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

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 segmental resection with ileostomy (option D). This patient has clinical signs of small bowel obstruction with imaging confirming a single stricture at the terminal ileum near the ileocecal valve. Given her acute presentation with obstructive symptoms that appear to be worsening, surgical intervention is necessary.

Key Considerations

• The patient's symptoms and imaging results indicate a need for prompt surgical intervention to relieve the obstruction and prevent further complications.
• The recent normal colonoscopy suggests this is likely a small bowel complication of her IBD rather than colonic disease, further supporting the targeted approach of segmental resection.
• Segmental resection with temporary ileostomy is preferred over stricturoplasty or right hemicolectomy because it removes only the diseased segment while preserving maximum bowel length, and the temporary ileostomy allows the bowel to heal before restoring continuity.
• According to the ECCO-ESCP consensus on surgery for Crohn's disease 1, segmental resection is a main indication for complications such as localized sepsis and the absence of a residual lumen.
• The ECCO guidelines on therapeutics in Crohn's disease: surgical treatment 1 also support the use of surgical intervention for small-bowel strictures, particularly when technical expertise is available.

Management Options

• Segmental resection with ileostomy (option D): This approach is particularly appropriate for IBD patients with isolated terminal ileal strictures causing acute obstruction.
• Stricturoplasty: While stricturoplasty is a viable option for some patients with Crohn's disease, it may not be the best choice for this patient given her acute presentation and the location of the stricture.
• Right hemicolectomy: This approach may be too aggressive and could result in unnecessary removal of healthy bowel tissue.
• Conservative management: This would be inappropriate given her acute presentation with signs of obstruction.

From the Research

Management Options for Crohn's Disease-Related Stricture

The patient's symptoms and diagnosis suggest a stricture at the terminal ileum, which is a common complication of Crohn's disease. The management options for this condition include:

• Stricturoplasty: a surgical procedure that involves making a longitudinal incision in the stricture and then closing it in a transverse fashion to widen the lumen 2, 3, 4, 5
• Right hemicolectomy: a surgical procedure that involves removing the right side of the colon, which may be necessary if the stricture is severe or if there are other complications such as perforation or abscess
• Conservative management: a non-surgical approach that involves managing the patient's symptoms with medication and other interventions, which may be suitable for patients with mild symptoms or those who are not good candidates for surgery
• Segmental resection with ileostomy: a surgical procedure that involves removing the affected segment of the intestine and creating an ileostomy, which may be necessary if the stricture is severe or if there are other complications such as perforation or abscess

Considerations for Choosing a Management Option

When choosing a management option for the patient, several factors should be considered, including:

• The severity of the stricture and the patient's symptoms
• The patient's overall health and medical history
• The risks and benefits of each management option
• The potential for complications and the need for repeat surgery
• The patient's preferences and quality of life considerations

Evidence-Based Recommendations

Based on the available evidence, stricturoplasty is a safe and effective option for managing strictures in patients with Crohn's disease 2, 3, 4, 5. This procedure can help to preserve the intestine and reduce the need for repeat surgery. However, the choice of management option will depend on the individual patient's circumstances and should be made in consultation with a healthcare provider. Endoscopic stricturotomy is also a viable option for patients with primary distal ileum stricture, with comparable surgery-free survival rates to ileo-colonic resection, but with a lower post-procedural complication rate 6.