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 dilatation, as it is a less invasive procedure that can effectively manage the stricture and avoid the need for surgery, especially in the context of COVID-19 pandemic where hospital resources may be limited 1.
Given the patient's symptoms and the presence of a single stricture at the terminal ileum, endoscopic dilatation is a viable option, especially since the stricture is less than 4 cm in length. This approach is supported by the study published in Nature Reviews Gastroenterology and Hepatology, which recommends endoscopic dilatation as a therapeutic option for patients with Crohn's disease and a known stricture, especially in cases of repeated obstructive episodes 1.
The patient's clinical presentation, including abdominal pain, bilious vomiting, and abdominal distension, suggests an acute obstruction, which requires prompt intervention. While segmental resection with ileostomy (option D) may be considered in some cases, it is a more invasive procedure that may not be necessary in this scenario, especially given the patient's age and the potential for future surgeries.
Some may argue that stricturoplasty (option A) could be considered for short strictures, but the presence of acute obstruction with significant symptoms warrants a more definitive and less invasive approach, such as endoscopic dilatation. Right hemicolectomy (option B) would be overly aggressive, as the stricture is isolated to the terminal ileum and the colonoscopy was normal. Conservative management (option C) would be inappropriate given the patient's acute obstruction symptoms.
In terms of dietary management, the patient may benefit from a Mediterranean-style diet rich in fruits and vegetables, complex carbohydrates, and monounsaturated fats, which can help improve symptoms and overall health 1. However, given the patient's current symptoms and the need for immediate intervention, endoscopic dilatation is the most appropriate management option.
Key points to consider in this patient's management include:
- The presence of a single stricture at the terminal ileum, which is amenable to endoscopic dilatation
- The patient's acute obstruction symptoms, which require prompt intervention
- The potential for future surgeries and the need to minimize bowel loss
- The importance of dietary management in improving symptoms and overall health.
From the Research
Management Options for IBD-Related Stricture
The patient's symptoms and diagnosis suggest a stricture at the terminal ileum, which is a common complication of Inflammatory Bowel Disease (IBD). 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
- 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 bleeding or perforation
- Conservative management: a non-surgical approach that involves managing the patient's symptoms with medication and monitoring the stricture for any changes
- 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
Efficacy and Safety of Stricturoplasty
Studies have shown that stricturoplasty is a safe and effective procedure for managing IBD-related strictures. A study published in 2013 found that stricturoplasty was effective in managing strictures in patients with Crohn's disease, with a low rate of complications 2. Another study published in 2024 found that endoscopic stricturotomy and strictureplasty were safe and effective in treating stoma closure site strictures in patients with ileal pouches, with a high rate of technical success and a low rate of complications 3.
Comparison of Management Options
A study published in 2020 compared the efficacy and safety of endoscopic stricturotomy and ileo-colonic resection in patients with primary Crohn's disease-related distal ileum strictures. The study found that both procedures were effective in managing the strictures, with similar rates of surgery-free survival and post-procedural complications 4. Another study published in 2017 found that endoscopic stricturotomy with needle knife was effective and safe in treating strictures in patients with IBD, with a high rate of technical success and a low rate of complications 5.
Surgical Stricturoplasty
A study published in 2013 evaluated the efficacy of surgical stricturoplasty in the treatment of ileal pouch strictures. The study found that surgical stricturoplasty was effective in managing the strictures, with a longer time interval to stricture recurrence or pouch failure compared to endoscopic balloon dilation 6.
Most Appropriate Management
Based on the patient's symptoms and diagnosis, the most appropriate management option would be stricturoplasty, as it is a safe and effective procedure for managing IBD-related strictures, especially in patients with a history of prior resections who are at increased risk for short bowel syndrome with additional resections 2.