Definition and Overview

Gastrointestinal (GI) anastomotic stricture (AS) refers to the narrowing of the surgical connection between two structures in the GI tract. To better understand this condition, it helps to define the terms.

  • GI tract - The GI tract consists of organs located between the mouth and the anus. These include the oesophagus, stomach, and the small and large intestines. The GI tract digests the food a person eats. It also absorbs nutrients and gets rid of waste (faeces).

  • Anastomosis - This refers to the surgical connection that joins two structures. It is made when a diseased part of the GI tract has to be removed, and the two remaining ends are reconnected. This is done to restore the normal flow of food or gastric juices in the GI tract.

  • Stricture - This term translates to the narrowing of a body passage.

The condition is serious. It can be fatal in some cases. It restricts the flow of food in the GI tract. It can also prevent faecal material from leaving the body. Thus, it causes build up behind the blockage. This can cause constipation and abdominal pain. It also increases the risk of infection in the GI tract.

The condition affects up to 13% of patients who have undergone gastric resections. It can occur a few days or weeks after surgery. However, in some cases, it develops several years after the operation.

Causes of Condition

It is not clear what causes the condition to occur. However, some factors are known to play a role. These include:

  • Scarring and inadequate blood supply to the connection.

  • Smoking and prolonged use of certain medications - These can cause the connection to develop tears or ulcers.

  • Certain diseases in the GI tract, such as stomach cancer.

  • Anastomotic leak (AL) - Many cases of AL leads to anastomotic stricture. It can occur when the new connection fails to heal fully. This causes the contents of the stomach to leak into surrounding tissue. AL is a serious condition that must be treated right away. Unless treated promptly, it can cause internal bleeding and fatal infections.

  • Tumours in the GI tract - Abnormal growths can compress the connection.

A small number of cases are attributed to the surgeon’s lack of experience and the use of poor surgical techniques.

Key Symptoms

The condition can cause a range of symptoms. This depends on the severity of the stricture. If the connection is only slightly narrowed, the symptoms are mild. This is because food and faeces are still able to pass through the GI tract. However, if the blockage is severe, it can cause chronic constipation and abdominal pain. Other signs include loss of appetite, fever, and diarrhoea. Vomiting and swelling of the abdomen are also very common.

If the connection is also leaking, patients will show other symptoms. These include signs of infection, such as rapid heart rate, low blood pressure, and decreased urine output. Drainage from the surgical wound is also common.

Patients who have an anastomosis are advised to look out for these signs. If they develop any of them, it is a must that they see their doctor right away. Prompt treatment is key to preventing complications.

Who to See and Types of Treatments Available

The condition is treated by gastroenterologists. These are doctors who specialise in the treatment of diseases of the digestive system. Tests used to diagnose the condition are:

  • Physical exam - This is used to check the patient for signs of the condition. The most common is a swollen abdomen. This occurs when faeces or food builds up behind the blockage.

  • Review of medical history - Patients are also asked about their medical history and symptoms. They must inform their doctor right away if they have an anastomosis. This can help doctors narrow down the cause of their symptoms faster.

  • Contrast study and imaging tests - Using these tests, doctors can confirm if the connection is blocked or has narrowed. They can also confirm if surrounding tissues or tumours are compressing it. This is important in choosing the best possible treatment option for the patient.

Treatment options include:

  • Endoscopic balloon dilation - This procedure is used to widen the narrowed connection. It is performed using an endoscope. This is a thin, flexible tube with a balloon on its tip. It is inserted into the GI tract through the mouth. It is then advanced to the narrowed connection. Once there, the balloon is inflated to make the connection wider. A stent may be left in place to keep it from narrowing again.

  • Surgery - Surgery becomes necessary if the condition is caused by tumours. The tumours can be removed with traditional or keyhole surgery depending on their size and location.

  • Reconstruction of the connection - If the problem occurs due to tissue death, surgeons may remove the connection entirely. They will then create another connection to rejoin the two remaining ends of the GI tract.

References:

  • Mahmoud NN, Bleier JIS, Aarons CB, Paulson EC, Shanmugan S, Fry RD. Colon and rectum. In: Townsend CM Jr., Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 20th ed. Philadelphia, PA: Elsevier; 2017:chap 51.

  • Rullier E, Laurent C, Garrelon L, et al. Risk factors for anastomotic leakage after resection of rectal cancer. Br J Surg. 1998;85:355–358.

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