ECCO 2026,Stockholm, Sweden

Patients with long-standing Inflammatory Bowel Disease (IBD) , particularly Ulcerative colitis and colonic Crohn's disease , are at increased risk of developing Colorectal dysplasia , a precursor to Colorectal cancer . Histologically, dysplasia in IBD is broadly categorised into conventional dysplasia and non-conventional dysplasia , each with distinct morphological characteristics and clinical implications. Conventional dysplasia is the most common type encountered in IBD surveillance biopsies. It resembles the dysplasia seen in sporadic colorectal adenomas and is classified as low-grade or high-grade dysplasia based on architectural and cytological abnormalities. Histologic features include elongated hyperchromatic nuclei, loss of nuclear polarity, increased mitotic activity, glandular crowding, and epithelial stratification . Conventional dysplasia may present endoscopically as visible lesions or be detected incidentally on random biopsies during surveillance colonoscopy. In contrast, non-conventional dysplasia encompasses several less common histological patterns that differ from the classical adenoma-like morphology. These include serrated dysplasia, hypermucinous dysplasia, crypt cell dysplasia, goblet cell–deficient dysplasia, and sessile serrated–like lesions . These variants may have subtle or atypical microscopic features, making them more difficult to recognise and potentially leading to underdiagnosis. Recent studies have highlighted that certain forms of non-conventional dysplasia may carry a higher risk of progression to advanced neoplasia compared with conventional dysplasia. Therefore, accurate histological recognition is crucial for appropriate clinical management. In clinical practice, detection of dysplasia typically prompts close surveillance, endoscopic resection of visible lesions, or surgical management in selected cases . Increasing use of advanced endoscopic techniques, such as chromoendoscopy , has improved the detection of dysplastic lesions in IBD patients undergoing surveillance. Overall, awareness of both conventional and non-conventional dysplasia patterns is essential for pathologists and clinicians to ensure early detection and effective prevention of colorectal cancer in patients with IBD.

Artificial Intelligence (AI) is rapidly transforming the diagnosis, monitoring, and management of Inflammatory Bowel Disease (IBD) , including Crohn's disease and Ulcerative colitis . With the growing availability of large clinical datasets, imaging libraries, and digital pathology platforms, AI tools are increasingly being integrated into routine IBD care. One of the most promising applications of AI is in endoscopy . AI-assisted systems can automatically detect mucosal abnormalities, quantify disease severity, and identify subtle inflammatory changes during colonoscopy. These tools help improve diagnostic accuracy and reduce interobserver variability among endoscopists. AI algorithms are also being developed to assist in the detection of dysplasia during surveillance colonoscopy , which is critical for cancer prevention in long-standing IBD. AI is also advancing the field of digital pathology . Machine learning models can analyze histological slides to quantify inflammatory activity, identify dysplasia, and standardize histological scoring systems. This may improve reproducibility and reduce variability in histopathological assessment. Another important application is in predictive analytics . AI models can integrate clinical data, biomarkers, imaging findings, and genetic information to predict disease course, treatment response, and risk of complications. Such tools may help clinicians personalize therapy and select the most appropriate treatment strategy for individual patients. AI is further being used to analyze radiological imaging and intestinal ultrasound, assisting in automated assessment of bowel wall thickness, inflammation, and complications. Despite its promise, challenges remain, including the need for high-quality datasets, validation across diverse populations, and integration into clinical workflows. Nevertheless, AI is clearly entering a new phase in IBD care, offering opportunities to enhance diagnostic precision, improve treatment decisions, and support personalized medicine in the management of IBD.

Strictures are a common complication of Crohn's disease , resulting from chronic, transmural inflammation of the intestinal wall that leads to progressive fibrosis and luminal narrowing. Histologically, Crohn’s strictures reflect a complex interplay between ongoing inflammation, tissue remodelling, and fibrogenesis . In the early stages, strictures often demonstrate active inflammatory changes , including dense infiltration of lymphocytes, plasma cells, and macrophages within the mucosa and submucosa. Neutrophilic activity may be present in areas of acute inflammation, along with mucosal ulceration and crypt distortion. As the disease progresses, transmural inflammation extends through the entire bowel wall, involving the muscularis propria and serosa. A hallmark of Crohn’s strictures is the development of fibrosis , characterised by excessive deposition of extracellular matrix proteins such as collagen. This process is driven by activation of fibroblasts and myofibroblasts, stimulated by pro-fibrotic cytokines including transforming growth factor-β (TGF-β). Histologically, this leads to submucosal fibrosis, thickening of the muscularis propria, and hypertrophy of smooth muscle layers , contributing to progressive luminal narrowing. Additional pathological features include neural hyperplasia, lymphoid aggregates, and mesenteric fat wrapping (“creeping fat”) , reflecting chronic immune activation and structural remodelling. Over time, strictures may evolve into predominantly fibrotic lesions with minimal active inflammation. Clinically, differentiating inflammatory versus fibrotic strictures is important because inflammatory strictures may respond to medical therapy, whereas fibrotic strictures often require endoscopic dilation or surgical intervention. Understanding the pathological mechanisms underlying Crohn’s strictures is crucial for developing anti-fibrotic therapeutic strategies , an area of growing research interest aimed at preventing long-term structural damage in Crohn’s disease.

In vivo histology refers to advanced endoscopic techniques that allow real-time microscopic visualisation of the intestinal mucosa during endoscopy , enabling assessment of cellular and vascular structures without the need for immediate tissue biopsy. This concept is increasingly relevant in the management of Inflammatory Bowel Disease (IBD) , particularly Ulcerative colitis and colonic Crohn's disease , where accurate evaluation of mucosal inflammation and dysplasia is essential. Several advanced imaging modalities enable in vivo histology. Confocal Laser Endomicroscopy (CLE) provides high-resolution images of the mucosa at nearly cellular magnification after administration of fluorescent contrast agents. CLE allows visualisation of crypt architecture, epithelial integrity, and inflammatory cell infiltration, helping identify microscopic inflammation and early neoplastic changes. Another technique, Endocytoscopy , offers ultra-high magnification imaging that can directly visualise cellular details such as nuclei and goblet cells. This technique can help differentiate inflammatory changes from dysplasia during endoscopic examination. In vivo histology has several clinical applications in IBD , including the detection of microscopic inflammation, the evaluation of mucosal healing, and the identification of dysplasia during surveillance colonoscopy. It may also reduce the need for multiple random biopsies by enabling targeted sampling of suspicious areas. However, there are limitations . These techniques require specialised equipment, additional training, and may increase procedure time. Interpretation can also be operator-dependent, and standardised diagnostic criteria are still evolving. Overall, in vivo histology represents a promising advancement in endoscopic imaging, bringing endoscopy closer to “optical biopsy.” As technology and expertise improve, it may play an increasing role in precision diagnosis and surveillance in IBD management.

Histopathological assessment has become an increasingly important endpoint in Inflammatory Bowel Disease (IBD) , particularly in Ulcerative colitis , where histologic remission is now recognised as a predictor of improved clinical outcomes, including lower relapse rates and reduced risk of hospitalisation or surgery. ( The Belgian Society of Pathology ) Over the last decade, several standardised histological scoring systems have been developed to quantify microscopic inflammation. The three most widely used and validated indices are the Geboes Score , Robarts Histopathology Index (RHI) , and Nancy Index (NI) . These scoring systems evaluate features such as chronic inflammatory infiltrate, neutrophilic activity, epithelial damage, and ulceration to assess the degree of mucosal inflammation. ( Wjgnet ) The Nancy Index is a relatively simple scoring system based on three histological components—chronic inflammation, acute inflammation, and ulceration—graded from 0 to 4, making it easier to apply in routine practice. ( PMC ) In contrast, the Robarts Histopathology Index provides a broader quantitative assessment of histologic activity and may offer greater sensitivity to changes during treatment. ( SRS Journal ) Recent comparative studies have demonstrated that the Geboes Score, RHI, and Nancy Index all show good reliability and responsiveness to changes in disease activity , although the Geboes Score and RHI may perform slightly better in detecting treatment-related improvement in clinical trials. ( OUP Academic ) Despite these advances, challenges remain. Routine clinical adoption is limited by interobserver variability, complexity of scoring systems, and lack of universal reporting standards . ( SRS Journal ) Additionally, standardised histologic scoring in Crohn's disease remains difficult because of the patchy and transmural nature of the disease. ( MDPI ) Future directions include simplified scoring systems, integration with endoscopic and biomarker endpoints, and the use of digital pathology and artificial intelligence to improve reproducibility. These developments are expected to further establish histologic remission as a key therapeutic target in modern IBD management.

Diagnosing Inflammatory Bowel Disease (IBD) in children can be particularly challenging due to the overlap of symptoms with several other gastrointestinal and systemic conditions . Pediatric patients with suspected Crohn's disease or Ulcerative colitis may present with nonspecific symptoms such as chronic diarrhoea, abdominal pain, weight loss, fatigue, and growth failure. These features can also be seen in infections, food intolerances, functional gastrointestinal disorders, or other inflammatory conditions, making early diagnosis difficult. An additional complexity in pediatric patients is the variation in disease presentation . Children often show extraintestinal manifestations such as delayed puberty, anaemia, or poor linear growth before classic gastrointestinal symptoms appear. These atypical presentations may delay recognition of underlying IBD. Accurate diagnosis requires a comprehensive and multidisciplinary approach . Initial evaluation typically includes laboratory markers of inflammation, stool tests to exclude infections, and imaging studies. Ileocolonoscopy with biopsy remains the cornerstone of diagnosis , allowing direct visualisation of mucosal inflammation and histological confirmation. In addition, cross-sectional imaging such as Magnetic Resonance Enterography is valuable for assessing small bowel involvement and complications. Another challenge is distinguishing IBD from other conditions, such as infectious enterocolitis, celiac disease, intestinal tuberculosis, or primary immunodeficiency disorders , which may present with similar clinical and histological features. Because of these complexities, optimal care requires collaboration among pediatric gastroenterologists, radiologists, pathologists, nutritionists, and paediatricians . Early recognition and accurate diagnosis are crucial to initiate appropriate therapy, prevent growth impairment, and improve long-term outcomes in pediatric IBD patients.

Patients with Inflammatory Bowel Disease (IBD) , including Ulcerative colitis and Crohn's disease , are at increased risk of superinfections due to chronic intestinal inflammation, mucosal barrier disruption, and the frequent use of immunosuppressive therapies. These infections can mimic disease flares and significantly influence disease course and treatment decisions. One of the most important superinfections in IBD is Clostridioides difficile infection , which can occur even in the absence of prior antibiotic exposure. It often presents with worsening diarrhoea, abdominal pain, and systemic symptoms, and should always be considered when patients experience an acute flare. Early testing and prompt treatment are essential to prevent complications. Another significant pathogen is Cytomegalovirus colitis , particularly in patients with severe or steroid-refractory ulcerative colitis. CMV infection can exacerbate mucosal inflammation and lead to poor response to conventional therapies. Diagnosis typically requires endoscopic biopsy with histology or PCR-based detection. Other infections that may complicate IBD include bacterial enteric infections (such as Salmonella or Campylobacter), parasitic infections , and opportunistic pathogens associated with immunosuppressive therapy. These infections may present with symptoms similar to active IBD, making differentiation challenging. Accurate diagnosis requires a combination of stool studies, endoscopic evaluation, and histological examination . Identifying superinfection is crucial because management differs from standard IBD flare treatment and may require antimicrobial or antiviral therapy. In summary, clinicians should maintain a high index of suspicion for superinfections in patients with worsening symptoms of IBD, especially those receiving corticosteroids, immunomodulators, or biologic therapies. Early recognition and appropriate treatment are key to improving patient outcomes and avoiding unnecessary escalation of immunosuppressive therapy.

Pouchitis is an inflammatory condition affecting the ileal pouch created after Ileal pouch–anal anastomosis (IPAA) , most commonly performed for patients with Ulcerative colitis . Histological examination of pouch biopsies provides important insights into the underlying inflammatory processes and helps differentiate pouchitis from other pouch disorders. On microscopic evaluation, acute pouchitis is characterised by neutrophilic infiltration of the lamina propria and epithelium , often with cryptitis and crypt abscess formation . Surface epithelial damage, mucosal oedema, and ulceration may also be present. In contrast, chronic pouchitis demonstrates architectural distortion of crypts, villous atrophy, increased lymphoplasmacytic infiltration, and basal plasmacytosis , reflecting persistent mucosal injury. Advanced histological studies have shown alterations in mucosal immune responses , including increased infiltration of T lymphocytes, macrophages, and dendritic cells. Upregulation of pro-inflammatory cytokines such as tumour necrosis factor (TNF), interleukin-1β, and interleukin-6 contributes to sustained inflammation. Changes in epithelial barrier function and dysbiosis of the pouch microbiota also play significant roles in disease pathogenesis. In some patients, histology may reveal features suggestive of Crohn's disease–like pouch complications , including granulomas, deep fissuring ulcers, or transmural inflammation. These findings raise the possibility of Crohn’s disease of the pouch rather than simple pouchitis. Advanced diagnostic approaches, including immunohistochemistry and molecular profiling , are increasingly being explored to better characterise inflammatory pathways and differentiate various pouch-related disorders. Such insights may help guide targeted therapeutic strategies in patients with refractory pouchitis.

Terminal ileitis refers to inflammation of the terminal ileum , and histological examination plays a critical role in differentiating underlying etiologies. In the context of Crohn's disease , the characteristic histologic features include focal, patchy transmural inflammation , often with discontinuous involvement of the intestinal wall. The mucosa may demonstrate architectural distortion of crypts, focal cryptitis, and crypt abscesses , accompanied by infiltration of lymphocytes and plasma cells in the lamina propria. A key diagnostic feature is the presence of non-caseating granulomas , although these are identified in only a subset of cases. Additional findings include lymphoid aggregates, mucosal ulceration, and fissuring ulcers extending deep into the bowel wall. Chronic disease may also show submucosal fibrosis, muscular hypertrophy, and neural hyperplasia , reflecting long-standing inflammation and tissue remodeling. Infectious causes of terminal ileitis may show different histological patterns. For example, intestinal tuberculosis often demonstrates caseating granulomas with central necrosis , whereas bacterial infections may show acute neutrophilic infiltration with mucosal erosions. Advanced histological techniques, including immunohistochemistry and molecular assays , can further characterize immune cell populations and inflammatory pathways involved in ileal inflammation. These approaches help distinguish Crohn’s disease from other causes of terminal ileitis and contribute to a more precise understanding of disease pathogenesis.

Patients with Inflammatory Bowel Disease (IBD) , including Ulcerative colitis and Crohn's disease , have an increased risk of certain malignancies, primarily due to chronic intestinal inflammation, disease duration, and long-term immunosuppressive therapy . The most well-recognised cancer associated with IBD is Colorectal cancer , particularly in patients with extensive colitis and long-standing disease. The risk of colorectal cancer generally increases after 8–10 years of disease duration , especially in individuals with pancolitis, persistent inflammation, or a family history of colorectal cancer. Patients with concomitant Primary sclerosing cholangitis have an even higher risk and require more intensive surveillance. Regular endoscopic surveillance with targeted biopsies or chromoendoscopy is therefore recommended to detect dysplasia at an early stage. Apart from colorectal cancer, patients with IBD may also have an increased risk of small bowel adenocarcinoma, lymphoma, and certain skin cancers . Some of these risks are influenced by the use of immunosuppressive therapies such as thiopurines or biologic agents. For example, long-term thiopurine therapy has been associated with an increased risk of lymphoma and non-melanoma skin cancers, although the absolute risk remains relatively low. Despite these concerns, modern IBD management aims to balance the potential risks of therapy with the benefits of adequate disease control . Persistent uncontrolled inflammation itself is a major driver of carcinogenesis. Therefore, effective treatment strategies that achieve mucosal healing may ultimately reduce cancer risk. Preventive strategies include regular colonoscopic surveillance, careful selection and monitoring of immunosuppressive therapies, sun protection, dermatologic screening, and vaccination programs . Risk stratification based on disease extent, duration, and individual patient factors helps guide surveillance intervals. In summary, malignancy remains an important long-term complication of IBD, but with appropriate surveillance and modern therapeutic approaches, early detection and risk reduction are increasingly achievable in routine clinical practice.

Management strategies for Inflammatory Bowel Disease (IBD) , including Crohn's disease and Ulcerative colitis , vary considerably across different regions of the world. These variations arise from differences in healthcare infrastructure, availability of advanced therapies, economic resources, epidemiology, and clinical practice guidelines. In Western countries, particularly Europe and North America, IBD care often follows a treat-to-target strategy , with early use of biologic therapies, therapeutic drug monitoring, and regular assessment using endoscopy or cross-sectional imaging. Multidisciplinary IBD centres with access to gastroenterologists, colorectal surgeons, radiologists, dietitians, and IBD nurse specialists are commonly available. Advanced diagnostic tools such as intestinal ultrasound, MRI, and faecal biomarkers are frequently used for disease monitoring. In contrast, many developing regions—including parts of Asia, Africa, and Latin America—face challenges related to limited healthcare resources, restricted access to biologic therapies, and variable availability of specialized IBD services . As a result, treatment strategies in these settings may rely more heavily on conventional therapies such as corticosteroids and immunomodulators. Cost considerations and healthcare policies also influence the choice and timing of advanced treatments. Another important factor contributing to geographical variation is the difference in disease epidemiology and phenotype . For example, the incidence of IBD is rapidly increasing in newly industrialised countries, and patients may present with different environmental exposures, genetic backgrounds, and disease patterns compared with Western populations. Clinical guidelines developed by international organisations such as the European Crohn's and Colitis Organisation provide standardized recommendations; however, their implementation must often be adapted to local healthcare systems and resource availability. Overall, understanding geographical differences in IBD management is important for developing region-specific strategies that balance evidence-based care with practical realities. Collaborative global research and knowledge sharing will be essential to improve IBD outcomes worldwide.

In recent years, Patient-Reported Outcomes (PROs) have become an important component of evaluating disease activity and treatment response in Inflammatory Bowel Disease (IBD) , including Crohn's disease and Ulcerative colitis . PROs capture the patient’s perspective on symptoms, quality of life, functional status, and treatment impact, offering insights that may not always be evident through clinical tests or endoscopic findings. Traditional clinical assessments in IBD often focus on objective markers such as endoscopy, imaging, and biomarkers. However, these measures may not fully reflect the patient’s daily experience of the disease. PROs help bridge this gap by systematically collecting information directly from patients about symptoms such as abdominal pain, stool frequency, urgency, fatigue, and overall well-being. The key message highlighted in this ECCO session was that the quality of information obtained from PROs largely depends on the questions asked . If clinicians focus only on a limited set of symptoms, important aspects of disease burden—such as fatigue, mental health, social functioning, and treatment-related concerns—may be overlooked. Therefore, well-designed PRO tools must capture both disease-specific symptoms and broader quality-of-life domains. Validated PRO instruments are increasingly used in clinical trials and routine practice to assess treatment effectiveness and patient satisfaction. They can also guide therapeutic decisions, identify unmet needs, and improve patient–physician communication. However, PROs also have limitations. Responses may be influenced by psychological factors, patient expectations, and external stressors unrelated to intestinal inflammation. Therefore, PROs should be interpreted alongside objective measures such as biomarkers, imaging, and endoscopy. In summary, PROs provide a critical patient-centred perspective in IBD care. When the right questions are asked, they reveal dimensions of disease impact that traditional clinical assessments may miss, helping clinicians deliver more personalised and holistic care.

The management of Inflammatory Bowel Disease (IBD) requires a comprehensive multidisciplinary team (MDT) approach , as patients often present with complex clinical, surgical, nutritional, and psychological challenges. Conditions such as Crohn's disease and Ulcerative colitis are chronic, relapsing diseases that affect multiple aspects of patient health, making coordinated care essential for optimal outcomes. At the centre of the MDT is the IBD specialist gastroenterologist , responsible for diagnosis, disease monitoring, and therapeutic strategy. However, effective care requires collaboration with several other specialists. Colorectal surgeons are crucial for managing complications such as strictures, fistulas, abscesses, and medically refractory disease. Early surgical input can improve decision-making and prevent delays in necessary interventions. Radiologists and pathologists play a key role in accurate diagnosis and disease assessment through imaging and histological evaluation. Imaging modalities such as intestinal ultrasound and MRI help evaluate disease activity, complications, and treatment response, while histopathology confirms diagnosis and differentiates between disease subtypes. IBD nurse specialists serve as an important link between patients and clinicians. They provide patient education, coordinate biologic therapy administration, monitor treatment adherence, and help manage disease flares. Dietitians are also vital, as nutritional deficiencies, malnutrition, and specific dietary needs are common in IBD. Tailored nutritional support can improve patient outcomes and quality of life. Psychological support is another essential component of MDT care. Chronic disease burden, frequent hospital visits, and long-term therapies can significantly affect mental health. Access to psychologists or mental health professionals helps address anxiety, depression, and coping strategies. In summary, the MDT approach ensures that all aspects of IBD management—clinical, surgical, nutritional, and psychosocial—are addressed collaboratively. When all pieces of the puzzle come together, patient-centred care improves, leading to better disease control, reduced complications, and enhanced quality of life.

Elastography is an ultrasound-based imaging technique that measures tissue stiffness and has emerged as a promising adjunct in the evaluation of Inflammatory Bowel Disease (IBD) , particularly in Crohn's disease . Elastography works by assessing how tissues deform in response to mechanical stress, allowing differentiation between soft inflammatory tissue and stiffer fibrotic tissue. This capability is particularly relevant in Crohn’s disease, where distinguishing inflammatory strictures from fibrotic strictures is critical for selecting appropriate therapy. One of the main indications of elastography in IBD is the evaluation of bowel strictures . Inflammatory strictures typically show lower stiffness values due to active oedema and inflammation, whereas fibrotic strictures exhibit higher stiffness because of collagen deposition and tissue remodelling. Identifying the dominant component of a stricture helps guide management decisions—patients with inflammatory strictures may respond to medical therapy, while fibrotic strictures are more likely to require endoscopic dilation or surgical intervention. Elastography is also being explored for monitoring disease progression and treatment response , as changes in bowel wall stiffness may reflect evolving inflammatory or fibrotic processes. In addition, it may provide insight into transmural healing , which is increasingly recognized as an important treatment target in Crohn’s disease. Despite its potential, elastography has several limitations . The technique is operator-dependent and requires specialised equipment and expertise. Measurements may be affected by patient factors such as obesity, bowel gas, and deep bowel location. Standardised cut-off values for differentiating inflammation from fibrosis are still under investigation, and current evidence remains limited compared with established imaging modalities. In summary, elastography is a promising adjunct tool for assessing bowel fibrosis and stricture characterisation in IBD. However, it is currently best used as a complementary technique alongside conventional ultrasound, Magnetic Resonance Imaging, and endoscopy rather than as a standalone diagnostic modality.

Small Intestine Contrast Ultrasound (SICUS) is a specialised ultrasound technique used for evaluating small bowel involvement in Inflammatory Bowel Disease (IBD) , particularly in Crohn's disease , which frequently affects the small intestine. In SICUS, the patient ingests an oral contrast solution—usually polyethene glycol or another iso-osmolar fluid—to distend the small bowel loops, allowing better visualisation of the intestinal wall and lumen during ultrasound examination. One of the primary indications of SICUS is the detection and assessment of small bowel Crohn’s disease . By improving luminal distension, SICUS enhances the detection of bowel wall thickening, strictures, prestenotic dilatation, and inflammatory lesions that may not be easily identified on conventional ultrasound. It is particularly useful in patients with suspected small bowel disease where colonoscopy findings are normal or inconclusive. SICUS also plays a role in evaluating disease extent and complications , including strictures and fistulas. It can help assess whether a narrowing is associated with upstream dilatation, which may indicate clinically significant obstruction. Additionally, SICUS is useful for monitoring disease progression and treatment response , as repeated examinations can be performed without radiation exposure. However, SICUS has several limitations . The technique is time-consuming and requires patient preparation, including ingestion of a significant volume of oral contrast. It is also operator-dependent , requiring experienced ultrasonographers for accurate interpretation. Visualization may be limited in patients with obesity or excessive bowel gas. Furthermore, SICUS provides less comprehensive anatomical information compared with cross-sectional imaging such as Magnetic Resonance Enterography. In summary, SICUS is a valuable radiation-free modality for evaluating small bowel Crohn’s disease, particularly for detecting strictures and assessing disease extent. When combined with clinical assessment and other imaging modalities, it contributes to a more precise and patient-friendly approach to IBD monitoring.

Contrast-Enhanced Ultrasound (CEUS) is an advanced ultrasound technique increasingly used in the evaluation of Inflammatory Bowel Disease (IBD) , particularly in Crohn's disease . CEUS involves intravenous administration of microbubble contrast agents that enhance visualisation of bowel wall vascularity and perfusion in real time. This technique allows clinicians to assess the degree of intestinal inflammation and differentiate active inflammatory lesions from fibrotic changes. One of the key indications of CEUS is the assessment of disease activity . Increased bowel wall enhancement on CEUS reflects hypervascularity associated with active inflammation, helping clinicians distinguish inflammatory strictures from fibrotic ones. This distinction is clinically important because inflammatory strictures may respond to medical therapy, whereas fibrotic strictures often require endoscopic dilation or surgery. CEUS is also useful for monitoring response to therapy , particularly in patients receiving biologic or targeted therapies. Reduction in contrast enhancement over time may indicate decreasing inflammatory activity and treatment response. Additionally, CEUS can help evaluate complications such as intra-abdominal abscesses , where contrast enhancement patterns assist in distinguishing abscess cavities from inflammatory masses. Despite its advantages, CEUS has several limitations . The technique is operator-dependent and requires specific expertise and training. Visualization may be difficult in patients with obesity, excessive bowel gas, or deep pelvic bowel segments. Furthermore, CEUS evaluates only a limited bowel segment at a time and cannot provide the comprehensive anatomical overview offered by cross-sectional imaging modalities such as Magnetic Resonance Imaging. In summary, CEUS is a valuable adjunct imaging modality in IBD for assessing bowel perfusion and inflammatory activity. While it cannot replace endoscopy or MRI, it provides important functional information and can support treatment decisions when used as part of a multimodal diagnostic approach.

Optimal management of Inflammatory Bowel Disease (IBD) requires the appropriate use of different diagnostic modalities, including Intestinal Ultrasound (IUS) , Magnetic Resonance Imaging (MRI) , and **Endoscopy. Each modality provides complementary information and should be selected based on the clinical scenario. Intestinal Ultrasound (IUS) is increasingly used as a first-line bedside tool for the evaluation and monitoring of IBD activity. It is non-invasive, radiation-free, and can be performed repeatedly during outpatient visits. IUS is particularly useful for assessing bowel wall thickness, vascularity, and transmural inflammation in patients with **Crohn's disease. It is ideal for rapid assessment during disease flares, routine monitoring of treatment response, and follow-up in postoperative recurrence . However, its accuracy may be limited in deep pelvic segments or obese patients. Magnetic Resonance Imaging (MRI) is preferred when detailed cross-sectional imaging is required. MRI is especially valuable for evaluating small bowel disease, strictures, penetrating complications, and perianal fistulas . Techniques such as Magnetic Resonance Enterography (MRE) provide comprehensive visualisation of the bowel and surrounding structures. MRI is therefore recommended when complications are suspected, when ultrasound findings are inconclusive, or when precise anatomical mapping is required before surgery. Endoscopy , including Ileocolonoscopy , remains the gold standard for diagnosis and mucosal assessment . It allows direct visualisation of the intestinal mucosa, biopsy sampling, and evaluation of mucosal healing. Endoscopy is essential for initial diagnosis, assessment of disease extent, dysplasia surveillance, and confirmation of postoperative recurrence . In daily clinical practice, these modalities should be used complementarily . IUS serves as a rapid monitoring tool, MRI provides detailed structural evaluation, and endoscopy remains crucial for mucosal assessment and histological confirmation. A tailored approach based on disease phenotype and clinical question helps optimise patient care and treatment decisions.

Perianal involvement is a common and challenging complication of Crohn's disease , affecting up to one-third of patients during the course of the disease. Accurate evaluation of perianal fistulas, abscesses, and associated complications is essential for guiding treatment and improving outcomes. Traditionally, Magnetic Resonance Imaging (MRI) and Endoanal ultrasound have been considered the standard imaging modalities for assessing perianal disease. However, Transperineal Ultrasound (TPUS) is increasingly gaining recognition as a valuable, non-invasive bedside tool. TPUS involves placing a high-frequency ultrasound probe externally over the perineum to visualize the anal canal, sphincter complex, and surrounding soft tissues. This technique allows clinicians to identify fistulous tracts, abscess cavities, and inflammatory changes without the need for invasive procedures. TPUS can effectively detect intersphincteric and transsphincteric fistulas and can help assess the presence of fluid collections that may require drainage. One of the major advantages of TPUS is its simplicity, accessibility, and repeatability . Unlike MRI, it can be performed at the bedside or in the outpatient clinic and repeated frequently to monitor disease activity and response to therapy. This is particularly useful in patients receiving biologic therapies, where serial imaging can help evaluate healing of fistulous tracts. TPUS also plays a role in treatment monitoring and follow-up , enabling clinicians to track changes in fistula size, tract complexity, and abscess resolution over time. Although MRI remains the reference standard for complex fistula mapping, TPUS serves as an excellent first-line or complementary imaging modality for routine evaluation. Overall, TPUS represents a practical and patient-friendly imaging approach in the management of perianal Crohn’s disease. Its non-invasive nature and ability to provide real-time assessment make it an increasingly important component of the multidisciplinary management of perianal IBD.

Post-operative recurrence (POR) remains a major challenge in patients with Crohn's disease following ileocolonic resection. Despite surgical removal of diseased bowel segments, endoscopic recurrence can occur in up to 70–80% of patients within the first year if no preventive therapy is instituted. Early detection of recurrence is therefore essential for timely treatment escalation and prevention of clinical relapse. Traditionally, Ileocolonoscopy has been considered the gold standard for assessing POR, typically performed 6–12 months after surgery and graded using the Rutgeerts score . However, colonoscopy is invasive, resource-intensive, and often inconvenient for patients, limiting its frequent use in routine monitoring. In this context, Intestinal Ultrasound (IUS) has emerged as a promising non-invasive alternative for evaluating post-operative recurrence. IUS allows real-time assessment of the neoterminal ileum and anastomotic site, enabling clinicians to detect early inflammatory changes. Key ultrasonographic features suggesting recurrence include bowel wall thickening (typically >3 mm), increased Doppler vascularity, loss of bowel wall stratification, and mesenteric inflammatory changes . Recent studies presented at ECCO highlight that IUS demonstrates good correlation with endoscopic findings and the Rutgeerts score. In many patients, abnormal IUS findings can predict endoscopic recurrence before symptoms develop, allowing earlier therapeutic intervention. Additionally, IUS can be repeated frequently without radiation exposure, making it particularly suitable for longitudinal monitoring. IUS also offers advantages in assessing transmural disease activity , which may not always be fully captured by mucosal evaluation alone. This aligns with the modern concept of transmural healing as an important treatment target in Crohn’s disease. Overall, intestinal ultrasound is increasingly being integrated into post-operative monitoring algorithms. When used alongside clinical assessment and biomarkers such as faecal calprotectin, IUS provides a practical and patient-friendly strategy for the early detection and management of post-operative recurrence in Crohn’s disease.

Intestinal Ultrasound (IUS) has emerged as a valuable non-invasive tool for the assessment and monitoring of Inflammatory Bowel Disease , including Crohn's disease and Ulcerative colitis . In recent years, IUS has gained significant attention for its role in several special clinical settings , where rapid, bedside evaluation is essential. One important setting is pregnancy , where minimizing radiation exposure and invasive procedures is critical. IUS provides a safe and repeatable imaging modality to assess disease activity, bowel wall thickness, vascularity, and complications without exposing the mother or fetus to ionizing radiation. Another key application is in acute severe disease or hospitalized patients . IUS allows rapid bedside evaluation of bowel inflammation, helping clinicians differentiate active inflammation from complications such as abscess, obstruction, or strictures. This facilitates timely therapeutic decisions and monitoring of response to treatment. IUS is also particularly useful in pediatric IBD , where repeated endoscopy or cross-sectional imaging may be challenging. Its non-invasive nature, absence of radiation, and ability to be repeated frequently make it ideal for monitoring disease activity in children. In the postoperative setting , especially in patients with Crohn’s disease following ileocolonic resection, IUS can help detect early disease recurrence. Bowel wall thickening and increased Doppler vascularity may indicate early inflammatory activity before clinical symptoms appear. Finally, IUS is increasingly used for treatment monitoring . Serial examinations allow clinicians to assess early response to biologic or small-molecule therapies by evaluating changes in bowel wall thickness, Doppler signal, and transmural healing. Overall, IUS is becoming an integral part of modern IBD management. Its non-invasive, bedside, radiation-free, and repeatable nature makes it particularly valuable in special clinical settings where rapid assessment and continuous monitoring are required.

The management of inflammatory bowel disease (IBD), including Crohn's disease and Ulcerative colitis , has evolved from a gastroenterologist-centric approach to a comprehensive multidisciplinary care model . IBD is a complex, chronic disease that affects not only the gastrointestinal tract but also multiple systemic and psychosocial domains. Therefore, optimal outcomes require coordinated care involving several healthcare professionals. The core of the multidisciplinary team is the IBD specialist gastroenterologist , who is responsible for diagnosis, disease monitoring, and therapeutic decision-making. Close collaboration with colorectal surgeons is essential, particularly for patients with complications such as strictures, fistulas, abscesses, or medically refractory disease. Early surgical consultation can improve outcomes and prevent disease progression. IBD nurses play a crucial role in patient education, medication monitoring, biologic therapy administration, and patient support. They often serve as the first point of contact for patients experiencing disease flares or treatment-related concerns. Dietitians are equally important, as nutritional deficiencies, malnutrition, and specific dietary needs are common in IBD. Nutritional therapy may also be part of the treatment strategy, especially in selected patients. Psychological support is another key component of multidisciplinary care. Anxiety, depression, and reduced quality of life are common among patients with chronic diseases such as IBD. Access to psychologists or mental health professionals can significantly improve coping mechanisms and treatment adherence. Additionally, collaboration with radiologists, pathologists, pharmacists, and primary care physicians ensures accurate diagnosis, monitoring of disease activity, safe medication use, and management of comorbidities. Overall, the multidisciplinary approach enhances patient-centered care , improves disease control, reduces complications, and optimizes long-term outcomes. Modern IBD centers increasingly adopt structured multidisciplinary clinics where coordinated decision-making enables individualized treatment strategies tailored to each patient’s disease phenotype, severity, and lifestyle needs.

Inflammatory bowel disease (IBD), encompassing Crohn's disease and Ulcerative colitis , is a chronic immune-mediated disorder of the gastrointestinal tract characterised by relapsing intestinal inflammation. Over the past few decades, the global epidemiology of IBD has changed substantially. Traditionally prevalent in North America and Europe, IBD is now increasingly recognised in newly industrialised regions, including Asia, the Middle East, and Latin America. This shift reflects the role of environmental and lifestyle factors such as urbanisation, dietary changes, antibiotic exposure, and alterations in gut microbiota. Consequently, IBD is now considered a global disease with a rising incidence in developing countries. The immunopathogenesis of IBD involves a complex interaction between genetic susceptibility, environmental triggers, intestinal microbiota, and dysregulated immune responses . Genome-wide association studies have identified multiple susceptibility loci involved in epithelial barrier function, innate immunity, and adaptive immune regulation. Defects in mucosal barrier integrity allow luminal antigens and microbes to interact with immune cells in the intestinal mucosa, triggering an exaggerated immune response. This leads to activation of pro-inflammatory pathways involving cytokines such as tumour necrosis factor (TNF), interleukins (IL-12, IL-23), and other mediators that perpetuate chronic inflammation and tissue damage. Advances in understanding the immune mechanisms underlying IBD have directly influenced therapeutic strategies. Traditional therapies focused mainly on broad immunosuppression with corticosteroids and immunomodulators. However, improved knowledge of immune pathways has enabled the development of targeted biologic therapies, including anti-TNF agents, anti-integrin antibodies, and IL-12/23 inhibitors. More recently, small-molecule therapies targeting intracellular signalling pathways, such as Janus kinase (JAK) inhibitors, have further expanded the therapeutic armamentarium. Understanding the epidemiology and immunopathogenesis of IBD is therefore essential for guiding personalised treatment strategies. It allows clinicians to identify disease mechanisms in individual patients and select therapies that specifically target key inflammatory pathways. As research continues to unravel the complex interactions between genetics, microbiota, and immune responses, future therapeutic approaches are likely to become increasingly precise, aiming not only to control inflammation but also to modify disease course and prevent complications.