Post written by Partha Pal, MD, DNB, MRCP (UK), ESEGH, FASGE, from the Asian Institute of Gastroenterology, Hyderabad, India.

We present the case of a 47-year-old man with ileocolonic Crohn’s disease who developed recurrent obstructive symptoms despite biologic therapy. Preprocedural intestinal ultrasound (IUS) identified a short, predominantly fibrotic ascending colon stricture with upstream fecaliths. Colonoscopy confirmed a tight narrowing, and a hybrid endoscopic approach was undertaken.

Mucosectomy was first performed to improve visualization and provide a clear field of view for stricturotomy. Endoscopic stricturotomy using an insulated-tip knife (ITknife; Olympus Medical Systems, Tokyo, Japan) was then carried out in a stepwise manner, with controlled balloon dilation performed in between to gently stretch the lumen, expose the fibrotic ring, and facilitate further stricturotomy.

Finally, luminal patency was restored, and cecal fecaliths were retrieved with a Roth Net (US Endoscopy, Mentor, Ohio, USA). Minor bleeding was controlled with a Coagrasper (Olympus Medical Systems), and the stricture was successfully traversed. The patient was discharged the following day and remained symptom-free at 9-month follow-up.

Crohn’s disease strictures are often complex, involving variable degrees of inflammation and fibrosis. Balloon dilation alone is associated with risk of perforation and frequent recurrence, but stricturotomy by itself can be technically demanding. This case demonstrates how a hybrid approach—using minimal controlled balloon dilation to stretch the lumen, expose the fibrotic ring, and reduce stricturotomy time, followed by targeted stricturotomy under real-time IUS guidance—offers a safe and effective alternative to surgery. It also features the expanding role of IUS as a point-of-care tool that personalizes procedural planning and follow-up while reducing reliance on repeated cross-sectional imaging.

Endoscopists can learn that IUS provides real-time, precise characterization of stricture length, wall thickness, and prestenotic dilation, invaluable for procedural planning. Although uncontrolled balloon dilation in fibrotic strictures carries a high risk of perforation, minimal controlled dilation can gently stretch the lumen, clearly expose the fibrotic ring, and reduce overall time required for stricturotomy. A hybrid approach therefore maximizes the complementary strengths of both techniques. On follow-up, IUS serves as a reliable modality to monitor luminal remodeling and to ensure durable symptom relief.

To my knowledge, this is among the first articles highlighting the integration of IUS into therapeutic endoscopy for Crohn’s strictures. Wider adoption of such multimodal, imaging-guided approaches may reduce surgical referrals and help preserve bowel in patients with complex strictures.

Intestinal ultrasound demonstrating an ascending colon stricture with upstream fecaliths, confirming luminal narrowing and prestenotic dilation.

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