How Do I Know If My IBD Is in Remission?

Clinical remission — when your symptoms subside, and you feel better most of the time — is only one type of remission. Other levels of remission represent deeper healing.

Everyone wants to feel well and stay well! If you have Crohn’s disease or ulcerative colitis, what you ultimately want is called remission. Remission means the inflammation that causes your inflammatory bowel disease (IBD) is under control and no longer causing symptoms or damage to your intestines.

How do you know you’ve arrived at remission? Well, it’s not as simple as just feeling better. Think of it like a staircase, with each descending step, or level, bringing more healing.

Keep in mind that remission is a progression. The levels following clinical remission often overlap and do not necessarily happen in this specific order.

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What are the levels of remission?

While we know IBD never completely goes away, with treatment it’s possible to achieve multiple levels of remission. Deeper levels of remission (endoscopic, histologic, and transmural) are associated with longer-lasting remission and lower rates of hospitalization and surgery.

Clinical remission

Clinical remission happens when your IBD symptoms, such as pain, diarrhea, and blood in the stool, go away. Extraintestinal symptoms such as fatigue, joint pain, and night sweats also tend to improve in clinical remission.

Clinical remission typically happens after starting treatment for IBD. This does not include feeling better after treatment with prednisone; that’s because prednisone is a short-term medication and cannot maintain clinical remission long-term.

Other medications, such as aminosalicylates, immunomodulators, and biologics, are used to treat IBD long-term. Dietary and lifestyle changes can also contribute to clinical remission.

Be patient if you’re not yet in clinical remission — it can take weeks or sometimes months for treatment to work, depending on your condition and medications. Your healthcare team can recommend a change to your treatment if you continue to have symptoms.

Once you feel well, you can be assured you’re headed in the right direction! However, feeling well does not always mean the inflammation and damage to your intestines is getting better. This is why the next three levels are equally important and need to be checked by your doctor gularly.

Biochemical remission

When lab tests that measure inflammation in the blood and stool are normal, you’ve achieved biochemical remission. C-reactive protein (CRP) and erythrocyte sedimentation rate (sed rate) are blood tests that measure general inflammation in the body. They can be elevated when IBD is active.

Fecal calprotectin is a stool test that can specifically measure inflammation in the intestines. Calprotectin is a protein found in white blood cells that are present in intestinal inflammation.

High levels of calprotectin can predict flares and active disease, and low levels are associated with deeper endoscopic and histological remission.

Since these biochemical tests are the least invasive and least costly tests available to monitor inflammation in IBD, they can be used more frequently and can help determine if further tests are needed.

Endoscopic remission

Endoscopic remission, sometimes called mucosal remission, means that there is no visible inflammation in the lining of the intestines.

To confirm this, a gastroenterologist performs an endoscopy or colonoscopy. During the procedure, the doctor uses a high-definition camera attached to a scope to visualize the lining, or mucosa, of the stomach or intestines.

If you’re in endoscopic remission, previous abnormalities like redness, ulcers, fissures, and other inflammatory changes to the bowel lining appear healed. This level of remission is ultimately the goal of treatment and, when combined with clinical and biochemical remission, is considered deep remission.

Histologic remission

During an endoscopy, the doctor takes biopsies from the lining of the intestines and sends them to a pathologist.

The pathologist examines the biopsies under a microscope; if they see little to no signs of inflammation, you’re in histologic remission, a deeper level than endoscopic.

It’s difficult to achieve and generally not a goal of treatment. However, some research suggests that people with ulcerative colitis in histologic remission have fewer relapses than people in endoscopic remission alone.

Transmural remission

The word transmural means “through the walls.” Transmural remission happens when all layers of the bowel wall have healed.

Often in Crohn’s disease, and sometimes in ulcerative colitis, the bowel wall can thicken due to inflammation. If the thickening is substantial, the intestines may become narrower. Inflammation can also cause abscesses and fistulas to develop through the layers of the bowel wall.

Imaging tests that measure bowel thickness can determine if transmural abnormalities have healed. These tests include magnetic resonance imaging (MRI), computerized tomography (CT) scans, and intestinal ultrasound. Intestinal ultrasound is a promising new way some doctors are testing for remission.

New research suggests that transmural remission in people with Crohn’s disease predicts even better outcomes (like fewer flares, hospitalizations, or surgeries) than endoscopic remission alone.

The takeaway

Remission in IBD is multifaceted. When you feel better you’re considered to be in clinical remission. Remission can progress to deeper levels such as endoscopic, histologic, and transmural remission. People who reach these levels tend to stay well longer and have fewer disease complications.

Although all aspects of remission should be monitored, endoscopic remission is currently the goal of treatment.