Postoperative recurrence remains a major challenge in Crohn's disease (CD), with ileocolonoscopy still considered the reference standard for detecting recurrence and guiding postoperative management. However, repeated endoscopic assessment is invasive, costly, and poorly tolerated, highlighting the need for reliable non-invasive monitoring strategies. Intestinal ultrasound (IUS) has emerged as a promising complementary tool for postoperative surveillance, allowing real-time evaluation of transmural and extramural inflammation. Recent studies and meta-analyses have demonstrated good diagnostic performance of IUS for detecting postoperative recurrence, with pooled sensitivities and specificities reaching 94% and 84%, respectively, while higher bowel wall thickness thresholds (≥5.5 mm) are strongly associated with severe postoperative recurrence. Current evidence supports the integration of IUS with fecal calprotectin, clinical assessment, and endoscopy within a multimodal and risk-adapted follow-up strategy. In particular, IUS may help identify patients requiring closer surveillance, earlier ileocolonoscopy, therapeutic escalation, or additional cross-sectional imaging. Emerging data also suggest that the timing of postoperative IUS assessment is clinically relevant, as very early examinations may be confounded by postoperative inflammatory and remodeling changes. Nevertheless, important limitations remain. No IUS score has yet been specifically validated for postoperative CD anatomy, standardized postoperative-specific thresholds are lacking, and interpretation may be influenced by surgical configuration and operator expertise. This review summarizes the current evidence regarding the role of IUS in postoperative CD, discussing its diagnostic performance, integration with biomarkers and endoscopy, current limitations, and potential role in personalized postoperative monitoring strategies.

Personalized medicine is increasingly shaping the management of inflammatory bowel disease (IBD), with the goal of tailoring diagnostic and therapeutic strategies to individual patients. Intestinal ultrasound (IUS) has emerged as a pivotal, non-invasive, and repeatable tool for assessing disease activity, treatment response, and complications in both Crohn’s disease and ulcerative colitis. Beyond its role in routine monitoring, IUS enables real-time decision-making and facilitates tight control strategies, aligning with the principles of precision medicine. By combining morphological assessment with advanced techniques, such as contrast-enhanced ultrasound and elastography, IUS offers unique opportunities for risk stratification and individualized treatment planning. Moreover, its accessibility, safety, and patient acceptability make IUS particularly suited for longitudinal follow-up and early detection of therapeutic failure, thereby reducing the need for invasive procedures. This review discusses the integration of IUS into personalized IBD care pathways, highlighting current evidence, clinical applications, and future perspectives.

Introduction The optimal treatment target for Crohn’s disease (CD) is unknown. Targeting transmural healing (TMH) may be associated with a lower risk of complications than clinical and endoscopic outcomes. The Study to Evaluate Transmural Healing as a Treatment Target in Crohn’s Disease (VECTORS) aims to investigate TMH as a potential treatment target and its long-term benefits in patients with CD.Methods and analysis VECTORS is a phase 4, interventional, parallel-group, multicentre, randomised controlled trial. Approximately 304 adult patients with moderately to severely active CD from multiple international sites will be enrolled and randomly assigned in a 1:1 ratio to treatment target group 1 (corticosteroid-free intestinal ultrasound-based response or TMH plus clinical and biomarker remission) or group 2 (corticosteroid-free clinical and biomarker remission). All patients receive vedolizumab according to the standard dosing regimen, with an additional dose at week 10, followed by a treatment escalation algorithm to reach the assigned targets. Randomisation will be stratified by prior advanced therapy exposure, disease location and disease duration. The primary objective is to determine if treatment target group 1 is superior to group 2 for the primary efficacy outcome of corticosteroid-free endoscopic remission at week 48. CD-related complications (key secondary outcome) are assessed at week 96.Ethics and dissemination The trial is conducted in compliance with the protocol and applicable regulatory requirements and is approved by institutional review boards/independent ethics committees at the country or site level. Patients’ written informed consents are obtained and documented prior to trial participation. Findings will be disseminated in peer-reviewed journals and at scientific congresses.Trial registration numbers NCT06257706; EUCT, 2023-509096-16-00.

Imaging has become a central and rapidly evolving domain in inflammatory bowel disease (IBD) because it captures disease manifestations that extend beyond the mucosa and, therefore, beyond what can be visualized by endoscopy, including transmural inflammation, extraintestinal complications and small-bowel involvement that are not adequately assessed by conventional approaches. In this narrative review, we synthesize the latest evidence on non-invasive cross-sectional imaging—intestinal ultrasound (IUS) and magnetic resonance imaging/enterography (MRI/MRE)—and outline a pragmatic framework for integrating these modalities into clinical trials. The timing of this review reflects the recent publication of two major consensus statements that specifically address how IUS and MRI can be standardized and operationalized as trial endpoints. We first summarize recommended technical standards for acquisition and reporting. We then outline trial-ready definitions of response and remission for clinical trials using validated scores and discuss the emerging but still variably defined construct of transmural healing, understood as the resolution of inflammation across the full thickness of the bowel wall and increasingly associated with improved long-term outcomes. Building on these components, we propose a practical pathway to incorporate imaging from screening, through on-treatment monitoring at predefined windows to adjudicate response/remission, and, where appropriate, to evaluate transmural healing. We emphasize central reading, harmonized timing, and standardized data repositories to minimize bias. Even though meaningful steps have been taken to integrate cross-sectional imaging, it remains essential to evaluate its use pragmatically in both trials and routine care. Furthermore, cost-effectiveness analyses are needed to determine whether widespread implementation is economically justified, and studies should examine whether incorporating IUS/MRI improves patient adherence to clinical trial protocols and follow-up compared with traditional assessment pathways.

INTRODUCTION:Ulcerative colitis (UC) is an inflammatory bowel disease with a relapsing- remitting course, whose etiology is still unknown. Mild forms are generally managed with mesalazine, whereas moderate-to-severe disease may be addressed through a stepwise approach, often starting with corticosteroids and immunomodulators, and, when needed, progressing to advanced therapies targeting specific molecular pathways. Even though these therapies have led to substantial improvements in patients' quality of life and prognosis over recent decades, consistent and lasting therapeutic responses remain challenging to attain. AREAS COVERED:This review aims to outline emerging small molecules for UC, emphasizing efficacy and safety data from recent phase II-III clinical trials, including both published studies and ongoing research. We performed a thorough literature search using PubMed, Scopus, and ClinicalTrials.gov, excluding earlier-phase studies, and identified additional relevant articles through reference screening. EXPERT OPINION:It is essential to investigate innovative, safe, and easy-to-administer therapies that target alternative immunological pathways to enhance UC treatment. Some molecules, such as miRNA-124 upregulators, JAKi, S1P modulators, and LANCL2 agonists, may enrich our therapeutic armamentarium in UC management. To further optimize therapeutic strategies, combining small molecules with biologic agents could enhance treatment effectiveness, reduce immunogenicity, and improve long-term durability by targeting complementary inflammatory pathways.

This is the second of two articles presenting the European Crohn's and Colitis Organisation [ECCO] evidence‑based consensus guidelines on the management of adult patients with ulcerative colitis [UC]. The first article covers the medical management of UC, including acute severe colitis. The present article addresses the surgical management of medically refractory UC, including the general surgical approach and perioperative optimisation, surgical strategies and techniques, and recommended levels of centre expertise and surgical specialisation. Together, these two articles aim to inform shared decision‑making and to guide clinicians and healthcare professionals involved in the care of patients with UC, drawing on the best available evidence.

Up to 75% of CD patients require surgery during disease course, and post-operative recurrence (POR) occurs in up to 70% patients within 1 year. Early, accurate and frequent monitoring is therefore critical for optimal management. Intestinal ultrasound (IUS) has emerged as a safe and widely available tool to assess CD activity. Bowel wall thickness (BWT) is a key feature that correlates with the presence of endoscopic recurrence. However, IUS interpretation is often burdened by subjectivity and high interobserver variability, underscoring the need for standardised, objective assessment tools. Artificial intelligence (AI) offers an opportunity to enhance precise and reproducible IUS-based disease evaluation. We aimed to develop a novel computer-aided model for automated quantitative measurement of BWT across different intestinal segments. IUS videos from CD patients enrolled in the international, multicentre PROSPER study (NCT06505304) were included. 70 high-quality frames from 22 videos were manually and randomly extracted. Additional 12 frames were extracted to develop the computer-aided system to detect bowel wall layers from the cross section of bowel wall. Regions of interest (ileum, anastomosis, and colon) were identified and bowel wall layers were manually segmented as ground truth. Drawing a line across the bowel wall (from lumen to serosa) was required as input. After extracting the grey-level intensity from the frames along this line, the intensity profile was smoothed to reduce noise. Layers’ boundaries were automatically identified by detecting most relevant peaks and valleys in the grey-level intensity profile. Considering the sequence and echogenicity of layers, the thickness of each layer was computed, enabling accurate estimation of overall BWT (Figure 1). The diagnostic performance was evaluated by correlating computer-derived measurements with experts manual assessment. Table 1 details model performance. A very high correlation (r 0.98; mean absolute error 3.8 pixels, mean percentual error 8.63%) was identified between the manual and the automated estimation of BWT. Excellent performance was confirmed in assessed intestinal tracts: r 0.97 in the neo-terminal ileum, r 0.98 in the anastomosis and r 0.97 in the colon proximal to the anastomosis. Our semi-automated method accurately measure BWT through reliable layer stratification and demonstrates excellent concordance with manual assessment. This approach offers a promising avenue for fully automated identification and quantification of bowel wall layers on IUS. Further refinement and integration of additional sonographic features will enhance standardization and clinical utility in POR monitoring. Conflict of interest: Iacucci, Marietta: No conflict of interest Dr. Zammarchi, Irene: No conflict of interest Verstockt, Bram: No conflict of interest Allocca, Mariangela: Personal Fees: consulting fees from Nikkiso Europe, Mundipharma, Janssen, Abbvie, Pfizer, Ferring, Galapagos, Sandoz, Lilly and Alfasigma Bezzio, Cristina: Personal Fees: I received consulting/advisory board/lecture fees from Alfa Sigma, AbbVie, Celltrion, Eli Lilly, Ferring, Gilead, Johnson & Johnson MSD, Pfizer and Takeda Banai Eran, Hagar: No conflict of interest Castiglione, Fabiana: Honoraria from: Takeda, AbbVie, Celltrion, Johnsson Johnsson, Cadigroup, Sandoz, Pfizer, Lilly, Lionhealth, Nestlè Cannatelli, Rosanna: No conflict Dal Buono, Arianna: speaker’s fees from AbbVie, Alphasigma, Ferring, Lilly, Janssen, and Celltrion Doherty, Glen: No conflict of interest Furfaro, Federica: Grant: IG-IBD Personal Fees: Pfizer, Biogen, J&J, Abbvie, Amgen, Janssen Lepore, Federica: No conflict of interest Lo Bello, Antonio: No conflict of interest Lu, Cathy: No conflict of interest Maconi, Giovanni: No conflict of interest Nardone, Olga Maria: No conflict of interest O’grady, John: No conflict of interest Piazza O Sed, Nicole: No conflict of interest Ricci, Chiara: No conflict of interest Ghosh, Subrata: No conflict of interest Naranjo, Valery: No conflict of interest Grisan, Enrico: No conflict of interest

BACKGROUND & AIMS:Mirikizumab, an IL-23 p19-targeting monoclonal antibody, is approved for moderate-to-severe ulcerative colitis (UC). Real-world evidence on its effectiveness and safety remains limited. We evaluated its effectiveness and safety in a real-world setting. METHODS:This retrospective multicenter study included adult UC patients treated with mirikizumab at 5 Italian centers (June 2024-October 2025), with ≥24 weeks of follow-up. The primary outcome was clinical remission (CR, pMS ≤ 2 with rectal bleeding 0) at week(w)12. Secondary outcomes included intestinal ultrasound (IUS) remission, endoscopic remission, bowel urgency (BU) remission, fecal calprotectin (FC) normalization, and safety profile. RESULTS:A total of 236 patients (60.2% male; median age 47) were included. 77.5% had prior exposure to advanced therapy. Mirikizumab significantly reduced pMS at w12 and w24 (both P < .001), with clinical remission in 46.6% and 55.5%, respectively. Mayo endoscopic score improved at both timepoints (P < .01 and P < .001) with 38% achieving endoscopic remission at w24. IUS remission was nonsignificant at w12 but significant at w24 (P < .0001). BU and FC improved at both timepoints (P < .001). Remission rates were similar in biologic-naive and biologic-exposed patients. Discontinuations were uncommon, adverse events were infrequent and non-serious, and liver tests showed no clinically relevant changes. CONCLUSIONS:In this real-world multicenter cohort, mirikizumab was associated with meaningful improvements across clinical, endoscopic, biochemical, and ultrasound outcomes, with low discontinuation rates and a favorable safety profile through 24 weeks. These findings support the effectiveness of selective IL-23 inhibition in routine care, including in patients with prior exposure to advanced therapies.

INTRODUCTION:Primary sclerosing cholangitis (PSC) represents a progressive fibroinflammatory cholangiopathy intricately linked to inflammatory bowel disease (IBD), forming a distinctive overlap syndrome driven by immune dysregulation and gut-liver axis disruption and characterized by a markedly increased risk of colorectal and hepatobiliary cancers. AREAS COVERED:This review summarizes current understanding of the immunopathogenesis and clinical spectrum of PSC-IBD. Key mechanisms include aberrant lymphocyte homing through the α4β7/MAdCAM-1 axis, shared genetic susceptibility loci, alterations in bile acid metabolism, and gut microbial dysbiosis. The clinical course and malignancy risk of PSC-IBD are contrasted with those of isolated PSC and IBD, and surveillance strategies are discussed. Therapeutic approaches under investigation, such as advanced therapies and microbiome-targeted interventions including oral vancomycin, are critically appraised based on recent translational and clinical studies. EXPERT OPINION:PSC-IBD demands multidisciplinary, risk-stratified management and intensive cancer surveillance. Although no medical therapy currently halts disease progression, novel agents modulating immune and microbial pathways represent promising avenues. In the future, integration of hepatology, gastroenterology, and immunology within a precision-medicine framework is expected to reshape disease stratification and therapeutic decision-making for this complex overlap syndrome.

BACKGROUND AND AIMS:Artificial intelligence (AI) is increasingly being applied in various fields of medicine, including inflammatory bowel diseases (IBD). This systematic review, conducted as part of the ECCO 9th Scientific Workshop on AI in IBD, explores AI applications in multiomics precision medicine, large language models (LLMs) for textual tasks, and utilization of wearable and remote care technologies. METHODS:A comprehensive systematic analysis of the literature was undertaken, emphasizing three topics: multiomics predictive models in IBD; natural language processing (NLP) and LLMs for clinical practice, research and patient communication; and the role of remote monitoring and wearable devices. RESULTS:Key areas of promise include the implementation of NLP and LLMs for case identification and differentiation, tracking disease activity, pharmacovigilance, quality assurance, and patient support. Multiomic approaches, integrating genomics, transcriptomics, proteomics, metabolomics, and metagenomics, show potential for developing more accurate diagnostic and risk prediction models and improving treatment response prediction and detection of actionable drug targets for future therapeutics. Wearables and remote monitoring technologies can transform IBD management from episodic assessments to continuous, less biased tracking of patient-reported outcomes and physiological biomarkers. CONCLUSIONS:While AI and multiomics approaches hold substantial promise for advancing IBD management and research, further refinement is necessary to ensure content validity and address safety concerns, thereby allowing integration of AI into clinical workflows and safeguarding of data privacy. Future research should prioritize the integration of diverse omic data, conduct of longitudinal studies, and validation in large and diverse cohorts.

BACKGROUND:Intestinal ultrasound (IUS) is increasingly valuable in inflammatory bowel disease (IBD) management. OBJECTIVE:This study aimed to determine the learning curve for basic and advanced IUS parameters and establish the minimum number of examinations required for diagnostic proficiency. DESIGN:We conducted a prospective, multicenter study across eight Italian tertiary IBD centers. Eight gastroenterology trainees with extensive abdominal ultrasound experience but limited IUS exposure completed standardized training comprising theoretical education, 30 supervised examinations, and 99 independent assessments. Expert sonographers independently and blindly reassessed all independent examinations using identical protocols. Interobserver agreement was quantified using Cohen's kappa coefficients across 12 predefined categories, stratified into basic (bowel wall thickness, vascularity, stratification) and advanced (fistulas, collections, strictures) findings. RESULTS:Following initial training, trainees demonstrated substantial baseline competency. Basic parameters achieved consistently high performance throughout the study period (from κ = 0.792 to κ = 0.842), while advanced findings showed more pronounced learning curves, improving from κ = 0.728 to κ = 0.854. Small bowel dilation exhibited the steepest learning trajectory (κ = 0.674 to κ = 0.921, 36.6% improvement, P = .204). Sustained primary competence (κ ≥ 0.8) was achieved by 37.5-62.5% of trainees for basic parameters within 99 examinations, with bowel wall stratification proving most challenging (37.5% success rate). CONCLUSION:This study establishes the first comprehensive, parameter-specific learning thresholds for IUS competency in IBD. Our findings demonstrate that structured training enables basic IUS proficiency within 69-112 examinations for experienced ultrasonographers, while advanced skills require extended practice. These data represent an important step toward defining evidence-based benchmarks for IUS training, supporting the development of standardized international curricula and safe clinical implementation.

In this review, a comprehensive overview of the current state of artificial intelligence (AI) research in inflammatory bowel disease (IBD) diagnostics in the domains of endoscopy, radiology, and histology is presented. Moreover, key considerations for the development of AI algorithms in medical image analysis are discussed. AI presents a potential breakthrough in real-time, objective, and rapid endoscopic assessment, with implications for predicting disease progression. It is anticipated that, by harmonizing multimodal data, AI will transform patient care through early diagnosis, accurate patient profiling, and therapeutic response prediction. The ability of AI in cross-sectional medical imaging to improve diagnostic accuracy, automate and enable objective assessment of disease activity, and predict clinical outcomes highlights its transformative potential. AI models have consistently outperformed traditional methods of image interpretation, particularly in complex areas such as differentiating IBD subtypes, identifying disease progression, and complications. The use of AI in histology is a particularly dynamic research field. Implementation of AI algorithms in clinical practice is still lagging, a major hurdle being the lack of a digital workflow in many pathology institutes. Adoption is likely to start with implementation of automatic disease activity scoring. Beyond matching pathologist performance, algorithms may teach us more about the pathophysiology of IBD. While AI is set to substantially advance IBD diagnostics, various challenges such as heterogeneous datasets, retrospective designs, and assessment of different endpoints must be addressed. Implementation of novel standards of reporting may drive an increase in research quality and overcome these obstacles.

Inflammatory bowel diseases (IBDs), including ulcerative colitis (UC) and Crohn’s disease (CD), are consistently associated with alterations in gut microbial communities, although the extent and characteristics of these alterations vary across studies, supporting a potential role of the microbiota in disease pathogenesis and therapeutic modulation. We conducted a systematic review to synthesize current evidence on microbiota alterations in IBD and the clinical application of fecal microbiota transplantation (FMT). A total of 118 studies were included (76 focused on microbiota profiling and 42 evaluated FMT as therapy). Across heterogeneous study designs and microbial characterization methods, reduced microbial diversity was the most consistently reported alteration, generally more pronounced in CD than in UC. Depletion of Faecalibacterium prausnitzii—a key butyrate producer with anti-inflammatory properties—was commonly reported, often accompanied by functional impairment in short-chain fatty acid production. Microbial patterns were frequently associated with mucosal inflammation and varied across disease phenotypes; these patterns have been increasingly explored as predictors of treatment response and relapse, although mechanistic interpretation remains limited and causal relationships are difficult to establish. Evidence from randomized controlled trials suggests potential efficacy of FMT in UC, particularly with intensive or repeated protocols, whereas data in CD remain limited and heterogeneous, with signals of benefit often appearing transient. FMT was generally well tolerated, but long-term safety data remain scarce. Emerging multi-omic approaches are reshaping the field by integrating taxonomic and functional insights, with potential implications for risk stratification, diagnosis, prognosis, and therapeutic optimization. Further standardized, longitudinal, and mechanistically oriented studies are required to translate microbiome research into clinically actionable strategies in IBD.