Clinical management for small bowel of Crohn's disease in the treat-to-target era: now is the time to optimize treatment based on the dominant lesion

Abstract

A treat-to-target strategy, in which treatment is continuously adjusted according to the results of scheduled objective monitoring, is optimal for patients with Crohn's disease (CD) in the era of biologics. The small bowel is a common site of intractable CD, which may result from multiple strictures or expanding lesions. To improve the prognosis of patients with small bowel CD, lesions should be proactively monitored within the subclinical phase. Objective assessment of small bowel lesions is technically difficult, however, due to the relatively poor correlation between endoscopic activity and clinical symptoms or biomarker titers. The presence of proximal small bowel lesions and asymptomatic "Real Silent CD" must be considered. Endoscopy remains the gold standard to assess these lesions. In clinical practice, the advantages and disadvantages of each imaging modality and biomarker must be carefully weighed for appropriate application and reliable monitoring. The prevalence of small bowel lesions depends on the precision of the imaging modality used for detection. Clinical management should be based on the dominant location of the intestinal lesions rather than classical classification. Optimal strategies for detecting and treating small bowel lesions in patients with CD must be developed utilizing reliable, precise, and objective monitoring.

Keywords: Crohn disease; Dominant; Silent Crohn’s disease; Small bowel; Treat-to-target.

Fig. 1.

Flowchart of the diagnostic strategy for achieving a definite diagnosis in difficult cases of patients with suspected Crohn’s disease (CD). MR, magnetic resonance; CT, computed tomography; IBS, irritable bowel syndrome; DBE, double balloon enteroscopy; SBE, single balloon enteroscopy; IBDU, inflammatory bowel disease unclassified. Modified from Watanabe K, et al. Nihon Shokakibyo Gakkai Zasshi 2015;112:1259-1269, with permission from the Japanese Society of Gastroenterology [12].