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 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 length is not explicitly mentioned, but given the context, it's likely short, making endoscopic balloon dilatation a viable option, as recommended by the ECCO guidelines 1.
- However, since endoscopic balloon dilatation is not an option, 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 reanastomosis, particularly important in a patient on steroids which can impair wound healing.
- Conservative management would be inappropriate given her acute presentation with signs of obstruction.
- The recent normal colonoscopy suggests this is likely a small bowel Crohn's stricture rather than a malignancy, but the obstructive symptoms require immediate surgical intervention regardless of etiology.
Surgical Approach
- The ECCO-ESCP consensus on surgery for Crohn's disease suggests that side-to-side, isoperistaltic stricturoplasty is the preferred technique for the treatment of long stenotic segments or multiple and close strictures 1.
- However, in this case, segmental resection with ileostomy is more appropriate due to the patient's acute presentation and the need for immediate relief of obstructive symptoms.
Quality of Life and Morbidity
- The goal of treatment is to alleviate symptoms, prevent complications, and improve quality of life while minimizing morbidity and mortality.
- Segmental resection with ileostomy, although more invasive, offers a better balance of these factors in the context of this patient's presentation.
From the Research
Management of Intestinal Stricture in Inflammatory Bowel Disease
The patient's symptoms of abdominal pain, bilious vomiting, and abdominal distension, along with the presence of a single stricture at the terminal ileum, suggest a complication of inflammatory bowel disease (IBD). The management of intestinal stricture in IBD can be challenging and requires a multidisciplinary approach.
Surgical Options
- Strictureplasty: 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. Strictureplasty is a viable option for patients with short-segment strictures, especially those with a history of prior resections who are at risk of short bowel syndrome.
- Segmental resection with ileostomy: This involves resecting the strictured segment of the intestine and creating an ileostomy 3, 5. This option may be considered for patients with longer strictures or those who have failed other treatments.
- Right hemicolectomy: This involves resecting the right side of the colon, including the terminal ileum 3. This option may be considered for patients with extensive disease or those who have failed other treatments.
- Conservative management: This involves managing the patient's symptoms with medication and avoiding surgery whenever possible 3, 5.
Comparison of Surgical Options
- A study comparing endoscopic stricturotomy and ileo-colonic resection found that both procedures had similar surgery-free survival rates, but endoscopic stricturotomy had a lower post-procedural complication rate 5.
- Strictureplasty has been shown to be a safe and efficacious technique that is comparable to bowel resection for stricturing Crohn's disease, with the advantage of sparing bowel length and reducing the risk of short bowel syndrome 2, 4.
Most Appropriate Management
Based on the patient's presentation and the available evidence, strictureplasty (Option A) may be the most appropriate management option. This procedure is suitable for short-segment strictures, such as the one described in the patient's case, and has been shown to be safe and effective in managing intestinal stricture in IBD patients 2, 3, 4. However, the final decision should be made by a multidisciplinary team, taking into account the patient's individual circumstances and the potential risks and benefits of each option 3.