Stricture of intestine: STRICTURES | Crohn’s & Colitis Foundation

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Colon Strictures: What to Know

Written by Alyson Powell Key

Types and Causes
Symptoms
Treatments

Your body is like a network of highways, carrying food, fluids, and waste around and out. When certain sections of those roadways narrow because of disease or other reasons, it’s called a stricture.

When this roadblock happens in your large intestine, it’s called a colon stricture. Your large intestine, or bowel, is where your body converts digested food into poop. A colon stricture slows or stops that waste from passing through.

Strictures can happen in different parts of your body. They include the tube that carries food to your stomach (esophagus) and your urethra, which channels pee out of your body.

No matter the location, strictures come in two types. You could have one or the other, or both.

Inflammatory strictures result from swelling in your digestive tract. Doctors can treat them with medication or surgery.

Fibrotic strictures happen when scar tissue builds up in the bowel from chronic inflammation. They require surgery.

One main cause of colon strictures is inflammatory bowel diseases (IBDs) like Crohn’s disease and ulcerative colitis. A cycle of inflammation and healing leads to scar tissue that narrows the intestine. Other possible causes include:

Bulging on the intestine wall (diverticulosis)
Protruding colon tissue (hernia)
Bacterial infection in the stomach
Tumors
Radiation
Reduced blood flow (ischemia)

One in two adults with Crohn’s disease may get intestine problems like fistulas (sores) or strictures within 20 years of their diagnosis.

Some signs of strictures can feel vague. Other times, the symptoms may be more obvious. Your colon’s job is to process digested food and liquids and push the waste down to your rectum to be eliminated as stool. A serious stricture can block your bowels and make it hard for you to poop.

Symptoms of a colon stricture may include if you:

Are nauseated or feel sick to your stomach
Throw up
Have stomach cramping, pain, or bloating
Are constipated
Have diarrhea
Notice swelling
Lose your appetite
Feel tired

If you don’t treat it early, a stricture can turn deadly.

Lifestyle changes, medicine, and surgery are the three main ways to treat strictures. Your doctor will recommend a treatment plan tailored to your needs:

Changes to your diet. A low-fiber or low-residue diet reduces the risk of blocks in your intestine and the number and size of your poops. Studies also show a connection between a gluten-free diet and IBD symptom relief, which could lower your risk of strictures.

Anti-TNF treatment. This medicine eases inflammation from a protein called tumor necrosis factor (TNF) and prevents new strictures from forming. It only works on strictures related to inflammation, not fibrosis.

Colonoscopy. Doctors widen the colon with a balloon inserted through a flexible tube (endoscope). They may use a stent to keep the narrowed area open.

Your doctor may also suggest surgery. Studies show that most people with Crohn’s disease who also have a stricture will need at least one surgery at some point. There are two kinds:

Strictureplasty widens the narrow part of your intestine without removing it. This surgery is most helpful in the lower part of your small intestine.

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Intestinal Stricture in Crohn’s: Symptoms, Treatment, and More

Depending on the severity of the blockage, an intestinal stricture can cause symptoms ranging from bloating and cramping to severe abdominal pain and nausea.

One of the most common complications of Crohn’s disease is the development of an intestinal stricture. An intestinal stricture is a narrowing in the intestine that makes it difficult for food to pass through. Sometimes, it can lead to intestinal blockage. At least one-third of people with Crohn’s will develop a stricture within the first 10 years of a diagnosis.

If you have Crohn’s disease, it’s a good idea to familiarize yourself with the signs of an intestinal stricture in case you develop one. Read on to learn about what causes strictures, some of the symptoms and risk factors, and what the available treatments are.

There are two main classifications for intestinal strictures: inflammatory and fibrotic. Inflammatory strictures are caused by the inflammation of the digestive tract that accompanies a Crohn’s flare-up. Fibrotic strictures are the result of scar tissue building up in the bowel due to long periods of inflammation.

Most intestinal strictures from Crohn’s are a combination of both these classifications. Strictures that are predominantly fibrotic tend to be more severe and typically require more invasive forms of treatment.

The symptoms of an intestinal stricture can vary depending on the severity of the blockage. For mild to moderate strictures, symptoms typically include:

abdominal cramping
abdominal pain
bloating
loss of appetite
fatigue

In more severe cases, symptoms may include:

severe abdominal pain
nausea
vomiting
constipation
abdominal bloating and distension

If you think you’re experiencing any of the more severe symptoms, contact your doctor immediately.

Several risk factors may increase your likelihood of developing a Crohn’s-related intestinal stricture. For instance:

if you get a diagnosis of Crohn’s disease before the age of 40
if you require steroid treatment during your first Crohn’s flare-up
if you have perianal disease at the time of diagnosis
if you had an appendectomy prior to diagnosis

Certain genetic factors may also make you more susceptible to intestinal strictures. Check with your doctor about whether your family’s medical history increases your risk.

Smoking is a risk factor as well. If you’re a smoker, take steps to quit as soon as possible.

Treatment for intestinal strictures varies from person to person, depending on the type, length, and location of the stricture. Strictures mainly related to inflammation can sometimes be treated with prescription drugs, such as steroids, immunomodulators, and anti-TNF agents. However, since most Crohn’s-related strictures are a mix of inflammatory and fibrotic, these treatments aren’t always effective on their own.

For intestinal strictures that don’t respond to medication, endoscopic treatment may help you delay or avoid surgery. Endoscopic balloon dilation (EBD) is when a balloon is used to expand the narrow part of the bowel. It’s effective in treating single, short strictures that are accessible by endoscopy and free from complications. Unfortunately, the recurrence rate for intestinal strictures is quite high. There’s also a chance that you’ll need another EBD within five years.

Intestinal strictures that don’t respond to medication or aren’t reachable by endoscopy are usually treated with surgery. For short, simple strictures, a bowel-preserving procedure called strictureplasty can be performed. In this procedure, the damaged portion of the bowel is cut open and reshaped. When strictures are longer and more complicated, resection surgery is performed. This involves completely removing the damaged part of the bowel.

If you have an intestinal stricture, you may need to temporarily modify your diet to avoid blocking up the narrowed part of your bowel. Try to eat small, frequent meals and make sure you chew your food thoroughly before swallowing. You might also want to avoid foods that are hard to digest, such as gristly meats, nuts, seeds, fruit and vegetable skins, and beans.

You should always consult with your doctor before making any major changes to your diet. Cutting certain things out could lead to vitamin and mineral deficiencies that may make your symptoms worse.

Although intestinal strictures are quite common among people with Crohn’s disease, if left untreated, they can cause life-threatening issues. If you think you might have a Crohn’s-related stricture, contact your doctor immediately.

Read this article in Spanish.

Intestinal stoma – colostomy, ileostomy, jejunostomy

What is an intestinal stoma

An intestinal stoma (εντερικό στόμιο–Greek) is an artificially created fistula (message) between one or another section of the human intestine and the surface of the skin.

There are several types of intestinal stoma. If a stoma is formed from a loop of the small intestine, then its name will correspond to the section of the small intestine on which it is formed: a stoma formed from a loop of the jejunum is called an jejunostomy, from a loop of the ileum – an ileostomy. When a stoma is formed from any section of the colon, it is called a colostomy – this is the general name for all artificial fistulas of the colon.

In addition, the name of the stoma may indicate the part of the colon that was used to form it. Thus, a cecostoma can be formed from the caecum (caecum – lat.), an ascendostomy can be formed from the ascending colon (colonascendens – lat.), a transversostomy can be formed from the transverse colon (colontransversum – lat.), from the descending colon (colondescendens – lat. .) form a decendostomy, and from the sigmoid colon (colonsygmoideum – lat.) form a sigmostomy. The most common stoma is formed on the most mobile part of the large intestine – on the loop of the transverse colon.

In what cases and why intestinal stoma is formed

The range of diseases and conditions in which it is necessary to form an intestinal stoma is quite wide. Among the diseases, colorectal cancer can be distinguished: rectal cancer or colon cancer complicated by intestinal obstruction, severe and complicated forms of nonspecific ulcerative colitis, Crohn’s disease, complicated forms of acute diverticulitis, in the surgical treatment of multiple stab and gunshot wounds of the intestine.

Many patients with neoplastic diseases of the intestine are admitted to the hospital in serious condition, often with complicated forms of the disease. These patients urgently undergo operations, which end with the formation of an intestinal stoma. As a rule, the creation of a stoma allows (in this situation) to prepare the patient for more complex and radical treatment.

In other cases, when performing certain types of elective operations, for example, with a low anterior resection of the rectum for rectal cancer, the formation of a stoma is a necessary condition to reduce the risk of failure of the newly formed connection between two fragments of the intestine and, accordingly, is a measure prevention of the occurrence of intra-abdominal abscesses and peritonitis – serious surgical complications that may result from the failure of the inter-intestinal anastomosis.

Is an intestinal stoma permanent?

Stoma may be temporary or permanent.

Temporary stoma

Temporary stoma is formed to limit the passage of intestinal contents through the intestine, if necessary, to exclude the impact of feces on the anastomosis zone – a surgically formed connection between the two ends of the intestine; or in the event that it is not possible to achieve good preparation of the intestine for surgery (in violation of intestinal patency due to a tumor or adhesions). Also, the formation of a temporary stoma may be required in the staged surgical treatment of patients with Crohn’s disease, familial adenomatous polyposis, when the first stage is the removal of the entire colon or the entire colon together with the rectum with the formation of a J-shaped reservoir; with severe incontinence (anal incontinence).

Surgical treatment of complicated forms of acute diverticulitis (Hartmann operation or operations of the Hartmann type) ends with the formation of a terminal sigmostoma. Subsequently, in the absence of contraindications, it is possible to carry out a reconstructive operation, in which the stoma is removed and intestinal patency is restored.

In case of low rectal resection, the creation of a protective (preventive) stoma is also temporary. At a certain time, after carrying out proctography – a research method confirming the viability of the anastomosis, the stoma is eliminated.

Permanent ostomy

A permanent stoma is most often performed in patients with colorectal cancer when radical surgery is not possible to remove or prevent intestinal obstruction.

In case of radical surgical treatment of cancer of the rectum and cancer of the anal canal with the spread of the tumor process to the sphincter apparatus of the rectum (anal sphincters), the sphincter apparatus is removed along with the tumor. In this situation, the surgeon forms a terminal permanent stoma on the anterior abdominal wall, which is the new unnatural anus (anuspraeternaturalis – lat.).

Whether the stoma will be temporary or permanent depends largely on the underlying disease, as well as on many other factors: the person’s age, concomitant diseases, complications after surgery, anatomical features of the patient. You can get a clear answer about the possibility of eliminating the stoma from your doctor.

How a stoma is formed

The specific localization of the colostomy is determined by the surgeon, taking into account the clinical situation and anatomical features of the patient. In addition, the condition of the outer integument and the abdominal wall must be taken into account – scars and scars greatly complicate the installation of the colostomy bag. An ileostomy is most often located in the right iliac region, a section of the ileum is displayed on the anterior abdominal wall.

Colostomy:

Ascendostoma cecostoma is located in the right iliac region or right mesogastrium, formed from the ascending, cecum. Intestinal secretions are similar in composition to the small intestine contents.
Transversostomy can be placed in the right or left hypochondrium, and in the midline of the abdomen above the navel, at the level of the umbilicus to the left or right of it. This type of stoma is formed from the transverse colon. In most patients, there is a release of mushy contents that easily irritate the skin around the stoma.
Sigmostoma is located in the left iliac region, the sigmoid colon is displayed. According to the sigmostome, the feces are excreted, as a rule, once or twice a day, according to the consistency – semi-formed.

How does a stoma work? Physiology of the stoma

The consistency, color of the stool and the frequency of changing or emptying the bag will differ depending on which part of the intestine was used to form the intestinal stoma.

Small bowel stoma

The contents of the small intestine are liquid and alkaline, therefore, the same in chemical composition and consistency is discharged along the small intestine stoma and is excreted. The alkaline reaction of the discharge of this type of stoma is the reason why there is a strong irritation of the skin – when the contents of the stoma get on it. Prolonged contact of chyme with the skin leads to the formation of non-healing erosions and ulcers on the skin.

When comparing the volume of discharge per day, the daily volume of liquid chyme from small intestinal stomas significantly exceeds the volume of discharge from the colostomy. Due to electrolyte losses in stoma formed on a loop of the small intestine, a significant amount of fluid with a high content of potassium and sodium (so-called blood electrolytes) – most people with a small bowel stoma are prone to dehydration (dehydration) and blood electrolyte imbalance. It is also possible to form kidney and gallbladder stones: when dehydrated, the kidneys reabsorb water from primary urine, thereby producing more concentrated urine. From such concentrated urine, a mineral precipitate can “fall out” and the formation of stones can occur – in the kidneys and other parts of the urinary tract.

Stomas of the large intestine (colostomy)

For the process of digestion (fermentation) of food, the large intestine is of relatively little importance, since, with the exception of certain substances, the food is almost completely digested and absorbed already in the small intestine. From the small intestine to the caecum – the initial section of the large intestine – an average of 500-800 ml of liquid content per day enters. In the large intestine, the formation of fecal masses occurs due to the absorption of water, and already fully formed feces enter the sigmoid colon. Thus, the segment of the intestine from which the colostomy is formed will act as an artificial anus. Colostomy discharge has an odor that depends on the quality of the food consumed. The volume and consistency of feces can be adjusted by selecting the appropriate diet, the amount of fluid (juice, water) drunk per day.

What is the preferred diet for an ostomy patient

It is very important that the diet of ostomy patients is balanced and varied, including a wide variety of foods. As a rule, a special diet is not required. After the operation, it is necessary to return to the usual regular diet. It is best to gradually expand the diet, adding one type of product per day, while noting changes in the nature and frequency of stools and draw conclusions accordingly. We must try to eat slowly, often and little by little, chewing food well.

Keep in mind that some foods fix the stool, while others, on the contrary, cause it to loosen. By changing his diet, the patient can adjust the frequency of bowel movements to one or two times a day. A fixing effect is provided by white bread, pasta, mucous soups, rice porridge on the water, butter, boiled meat and fish, hard-boiled eggs, broths, mashed potatoes, black tea, cocoa, some fruits (pear, quince).

Relax: black rye bread, oatmeal, fried meat, fish and lard, raw milk, kefir, curdled milk, sour cream, most vegetables and fruits (cabbage, beets, cucumbers, grapes, apples, plums, figs). Legumes, cabbage, sugar, carbonated drinks contribute to increased gas formation. An unpleasant smell from the colostomy can appear if the patient consumes too many eggs, onions, garlic.

Will I be able to control my bowel movements if I have a stoma

An intestinal stoma should be considered as an anus (unnatural anus) but located elsewhere, on the abdomen. A feature of the new unnatural anus is the absence of a sphincter apparatus, and hence the function of holding.

Often you will not feel the urge to defecate, feces and gases will pass spontaneously, you will not be able to control this process. However, having received the necessary advice on care and modern colostomy bags, you can cope with this new feature of self-hygiene and everyday life.

Modern colostomy bags compensate for the functions lost after surgery, the contents of the intestine (feces and gases) are reliably isolated in a sealed ostomy bag made of gas-tight materials. The colostomy bags are designed not only to collect feces, but also to protect the skin around the stoma, and are fixed on the skin of the abdomen immediately after the formation of the stoma at the end of the operation. Modern colostomy bags offered by manufacturers are compact, invisible under clothing.

Complications of an intestinal stoma

Peristomal dermatitis (irritation of the skin in the stoma area)

Dermatitis is observed quite often, is the result of mechanical irritation (frequent change of colostomy bags, careless treatment of the skin), or chemical effects of intestinal discharge (leakage under the plate, poorly fitting, leaky colostomy bag).

Manifestations of dermatitis: redness, blisters, cracks, weeping sores on the skin around the stoma. Skin irritation causes itching, burning, and sometimes severe pain. It is possible to develop an allergic skin reaction to devices and products for the care of the stoma. If the allergy is pronounced, then you should stop using glued bags for a while. In such cases, the question of choosing the type of colostomy bag should be decided by the doctor. Often, the cause of skin complications is simply insufficient skin care in the stoma fixation area. In case of irritation of the skin around the stoma, a consultation with a coloproctologist or specialist in the rehabilitation of stoma patients is necessary.

Hypergranulations in the stoma area

With frequent dermatitis around the stoma – on the border between the skin and the mucous membrane, polypoid outgrowths are formed that bleed easily. Usually these formations are small, a few millimeters in diameter. If such skin changes occur, consult a doctor.

Small bowel event

Small bowel event – prolapse of small bowel loops into the parastomy wound – occurs when too wide an incision is made to form a stoma. This complication often occurs in restless children who cry a lot in the coming days after the operation, which causes an increase in intra-abdominal pressure and, as a result, the formation of eventration. In adult patients, a prolonged increase in intra-abdominal pressure (persistent cough, repeated vomiting) and a violation of the therapeutic regimen (lifting weights) also leads to eventration. Prolapse of the loops of the small intestine requires emergency surgical assistance.

Evagination

Evagination – bowel eversion. More often occurs in children. A certain role in the occurrence of this complication can be played by constantly increased intra-abdominal pressure, increased peristaltic activity of the adducting intestine, and an excessively free aponeurosis defect. Evagination may be minor and can be corrected with gentle pressure, but sometimes it is massive, for example, cecostomy is often complicated by ileocecal angle evagination. In most cases, surgical care is not required, but the patient has to constantly adjust the prolapsed intestine.

Stoma stricture

Stoma stricture – narrowing of the stoma outlet. It develops most often with a tendency of tissues (skin) to form keloid scars. Less often, stenosis can be caused by suturing the anterior abdominal wall around the stoma. With this complication, emptying is delayed, and in rare cases, intestinal obstruction may develop. With the gradual formation of a narrowing (stricture) of the stoma outlet, the patient’s struggle with this complication is reduced to a change in diet and the formation of soft feces, which greatly facilitates their passage through the narrowed opening. In the future, it is possible to expand the narrowing by the method of bougienage, by introducing medical items (rubber probe, catheter) into the narrowed opening. It is not always possible to eliminate the stricture in a conservative way (by bougienage), then they resort to an operational aid. During the operation, according to indications, the stoma is eliminated or its reconstruction is performed.

Bloody discharge from the stoma

In most cases, bleeding is caused by damage to the intestinal mucosa due to poor care of the stoma or the use of rough materials. The edge of a tight hole in the plate, the rigid flange of the colostomy bag can also injure the intestine and cause bleeding. Bleeding usually stops spontaneously. But if the bleeding is heavy, you need to see a doctor.

Retraction (stoma retraction)

This is a gradual dislocation of the stoma below the level of the skin, retraction may be around the entire circumference of the stoma or partial. The presence of a funnel-shaped recess significantly complicates the care of the stoma and requires the use of special colostomy bags with a convex (concave) plate and additional care products (special pastes for leveling the skin surface and protecting it). If these measures are ineffective, surgical treatment (stoma reconstruction) is undertaken.

Parastomal hernias (hernias in the area of stoma formation)

This is a protrusion of the abdominal organs around the stoma due to weakness of the muscular layer of the anterior abdominal wall at the site of stoma formation, often against the background of increased intra-abdominal pressure. The risk of a hernia increases if the patient is obese. Contribute to the formation of hernias – prolonged cough and repeated vomiting in the early postoperative period. To prevent this complication, elastic bandages are used immediately after the operation. In the future, the bandage is worn for 2-3 months.

Patients with even small parastomal hernias may experience pain, constipation, and difficulty using colostomy bags. With infringement of parastomal hernias, only surgical treatment is possible.

Surgical rehabilitation of patients with intestinal stoma

Surgical rehabilitation is an important part of the medical rehabilitation of stoma patients. The timing of reconstructive and reconstructive-restorative operations is determined individually and depends on the initial diagnosis, the type of proposed intervention, the general condition of the patient.

Reconstructive and plastic surgeries are among the most complex in coloproctology and should be performed exclusively by qualified surgeons with special training and sufficient experience for this.

Currently, the restoration of intestinal continuity in the elimination of stoma is one of the urgent tasks of abdominal surgery. Performing reconstructive and restorative operations on the colon is becoming highly relevant for social and labor rehabilitation and improving the quality of life of stoma patients (patients with ileo- or colostomy). This intervention, in terms of technical complexity, sometimes exceeds the primary operation, but at the same time, the methods of surgical correction for the elimination of stoma over the past 10 years have not undergone fundamental changes.

To date, the exact timing of the restoration of intestinal continuity with stoma has not been determined and, depending on various factors, ranges from 2-3 weeks to 1.5 years. With a double-barreled type of colostomy, a loop of the intestine is isolated from the surrounding tissues, and then an anastomosis is formed from the walls of the intestine.

In patients with a single-barrel end colostomy after Hartmann-type surgery, complex reconstructive surgery is required to restore colonic continuity. The sections of the intestine are connected by the methods “end-to-end” or “side-to-side”. Immediately after the formation of the anastomosis, before suturing the wound of the anterior abdominal wall, it is imperative to check the tightness of the connection by contrast or air test

The presence of aggravating factors in the form of colostomy and paracolostomy complications complicates the surgeon’s task at the stage of re-intervention. Paracolostomy and ventral hernias, colostomy strictures, ligature fistulas, ostomy evaginations lead to additional infection of the upcoming surgical access.

The KKMC Clinic performs all types of reconstructive and restorative operations on the colon, as well as reconstructive operations in the presence of an ileostomy – with or without parastomal complications.

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