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 stricture is located at the terminal ileum, which is a common site for Crohn's disease complications, as noted in the ECCO-ESCP consensus on surgery for Crohn's disease 1.
• The patient's symptoms and imaging findings suggest a mechanical obstruction, which requires prompt surgical intervention to prevent further complications.
• Segmental resection with temporary ileostomy is preferred over stricturoplasty or right hemicolectomy because it removes only the diseased segment while preserving bowel length, and the temporary ileostomy allows the bowel to heal before restoring continuity.
• This approach is particularly important in a young IBD patient where bowel preservation is crucial for long-term quality of life, as highlighted in the ECCO guidelines on therapeutics in Crohn's disease: surgical treatment 1.

Rationale for Choice

• Conservative management would be inappropriate given her acute obstruction symptoms and the confirmed mechanical cause (stricture).
• 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.
• Endoscopic balloon dilatation may be considered for short strictures (< 5 cm) as noted in the ECCO guidelines 1, but in this case, the patient's acute presentation and worsening symptoms require a more definitive surgical approach.
• Stricturoplasty may be an option for patients with multiple or long strictures, but in this case, the single stricture at the terminal ileum is more amenable to segmental resection with ileostomy.

From the Research

Management Options for Stricture in Terminal Ileum

The patient's condition involves a single stricture at the terminal ileum, 1 cm from the ileocecal valve, with symptoms of abdominal pain and bilious vomiting. Considering the provided evidence, the management options can be evaluated as follows:

• Stricturoplasty: This surgical technique is a viable option for managing stricturing Crohn's disease, especially in patients at risk of short bowel syndrome 2, 3, 4, 5. It involves making a longitudinal incision in the stricture and then closing it in a transverse fashion to widen the lumen. Stricturoplasty can be performed using different techniques, such as Heineke-Mikulicz or Michelassi stricturoplasty.
• Right Hemicolectomy: This surgical procedure involves the removal of the right side of the colon, which may be considered in cases of severe disease or complications such as obstruction, perforation, or bleeding. However, it may not be the most appropriate option for a single stricture in the terminal ileum.
• Conservative Management: Conservative management may involve medical therapy, such as steroids, immunomodulators, or biologics, to control the disease and manage symptoms. However, in cases of severe stricturing disease, surgical intervention may be necessary.
• Segmental Resection with Ileostomy: This surgical procedure involves the removal of the affected segment of the intestine and the creation of an ileostomy. While it may be considered in some cases, it may not be the most appropriate option for a single stricture in the terminal ileum.

Considerations for Management

When considering the management options, the following factors should be taken into account:

• The patient's disease severity and extent
• The location and number of strictures
• The patient's surgical history and risk of short bowel syndrome
• The potential benefits and risks of each management option

According to the evidence, stricturoplasty is a safe and effective technique for managing stricturing Crohn's disease, especially in patients at risk of short bowel syndrome 2, 3, 4, 5. However, a systematic review and meta-analysis found that bowel resection may be associated with a lower risk of recurrence compared to stricturoplasty 6. Therefore, the most appropriate management option should be determined on a case-by-case basis, taking into account the individual patient's characteristics and disease severity.

Key Points to Consider

• Stricturoplasty is a viable option for managing stricturing Crohn's disease, especially in patients at risk of short bowel syndrome.
• The choice of management option depends on the individual patient's characteristics and disease severity.
• Bowel resection may be associated with a lower risk of recurrence compared to stricturoplasty, but it may also increase the risk of short bowel syndrome.