Upper gastrointestinal (GI) tract involvement in Crohn’s disease is increasingly recognized due to improved endoscopic techniques[1]. However, data on managing esophageal strictures endoscopically is limited due to their rarity and the complexity of the disease, which often requires surgery[2]. Endoscopic balloon dilation (EBD) is the cornerstone for short fibrotic strictures management[3]. Nevertheless, many strictures cannot be traversed with a conventional gastroscope, making interventions challenging. In these cases, ultra-slim endoscopes may offer a feasible, minimally invasive alternative[4]. 

We describe a case where a digital cholangioscope was used, enabling successful dilation of two non-passable (with conventional gastroscopes) esophageal strictures. A 32-year-old woman with Crohn’s disease (Montreal A2/L3+L4/B2), on 4-week intensified intravenous infliximab therapy, presented with progressive dysphagia. Upper GI Endoscopy revealed two short esophageal strictures at 21 cm and 30 cm from the incisors, both non-traversable with a standard gastroscope. A digital cholangioscope with adaptation for air insufflation was used to assess both strictures that looked fibrostenotic without inflammatory component. The cholangioscope easily traversed the proximal stricture, allowing guidewire placement through the distal, tighter stricture (estimated diameter:3-4 mm). With gentle manipulation, the cholangioscope reached the stomach and guidewire was left in place. The cholangioscope was then withdrawn and reinserted alongside the guidewire. Finally, over-the-wire balloon dilation of the distal stricture was performed under direct endoscopic visualization, with biliary balloons at 4mm and 6mm, with superficial therapeutic mucosal tear at 5o’clock.

Following that, the patient underwent two more EBD sessions, in steps, at 6-7-8mm and 8-9-10mm respectively, finally allowing the standard gastroscope to pass through. She experienced significant improvement of her symptoms, was able to resume oral intake, and did not encounter any post-procedural complications.

This case illustrates an innovative and minimally invasive technique for managing tight and complex esophageal strictures in patients with Crohn’s disease. The off-label use of a digital cholangioscope allowed for access and real-time visualization of previously non-passable strictures, enabling safe and delicate  EBD without the need for obsolete and rough fluoroscopic guidance.