What are strictures in Crohn’s disease. How do strictures form in the intestines. What are the symptoms of intestinal strictures. What treatments are available for Crohn’s disease strictures. When is surgery necessary for strictures. How can strictures be prevented in Crohn’s disease.

Understanding Intestinal Strictures in Crohn’s Disease

Crohn’s disease is a chronic inflammatory bowel condition that can lead to serious complications, including intestinal strictures. A stricture is a narrowing of a section of the intestine caused by recurrent inflammation, which results in thickening of the intestinal walls or formation of scar tissue. This narrowing can slow or block the movement of food through the digestive tract, leading to various symptoms and potential complications.

Strictures are a common complication of Crohn’s disease, affecting approximately 50% of patients at some point in their disease course. Notably, about 20% of Crohn’s patients already have strictures at the time of their initial diagnosis. While strictures can occur anywhere along the gastrointestinal tract, they most frequently develop in the ileum (the last part of the small intestine) and the ileocecal valve (the junction between the small and large intestines).

Recognizing the Symptoms of Intestinal Strictures

Identifying the symptoms of strictures is crucial for timely intervention and treatment. Common signs of intestinal strictures include:

• Abdominal pain
• Cramping
• Bloating
• Nausea
• Vomiting
• Severe cramping
• Constipation

In severe cases, strictures can progress to a complete intestinal obstruction, which may cause additional symptoms such as:

• Intense abdominal pain
• Abdominal distention
• Persistent nausea and vomiting
• Inability to pass gas or stool

Diagnosis and Assessment of Intestinal Strictures

Accurate diagnosis of strictures is essential for determining the appropriate treatment approach. Healthcare providers may use various diagnostic tools and techniques to identify and assess strictures, including:

• Imaging studies (CT scans, MRI enterography)
• Endoscopic procedures (colonoscopy, capsule endoscopy)
• Contrast studies (small bowel follow-through)

These tests help determine the location, severity, and extent of the stricture, guiding treatment decisions and surgical planning if necessary.

Medical Management of Crohn’s Disease Strictures

The initial approach to managing strictures in Crohn’s disease typically involves medical therapies aimed at reducing inflammation and potentially improving the narrowing of the intestines. Some common medical treatments include:

1. Anti-inflammatory medications (e.g., corticosteroids, 5-aminosalicylates)
2. Immunosuppressants (e.g., azathioprine, methotrexate)
3. Biologic therapies (e.g., anti-TNF agents, anti-integrin medications)

These medications work to control the underlying inflammation that contributes to stricture formation. In some cases, medical management may help alleviate symptoms and potentially delay or prevent the need for surgical intervention.

Surgical Options for Treating Intestinal Strictures

When medical therapies are insufficient or complications arise, surgical intervention may become necessary. Two primary surgical approaches for treating strictures in Crohn’s disease are:

1. Strictureplasty

Strictureplasty is a surgical procedure that widens the narrowed area of the intestine without removing any portion of the bowel. This technique is particularly beneficial as it preserves intestinal length and function. Key aspects of strictureplasty include:

• It is most effective in the lower sections of the small intestine (ileum and jejunum)
• The surgeon makes lengthwise cuts along the narrowed areas and then sews the intestine crosswise
• Multiple strictures can be repaired during a single surgery
• It helps avoid potential complications associated with bowel resection, such as short bowel syndrome

2. Small Bowel Resection

In some cases, particularly when strictures are accompanied by significant disease activity or complications, a small bowel resection may be necessary. This procedure involves removing the diseased portion of the intestine and reconnecting the healthy ends.

Endoscopic Balloon Dilation: A Minimally Invasive Alternative

For certain patients with short, uncomplicated strictures, endoscopic balloon dilation may be a viable alternative to surgery. This procedure involves:

• Inserting a balloon-tipped catheter through an endoscope
• Positioning the balloon at the site of the stricture
• Inflating the balloon to widen the narrowed area

While less invasive than surgery, endoscopic balloon dilation may need to be repeated and carries a risk of perforation. It is typically reserved for select cases and may be used in combination with other treatments.

Preventing Stricture Formation in Crohn’s Disease

While it may not always be possible to prevent strictures entirely, certain strategies may help reduce the risk or delay their development:

• Adhering to prescribed medications and treatment plans
• Regular follow-up with healthcare providers
• Maintaining a healthy diet and lifestyle
• Avoiding smoking, as it can exacerbate Crohn’s disease
• Promptly reporting new or worsening symptoms to healthcare providers

Early intervention and aggressive treatment of active inflammation may help prevent or minimize stricture formation in some patients with Crohn’s disease.

Living with Strictures: Dietary Considerations and Lifestyle Adjustments

For individuals with known strictures or those at risk of developing them, certain dietary and lifestyle modifications may help manage symptoms and reduce the risk of complications:

Dietary Recommendations

• Following a low-residue or low-fiber diet during flare-ups
• Avoiding large meals and opting for smaller, more frequent meals
• Chewing food thoroughly to aid digestion
• Staying well-hydrated to prevent constipation
• Limiting intake of foods known to cause individual symptoms or discomfort

Lifestyle Adjustments

• Managing stress through relaxation techniques or counseling
• Engaging in regular, low-impact exercise as tolerated
• Getting adequate rest and sleep
• Avoiding alcohol and tobacco
• Maintaining open communication with healthcare providers about symptoms and concerns

By implementing these strategies, individuals with Crohn’s disease may better manage their symptoms and potentially reduce the risk of stricture-related complications.

Long-term Outlook and Follow-up Care for Patients with Strictures

The long-term prognosis for patients with Crohn’s disease-related strictures can vary depending on several factors, including:

• The location and severity of the strictures
• The overall disease activity and progression
• The effectiveness of medical and surgical interventions
• The patient’s adherence to treatment plans and follow-up care

Regular follow-up care is essential for monitoring disease activity, assessing treatment efficacy, and detecting potential complications early. This may involve:

• Periodic imaging studies to evaluate stricture progression or recurrence
• Regular blood tests to monitor inflammation markers and nutritional status
• Endoscopic evaluations as needed
• Ongoing assessment of symptoms and quality of life

With appropriate management and close follow-up, many patients with Crohn’s disease-related strictures can maintain a good quality of life and minimize the impact of this complication on their overall health and well-being.

Understanding the nature of strictures in Crohn’s disease, recognizing their symptoms, and being aware of available treatment options empowers patients to actively participate in their care and make informed decisions alongside their healthcare team. While strictures can be a challenging aspect of Crohn’s disease, advances in medical and surgical treatments continue to improve outcomes for many patients living with this condition.

Strictureplasty | Crohn’s & Colitis Foundation

Chronic inflammation in the intestines can cause the walls of your digestive tract to thicken or form scar tissue. This can narrow a section of intestine, called a stricture, which may lead to an intestinal blockage. A strictureplasty is a surgical procedure to repair a stricture by widening the narrowed area without removing any portion of your intestine.

It is important to repair strictures because the narrowing of your intestine could lead to a blockage that prevents stool from passing through the body. When strictures are caused by disease inflammation, initial treatment may typically include medication to help improve the narrowing of the intestines. Surgery may also be a necessary option. Strictureplasty and small bowel resection are two surgical procedures to repair a stricture.

Symptoms of a stricture

• Nausea

• Vomiting

• Severe cramping

• Constipation

What You Should Know About Strictureplasty

Any surgery is concerning, but learning about the procedure can lessen your concerns and give you information to discuss with your healthcare team.

• Strictureplasty is a generally safe procedure. It is most effective in the lower sections of the small intestine, called the ileum and the jejunum.

• Strictureplasty is less effective in the upper section of the small intestine, called the duodenum.

• Strictureplasty avoids the need to remove a section of your small intestine. It is preferred when possible, because removing portions of your small intestine cause sometimes cause other complications, including a condition called short bowel syndrome (SBS) which occurs when large sections of the small intestine are removed due to surgery (or various surgeries) and the body is unable to absorb adequate amounts of nutrients and water.

During the procedure

• Your surgeon will make cuts lengthwise along the narrowed areas of your intestine, then sew up the intestine crosswise.

• This type of incision and repair shortens and widens the affected part of your bowel, allowing food to pass through.

• Your surgeon may repair several strictures during the same surgery.

Ask Your Doctor

• How is the stricture diagnosed?

• What preparations will I need to make before my strictureplasty?

• What are the potential complications from surgery?

• What kind of restrictions will I have after my surgery?

• How long will it take me to recover from my strictureplasty?

• How will the surgery affect my diet and bowel movements?

Related Resources

Short Bowel Syndrome & Crohn’s.

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Information on Short Syndrome and Crohn’s Disease updated 3.18

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3 Medical Therapies to Treat Strictures in Crohn’s Disease

Crohn’s disease can cause a narrowing of the intestines called strictures, which result in problems with digestion. Find out about the symptoms and treatment options for this Crohn’s complication.

By Kristen StewartMedically Reviewed by Ira Daniel Breite, MD

Reviewed: May 18, 2023

Medically Reviewed

Surgery is the most effective treatment for strictures. Audrey Shtecinjo/Stocksy

Anyone who has Crohn’s disease knows that its symptoms — abdominal cramps, diarrhea, constipation — are unpleasant. Worrying about more serious complications of Crohn’s disease, such as strictures, is yet another challenge that patients may face.

A stricture is a narrowing of a section of the intestine that causes problems by slowing or blocking the movement of food through the area. Strictures, which are caused by recurrent inflammation, can lead to hospitalization and also to surgery to correct them.

This complication is common; about half of people with Crohn’s develop strictures at some point, and 20 percent of patients have strictures at the time of diagnosis, according to a review published in 2021 in the journal Expert Review of Gastroenterology & Hepatology. Depending on where the stricture forms, symptoms can include:

• Abdominal pain
• Cramping
• Bloating

In serious cases, strictures can progress to the point of causing a complete intestinal obstruction, which may result in nausea, vomiting, abdominal distention, and severe abdominal pain.

It is possible for strictures to occur anywhere along the gastrointestinal tract, but they are most often found in the last part of the small intestine — the ileum — and the entrance to the large intestine, called the ileocecal valve.

“Between 70 and 90 percent of people with Crohn’s disease will require surgery after 5 to 10 years,” says Anita K. Gregory, MD, a colorectal surgeon at St. Joseph Hospital in Orange, California, and a former member of the medical advisory committee for the Orange County chapter of the Crohn’s & Colitis Foundation. “Of those requiring surgery, 50 percent are due to strictures.”

Ways to Treat Strictures

The treatment of strictures can be difficult, and the risk of recurrence after treatment is relatively high. According to a review published in February 2022 in the journal Frontline Gastroenterology, what treatment your healthcare team chooses will depend on a few factors, including the type of stricture — inflammatory, caused by inflammation, or fibrotic, when chronic inflammation causes scar tissue buildup in the intestine — how big it is, its location, and the severity of the obstruction.

There are three options available to treat strictures, says Bo Shen, MD, the director of the IBD center at Columbia University Irving Medical Center in New York City:

1. Medical therapy with steroids, immunosuppressive agents, or anti-inflammatory agents
2. Endoscopic therapy using a scope that is inserted into the body (balloon dilation, endoscopic needle knife, or insulated tip knife therapy to open up the stricture)
3. Bowel resection and anastomosis, or strictureplasty

According to the Crohn’s & Colitis Foundation, when strictures are caused by disease inflammation, medication may be prescribed as an initial treatment to relieve the narrowing of the intestines.

Endoscopic balloon dilation is technically successful in 75 to 90 percent of cases, Dr. Gregory says. If an endoscopic balloon dilation isn’t successful, some patients may be eligible for another endoscopic treatment called fully covered self-expandable metal stents (FCSEMS), essentially a metal tube that expands in the intestines and holds strictures open. But a small study published in April 2022 in the Lancet found it may have a lower success rate than endoscopic balloon dilation. The randomized study included 80 people who needed stricture treatment for Crohn’s disease. Half underwent an endoscopic balloon dilation and half underwent FCSEMS. After one year, 80 percent of the patients who underwent the endoscopic balloon dilation did not require another therapy to treat strictures, compared with about 50 percent of those who underwent FCSEMS. Still, it may be an option for those who do not respond to endoscopic balloon dilation. According to the Crohn’s & Colitis Foundation, medication can quell inflammation, which can be enough to relieve strictures in some people.

The two types of surgery to treat strictures are small bowel resection and strictureplasty. A small bowel resection removes diseased parts of the intestines in order to preserve the healthy parts of the organ. This option may not be good for people with multiple individual strictures, or with a history of resections, because it may lead to complications like short bowel syndrome.

With strictureplasty, a surgeon widens the narrowed part of the intestine without removing any of it. Instead, the surgeon makes careful incisions that shorten and widen the strictured areas.

“Strictureplasty evolved as a surgical procedure designed to preserve intestinal length,” says Gregory. “It is appropriate for diffusing multiple strictures, patients with previous resections of more than 100 centimeters of small intestine, and those with short bowel syndrome.”

While living with Crohn’s complications can be very difficult, it is likely that periods of disease flares, when symptoms are worse, will be followed by times of remission, when these symptoms are less noticeable or maybe even nonexistent. And while perhaps not permanent or perfect, treatment options that can make life a little bit easier certainly do exist.

Additional reporting by Kaitlin Sullivan.

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Intestinal strictures and Crohn’s disease

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Mar

Intestinal strictures and Crohn’s disease

What is intestinal stricture?

Intestinal strictures are essentially narrowing of the intestines that can make it difficult for food to pass through.
Strictures can be mild or severe, and in severe cases can lead to complete intestinal obstruction, meaning that no food or liquid can pass through that part of the intestine. If this happens, emergency surgery is needed to ensure a free exit for the products of digestion.

How do intestinal strictures occur?

Strictures tend to occur more often in Crohn’s disease, although strictures can occasionally occur in people with ulcerative colitis.
Strictures occur when scar tissue builds up in the wall of the large or small intestine. This scar tissue results from long periods of inflammation caused by Crohn’s disease. Inflammation can lead to damage to the intestinal mucosa, which, when repaired, leads to the formation of scar tissue. Then the accumulation of scar tissue in the same place can cause strictures. If the area also has swollen (inflamed) tissues, this can contribute to the narrowing of the bowel.

What are the symptoms of a stricture?

If you have a mild stricture, you may not feel any symptoms unless it slows or stops the passage of food.
If the stricture slows down the passage of food through the intestines, you may experience:
• Abdominal pain
• Abdominal cramps
• Bloating
If the stricture causes complete or partial obstruction, then food and fluid may not pass at all. In these cases, you may experience:
• Severe abdominal pain
• Bloating or distended abdomen
• Nausea
• Vomiting
• Inability to pass a stool
If you experience these symptoms, you should go to the hospital immediately.

How are strictures diagnosed?

If a stricture is suspected, the following tests may be used to diagnose it:
• X-ray – You may be asked to swallow barium or give it to the colon as an enema. This substance coats the lining of the intestine and appears on X-ray showing any strictures;
• Endoscopy – if a stricture in the small intestine is suspected, you may have an upper gastrointestinal endoscopy (gastroscopy), or if a stricture in the colon is suspected, you may have a colonoscopy. During an endoscopy, the inside of the digestive system is examined using an instrument called an endoscope, a long, thin, flexible tube with a camera on the end that is inserted into the digestive system through the mouth or anus.

Colon x-ray with barium enema

How are strictures treated?

Treatment for bowel stricture depends on the severity of the narrowing and what is believed to be the cause.
If the stricture is mild and tissue swelling is a contributing factor, treatment may be to try to reduce inflammation with medication while making dietary changes to avoid high-fiber foods that can lead to severe stricture. It may also be suggested to chew food well before swallowing and reduce food portions.
For moderate strictures that can be viewed with an endoscope, treatment may be to distend the bowel during endoscopy. During treatment, a balloon is used at the end of the endoscope to stretch the bowel. This is known as endoscopic balloon dilation. If this procedure doesn’t work or doesn’t last long after it’s done, surgery may be needed.
Where surgery is required, strictureplasty or bowel resection may be performed.
• Stricturoplasty – damaged parts of the intestine are cut and reshaped. How this is done will depend on the size of the stricture, but usually the damaged part of the bowel is cut across and then reshaped, sutured in the opposite direction;
• Intestinal resection – damaged sections of the intestine are completely removed, and the healthy ends are sutured back.
Stricturoplasty and resection procedures are the two most common types of surgery performed on people with Crohn’s disease.

Is there anything else I should know about strictures?

Strictures can lead to bowel perforation. As the intestines move food through the digestive system, it contracts. If he has to work hard (strong contractions) to move the food forward due to constriction, then pressure may increase. This pressure can cause the intestinal wall to weaken, which can cause it to rupture (perforate).

Source: https://www.ibdrelief.com/learn/complications-of-ibd/intestinal-strictures-and-crohns-disease?fbclid=IwAR3AH606Mr5b4U0Lyd8Heg0oqGe85kjkDSw95y86s_w3A5Gu7FdaRR2LjZQ

Tags: Crohn’s disease

STRICTUROPLASTY AS AN ORGANO PRESERVING TECHNIQUE IN PATIENTS WITH SMALL INTESTINAL CROWN DISEASE (clinical case) | Vardanyan

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