Phenotype-driven management in ileocecal Crohn's disease: a narrative review with a proposed research framework

The management of localized ileocecal Crohn's disease (CD) requires balancing escalation of medical therapy against early surgical resection. While clinical phenotyping guides initial management, standard assessments often fail to distinguish reversible inflammation from irreversible fibrosis. This limitation remains a major barrier to personalized care. This narrative review aims to review current evidence on clinical features, imaging modalities, and biomarkers relevant to intestinal fibrosis and to propose a phenotype-driven framework for treatment selection in localized ileocecal CD. To address this, we synthesized current literature on intestinal fibrogenesis, cross-sectional imaging (magnetization transfer MRI (MT-MRI), shear wave elastography (SWE)), and therapeutic outcomes. Evidence was integrated to develop a conceptual algorithm incorporating disease phenotype, quantitative imaging markers, and multidisciplinary decision-making. The proposed two-tiered framework begins with the Montreal classification (Tier 1). B1 phenotypes are directed toward early intensive treat-to-target medical strategies, while B3 phenotypes may require individualized surgical management, sometimes preceded by short-term medical optimization depending on complication severity. For the challenging B2 phenotype, we propose a precision medicine pathway (Tier 2) utilizing quantitative imaging, such as MT-MRI or SWE. This pathway is intended to help stratify B2 strictures into fibrosis-dominant, inflammation-dominant, or indeterminate phenotypes within a multidisciplinary decision-making process. A phenotype-driven approach incorporating clinical and imaging information may help inform therapeutic decision-making across the spectrum of ileocecal CD, particularly in the management of stricturing disease. The proposed framework provides a roadmap for prospective validation and future clinical trials aimed at optimizing treatment selection in stricturing disease.