How to manage a stricture 20 cm from the ileocaecal valve with symptoms of diarrhea and mild weight loss, but no fever or severe pain?

Management of Ileal Stricture 20 cm from Ileocaecal Valve

For a stricture 20 cm from the ileocaecal valve with diarrhea and mild weight loss but no fever or severe pain, strictureplasty is the recommended treatment approach.

Assessment and Decision-Making Process

Initial Evaluation

• Assess the length of the stricture through imaging (MRI enterography preferred)
• Evaluate for signs of active inflammation vs fibrotic stricturing
• Check for presence of fistulae, abscesses, or possible malignancy (contraindications to strictureplasty)
• Assess nutritional status due to weight loss

Treatment Algorithm

1. Medical Management Assessment

   • Consider trial of medical therapy if:
     • Stricture is <12 cm in length
     • Moderate proximal small bowel dilatation (18-29 mm)
     • No evidence of fistulae
     • Symptoms are mild to moderate
   • The CREOLE study showed 64% success rate with adalimumab for symptomatic small bowel strictures at 24 weeks 1

2. Surgical Approach Decision

   • Strictureplasty is recommended because:
     • The stricture is 20 cm from ileocaecal valve (>15 cm from valve)
     • Patient has mild symptoms (diarrhea, weight loss) without severe obstruction
     • No signs of acute inflammation (no fever)
     • Need to preserve bowel length in Crohn's disease

3. Type of Strictureplasty Based on Length

   • For strictures <10 cm: Conventional Heineke-Mikulicz strictureplasty 1
   • For strictures 10-25 cm: Modified techniques like Finney procedure 1
   • For strictures >25 cm: Side-to-side isoperistaltic strictureplasty (Michelassi procedure) 1, 2

Rationale for Strictureplasty

1. Preservation of Bowel Length

   • Critical in Crohn's disease to prevent short bowel syndrome
   • Particularly important when the stricture is >15 cm from the ileocaecal valve 1

2. Efficacy and Safety

   • Strictureplasty is not associated with increased recurrence compared to resection 1
   • Long-term studies show 92% of patients maintain the original strictureplasty at median follow-up of 5.9 years 2
   • Clinical recurrence rates of 29.7% at 3 years and 39.6% at 5 years 2

3. Contraindications to Consider

   • Presence of fistulae
   • Fistula-associated abscesses
   • Possible carcinoma 1
   • Active inflammation at the stricture site is NOT a contraindication

Perioperative Considerations

1. Preoperative Optimization

   • Nutritional assessment and support is recommended 1
   • Enteral nutrition should be the strategy of choice for preoperative optimization 1
   • Joint medical and surgical assessment to optimize therapy 1

2. Surgical Planning

   • If multiple strictures are present close together and adequate healthy bowel remains, a single resection may be preferable to multiple strictureplasties 1
   • For extensive disease (>20 cm), modified side-to-side isoperistaltic strictureplasty techniques may be considered 3, 2

Alternative Approaches

1. Endoscopic Balloon Dilatation

   • Only recommended for strictures <5 cm in length 1
   • Every additional centimeter increases need for surgery by 8% 1
   • Not suitable for this case due to likely longer stricture length

2. Surgical Resection

   • Generally reserved for:
     • Small strictures <15 cm from ileocaecal valve
     • Large bowel strictures
     • Cases with fistulae or abscesses
     • Suspected malignancy

Post-Procedure Management

• Monitor for small bowel bacterial overgrowth (common after strictureplasty)
• Treat with broad-spectrum antibiotics if bacterial overgrowth develops 1
• Consider maintenance therapy to prevent recurrence
• Follow-up imaging and/or endoscopy to assess healing

This approach prioritizes bowel preservation while effectively treating the stricture, which is crucial for long-term quality of life and prevention of short bowel syndrome in Crohn's disease patients.