Questions on Strictures/Treatment of Strictures

One colorectal surgeon told me that a patient had a stricture at the anastamosis site, and by the time he saw her, there was a huge buildup of stool above the stricture. I don't know if it will completely close up, but I think it can get backed up, if that makes sense. Strictures are often "web-like" in nature, so it depends how thick the web is.

I have experience with finger dilation only (ouch! ) from an anastamosis stricture.

I guess it depends on the cause of the narrowing. Is it scar tissue or inflammation/crohn's?

@ kjeane - interesting about the balloon stricture. I had a similar experience recently. My surgeon (who has also done a vast amount of j-pouches) did a finger dilation, whereas another surgeon (also reputable) was very much against that and said balloon dilation is less traumatic to the area because it is more gradual. He also said strictures are often related to surgical technique, or could be indicative of crohn's.

In my case all signs point to Crohn's/inflammation, rather than scar tissue as the reason for the stricture. My last surgery was in 2000 (J Pouch revision) and the issues we are seeing now, namely inflammation at the inlet and above the pouch, did not surface until a pouchoscopy in 2008. I had a CT Enterography done in October 2008 which did not show the narrowing I have now, although I am going to get a CD burned of that study, at Dr. O's request, so that he can review it.

Is the balloon dilation done under general anesthesia or the same sedation that they give for a pouchoscopy? If my stricture is related to inflammation, as I suspect, will the balloon dilation be more likely to provide relief? kjeane, what problems does Milsom think that the balloon dilation causes?

kjeane, very sorry to hear of your situation. It's very frustrating not being able to have a productive, efficient bowel movement.

I've never heard of a stricture being caused by inflammation, I always thought it was related to scar tissue only.

If there is indeed such a thing as 'inflammation induced' stricture, it seems to me that the way to treat it would be through anti-inflammatory drugs, not dilation. Has your doctor mentioned going back on medication, or possibly trying Remicade?

Sue

quote:

Do you have to drink that lovely chalky substance?

kjeane,

I drank Volumen for my MRI Enterography and I gave a description of the experience in my thread on the MRI Enterography in the pouchitis forum. I found it to be barely tolerable and the radiology tech told me she was very proud that I drank all 3 450 ml bottles. She said most patients cannot finish all 3 bottles like I did. It's not quite as bad as drinking Barium "milkshakes" in the old days, or GoLytely, in my opinion. It's also not very pleasant. Probably the worst thing I ever had to drink for any bowel related issue or procedure was liquid potassium when my potassium level show down after step 1. Utterly vile tasting substance but only had to drink a dixie cup filled with it, probably the equivalent of 2 shots.

I am going to speak with Dr. O about possible issues with a balloon dilation. Hopefully the antibiotics and Entocort will bring down the inflammation and I will lose the problem with incomplete evacuation/unproductive dribs and drabs type BMs. However I do not seem to be going in the right direction at this time.

quote:

Has your doctor mentioned going back on medication, or possibly trying Remicade?

I am back on antibiotics as of yesterday, together with pentasa and Entocort. The stricture like symptoms developed in the past few days, after I had been off antibiotics for over a week. I very much doubt that the narrowing they are seeing is caused by anything but inflammation, because my last surgery was in 2000 and it was to correct issues in an area within my pouch, not at the inlet. I have had 12 years with no symptoms like this - actually more like 18 years if you except the periods immediately preceding my 1998 and 2000 Pouch revision surgeries. I don't know how scar tissue would develop without surgery or on its own in the intervening 12 years. Plus, my 2008 CT Enterography did not show the situation now being seen.

What they told me is the MRI on Friday showed a thickening of the bowel and a narrowing of the bowel at the pouch inlet and that the ulcerations and inflammation above the pouch are being caused by fecal stasis or a pooling of the feces which is not getting through the pouch inlet properly. This was clearly shown on the MRI Enterography from what he told me.

My doctor wants to review the MRI films with his trusted radiologist, and my 2008 CT Enterography film which I will be dropping off to him at lunch today, so precisely what is causing all of this is still undetermined.

I can only speak from my daughter's case. She had a stricture at the inlet to her pouch and in '07 had her first blockage and she had a balloon dilation to release that, and it did. In '08 she required another balloon dilation because it had narrowed again. The thought was to dilate and "break up" the scar tissue and as it heals it would hopefully, eventually stay open. Kinda like the finger dilation at the bottom of the pouch, if it is strictured, the idea is after a while it will stay open.
She also had to have a strictureplasty later in '08 because the surgeon said that would be the better way to go and it should fix it. In her case it did not, But from '08 to 2011 she only required yearly dilations. Then in 2011, with increased inflammation in that area and a huge bleeding ulcer that added to it she had many dilations and had a pouch revision this past May. The revision changed the inlet of the pouch to the other side of the pouch so the stricture is no longer an issue.

Balloon dilations can be done with light anesthesia and a local. She also had one balloon dilation done without, but will never do that again.

With her present surgeon for the last 4 years he had thought it could be crohn's due to the narrowing, but after this last surgery, which was open and he looked at everything he feels it is not crohn's but the way she healed, scaring at the surgical site.

Also, I took her to Cleveland last year and was told that balloon dilations could be done every 3 months to avoid surgery and that was the way to go. However, this past year she bled too often due to the ulcer that was right in the path of that inlet and stricture.

Hoping for the best for you. Any questions pm me, I'm not always on. Take care.

Thanks for your input, beckysmom. My narrowing is also at the pouch inlet thought it has not officially been diagnosed as a stricture yet, as they do not know what is causing the narrowing. Today I dropped off my 2008 CT Enterography films so that this study can be compared with the 2012 MRI Enterography done last Friday. They did not see in the 2008 study what they are seeing now, so it is not clear if scar tissue is the culprit as opposed to inflammation. However, I read some of the other threads on strictures and the symptoms I had this weekend were strikingly similar to those described in those threads. I have two days of antibiotics in me and I am feeling better today. The whole thing is a big mystery that has been perplexing my doctors for the last 4 plus years. It has led to numerous tests being done on me with no conclusions being drawn. I am a radiologist's dream, a subject who can be tested endlessly with no firm conclusions ever being drawn. I feel like an alien, someone who has something nobody has seen before. However I do know that my blood is red and my eyes are brown.

Please, DJB, are not an alien! Nor is anyone having issues with these damn diseases and the problems they give people.

My daughter has been referred to as "difficult" and "interesting" they were right on the last one, she IS interesting as a person, and this disease and her problems, like yours, do not define you

I forgot to add that the inflammation can cause thickening because you are inflamed, or not, and are then dilated, and then are inflamed from the dilation then you heal and scar and on and on... but it could just be a few dilations and it would stay open, if that is the issue. Your dr would know about this better.

I think it is encouraging that 2 days on the antibiotics and you feel better, even though your dr doesn't want you on them. When my daughter had a partial blockage no amount of antibiotics was going to help, she was just blocked.

Best wishes.

djb putting in my two cents here maybe all this latest develpoment is because you went off antibiotics..i can tell you that one of my awful symtoms when antiobiotic not working or if i were not on them is this terrible feeling of not emptying and straining to relieve myself.. like i have a stricture..so maybe it is just simple like that..my problems presently fall in pouchitis category but i sure as heck have that issue aside from some other goodies i know you did not have like severe irritation,burning...but if things are getting better with antibiotic i might be right..

you know i wonder if what they saw more ulceration etc.was as meaningful as the dr. thought because i recall you saying you did not have any real discomfort you pretty much felt as always..so maybe just adding entecort to your antibiotic s will get you back on track..entcort helping the ulceration and antibiotics your pouchitis..

i certainly hope so..you were doing real well..

rebe

I think my Doctor thought that the Entocort would kick in after 2 weeks of taking it with the antibiotics and that I would be able to go off the antibiotics. When I reported these problems to him he told me to go back on the antibiotics and that the Entocort may have needed more time. At this point and after experiencing the sensations I had in my gut this weekend, I would certainly rather play it safe.

The plan now is for my Doctor to study my recent MRI alongside my 2008 CT Enterography with his preferred radiologist and try to figure out what the problem is and why things seem to have deteriorated from 2008 to 2012, even though until recently I was feeling okay.

Dear DJB,

I had nothing to add, just sorry to hear your illness is taking a lot out of you. Hope things turn around soon.

Ray