What is the next step in managing a patient with a chronic segmental postinflammatory stricture of the proximal sigmoid colon (ex lap for gunshot wound (GSW)) with colon obstruction and prominent proximal stool retention, without diarrhea, fever, or weight loss?

Management of Chronic Segmental Postinflammatory Sigmoid Stricture with Colon Obstruction

Surgical resection of the strictured sigmoid colon segment is the recommended next step in management for this patient with chronic segmental postinflammatory stricture causing colon obstruction and prominent proximal stool retention.

Diagnosis

This patient presents with a chronic segmental postinflammatory stricture of the proximal sigmoid colon with colon obstruction and prominent proximal stool retention, identified on CT abdomen/pelvis (CTAP). The patient has a history of exploratory laparotomy for gunshot wound (GSW) and notably does not have symptoms of diarrhea, fever, or weight loss.

The diagnosis is likely a postoperative/post-traumatic stricture of the sigmoid colon resulting from:

• Previous trauma from GSW
• Subsequent surgical intervention (exploratory laparotomy)
• Postinflammatory changes leading to fibrosis and stricture formation

Initial Evaluation

Before proceeding with definitive management:

1. Review complete surgical history, including details of the exploratory laparotomy
2. Assess severity of obstruction and patient's current symptoms
3. Evaluate for signs of complete vs. partial obstruction
4. Check for electrolyte abnormalities and signs of dehydration

Management Algorithm

Step 1: Colonoscopy with Biopsy

• Perform colonoscopy to:
  • Visualize the stricture
  • Obtain biopsies to rule out malignancy
  • Assess the degree of narrowing

Colonoscopy is crucial as sigmoid strictures that prevent passage of a colonoscope should be resected when the cause is not apparent 1.

Step 2: Decompression (if needed)

• For significant obstruction causing acute symptoms:
  • Consider endoscopic decompression as a temporizing measure
  • Water-soluble contrast administration may help assess the degree of obstruction 2

Step 3: Definitive Treatment

• Surgical resection is the definitive treatment of choice:
  • Segmental sigmoid colectomy with primary anastomosis
  • Consider laparoscopic approach if technically feasible

The rationale for surgical management is based on:

1. Chronic nature of the stricture
2. Presence of obstruction with proximal stool retention
3. Risk of complete obstruction if left untreated
4. Need to rule out malignancy definitively (even with negative biopsies)

Special Considerations

Stenting vs. Surgery

Self-expanding metallic stents could be considered as a bridge to surgery in select cases, but are not recommended as definitive treatment for benign strictures due to:

• Risk of perforation and fistula formation 3
• High rate of stent migration in benign disease
• Need for definitive histopathological diagnosis

Conservative Management

Conservative management is generally not recommended for significant strictures with obstruction as:

• The risk of complete obstruction increases over time
• Strictures from post-inflammatory causes rarely resolve spontaneously
• Proximal stool retention can lead to bacterial overgrowth and translocation

Postoperative Care

• Early mobilization
• Gradual advancement of diet
• Monitor for signs of anastomotic leak
• Follow-up colonoscopy in 6-12 months to assess for recurrence

Pitfalls to Avoid

1. Delaying surgical intervention in a patient with significant obstruction
2. Assuming benign etiology without adequate tissue diagnosis
3. Prolonged conservative management leading to emergency surgery
4. Inadequate resection margins leading to recurrence

Sigmoid strictures represent a diagnostic dilemma, and while they commonly appear to be due to diverticular or post-inflammatory disease, carcinoma must always be excluded 1. Given the history of previous trauma and surgery, this is most likely a post-inflammatory stricture, but definitive diagnosis requires surgical resection with pathological examination.