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.

Risk factors and prognostic value of acute severe lower gastrointestinal bleeding in Crohn’s disease

“…In the present study, patients with ileal disease at diagnosis had a higher risk of bleeding compared with those with colonic disease at diagnosis, although the result did not reach statistical significance. This is in line with the results of previous studies that ileal disease is a predictor of complicated behavior[ 25 ] and surgery[ 17 , 26 , 27 ], whereas colonic disease is a predictor of a milder disease course[ 17 , 28 ]. However, other studies reported contrasting results in that bleeding was more common in patients with colonic involvement than in those with isolated small bowel disease[ 2 , 29 ].…”

Epithelial Regeneration Ability of Crohn’s Disease Assessed Using Patient-Derived Intestinal Organoids

“…Mucosal healing can be regarded as epithelial regeneration after injury of the intestinal lining. Mucosal healing is considered a therapeutic target of IBD [ 26 ]. To improve mucosal healing in patients with CD, additional treatment options to promote epithelial regeneration and wound healing ability should be explored and developed.…”

Is Paradigm for the Role of Balloon-Assisted Enteroscopy Changing in Crohn’s Disease?

“… 1 As SBCD is often associated with poor clinical outcomes, such as complicated disease course, stricturing behavior, and CD-related surgery, early diagnosis and objective evaluation of small bowel lesions are essential. 2 However, the evaluation of SBCD is more difficult than that of colonic lesions because the diseased segment of most small bowel lesions is difficult to reach during conventional endoscopy, and may appear normal on a cross-sectional image. 2 , 3 Thus, the diagnosis of SBCD is challenging and often delayed.…”

“… 2 However, the evaluation of SBCD is more difficult than that of colonic lesions because the diseased segment of most small bowel lesions is difficult to reach during conventional endoscopy, and may appear normal on a cross-sectional image. 2 , 3 Thus, the diagnosis of SBCD is challenging and often delayed.…”

“… 7 In line with this concept, the importance of adequate evaluation of small bowel lesions has been emphasized. 2 As BAE has been accepted to be the most sensitive modality for visualization of small bowel lesions in CD, it may enable not only a more objective diagnosis but also close monitoring of SB lesions in patients with CD. Thus, recently published Japanese guidelines also stated that BAE may be useful for close observation and monitoring of SB lesions in CD.…”