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 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 and the need for immediate relief, segmental resection with temporary ileostomy allows for removal of the diseased segment while providing bowel rest and reducing inflammation, with potential for later reconnection after the acute episode resolves and her nutritional status improves. Some may consider stricturoplasty, but the location of this stricture so close to the ileocecal valve and its short length make segmental resection a more appropriate option, as stricturoplasty is often preferred for longer stenotic segments or multiple and close strictures 1. Conservative management would be inadequate given her acute obstructive symptoms. Right hemicolectomy would be excessive since her colon appears normal on recent colonoscopy. It's worth noting that the ECCO-ESCP consensus on surgery for Crohn's disease 1 provides guidance on the surgical management of Crohn's disease, but the most recent and relevant guideline for this specific scenario is the ECCO guidelines on therapeutics in Crohn's disease: surgical treatment 1.

Key points to consider in the management of this patient include:

• The need for immediate relief of obstructive symptoms
• The location and length of the stricture
• The presence of normal colonoscopy findings
• The potential for future reconnection of the bowel after segmental resection
• The importance of considering the most recent and relevant guidelines in the management of Crohn's disease.

From the Research

Management Options

• The patient is a 25-year-old woman with inflammatory bowel disease (IBD) taking steroids, presenting with abdominal pain, bilious vomiting, and a distended abdomen tender to the right iliac fossa.
• A colonoscopy 2 weeks prior was normal, but a contrast barium study showed a single stricture at the terminal ileum 1 cm from the ileocecal valve.
• The most appropriate management options are:
  • A. Stricturoplasty: This procedure involves making a longitudinal incision in the stricture and then closing it in a transverse fashion to widen the lumen 2, 3, 4.
  • B. Right hemicolectomy: This involves the surgical removal of the right side of the colon, which may be considered if the stricture is causing significant symptoms or if there is concern for malignancy.
  • C. Conservative management: This approach involves managing the patient's symptoms with medication and monitoring the stricture for any changes.
  • D. Segmental resection with ileostomy: This involves surgically removing the segment of intestine containing the stricture and creating an ileostomy.

Considerations for Management

• The patient's history of IBD and the presence of a stricture at the terminal ileum suggest that the stricture may be due to fibrostenotic disease, which is a common complication of Crohn's disease 5, 6.
• Strictureplasty is a viable option for managing fibrostenotic strictures in patients with Crohn's disease, as it conserves bowel length and minimizes the risk of short bowel syndrome 2, 3, 4.
• However, strictureplasty may be associated with a higher risk of recurrence compared to bowel resection, and the decision to perform strictureplasty should be made on a case-by-case basis, taking into account the patient's overall health and the severity of their disease 6.