The availability of additional objective tools is transforming how we monitor Crohn’s disease (CD), moving beyond relying on symptoms alone to achieve more comprehensive, proactive care. This article explores how imaging, biomarkers, and future innovations are reshaping disease assessment and long-term treatment strategies for CD.

Years ago, monitoring and assessing CD activity were largely based on reported symptoms such as abdominal pain and diarrhea. As long as patients told us that they were feeling well, we imagined that all was well. However, we have learned over time that there is a dramatic disconnect between symptoms and the presence of inflammation, and it is the persistence of inflammation over time that determines the progression of disease. Therefore, while it is important to ask patients with CD about symptoms, we also need to evaluate them objectively.

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Historically, an ileocolonoscopy has been an important method for directly observing disease activity, but it is expensive and invasive, and, while it allows us to see inflammation firsthand and take biopsy samples, it does not reach much of the small bowel—and many patients with CD have more proximal disease. The use of capsule endoscopy has been a worthwhile addition, but one of the main limitations is that patients with CD may have strictures, which would increase the risk of capsule retention. Also, capsule endoscopy does not allow you to take biopsies and examine the histopathology, which is important when establishing a diagnosis of CD.

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The development of magnetic resonance enterography (MRE) has been extremely valuable because it allows us to accurately assess inflammation without ionizing radiation exposure. MRE can also show complications such as fistulas and strictures. More recently, some providers have started incorporating the use of intestinal ultrasound, which has the advantage of being a point-of-care examination that requires no bowel preparation and is relatively less expensive. This can allow you to track patients noninvasively over time. We also incorporate the following inflammatory biomarkers: CRP and fecal calprotectin. CRP somewhat correlates with the activity of bowel inflammation, but it is not highly sensitive or specific for CD or bowel inflammation. Fecal calprotectin is specific for bowel inflammation but has less sensitivity for disease confined to the small bowel.

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When thinking about assessing disease activity, we have come to rely on the strategy of using all these different modalities in concert so that we get the full picture and can track the disease over time. For diagnosis, we use ileocolonoscopy and biopsy, and I would recommend MRE as well, to get a relatively complete understanding of disease distribution and severity. When evaluating therapy over time, it is useful to get CRP levels in combination with fecal calprotectin levels. I would recommend that you get baseline levels so that you can track a patient’s levels over time and perhaps identify an increase in disease activity even without the presence of symptoms, since we believe that symptoms follow the presence of inflammation often by several months.

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In terms of the future, we know that artificial intelligence is rapidly making progress in interpreting imaging and permitting automated readings that will likely be highly accurate with less variance. This will probably become a part of our practice in just a few years. Beyond that, approaches such as multiomics profiling would give us a different way of monitoring the disease or even predicting response to treatment, so an improved precision medicine approach.