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Histology in CD
Interactive Case Challenge 3: Evolving Role of Histology in Crohn’s Disease Management 

Released: March 18, 2025

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Case History and Presentation  


Dan Smith is a 40-year-old man with a 15-year history of CD. He was diagnosed with CD at age 25 and his Montreal classification is L1 (disease location: terminal ileum). 


He presents for a follow-up visit with ongoing moderate to severe symptoms of CD. Mr Smith has experienced intermittent flares and poor symptom control. He reports abdominal pain, fatigue, and 4-5 loose stools daily. His weight has been stable. A recent colonoscopy showed mucosal inflammation and ulceration in the terminal ileum, with an SES-CD of 10. 


Mr Smith is currently receiving azathioprine 150 mg/day and adalimumab 40 mg every 2 weeks (on therapy for 2 years). Histology shows crypt architectural distortion, basal plasmacytosis, and focal active inflammation with neutrophilic infiltration.  


Vitals: blood pressure 120/76 mm Hg, heart rate 74 beats/min, BMI 23 kg/m² 


Laboratory results: 





    • CRP: 12 mg/L  

    • Fecal calprotectin: 350 µg/g  

    • Hemoglobin: 13.2 g/dL  

    • Albumin: 4.1 g/dL  

    • Liver function tests: normal 

    • White blood cell count: 6.8 x 109/L  

    • Trough adalimumab level: 3.4 mcg/mL  



What is the next step in the management of this patient based on histologic findings?