Crohn Stricture

A Crohn stricture is persistent luminal narrowing caused by inflammation, fibrosis or a mixture of both.

Inflammatory narrowing may improve with medical treatment. Established fibrosis does not reliably respond to anti inflammatory therapy and requires endoscopic or surgical mechanical treatment.

The major surgical challenge is relieving obstruction without sacrificing excessive small bowel.

Patients develop recurrent postprandial colicky pain, abdominal distension, nausea, vomiting and reduced oral intake.

Symptoms may fluctuate with dietary fibre and inflammation.

Complete obstruction, persistent vomiting, peritonism or continuous pain requires urgent assessment for perforation, abscess or strangulation rather than routine elective stricture management.

MR enterography: define stricture length, number and upstream dilatation and distinguish predominantly inflammatory from fibrotic disease as far as imaging allows.

Endoscopy is useful for accessible ileocolic or anastomotic strictures and permits dilation where appropriate.

Treat a predominantly inflammatory stricture medically when there is no abscess, high grade obstruction or other surgical complication.

A short accessible fibrotic stricture below approximately 5 cm can undergo endoscopic balloon dilation when there is no associated abscess, penetrating disease or strong suspicion of malignancy. The need for surgery rises as stricture length increases.

Dilation is generally performed gradually toward approximately 15 to 18 mm according to anatomy and endoscopist judgement. Perforation and bleeding are the major complications.

Operate for:

• Long fibrotic strictures
• Multiple symptomatic strictures unsuitable for endoscopy
• Recurrent obstruction despite dilation
• Associated fistula or abscess
• Perforation
• Suspicion of malignancy

Short segment disease can be resected.

Strictureplasty preserves bowel length:

• Heineke Mikulicz: short strictures, usually below about 10 cm
• Finney: intermediate strictures, approximately 10 to 20 cm
• Michelassi side to side isoperistaltic strictureplasty: selected long segments or multiple clustered strictures

Do not perform strictureplasty through active perforation, uncontrolled sepsis or suspected malignancy.

During surgery, examine the entire small bowel because clinically silent additional strictures may influence the reconstruction plan.