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 this approach is preferred for strictures less than 4 cm, especially in the context of acute obstructive symptoms, as suggested by 1.
Key Considerations
- The patient's symptoms, including abdominal pain, bilious vomiting, and abdominal distension, indicate an acute small bowel obstruction due to the stricture, which is a known complication of IBD, particularly Crohn's disease.
- The location of the stricture, 1 cm from the ileocecal valve, and its short length, make endoscopic dilatation a viable option, as it is less invasive compared to surgical interventions like segmental resection or stricturoplasty.
- Conservative management would be inadequate given her acute obstructive symptoms, and right hemicolectomy would be excessive since her colon appears normal on recent colonoscopy.
- Endoscopic dilatation, as recommended by 1, is the best management option in this scenario, especially considering the COVID-19 era, where minimizing invasive procedures and hospital stays is crucial.
Management Approach
- Endoscopic dilatation should be performed to relieve the obstruction and avoid intestinal occlusion and subsequent emergency room admission, as suggested by 1.
- This approach aligns with the ECCO-ESCP consensus on surgery for Crohn's disease, which emphasizes the importance of tailored approaches and considers stricturoplasty for long stenotic segments or multiple and close strictures, but does not directly apply to this patient's specific situation, as noted in 1.
- The patient's condition, with a short stricture and acute obstructive symptoms, makes endoscopic dilatation the most appropriate management option, prioritizing morbidity, mortality, and quality of life outcomes.
From the Research
Management of Stricture in Terminal Ileum
The patient's condition involves a stricture at the terminal ileum, which is a common complication in inflammatory bowel disease (IBD) patients. Considering the patient's history of IBD and the presence of a single stricture, the management options can be evaluated as follows:
Surgical Options:
- Stricturoplasty: This procedure involves making a longitudinal incision in the stricture and then closing it in a transverse fashion to widen the lumen 2. It is a viable option for patients with a history of prior resections who are at increased risk for short bowel syndrome.
- Right hemicolectomy: This involves the removal of the right side of the colon and is typically considered for patients with more extensive disease or those who have not responded to other treatments.
- Segmental resection with ileostomy: This involves the removal of the affected segment of the intestine and the creation of an ileostomy. It is often considered for patients with more severe disease or those who have failed other treatments.
Endoscopic Options:
- Endoscopic balloon dilation: This involves the use of a balloon to dilate the stricture and is a commonly used technique for managing strictures in IBD patients 3.
- Endoscopic stricturotomy: This involves making a cut in the stricture to widen the lumen and is a relatively novel technique for managing strictures in IBD patients 3, 4, 5.
- Endoscopic strictureplasty: This involves making a series of cuts in the stricture to widen the lumen and is a relatively novel technique for managing strictures in IBD patients 6.
Most Appropriate Management
Considering the patient's condition and the available evidence, the most appropriate management option would be Stricturoplasty (A). This procedure is a viable option for patients with a history of prior resections who are at increased risk for short bowel syndrome, and it has been shown to be both efficacious and safe 2. Additionally, endoscopic options such as endoscopic balloon dilation, endoscopic stricturotomy, and endoscopic strictureplasty may also be considered, but the patient's condition and the location of the stricture may make stricturoplasty a more suitable option.
Key Considerations
When considering the management of strictures in IBD patients, it is essential to take into account the patient's overall condition, the location and severity of the stricture, and the potential risks and benefits of each treatment option. The patient's history of prior colonoscopy and the presence of a single stricture at the terminal ileum suggest that stricturoplasty may be a suitable option. However, the decision should be made on a case-by-case basis, and the patient should be closely monitored for any potential complications.