From the Guidelines
Management of a stricture 20 cm from the ileocecal valve with diarrhea and mild weight loss should begin with endoscopic balloon dilation, as it has a high technical success rate and can provide short-term relief of symptoms. According to the study by 1, endoscopic balloon dilation has a technical success rate of 89 to 92% for fibrotic strictures, with 70 to 81% of patients experiencing short-term relief of symptoms.
Initial Management
- Start with endoscopic balloon dilation to reduce the stricture and alleviate symptoms
- Consider medical therapy with anti-inflammatory medications such as budesonide or prednisone to reduce inflammation at the stricture site
- Add an immunomodulator like azathioprine or 6-mercaptopurine for long-term management if the stricture is inflammatory in nature
Dietary Modifications
- Implement a low-residue diet to reduce mechanical obstruction risk, avoiding high-fiber foods, nuts, seeds, and raw vegetables
- Ensure adequate hydration and consider nutritional supplements like Ensure or Boost to address weight loss
- Consider a Mediterranean diet rich in fresh fruits and vegetables, monounsaturated fats, complex carbohydrates, and lean proteins, as recommended by 1
Monitoring and Further Management
- Monitor for worsening symptoms such as severe abdominal pain, vomiting, or fever, which may indicate obstruction requiring urgent intervention
- If symptoms persist despite endoscopic balloon dilation, consider surgery (strictureplasty or limited resection) as a last resort, as recommended by 1 and 1
- Exclusive enteral nutrition or partial enteral nutrition therapy may be considered as a steroid-sparing bridge therapy for patients with Crohn’s disease, as recommended by 1
From the Research
Management of Stricture
To manage a stricture 20 cm from the ileocaecal valve with diarrhea and mild weight loss, without fever or severe pain, several options can be considered:
- Endoscopic dilatation: This is a suitable option for short-segment isolated small bowel strictures 2, 3.
- Strictureplasty: This technique can be used to preserve the length of the intestine and is particularly useful for long strictures 4, 5, 6.
- Surgical resection: This is usually considered for predominantly fibrotic strictures that are not responsive to medical treatment 3.
- Modified side-to-side isoperistaltic strictureplasty: This is a variation of strictureplasty that can be used to treat extensive terminal ileal Crohn's disease 5, 6.
Considerations
When deciding on the best course of management, it is essential to consider the following factors:
- The length and location of the stricture
- The underlying cause of the stricture (inflammatory or fibrotic)
- The presence of any complications, such as bowel obstruction or abscess
- The patient's overall health and medical history
- The potential risks and benefits of each treatment option 4, 2, 5, 3, 6
Treatment Options
The treatment options for a stricture 20 cm from the ileocaecal valve with diarrhea and mild weight loss, without fever or severe pain, are:
- Endoscopic dilatation: This can be used to dilate the stricture and improve bowel function 2, 3.
- Strictureplasty: This can be used to preserve the length of the intestine and treat the stricture 4, 5, 6.
- Surgical resection: This may be necessary if the stricture is predominantly fibrotic or if other treatment options are not effective 3.
- Modified side-to-side isoperistaltic strictureplasty: This can be used to treat extensive terminal ileal Crohn's disease 5, 6.