From the Guidelines
This patient with Crohn's disease likely requires ileocecal resection due to the presence of fibrostenotic inflammation in the terminal ileum and significant proximal ileal dilatation of 5.9 cm, indicating intestinal obstruction. The fibrostenotic nature of the disease suggests chronic inflammation has led to scarring and narrowing that is unlikely to fully respond to medical management alone 1. According to the ECCO guidelines on therapeutics in Crohn's disease, laparoscopic resection is a reasonable alternative to infliximab therapy in patients with limited, non-stricturing, ileocaecal Crohn’s disease [diseased terminal ileum <40 cm] 1.
Key Considerations
- The patient's disease is limited to the terminal ileum, which is a common site for Crohn's disease involvement.
- The presence of fibrostenotic inflammation and significant proximal ileal dilatation suggests intestinal obstruction, which is a common complication of Crohn's disease.
- The ECCO guidelines recommend laparoscopic resection as a treatment option for patients with limited, non-stricturing, ileocaecal Crohn’s disease 1.
- Prior to surgery, the patient should undergo optimization of nutritional status and medical therapy to reduce active inflammation.
Surgical Approach
- The standard surgical approach would be ileocecal resection with primary anastomosis, removing the diseased terminal ileum and cecum.
- This approach addresses both the obstruction and the inflammatory disease focus while preserving as much bowel length as possible, which is important in Crohn's disease patients who may require future surgeries.
- Endoscopic balloon dilatation may be considered as an alternative treatment option for small-bowel strictures < 5 cm in length, but its effectiveness in this patient's case is uncertain 1.
Conclusion Not Applicable - Direct Answer Only
Ileocecal resection is the most appropriate treatment option for this patient, given the presence of fibrostenotic inflammation and significant proximal ileal dilatation, and the potential benefits of surgery in improving quality of life and reducing the risk of complications 1.
From the Research
Indication for Ileocecal Resection
The patient has mild active fibrostenotic inflammation of the terminal ileum and dilatation of 5.9 cm of the proximal ileum. Considering the provided evidence, the following points are relevant:
- Endoscopic balloon dilation is an alternative to surgical resection or stricturoplasty in selected patients with short strictures (<5 cm) and nonpenetrating disease, preferably at the ileocolonic anastomosis 2.
- The patient's stricture length of 5.9 cm is slightly above the recommended length for endoscopic dilation, which may increase the risk of complications.
- Fibrostenotic Crohn's disease does not respond to medical therapy and requires endoscopic or surgical treatment 3.
- There are no specific anti-fibrotic drugs yet, and up to 70% of CD patients still eventually undergo surgery mainly due to fibrostenotic strictures 4.
Treatment Options
The treatment options for the patient include:
- Endoscopic balloon dilation, although the stricture length is slightly above the recommended length
- Surgical resection, which may be necessary due to the fibrostenotic nature of the disease
- Stricturoplasty, which is a surgical procedure that can help to relieve the stricture without removing the affected portion of the intestine
- Medical management to control the active inflammation, although this will not address the fibrostenotic component of the disease 2, 3, 5, 6, 4
Key Considerations
Key considerations in the management of this patient include:
- The risk of complications associated with endoscopic dilation, which can be estimated at 2% 2
- The need for a multidisciplinary approach to diagnosis and management, including the use of biologic agents and other medical therapies to control the disease 6, 4
- The importance of standardizing endoscopic procedures and peri-procedural management strategies to improve outcomes 5