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 conservative management (option C). This approach is supported by the most recent and highest quality study 1, which recommends conservative management, including gastrointestinal nasogastric decompression, bowel rest, intravenous fluids, and electrolyte replacement, for patients with Crohn’s disease and a known stricture, especially when the stricture is less than 4 cm. Given the patient's symptoms and the presence of a single stricture at the terminal ileum, conservative management is the most appropriate initial approach, as it can help alleviate obstructive symptoms and avoid the need for immediate surgery. The patient's recent colonoscopy was normal, which suggests that the colon is not involved, and the stricture is limited to the terminal ileum, making conservative management a viable option. Additionally, the use of steroids may impair wound healing and increase the risk of anastomotic leak, making conservative management a more attractive option to avoid these potential complications. While segmental resection with ileostomy (option D) may be considered in the future if conservative management fails, it is not the most appropriate initial management strategy for this patient. Stricturoplasty (option A) and right hemicolectomy (option B) are also not the most appropriate options, as they are more invasive and may not be necessary given the patient's presentation and the location of the stricture. It is essential to prioritize the patient's morbidity, mortality, and quality of life when making management decisions, and conservative management is the most appropriate approach to achieve these goals. The patient's nutritional status should also be considered, and dietary modifications, such as a Mediterranean-style diet, may be beneficial in managing her IBD symptoms, as suggested by recent studies 1.
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.