Crohn’s disease hub
Monitoring Crohn’s Over Time
Last Updated Nov 11, 2025
Treat-to-target is a plan that tracks Crohn’s using symptoms, simple tests, and pictures of the bowel. The short-term goal is to quiet inflammation, the long-term goal is to heal the lining. This article outlines what to check and how often, including blood and stool tests, colonoscopy, and imaging for small bowel and perianal disease. Schedules are general and should be tailored.
Key Takeaways
Treat-to-target sets short-term goals (symptom relief and biomarker control) and long-term goals (healed bowel lining). (pubmed.ncbi.nlm.nih.gov)
In symptomatic remission, check C‑reactive protein (CRP) and fecal calprotectin every 6 to 12 months. With rising symptoms, check every 2 to 4 months. (gastro.org)
If fecal calprotectin is under 150 µg/g and CRP is normal, routine endoscopy can often be deferred, but this is less reliable in isolated ileal disease. (gastro.org)
After starting or changing therapy, confirm healing with colonoscopy 6 to 12 months later. Use magnetic resonance enterography or intestinal ultrasound for small bowel disease. (mdpi.com)
After surgery, most people need colonoscopy at 6 to 12 months. In low‑risk patients on prophylaxis, fecal calprotectin under 50 µg/g may avoid early scoping. (academic.oup.com)
How treat-to-target works in Crohn’s
Treat-to-target means testing on a schedule, not only when symptoms flare. The agreed targets are clinical remission (minimal pain and normal stool frequency), normalized blood and stool markers, and endoscopic healing. Transmural healing on imaging is considered an aspirational goal in Crohn’s. Time frames are weeks for symptom relief, months for biomarker control, and up to a year for mucosal healing. (pubmed.ncbi.nlm.nih.gov)
Why this matters: symptoms can be misleading. Quiet symptoms with high biomarkers often signal “silent” inflammation that raises the risk of strictures and fistulas. Regular checks help catch this early and guide timely adjustments. (pubmed.ncbi.nlm.nih.gov)
What to check and how often
The plan varies with disease phase, location, and recent treatments. The table shows common intervals used in guidelines and practice.
What to monitor | After starting or changing therapy | In stable symptomatic remission | Notes |
|---|---|---|---|
Symptoms and function (pain, stool frequency, urgency, fatigue) | Every 8–12 weeks until stable | Every 3–6 months | Use simple trackers at each visit. (mdpi.com) |
Blood tests: CRP, complete blood count, chemistries | Every 2–4 months while active | Every 6–12 months | CRP trends help, but some people do not mount CRP. (pubmed.ncbi.nlm.nih.gov) |
Stool test: fecal calprotectin (FCP) | Every 2–4 months while symptoms rise | Every 6–12 months if well | FCP <150 µg/g with normal CRP can avoid routine scope in selected patients. (pubmed.ncbi.nlm.nih.gov) |
Colonoscopy to confirm healing | 6–12 months after starting or intensifying therapy | Then as needed based on symptoms/biomarkers | Confirms mucosal healing, the long‑term target. (mdpi.com) |
Small bowel imaging (MRE or intestinal ultrasound) | 6–12 months to confirm response if ileal disease | Then as needed for relapse or discordant tests | IUS is increasingly used for routine monitoring. (pubmed.ncbi.nlm.nih.gov) |
Perianal disease imaging (pelvic MRI or endoanal ultrasound) | Reassess within 6 months after a treatment change | Then by symptoms and exam | Imaging detects “deep” healing beyond external closure. (academic.oup.com) |
Postoperative colonoscopy | 6–12 months after resection | Later based on findings and risk | Low‑risk on prophylaxis with FCP <50 µg/g may delay scoping. (academic.oup.com) |
Making sense of biomarkers
Fecal calprotectin reflects gut inflammation. In Crohn’s affecting the colon, it tracks well with endoscopic activity. In isolated ileal disease, it can be less sensitive, so pair it with imaging. Trends over time often matter more than one value. (pubmed.ncbi.nlm.nih.gov)
In symptomatic remission with a recent normal scope, FCP under 150 µg/g and CRP in the normal range can rule out active inflammation and help avoid routine endoscopy. If either is high, confirm with scoping before changing therapy. (pubmed.ncbi.nlm.nih.gov)
During symptom flares, checking CRP and FCP every 2 to 4 months can guide adjustments. Consider endoscopy or imaging before major treatment changes. (pubmed.ncbi.nlm.nih.gov)
Endoscopy and imaging: choosing the right tool
Colonoscopy remains the gold standard to confirm healing in the colon and terminal ileum. Many teams aim to document mucosal healing 6 to 12 months after starting or escalating therapy. For small bowel disease beyond reach of the scope, magnetic resonance enterography and intestinal ultrasound (IUS) provide noninvasive monitoring and can document transmural response. IUS is now highlighted as a first‑line, repeatable tool in updated multi‑society guidance. (mdpi.com)
Perianal Crohn’s requires combined clinical exam and imaging. Pelvic MRI is preferred to confirm deep fistula healing. After a treatment change, reimage within about 6 months. External closure can occur while internal tracts remain open, so imaging prevents premature treatment de‑escalation. (academic.oup.com)
When to act sooner
Escalate the plan, or reassess urgently, if any of the following occur:
Worsening pain, bleeding, fever, or weight loss.
Biomarkers rise on two checks, even if symptoms seem stable.
New perianal drainage or pain.
Postoperative patients with elevated FCP or abnormal imaging. (pubmed.ncbi.nlm.nih.gov)
FAQs
Do home fecal calprotectin tests fit into this plan
Yes, if quality is validated and the care team agrees. Home testing can support the 2–4 month checks during active disease and the 6–12 month checks in remission, with clinic follow-up for rising values. (pubmed.ncbi.nlm.nih.gov)
What if symptoms are quiet but tests are high
Trust the objective data. Elevated FCP or CRP in remission should prompt confirmation with endoscopy or imaging before therapy changes, because silent inflammation is common in Crohn’s. (pubmed.ncbi.nlm.nih.gov)