From the Guidelines
The treatment of subacute obstruction secondary to a stricture due to protein-losing enteropathy involves a comprehensive approach including bowel rest, nutritional support, and addressing the underlying inflammation, with exclusive enteral nutrition (EN) via a tube ending distal to the obstruction being a recommended approach in patients with intestinal strictures or stenosis and obstructive symptoms, as supported by a strong consensus with 91% agreement 1.
Immediate Management
The initial management of subacute obstruction due to a stricture from protein-losing enteropathy should focus on relieving the obstruction and managing the underlying condition. This includes:
- Bowel rest to reduce the workload on the intestine
- Nasogastric tube decompression to alleviate symptoms of obstruction
- Intravenous fluid resuscitation to correct electrolyte imbalances and maintain hydration
Nutritional Support
Nutritional support is crucial in the management of subacute obstruction due to a stricture from protein-losing enteropathy. The use of exclusive EN via a tube ending distal to the obstruction is recommended in patients with intestinal strictures or stenosis and obstructive symptoms 1. This approach can help in relieving inflammatory bowel strictures, as shown in a prospective observational study where 81.4% of patients achieved symptomatic remission with 12 weeks of exclusive EN 1.
Addressing Underlying Inflammation
For the underlying protein-losing enteropathy, addressing the inflammation is key. Corticosteroids such as prednisone may be used to reduce inflammation, although the specific dosage and duration should be tailored to the individual patient's needs. In cases where strictures persist despite medical management, endoscopic balloon dilation or surgical intervention may be necessary.
Long-term Management
Long-term management includes dietary modifications and potentially ongoing nutritional support. A diet with adapted texture or exclusive EN can be recommended for patients with intestinal strictures or stenosis and obstructive symptoms 1. The goal of long-term management is to restore normal intestinal function, prevent recurrence of obstruction, and improve the patient's quality of life.
Interventional Approaches
For patients with symptomatic fibrostenotic disease and obstruction, an interventional approach, either surgical or endoscopic, may be required 1. Endoscopic balloon dilation has proven successful in the management of primary intestinal strictures or anastomotic strictures in Crohn's disease, with a technical success rate of 89 to 92% and short-term relief of symptoms in 70 to 81% of patients 1. However, long-term results are less impressive, and surgical intervention may be necessary in cases of severe or refractory strictures.
From the Research
Treatment for Subacute Obstruction Secondary to Stricture
- The treatment for subacute obstruction secondary to a stricture due to protein-losing enteropathy (protein enteropathy) may involve endoscopic management, such as endoscopic balloon dilation (EBD) 2, which is safe and effective for the treatment of strictures.
- EBD can be used to treat strictures, including those caused by protein-losing enteropathy, and has been shown to have good short- and long-term outcomes 2.
- In some cases, treatment may also involve dietary modification, supportive care, and maintenance of nutritional status 3.
- Elemental diet and anti-TNFα agent may also be used to improve hypoalbuminemia after surgery 4.
- The treatment of perforation following stricture dilation is commonly multidisciplinary and should involve gastrointestinal, surgical, and interventional radiology teams 5.
Considerations for Treatment
- The choice of treatment modality depends on multiple factors, including the type, location, and complexity of the stricture, as well as the preference of the treating physician 6.
- Treatment options can be generally categorized into medical, endoscopic, and surgical, and the best approach may involve a combination of these categories 6.
- The primary goal of treatment is to re-establish an adequate and durable luminal patency that is sufficient to resolve the presenting clinical symptoms 6.