I am 31. Should I choose biologics or surgery for Crohn’s?

Question

Hello doctor,

I am a 31-year-old woman with Crohn’s disease affecting my terminal ileum. I have been on corticosteroids with only a partial response. My most recent MRI (magnetic resonance imaging) enterography, performed a few months ago, showed thickening and stricturing in the ileum. My doctor has suggested starting either Azathioprine or Biologics.

Please tell me,

How do we balance the risks of long-term immunosuppression against the option of surgery?
Can dietary modifications or probiotics help in controlling symptoms when used alongside medications?

Kindly help.

Answer 1

Hello,

Welcome to icliniq.com.

I have read your query and can understand your concern.

In Crohn’s disease affecting the terminal ileum, especially when stricturing is present, treatment decisions usually depend on whether the disease is mainly inflammatory (swelling and ulceration that can respond to medication) or fibrotic (scar tissue narrowing the bowel, which medications cannot reverse).

Since you have already tried corticosteroids (glucocorticoids) with only partial benefit, the next step involves starting an immunosuppressive therapy such as Azathioprine (immunosuppressant, thiopurine) or moving directly to Biologics (targeted immunotherapy). These include anti-TNF agents (tumor necrosis factor inhibitors, like Infliximab and Adalimumab), anti-integrin therapies, or anti-IL-12/23 therapies (interleukin inhibitors), which have stronger evidence for maintaining remission and preventing complications.

The concern with long-term immunosuppression is mainly the increased risk of infections, rare malignancies, and the need for ongoing monitoring. However, for many patients, the benefits of controlling inflammation, preserving bowel function, and avoiding repeated use of corticosteroids outweigh those risks.

Surgery (ileocecal resection) is considered when strictures cause obstruction or medical therapy cannot adequately control inflammation. It is important to note that surgery is not a cure; Crohn’s disease can recur at the surgical margins. Therefore, combining surgery with medical therapy often provides the best long-term outcome.

Diet and lifestyle also play supportive roles. Certain patients benefit from low-residue diets when strictures are present, as this reduces the risk of obstruction. Exclusive or partial enteral nutrition may help control inflammation in some cases. Probiotics have not shown strong evidence for Crohn’s disease (they are more effective in conditions such as ulcerative colitis or pouchitis).

I suggest to maintain the following:

Maintaining good nutrition.
Avoiding smoking.
Managing stress remains an important adjunct to medical therapy.

Ultimately, your gastroenterologist will weigh disease severity, the characteristics of the stricture, and your personal preferences when deciding whether to initiate immunosuppressive or biologic therapy now, or to consider surgery sooner if narrowing is advanced.

I hope this helps.

Thank you.