Probable Stricturing in Small Bowel Crohn Disease: In Support of SAR Consensus Recommendations

Crohn disease is a chronic immune-mediated gastrointestinal disorder affecting nearly 1 million people in the United States. Despite therapeutic advances, many patients do not achieve durable intestinal healing, and stricture-related complications, including internal penetrating disease, remain frequent. Disease often progresses radiologically from isolated active inflammation (characterized by bowel wall thickening), to associated luminal narrowing (i.e., > 50% diameter reduction), to associated upstream dilatation (i.e., overt stricture, with obstruction risk). The intermediate stage of wall thickening with luminal narrowing is associated with distinct biomarker profiles, microbial signatures, gene expression patterns, imaging features, and prognostic outcomes. Accordingly, consensus statements from the Society of Abdominal Radiology Inflammatory Bowel Disease Disease-Focused Panel indicate that patients with bowel wall thickening and fixed luminal narrowing without upstream dilatation should be considered to have probable strictures. Yet, current clinical classification systems do not fully incorporate this radiologic entity. For example, the Montreal and Paris classifications have historically classified patients with wall thickening and luminal narrowing as having the inflammatory rather than stricturing phenotype. This Perspective summarizes evidence supporting probable strictures as a distinct biologic and clinical entity that could aid individualized care and argues for integrating probable stricturing into radiology reports, clinical classification schemes, and treatment pathways.