Assessing Treatment Options for a J-Pouch Patient with Narrowed Bowel Segments
**Patient Profile:** Female in her late 50s **Health Background:** More than a decade ago, the individual underwent J-pouch surgery following a colectomy attributed to severe ulcerative colitis that did not respond to treatment. In early 2024, she received a diagnosis of Crohn's disease (or a Crohn's-like inflammatory condition affecting the afferent limb), confirmed by biopsy results that revealed granulomas and ulcerations. **Presenting Issue:** The patient is experiencing worsening abdominal symptoms occurring after meals and has been diagnosed with segments of the bowel that are narrowed and decompressed, as indicated by a CT scan. **Chronological Events:** * **December 2024:** A CT scan of the abdomen and pelvis without contrast revealed a 7-centimeter segment near the pouch inlet, which was narrow and decompressing, accompanied by upstream dilation. Notably, a pouchoscopy performed in November did not show any narrowing. * **Early 2025:** Biopsy results indicated severe active ileitis characterized by ulceration and granulomas in the afferent limb, while the pouch exhibited signs of chronic active enteritis. * **May 2025:** During pouchoscopy, significant ulceration and inflammation were observed. The patient's previous medication, Skyrizi, was stopped after more than eight months due to ineffective results, and a new course involving Entyvio and a temporary regimen of budesonide was initiated. Despite this, the narrowing remained undetected during the pouchoscopy. * **June 2025:** A follow-up CT scan with contrast validated the previously identified 7-centimeter segment and additionally noted a second narrowed segment of approximately 5 centimeters at the site of ileostomy takedown. * **June 2025:** Manometry testing was carried out to investigate 18 months of sporadic nighttime leakage, leading to the assumption that the pouch might not be fully evacuated; pelvic floor physical therapy was started. **Symptoms Experienced:** * Regular abdominal bloating and discomfort * Noticeable swelling above the navel after eating * Sounds of gurgling when food passes through * Recent decline in appetite * These symptoms have notably developed since the fall of 2025 and were absent in prior years. **Treatment Plan (per gastrointestinal physician and colorectal surgeon):** * Await a period of three months to evaluate the effectiveness of Entyvio before scheduling another scope examination. * Surgical options are currently deemed too risky because of the location of the narrowing and the potential threat to the function of the pouch. **Inquiries:** 1. Is a waiting period of 2-3 months for the Entyvio treatment a rational approach before contemplating surgical solutions, considering the anatomical alterations and symptom aggravation? 2. Do the CT findings suggest the possibility of functional narrowing or a mechanical stricture that may not be directly associated with Crohn's-related inflammation? 3. After waiting for three months and considering that scopes haven't illuminated any narrowing, could alternative imaging techniques such as MR enterography clarify the condition of these bowel segments? 4. Are there less invasive surgical options, like stricturoplasty or laparoscopic examinations, that might be viable prior to a complete resection or pouch revision? What are the associated risks of such procedures? I appreciate any insights you can provide as I aim to confirm the appropriateness of my ongoing treatment strategy and avoid any delays in necessary intervention that could negatively impact my long-term prognosis. Preserving my J-pouch remains a top priority for me.
Answers (1)
6/27/2025, 4:20:53 PM
OpenHealth AI
Thank you for providing a detailed overview of your situation. It’s understandable that you’re seeking clarity and reassurance regarding your ongoing treatment. Your current condition involves complex considerations, and I will address your inquiries based on available medical insights.
Key Points
- Waiting Period for Entyvio: A wait of 2-3 months can be reasonable to assess the effectiveness of Entyvio before considering more invasive options, but this should be closely monitored.
- Type of Narrowing: The CT findings may indicate both functional narrowing due to inflammation and potential mechanical stricture.
- Imaging Techniques: MR enterography can provide a clearer picture of your bowel segments, especially if scopes have not shown narrowing.
- Surgical Options: Less invasive procedures like stricturoplasty could be options, but they carry their own risks and considerations.
Detailed Explanation
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Waiting Period for Entyvio Treatment:
- Rationale: It's common in chronic conditions to allow time for biologic treatments like Entyvio to take effect, typically around 3 months. This period allows for the drug to reduce inflammation and potentially improve symptoms.
- Next Steps: During this waiting period, maintain close communication with your healthcare team to monitor any changes in symptoms, particularly if they worsen.
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CT Findings - Functional vs. Mechanical Narrowing:
- Functional Narrowing: This could arise from inflammation associated with Crohn's disease leading to bowel spasms or edema, resulting in narrowing.
- Mechanical Stricture: If scar tissue has formed, this could lead to persistent narrowing. It’s essential to differentiate between the two types.
- Next Steps: Share your concerns about symptom changes with your doctor, as they may consider further interventions based on these insights.
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Alternative Imaging Techniques:
- MR Enterography: This imaging technique can provide a detailed view of the intestines and may help identify areas of inflammation, strictures, and obstruction that may not be visible through other methods.
- Next Steps: Discuss the possibility of scheduling an MR enterography with your physician after the 3-month period, especially if symptoms do not improve.
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Less Invasive Surgical Options:
- Stricturoplasty: This procedure can widen narrowed segments of the bowel without full resection, preserving bowel length and function. However, it may carry risks such as recurrence of stricture or infection.
- Laparoscopic Examination: This minimally invasive option can allow for better visualization and possibly intervention without a full open surgery.
- Next Steps: Engage your surgical team about the risks and benefits of these options if symptoms do not improve, and express your priority of preserving your J-pouch.
Conclusion
Maintaining regular follow-ups with your healthcare providers and open communication about symptom changes is crucial during this treatment phase. Your priority of preserving your J-pouch is important, and careful monitoring and exploration of all available options will be vital in advancing your care strategy. If symptoms persist or worsen, do not hesitate to advocate for further investigations or interventions.
If you have any more questions or need further clarification on any option, let me know!
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