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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.<\/jats:p>","DOI":"10.1177\/17562848261446459","type":"journal-article","created":{"date-parts":[[2026,5,5]],"date-time":"2026-05-05T08:58:57Z","timestamp":1777971537000},"update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":1,"title":["Phenotype-driven management in ileocecal Crohn\u2019s disease: a narrative review with a proposed research framework"],"prefix":"10.1177","volume":"19","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-7703-0932","authenticated-orcid":false,"given":"Chuong Dinh","family":"Nguyen","sequence":"first","affiliation":[{"name":"Department of Gastroenterology, University Medical Center Ho Chi Minh City, Ho Chi Minh City, Vietnam"},{"name":"Clinical Sciences (International Program), Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9295-4308","authenticated-orcid":false,"given":"Luan Minh","family":"Dang","sequence":"additional","affiliation":[{"name":"IBD Unit, Department of Gastroenterology, University Medical Center Ho Chi Minh City, 215 Hong Bang Street, Cho Lon Ward, Ho Chi Minh City 700000, Vietnam"},{"name":"Department of Internal Medicine and Gastro-Hepato Integrated Research Team (GHIRT-002.TCM2025), School of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thong Duy","family":"Vo","sequence":"additional","affiliation":[{"name":"Department of Gastroenterology, University Medical Center Ho Chi Minh City, Ho Chi Minh City, Vietnam"},{"name":"Department of Internal Medicine, School of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hoang Huu","family":"Bui","sequence":"additional","affiliation":[{"name":"Department of Gastroenterology, University Medical Center Ho Chi Minh City, Ho Chi Minh City, Vietnam"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Partha","family":"Pal","sequence":"additional","affiliation":[{"name":"AIG Hospitals, Banjara Hills, Hyderabad, Telangana, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Taku","family":"Kobayashi","sequence":"additional","affiliation":[{"name":"Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Byong Duk","family":"Ye","sequence":"additional","affiliation":[{"name":"Department of Gastroenterology and Inflammatory Bowel Disease Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"179","published-online":{"date-parts":[[2026,5,5]]},"reference":[{"key":"e_1_3_4_2_2","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(16)31711-1"},{"key":"e_1_3_4_3_2","doi-asserted-by":"publisher","DOI":"10.1038\/ajg.2009.579"},{"key":"e_1_3_4_4_2","doi-asserted-by":"publisher","DOI":"10.1097\/00000658-200001000-00006"},{"key":"e_1_3_4_5_2","doi-asserted-by":"publisher","DOI":"10.1055\/s-0041-1740031"},{"key":"e_1_3_4_6_2","article-title":"Surgery for Crohn\u2019s disease: upfront or last resort?","volume":"10","author":"Ahmed Ali U","year":"2022","unstructured":"Ahmed Ali U, Kiran RP. 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