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

Management of Ileal Stricture 20 cm from Ileocecal Valve

Strictureplasty is the recommended management for a stricture located 20 cm from the ileocecal valve presenting with diarrhea and mild weight loss without fever or severe pain. 1

Rationale for Strictureplasty

• The European Crohn's and Colitis Organisation (ECCO) guidelines specifically recommend strictureplasty for strictures located more than 15 cm from the ileocecal valve with mild symptoms 1
• This approach preserves bowel length, which is critical in preventing short bowel syndrome, especially in patients with jejuno-ileal disease 1
• The patient's presentation (diarrhea, mild weight loss, absence of fever or severe pain) suggests a non-complicated stricture, making strictureplasty appropriate

Why Other Options Are Less Appropriate

• Endoscopic dilatation: Only recommended for strictures less than 5 cm in length according to the American Society for Gastrointestinal Endoscopy; every additional centimeter increases the need for surgery by 8% 1
• Surgical resection: Should be reserved for cases with complications like fistulae, abscesses, or when strictureplasty is not technically feasible 1
• Colonoscopy: Diagnostic rather than therapeutic; would not address the stricture itself
• Cortisone: Medical therapy may be considered for strictures less than 12 cm with moderate proximal small bowel dilatation and no evidence of fistulae, but surgical intervention is preferred for established strictures causing symptoms 1

Technical Considerations

• Conventional strictureplasty is advised for strictures less than 10 cm in length 1
• For longer strictures (10-25 cm), modified techniques like Finney procedure or side-to-side isoperistaltic strictureplasty (Michelassi technique) are recommended 1
• Complete assessment of the bowel is necessary during surgery to detect any additional strictures or skip lesions 1

Important Considerations

• Nutritional assessment is crucial before surgery, with potential need for vitamin B12 supplementation if more than 20 cm of distal ileum is involved 1
• Patients should be monitored for small bowel bacterial overgrowth post-surgery and treated with broad-spectrum antibiotics if it develops 1
• Preservation of the ileocecal valve is important when possible, as its loss is associated with chronic diarrhea even in patients without Crohn's disease or short bowel syndrome 2
• Recurrence rates after strictureplasty are similar to those after resection, with low incidence of recurrent disease at strictureplasty sites 1

Contraindications for Strictureplasty

• Presence of fistulae
• Fistula-associated abscesses
• Suspicion of carcinoma
• Colonic strictures 1

If any of these contraindications are present, surgical resection would be the preferred approach.