What is the likely cause of a patient's difficulty passing gas, intestinal inflammation, chronic worsening diarrhea, and pencil-thin stools, and how should it be treated?

Diagnosis: IBD-Related Stricture

This patient most likely has an inflammatory bowel disease (IBD) stricture causing luminal narrowing, which explains the constellation of intestinal inflammation, chronic worsening diarrhea, pencil-thin stools, difficulty passing gas, and near-obstructive episodes. 1, 2

Diagnostic Approach

Rule out active inflammation first using a stepwise approach before attributing symptoms to functional causes 1:

• Measure fecal calprotectin to assess for ongoing inflammatory activity (already positive in this patient, confirming active inflammation) 1
• Perform colonoscopy with biopsy to visualize the stricture, assess degree of narrowing, and obtain tissue for histologic confirmation 1, 2
• Obtain cross-sectional imaging (CT or MRI enterography) to evaluate stricture location, length, degree of obstruction, and presence of upstream bowel dilation 1, 2

The combination of elevated inflammatory markers, pencil-thin stools (indicating significant luminal narrowing), and recurrent near-obstructive episodes strongly suggests a fibrotic or inflammatory stricture rather than functional symptoms 2.

Treatment Strategy

Immediate Management

For patients with obstructive symptoms from IBD strictures, implement dietary texture modification while addressing the underlying inflammation 3:

• Prescribe a low-residue or adapted texture diet to reduce mechanical obstruction risk while the stricture is being treated 3
• Consider distal (post-stenosis) enteral nutrition if oral intake is severely limited 3
• Ensure adequate hydration with oral rehydration solutions containing sodium and glucose to prevent dehydration from high output or diarrhea 3

Medical Therapy for Active Inflammation

Initiate or optimize anti-inflammatory therapy to control the underlying IBD 1, 4:

• For mild to moderate ulcerative colitis: Start mesalamine 2.4-4.8g once daily for induction, then 2.4g daily for maintenance 4
• For Crohn's disease: Mesalamine has limited effectiveness; consider immunomodulators (azathioprine, mercaptopurine) or biologic agents targeting TNF-alpha or other inflammatory pathways 1, 5
• Monitor renal function before starting mesalamine and periodically during treatment 4

Symptom Management

For diarrhea in quiescent IBD: Use hypomotility agents (loperamide) or bile-acid sequestrants cautiously, only after confirming the stricture is not causing complete obstruction 1

For abdominal pain: Use antispasmodics (hyoscine butylbromide, dicycloverine, peppermint oil) as first-line agents, avoiding opiates entirely due to risk of dependence and worsening dysmotility 1, 6

Definitive Management

Surgery should be considered when 1:

• Stricture causes recurrent complete or near-complete bowel obstruction despite medical therapy
• Endoscopic balloon dilation fails or is not feasible
• Medical therapy fails to control inflammation adequately

For ulcerative colitis: Surgery (complete colonic resection) can be curative 1

For Crohn's disease: Surgery is reserved for complications or refractory disease, as CD is potentially panenteric and typically recurs post-operatively 1

Critical Pitfalls to Avoid

• Do not attribute obstructive symptoms to functional disorders when inflammatory markers are elevated and stool caliber is abnormal 1
• Never use opiates for pain management in IBD patients with strictures, as they worsen dysmotility and can precipitate complete obstruction 1, 6
• Do not delay cross-sectional imaging in patients with obstructive symptoms, as transition points may only be visible during acute episodes 3
• Avoid high-fiber or high-residue foods until the stricture is adequately treated, as they increase obstruction risk 3