What is the best treatment approach for a patient with ileocaecal Crohn's disease and stricture?

Treatment Approach for Ileocaecal Crohn's Disease with Stricture

Surgery is the preferred option for patients with localized ileocaecal Crohn's disease with obstructive symptoms due to stricture, especially when there is no significant evidence of active inflammation. 1

Initial Assessment and Management Algorithm

Step 1: Evaluate the Stricture Characteristics

• Imaging assessment: CT enterography or MR enterography to determine:
  • Length of stricture (critical decision point: <10 cm vs >10 cm)
  • Degree of proximal bowel dilatation
  • Presence of associated complications (fistulae, abscess)

Step 2: Treatment Decision Based on Stricture Type

For Predominantly Fibrotic Strictures (minimal inflammation):

1. Surgical intervention is the preferred first-line approach 1
   • For strictures <10 cm: Strictureplasty is recommended to preserve bowel length 2
   • For longer strictures or those with complications: Resection with wide lumen stapled ileocolic side-to-side anastomosis 1
   • Laparoscopic approach is preferred when expertise is available 1

For Predominantly Inflammatory Strictures:

1. Medical therapy first:
   • For mild-moderate disease: Ileal-release budesonide 9 mg once daily for 8 weeks 1
   • For moderate-severe disease: Systemic corticosteroids followed by maintenance therapy 1
   • Consider anti-TNF therapy (infliximab) for strictures <12 cm with moderate proximal dilatation 1, 3

For Short Anastomotic Strictures (post-surgical):

• Endoscopic dilatation is preferred for symptomatic and short anastomotic strictures (<4-5 cm) 1, 2
  • Should only be attempted in institutions with surgical backup 1

Step 3: Management of Complications

If Abscess Present:

• Antibiotics and percutaneous or surgical drainage, followed by delayed resection if necessary 1
• Once abscess is resolved, consider infliximab if anti-inflammatory therapy is required 1

If Nutritional Deficiencies Present:

• For obstructive symptoms: Diet with adapted texture or post-stenosis enteral nutrition 1
• For severe malnutrition before surgery: Preoperative nutritional support 1

Important Considerations and Caveats

Risk Factors for Recurrence

• Smoking is a major risk factor for both disease progression and post-operative recurrence 1
• All patients should be strongly encouraged to quit smoking 1

Post-Surgical Management

• Prophylactic treatment after resection is recommended to prevent recurrence 1
• Options include:
  • Thiopurines or anti-TNF agents for high-risk patients 1
  • High-dose mesalazine for isolated ileal resection 1

Monitoring

• Ileocolonoscopy within the first year after surgery to assess for recurrence 1
• Calprotectin, ultrasound, MR enterography can be used as less invasive monitoring tools 1

Pitfalls to Avoid

1. Delaying surgery when indicated can lead to worsening obstruction, perforation, or malnutrition
2. Overusing corticosteroids for maintenance therapy (ineffective and harmful)
3. Performing strictureplasty when contraindicated (presence of fistulae, abscesses, or suspected malignancy) 2
4. Failing to provide post-surgical prophylaxis against recurrence in high-risk patients

The treatment approach must be customized based on the specific characteristics of the stricture, the patient's overall condition, and the available expertise. A joint medical and surgical assessment is essential to optimize therapy and determine the most appropriate intervention timing.