What is the most appropriate management for a patient with IBD, presenting with abdominal pain, bilious vomiting, and a stricture at the terminal ileum?

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Last updated: May 22, 2025 • View editorial policy

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From the Guidelines

The most appropriate management for this 25-year-old woman with IBD on steroids presenting with abdominal pain, bilious vomiting, abdominal distension, and right iliac fossa tenderness is endoscopic balloon dilatation (not listed as an option), but given the options provided, segmental resection with ileostomy (option D) is the most suitable choice. This patient has developed a short terminal ileal stricture (1 cm from the ileocecal valve) that is causing obstructive symptoms despite normal colonoscopy findings two weeks ago. The presentation suggests an acute small bowel obstruction due to the stricture, which is a known complication of IBD, particularly Crohn's disease. According to the ECCO guidelines on therapeutics in Crohn's disease: surgical treatment 1, endoscopic balloon dilatation is recommended as a treatment option for small-bowel strictures < 5 cm in length when technical expertise is available. However, given the acute presentation with obstruction and the location near the ileocecal valve, segmental resection with temporary ileostomy may be more appropriate to immediately relieve the obstruction and allow the inflamed bowel to heal. Some key points to consider in the management of this patient include:

  • The length of the stricture, which is 1 cm, making it amenable to endoscopic balloon dilatation, but the acute presentation may require more urgent surgical intervention 1.
  • The location of the stricture near the ileocecal valve, which may make stricturoplasty more challenging 1.
  • The presence of obstructive symptoms, which requires prompt relief to prevent complications such as bowel ischemia or perforation.
  • The need to optimize the patient's IBD medications after surgery to prevent recurrence of strictures. Conservative management would be inadequate given the severity of symptoms and evidence of obstruction. Right hemicolectomy would be excessive since the colon appears normal on recent colonoscopy, and the stricture is limited to the terminal ileum. Stricturoplasty can be considered for some IBD strictures, but the acute presentation with obstruction and the location near the ileocecal valve makes segmental resection with temporary ileostomy more appropriate. It is essential to note that the patient's IBD medications would need to be optimized to prevent recurrence of strictures after surgery, as suggested by the ECCO-ESCP consensus on surgery for Crohn's disease 1.

From the Research

Management Options for Stricture in IBD Patient

The patient in question has a single stricture at the terminal ileum, 1 cm from the ileocecal valve, and is experiencing abdominal pain and bilious vomiting. Considering the provided evidence, the following management options are available:

  • Strictureplasty: This technique conserves bowel length and minimizes the risk of developing short bowel syndrome in patients undergoing surgery for Crohn's disease 2, 3. However, it may be associated with a higher risk of recurrence compared with bowel resection 4.
  • Right Hemicolectomy: This is a surgical procedure that involves the removal of the right side of the colon. While it may be considered for patients with Crohn's disease, the provided evidence does not specifically address its use in this scenario.
  • Conservative Management: This approach may be suitable for patients with inflammatory strictures that are responsive to medication. However, the patient in question has a fibrostenotic stricture, which usually requires surgical intervention 5.
  • Segmental Resection with Ileostomy: This is a surgical procedure that involves the removal of the affected segment of the intestine and the creation of an ileostomy. While it may be considered for patients with Crohn's disease, the provided evidence does not specifically address its use in this scenario.

Considerations for Management

When considering the management of the patient's stricture, the following factors should be taken into account:

  • The location and length of the stricture: The patient has a single stricture at the terminal ileum, 1 cm from the ileocecal valve.
  • The patient's history of prior resections: The patient has had one colonoscopy 2 weeks ago, which was normal.
  • The risk of short bowel syndrome: The patient is at risk for short bowel syndrome if additional resections are performed.
  • The risk of recurrence: Strictureplasty may be associated with a higher risk of recurrence compared with bowel resection 4.

Recommended Management

Based on the provided evidence, Strictureplasty may be the most appropriate management option for the patient, as it conserves bowel length and minimizes the risk of developing short bowel syndrome 2, 3. However, the decision should be made on a case-by-case basis, taking into account the patient's individual circumstances and the potential risks and benefits of each management option 5, 6, 4.

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Research

Strictureplasty.

Clinics in colon and rectal surgery, 2013

3
Research

A comprehensive review of strictureplasty techniques in Crohn's disease: types, indications, comparisons, and safety.

Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract, 2012

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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