is Stelera. The reason I would try that in your patient is because she's 78. Stelera will be safer than infliximab. I don't know whether she's probably had infliximab, I don't know. I wouldn't bother with Antivio at all in this scenario, even though Antivio is very safe. I'm just less confident about it in complicated Crohn's disease. Thank you. Actually, I try to send it back to the surgeon to do like surgical correction. And I heard some of the surgeons do the strictureplasty over stricture and anastomosis, but a lot of surgeons do it, but actually I have not seen anyone actually did it. So I think they leave all the room for the endoscopic therapy with the medical therapy, you know, together. I agree. Actually, the patient I did give the Stelera, we see some improvement of the symptoms. Hopefully the effect is well lasting, will be lasting. So actually next question actually is related to tomorrow's talk with Dr. Nemanethan, right? So basically the audience said there is meta-analysis showed that after blunt adaptation of the small bowel structure, one and a half of them get recurrent symptoms, two-thirds of them eventually require surgery or redo therapy. Is this electric incision with a needle knife or IT knife or stricturotomy provide additional benefits? Uday? Yeah. I mean, it's very hard to have a strong data because you don't have any randomized controlled trials comparing surgery or EBD or EST at this point. But what we have is data comparing two different techniques, EST and endoscopic stricturotomy and surgery. And EST appears to be as good as surgery in patients who have failed endoscopic balloon dilation. So I think it is definitely an option. I don't know if there's an option for lasting relief. We don't have data to support it because all the studies are short-term data, but in patients who are desperate for options and want to avoid surgery, putting the small intestine because of the risk of short bowel syndrome, EST is definitely a great option to offer at least the patients. I think it is, Dr. Agree. And we try to use the endoscopic electric incision. And then to address Dr. Powell's question regarding the repeated dilatation, actually this is normal. When you people have the balloon dilatation, it's not a one-time deal. It's not like the people had a website, web like the diaphragm, like the structure, like caused by the NSAID. Chronically they need to repeat the dilatation. In my book, it said if the patient required every three months dilatation, it's too often will be surgical option. If the patient required balloon dilatation every six months, every year, I can just do a repeated dilatation. And then use the electric incision with a needle knife or IT knife as a backup. Now I have a question for Reena, Dr. Connor, I hope that she's still here. So a lot of the index for the endoscopy index are now available, but it's a very time-consuming when you're at the busy schedule, you do the SES type of index, very, very hard to do. If you have the practice, what you would do at the simple, choose like between all the others, choose the simplest and easiest, most accurate one. Which one you will choose? Crohn's disease and ulcerative colitis, which one index you would use in clinical practice, not again, clinical trial? Yeah, absolutely. Thanks, Phil. And so I think that's a great question. And that's one of the drawbacks of the indices that currently exist. So actually one of my current research projects is to develop an entirely new index in Crohn's disease for two reasons. One, as you've mentioned, the current scales are far too cumbersome, I think, for clinical use. And I think the way we use them in clinical practice dichotomized, they don't perform as well as we'd like them to. So in truth, in ulcerative colitis, I still use the Mayo score in clinical practice. I think it has utility, it has prognostic value, and it's very easy to do. And I think communicating with your colleagues, it's intuitive to all of us. In Crohn's disease, I think it's a lot more challenging. So I have to say, I don't routinely record an SCSCD score. I record the items of the SCSCD in words and text, but I don't actually put a 44 or 36. I think most people that I communicate with wouldn't have an appreciation of what that even means. So I still think absence of ulceration is the easiest and probably the most valid. We know when you look across readers, we all as endoscopists agree on ulcer. All the other items like erythema, friability, a lot of that has to do with how close you are to the mucosa, how well distended the bowel is. It's very, very subjective. So I agree with you. The current Crohn's scales, although helpful, if we had to pick one, I'd pick SCSCD, but really, I don't think any of them are super helpful in clinical practice. Rina, can I ask you a question? Sure. Rina, that's endoscopy. What about in clinic? You know, for many years, I had filled out a modified Powell-Tuck that didn't include the Flex-SIG and a Harvey Bradshaw, probably for the first 15 to 18 years of my practice and had lots of data, never used it, actually. And so I just wonder if you use an index in clinic or whether you think we should. If you do, I would put in a plug for the IBD symptom inventory that we developed and validated. It's a little bit long because it's not five questions. It's closer to 15 or 18, but it really takes one to two minutes for the patient to complete. It's all the standard stuff we're asking them. And it's the same questionnaire for UC and for Crohn's, which makes it helpful. So what do you do in practice, in clinic rather, rather than endoscopy? Yeah, so I think even a couple of years ago, I was trying to get the Mayo items for UC and trying to do an HBI. We know HBI correlates well with CDAI, for what it's worth. So that's what I was collecting. I have to say, during the pandemic, some of those items are a bit more challenging. And I think general well-being is so difficult to understand what that means. I've moved towards the PRO items, similar to stride. So I try to collect abdominal pain, stool frequency, and Crohn's for sure. And then stool frequency, rectal bleeding, and ulcerative colitis. And then I do now have more of a focus on that patient aspect. So I'm also trying to collect the item that bothers the patient the most. So sometimes we're so focused on the bowel, but to them, it's the fatigue. Or for them, it's actually the knee that's all swollen. And so I think I'm trying to now focus on those items that I need for stride and that I think are clinically relevant, and then adding in what I think the patient finds most relevant. So that's what the IBDSI, it includes the extra intestinal stuff, the fatigue, the bowel symptoms, and pain symptoms. So there's the different categories. Absolutely. So I'll probably address the last question. Actually, the audience raised for Dr. Lubin, actually, in terms of how the MRE or CTE can help differentiate between Crohn's disease and ulcerative colitis. I can say it's the indeterminate colitis, the category is a pathological term. So it's in surgical specimens. When you have the indeterminate colitis, that means it has a transmural disease, but really associated with a severe colitis. The pathologist cannot tell it is a transmural disease because of Crohn's disease or because of severe UC. So there's a pathological term. But if the pathologist cannot tell, there's a CD versus UC in there. So they call it indeterminate colitis. I doubt the CTE or MRE will tell, because indeterminate colitis is a pathological term. Now, the last question would be... This is Nina. I just want to say there, though, that if you don't have a pathology specimen, because a patient has not had a colectomy, and you have a patient who presents with severe pancolitis, and the question is, is this ulcerative colitis or is this Crohn's colitis, and you're really not sure because maybe it started in the left and then it went to the right, and you don't have a great history, I would favor to say that you should get cross-sectional imaging at least once in a patient's... So you're probably not to use a word called indeterminate colitis. Correct. Indeterminate is a specific pathology term. If you try to use it in your situation, it may be called IBD unclassified. That's perfect. Yeah. But the plug is that we often see patients that have not had some sort of cross-sectional imaging, and it's very important because they could have occult small bowel disease that they're not yet symptomatic from that would otherwise be missed. Actually, it's a great question. IBD unclassified is like the mixed bag. For example, you have a classic ulcerative colitis patient, now all of a sudden there's a skin tags, elephant ear skin tag, called a UC or Crohn's disease, or if you have a say classic ulcerative colitis, now it's a duodenum involvement. The duodenum is chronic inflammatory changes. You cannot call it Crohn's disease, you cannot call it ulcerative colitis. I think this IBDU, which is unclassified, it's a term, an indeterminate colitis. Let's save this indeterminate colitis as specifically for the histopathology specimen evaluation. So last question, it is, yeah, so Naila, your comments are excellent. For the people with, for some reason, the biopsy cannot tell, and the colonoscopy cannot tell the cross, good quality cross-sectional imaging may help. And then last question, actually, is probably for all the audience and for the ASG, I need Lyle and Reddy, how to obtain the CMU credit? So just in case, if you have a question, you can also send an email to me, ds3270 at columbia.edu and we will figure it out from the ASG side. And Oday, could you wrap things up for tomorrow?

small bowel structure

Crohn's disease

balloon enteroscopy

biologic agents

anastomotic strictures