What is the best treatment for a 20-year-old woman with suspected Crohn's disease, characterized by structuring of the terminal ileum and dilation of the proximal small intestine?

Treatment of Stricturing Crohn's Disease with Terminal Ileum Involvement

For this 20-year-old woman with stricturing Crohn's disease of the terminal ileum and proximal small bowel dilation, surgery is the preferred treatment option, as localized ileocecal disease with obstructive symptoms but no significant active inflammation is best managed with surgical resection rather than medical therapy. 1

Clinical Context and Decision Framework

This patient presents with stricturing disease behavior characterized by:

• Terminal ileum narrowing with unequivocal upstream (proximal) dilation - the radiologic definition of a Crohn's stricture 1
• Obstructive symptoms from the stricture
• Young age at diagnosis, which is a risk factor for requiring surgery 1

The presence of proximal bowel dilation indicates hemodynamically significant obstruction that requires intervention beyond medical management alone.

Recommended Surgical Approach

Laparoscopic ileocolic resection with wide-lumen stapled side-to-side (functional end-to-end) anastomosis is the preferred surgical technique 1:

• Laparoscopic approach should be used when appropriate surgical expertise is available 1
• This technique is associated with quicker symptom reduction and proven safety 2
• The wide-lumen anastomosis technique reduces risk of anastomotic stricture recurrence 1

Alternative: Stricturoplasty Consideration

If the patient has:

• Multiple strictures throughout the small bowel
• Previous extensive bowel resection (>100 cm)
• Risk of short bowel syndrome

Then stricturoplasty can be used as first-line treatment 1. However, for isolated terminal ileal disease with significant obstruction, resection remains preferred.

Why Medical Therapy Alone is Insufficient

The ECCO-ESCP consensus specifically states that surgery is preferred for localized ileocecal disease with obstructive symptoms but no significant active inflammation 1:

• Strictures with established upstream dilation represent fixed fibrotic narrowing that responds poorly to anti-inflammatory medications
• Medical therapy (anti-TNF agents, immunomodulators) targets active inflammation, not established fibrosis 3
• Penetrating disease has not been observed to arise in strictures without active inflammation 1

Post-Operative Medical Management is Critical

After surgical resection, prophylactic medical therapy is essential to prevent postoperative recurrence 1:

High-Risk Features Present in This Patient:

• Young age at diagnosis (20 years old) - risk factor for early recurrence 1
• Stricturing disease behavior - predictor of postoperative recurrence 1

Recommended Post-Operative Prophylaxis:

Anti-TNF therapy (infliximab 5 mg/kg IV at weeks 0,2,6, then every 8 weeks) or thiopurines should be initiated post-operatively 1, 4:

• Anti-TNF therapy reduces risk of postoperative recurrence 1
• Early treatment with thiopurines is associated with reduced risk of requiring future surgery 1
• Absence of prophylactic treatment is a predictor of early postoperative recurrence 1

Post-Operative Monitoring:

• Ileocolonoscopy within the first year after surgery to assess for morphological recurrence and guide treatment decisions 1
• Alternative non-invasive monitoring includes fecal calprotectin, ultrasound, or MR enterography 1

Critical Pitfalls to Avoid

1. Do not attempt endoscopic balloon dilation for this primary stricture with significant upstream dilation - endoscopic dilation is indicated only for short strictures (≤4 cm) or anastomotic strictures, and requires surgical backup 1

2. Do not delay surgery in favor of prolonged medical therapy trials when obstructive symptoms are present - this increases risk of complications including perforation or abscess formation 5

3. Do not omit post-operative prophylaxis - this patient has multiple risk factors for recurrence (young age, stricturing behavior, ileal disease) 1

4. Ensure smoking cessation counseling if applicable - smoking is the strongest predictor of requiring surgery and postoperative recurrence 1

If Active Inflammation is Present

If imaging demonstrates concurrent active inflammation at the stricture site (mural hyperenhancement, wall thickening, comb sign) 1:

• Consider short course of corticosteroids (budesonide 9 mg daily for 8 weeks or prednisolone 40 mg daily with taper) to reduce inflammation pre-operatively 6, 7
• However, surgery should not be significantly delayed, as the stricture itself will not resolve with medical therapy alone

If Abscess is Present

If imaging reveals concomitant abdominal abscess 1:

• Manage with antibiotics and percutaneous or surgical drainage first
• Perform delayed resection after source control is achieved
• Do not proceed directly to surgery in the setting of active sepsis