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 case is endoscopic balloon dilatation, as the stricture is short and located at the terminal ileum, making it amenable to this treatment option, as recommended by the ECCO guidelines 1. This 25-year-old woman with inflammatory bowel disease (IBD) on steroids presents with symptoms of small bowel obstruction (abdominal pain, bilious vomiting, and abdominal distension) with a documented single short stricture at the terminal ileum. The ECCO guidelines recommend endoscopic balloon dilatation as a treatment option for small-bowel strictures < 5 cm in length when technical expertise is available 1. Given the stricture length is not specified to be greater than 5 cm and the patient's symptoms, endoscopic balloon dilatation is the preferred initial management, as it is less invasive and can help preserve bowel length. Some may consider stricturoplasty, but given the recent evidence, endoscopic balloon dilatation should be considered first, as it has been shown to be effective in resolving obstructive symptoms and can be repeated if necessary, with the added benefit of being a less invasive procedure compared to stricturoplasty or surgical resection 1. Conservative management would be inappropriate given her acute obstructive symptoms, while right hemicolectomy or segmental resection with ileostomy would be unnecessarily extensive for a single short stricture, especially considering her normal colonoscopy findings and the importance of bowel preservation in young IBD patients. Key points to consider in the management of this patient include:

• The length and location of the stricture, which make it amenable to endoscopic balloon dilatation
• The patient's symptoms, which require prompt relief of the obstruction
• The importance of preserving bowel length in IBD patients, who may require multiple surgeries throughout their lifetime
• The recent guidelines and evidence supporting the use of endoscopic balloon dilatation for short strictures, as seen in this case 1.

From the Research

Management of Stricture in Crohn's Disease

The patient's symptoms of abdominal pain, bilious vomiting, and distended abdomen, along with the presence of a single stricture at the terminal ileum, suggest a complication of Crohn's disease. The management of this condition can be approached in several ways:

• Strictureplasty: This technique involves making a longitudinal incision in the stricture and then closing it in a transverse fashion to widen the lumen 2, 3. It is a viable option for patients with a history of prior resections who are at increased risk for short bowel syndrome.
• Segmental resection: This involves removing the affected portion of the intestine and reanastomosing the remaining segments 4, 5. It is often considered the standard of care for obstruction secondary to Crohn stricture.
• Conservative management: This approach may involve medical therapy, such as corticosteroids, to reduce inflammation and manage symptoms 6.
• Right hemicolectomy: This is a surgical procedure that involves removing the right side of the colon and is typically performed for conditions such as colon cancer or diverticulitis.

Considerations for Management

When considering the management of the patient's stricture, several factors should be taken into account:

• The patient's history of prior colonoscopy, which was normal, suggests that the stricture is likely a complication of Crohn's disease rather than another condition.
• The presence of a single stricture at the terminal ileum, which is a common location for Crohn's disease-related strictures.
• The patient's symptoms, which suggest a significant obstruction that requires prompt management.
• The potential risks and benefits of each management option, including the risk of short bowel syndrome with repeated resections 2, 4.

Most Appropriate Management

Based on the available evidence, strictureplasty (option A) may be the most appropriate management option for this patient. This technique can help to conserve bowel length and minimize the risk of developing short bowel syndrome, while also providing relief from obstructive symptoms 2, 3. However, the decision should be made on a case-by-case basis, taking into account the individual patient's circumstances and the potential risks and benefits of each management option 4, 5.