The Role of Regular Hegar Dilations for Severe Primary Low Rectal Strictures: A Case Report

Abstract

Approximately 50% of patients with Crohn's disease (CD) develop fibro-stenosis in their lifetime, requiring endoscopic balloon dilation (EBD) or, in severe cases, stricturoplasty and/or bowel resection. The National Institute for Health and Care Excellence (NICE) guidelines recommend EBD for patients with a single stricture that is short, straight, and accessible by colonoscopy. However, despite a very good technical and clinical success rate, up to 52% of patients post-EBD require repeat dilation and 30% will eventually require surgery at the 12-month post-initial EBD mark. We describe a 61-year-old CD patient with a severe low rectal stricture (located 62mm above the anal verge, with a luminal diameter of 6mm and total stricture length of 55mm) causing incomplete bowel evacuation, abdominal and rectal pain, and weight loss. EBD was attempted twice but failed to provide adequate or lasting symptomatic relief. The patient underwent three sessions of Hegar dilation under general anaesthesia over 6 months, progressively dilating the stricture to a diameter of 18mm. These dilations, coupled with medical management of his CD with Infliximab and Upadacitinib, resulted in complete symptomatic relief. This case suggests the use of Hegar dilation as a safe, cheap, and effective alternative for managing primary benign low rectal strictures in order to increase the surgery-free interval for patients with CD.