Clinical–Biochemical Discordance in Fibrostenosing Crohn’s Disease:From Multiple Treatment Failures to Successful Surgical Management

Abstract

Fibrostenosing Crohn’s disease (CD) represents one of the most challenging phenotypes of the disease due to the coexistence of active inflammation and irreversible structural damage, which complicates therapeutic decision-making and may lead to discrepancies between clinical, biochemical, and imaging findings. Methods: We report the case of an 18-year-old female diagnosed with fibrostenosing ileocolonic Crohn’s disease (Montreal A2L3B2), managed with a step-up therapeutic strategy including corticosteroids, azathioprine, methotrexate, anti-TNF therapy, and subsequently a Janus kinase (JAK) inhibitor (Upadacitinib). Clinical, biochemical, and radiological outcomes were evaluated throughout follow-up. Results: Despite achieving normalization of inflammatory biomarkers while receiving Upadacitinib, the patient continued to experience recurrent obstructive abdominal symptoms. Magnetic resonance enterography revealed severe fibrotic stenosis of the terminal ileum with proximal bowel dilation, consistent with advanced fibrostenosing disease and clinical–biochemical discordance. Due to persistent symptoms and evidence of irreversible structural damage, a laparoscopic right hemicolectomy with ileocecal and terminal ileal resection was performed. Following surgery, the patient achieved sustained clinical and biochemical remission, with complete resolution of obstructive symptoms. Conclusion: This case highlights the importance of distinguishing active inflammatory disease from irreversible fibrostenotic damage in patients with Crohn’s disease. Persistent obstructive symptoms despite biochemical control of inflammation should prompt comprehensive structural assessment. Furthermore, it underscores the complementary role of surgery as an effective therapeutic strategy in patients with advanced fibrostenosing Crohn’s disease.