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Stricturing Crohn's disease — ESEGH MCQ

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HardInflammatory Bowel DiseaseStricturing Crohn's diseaseESEGH

A 44-year-old man with established Crohn's disease reports postprandial abdominal pain and bloating. Ileocolonoscopy cannot traverse a terminal ileal narrowing. CRP is 16 mg/L and faecal calprotectin is 210 micrograms/g. A routine contrast-enhanced CT abdomen shows a 6 cm segment of terminal ileal narrowing with mural thickening, but no mass, fistula or abscess. Which investigation would most appropriately characterise the stricture further and guide the choice between medical, endoscopic and surgical management?

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Correct answer: B — MR enterography with multiparametric mural assessment

MR enterography is the best answer. It characterises stricture length, severity of narrowing, upstream dilatation and occult penetrating complications while providing multiparametric features suggesting active inflammation, such as mural oedema and restricted diffusion, or predominant chronic fibrostenosis. These findings help an IBD multidisciplinary team judge the likely benefit of anti-inflammatory treatment versus endoscopic or surgical intervention. Imaging cannot precisely quantify histological fibrosis, and most Crohn's strictures contain mixed inflammatory and fibrotic elements. Capsule endoscopy without patency testing is unsafe because obstructive symptoms and failed ileal intubation indicate a substantial retention risk. Small-bowel follow-through depicts luminal anatomy but characterises mural and extramural disease poorly. FDG-PET/CT is not a routine stricture-characterisation test, and serum fibrosis-marker panels are not validated for clinical decision-making.

Reference: Dane B et al. SAR Consensus Recommendations for Defining Small Bowel Crohn Disease Strictures at CT and MR Enterography. Radiology. 2025;316(1):e243123. https://pubmed.ncbi.nlm.nih.gov/40662968/