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, 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.

Key Considerations

• 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 ileostomy is a more appropriate option in this scenario.
• Stricturoplasty can be considered for longer strictures, but the location near the ileocecal valve and the acute presentation make segmental resection more suitable.
• Conservative management would be inadequate given her acute obstructive symptoms.
• Right hemicolectomy would be excessive since her colon appears normal on recent colonoscopy.

Rationale for Choice

• Segmental resection with temporary ileostomy allows removal of the diseased segment while providing bowel rest, which is particularly important in a patient on steroids who may have impaired healing.
• After recovery, intestinal continuity can be restored with anastomosis in a second procedure.
• The ECCO-ESCP consensus on surgery for Crohn's disease 1 supports the use of segmental resection in cases with complications such as localized sepsis or absence of a residual lumen.

Summary of Evidence

• The ECCO guidelines 1 provide evidence for the use of endoscopic balloon dilatation in small-bowel strictures, but also highlight the importance of technical expertise and patient selection.
• The ECCO-ESCP consensus 1 provides guidance on the surgical management of Crohn's disease, including the use of segmental resection and stricturoplasty.

From the Research

Management Options for Intestinal Stricture in IBD

The patient's symptoms of abdominal pain and bilious vomiting, along with the presence of a single stricture at the terminal ileum, require careful consideration of the most appropriate management option. The following points summarize the key considerations:

• Strictureplasty: This technique involves surgically widening the narrowed section of the intestine to improve flow and relieve obstruction 2, 3, 4. It is particularly useful for patients with a history of prior resections who are at risk for short bowel syndrome.
• Bowel Resection: This involves surgically removing the affected portion of the intestine 5, 6. While it may reduce the risk of recurrence, it also increases the risk of short bowel syndrome, especially in patients with multiple resections.
• Conservative Management: This approach involves managing the patient's symptoms with medication and other non-surgical interventions. However, for patients with fibrostenotic strictures, surgical intervention is often necessary 5.
• Segmental Resection with Ileostomy: This involves removing the affected portion of the intestine and creating an ileostomy to divert fecal flow 6.

Considerations for the Patient's Condition

Given the patient's age, diagnosis of IBD, and presence of a single stricture at the terminal ileum, the following points are relevant:

• The patient's recent colonoscopy was normal, which suggests that the stricture is the primary cause of her symptoms.
• The presence of a single stricture at the terminal ileum suggests that strictureplasty may be a viable option.
• The patient's use of steroids for IBD management may impact her surgical risk and recovery.

Most Appropriate Management Option

Based on the available evidence, Strictureplasty (A) may be the most appropriate management option for this patient. This technique can help preserve intestinal length and reduce the risk of short bowel syndrome, while also relieving the patient's symptoms 2, 3, 4. However, the decision should be made in consultation with a multidisciplinary team, taking into account the patient's individual circumstances and the potential risks and benefits of each option 5, 6.