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 endoscopic balloon dilation, as it has a technical success rate of 89 to 92% and provides short-term relief of symptoms in 70 to 81% of patients 1. This approach is recommended due to the stricture's location and the patient's symptoms, which suggest a potential fibrostenotic stricture. The following steps should be taken:

• Start with a combination of medical therapy and dietary modifications to reduce inflammation and mechanical irritation of the stricture.
• Implement a low-residue diet, avoiding high-fiber foods, nuts, seeds, and tough meats, and ensure adequate hydration.
• Consider nutritional supplements like Ensure or Boost to address weight loss.
• Monitor for worsening symptoms, such as increased pain, vomiting, or complete obstruction, which would necessitate surgical intervention.
• If symptoms persist despite medical management for 4-6 weeks, consider endoscopic balloon dilation of the stricture. Regular follow-up every 3-6 months with imaging (MR enterography or CT enterography) is recommended to assess stricture progression and response to therapy 1. It is essential to note that surgery is warranted for small bowel CD stenosis that causes an intestinal obstruction with potential impending perforation, with long or multiple strictures, when the stricture is not endoscopically accessible, and when medical and/or endoscopic treatment fails to adequately improve the patient’s symptoms or when there is concern about concomitant malignancy 1. Additionally, stricturoplasty is not recommended for large bowel strictures due to the concern of potential risk for cancer 1. The most recent and highest quality study, published in 2021, provides the best evidence for the management of inflammatory bowel disease in the emergency setting, including the treatment of strictures 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.