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Noninvasive Imaging in CD

CE / CME

Interactive Case Challenge 2: Integrating Noninvasive Imaging in Crohn’s Disease Management 

Physician Assistants/Physician Associates: 0.50 AAPA Category 1 CME credit

Nurse Practitioners/Nurses: 0.50 Nursing contact hour

Physicians: maximum of 0.50 AMA PRA Category 1 Credit™

ABIM MOC: maximum of 0.50 Medical Knowledge MOC point

Released: March 20, 2025

Expiration: March 19, 2026

Marla Dubinsky
Marla Dubinsky, MD
CME/CE Information

Activity

Progress
1 2
Course Completed

Case Conclusion
Mr Burns has shown a partial but meaningful response to infliximab intensification, with reduced abdominal pain, diarrhea, and fatigue, though intermittent bloating and occasional constipation persist. His ileocolonoscopy findings indicate healing but not complete resolution, with mild ileocecal narrowing and fewer than five ulcers in the distal ileum, and biomarkers have improved (CRP 5 mg/L, fecal calprotectin 275 μg/g). Given these findings, continued infliximab at 10 mg/kg every 4 weeks with close symptom and biomarker monitoring is recommended, with repeat imaging or endoscopy if symptoms worsen or fail to improve further. If residual inflammation persists, additional therapeutic adjustments, including dual therapy or a biologic switch, may be considered. With proactive disease monitoring and a treat-to-target approach, Mr Burns has a strong potential for achieving deep remission and long-term disease control. 

 

Discussion  

Key Learning Points 

  • Role of noninvasive imaging: Cross-sectional imaging (MRE, CTE, and intestinal ultrasound) are noninvasive imaging tools that provide comprehensive evaluation of transmural disease and extramural complications, complementing traditional endoscopic findings. 
  • Biomarkers as adjuncts: CRP and fecal calprotectin are valuable inflammatory biomarkers and intermediate-term targets that can be used to optimize therapy before an endoscopic target is reached.  
  • Integrated approach to treat-to-target strategy: Combining imaging modalities with clinical, biomarker, and endoscopic data supports personalized therapy adjustments aimed at achieving sustained transmural and mucosal healing.1 

Discussion Summary: Integrating Noninvasive Imaging in CD Management
This case underscores the importance of noninvasive imaging within a treat-to-target framework for managing CD, aligning with the 2019 European Crohn’s and Colitis Organisation (ECCO) and European Society of Gastrointestinal and Abdominal Radiology’s (ESGAR’s) guidelines.1 A 35-year-old man with a 10-year history of CD presented with worsening abdominal pain, intermittent bloating, fatigue, and elevated inflammatory biomarkers (CRP 12 mg/L, fecal calprotectin 450 μg/g) despite ongoing infliximab and azathioprine therapy. 

MRE revealed significant transmural inflammation and mild narrowing in the terminal ileum, correlating with clinical and biomarker findings. Following infliximab dose intensification, repeat MRE demonstrated reduced bowel wall thickening and resolution of active inflammation, alongside biomarker improvements (CRP 5 mg/L, fecal calprotectin 275 μg/g). These findings reflect a partial response to treatment, supporting the need for ongoing monitoring and potential therapy optimization. 

The ECCO/ESGAR guidelines emphasize the integration of cross-sectional imaging (MRE, CTE, and intestinal ultrasound) into routine disease assessment, highlighting their roles in evaluating transmural healing and detecting extramural complications (fistulas, strictures, abscesses). Although ileocolonoscopy remains the gold standard for assessing mucosal healing, noninvasive imaging reduces the need for frequent invasive procedures, improving patient-centered care.1 

According to STRIDE-II and the ECCO/ESGAR recommendations, endoscopic remission remains the primary treatment goal to prevent disease progression, although transmural healing is an emerging long-term target. A multimodal approach that includes clinical, biomarker, endoscopic, and imaging assessment is crucial for optimizing outcomes. The integration of noninvasive imaging into routine monitoring allows for early detection of subclinical disease activity, enabling proactive therapy adjustments and minimizing long-term complications.1,2 

After this program, how often do you plan to use noninvasive imaging such as cross-sectional small bowel imaging to monitor treatment response for patients with CD?