How to manage a stricture 20 cm from the ileocaecal (ileocecal) valve with diarrhea and mild weight loss, without fever or severe pain?

From the Guidelines

Management of a stricture 20 cm from the ileocecal valve with diarrhea and mild weight loss should begin with a combination of medical therapy and dietary modifications, prioritizing endoscopic balloon dilation as the primary intervention for fibrostenotic disease, as supported by the most recent guidelines 1. The patient's symptoms, including diarrhea and mild weight loss, without fever or severe pain, suggest a possible inflammatory bowel disease (IBD) involvement, such as Crohn's disease.

• Key considerations in managing this patient include:
  • Reducing inflammation and preventing further complications
  • Improving nutritional status and minimizing obstruction risk
  • Regular monitoring to assess stricture progression Given the stricture's location and length, endoscopic balloon dilation is a viable option, with a technical success rate of 89 to 92% and short-term relief of symptoms in 70 to 81% of patients 1.
• However, it is essential to note that long-term results are less impressive, with 73.5% of patients requiring a repeat dilation and 43% requiring surgical intervention within 2 years 1.
• Surgical intervention, such as strictureplasty or limited resection, should be reserved for cases that fail medical therapy or develop complications, as it may be associated with increased recurrence or re-operation rates 1.
• Dietary modifications, including a low-residue diet and nutritional supplements, can help reduce mechanical irritation of the stricture and address weight loss, as recommended by recent guidelines 1.
• Regular monitoring with imaging (MR enterography or CT enterography) every 6-12 months is crucial to assess stricture progression and adjust treatment accordingly.
• The use of anti-inflammatory medications, such as budesonide or prednisone, and immunomodulators, like azathioprine or 6-mercaptopurine, may be considered to reduce inflammation and prevent further complications, as supported by recent studies 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, the following options can be considered:

• Strictureplasty: This surgical technique can be effective for long strictures, even if a narrow lumen is still present 2. Side-to-side isoperistaltic strictureplasty (SSIS) and its modification over the ileocaecal valve (mSSIS) have been shown to be safe and effective in patients with extensive Crohn's disease ileitis 3.
• Endoscopic dilatation: This procedure can be suitable for short-segment isolated small bowel strictures 4. However, the technical success and surgical recurrence rates of endoscopic balloon dilatation (EBD) vary, and it may not be as effective for longer strictures or those with more severe disease 5, 6.
• Surgical resection: This option may be necessary for strictures that are predominantly fibrotic or for patients who have not responded to other treatments 4. However, it is essential to balance the need for resection with the risk of short bowel syndrome and the potential for disease recurrence.
• Colonoscopy: While colonoscopy can be used to diagnose and assess the stricture, it is not a therapeutic option for managing the stricture itself.
• Cortisone: There is no evidence to suggest that cortisone is a suitable treatment for managing a stricture 20 cm from the ileocaecal valve with diarrhea and mild weight loss, without fever or severe pain.

Key Considerations

When managing a stricture, it is crucial to consider the following factors:

• The length and location of the stricture
• The presence of inflammation or fibrosis
• The patient's overall health and disease history
• The potential risks and benefits of each treatment option
• The need for a multidisciplinary approach to care, including involvement of gastroenterologists, surgeons, and other specialists 4