Crohn's disease (CD) is a chronic inflammatory bowel disease (IBD) that imposes a lifelong burden on patients and healthcare systems, characterized by transmural inflammation that can affect any part of the gastrointestinal tract, most commonly the terminal ileum and colon [1]. Despite major advances in biological therapies and the adoption of treat-to-target strategies, up to 50 % of patients still require surgery within 10 years of diagnosis. Conventional monitoring approaches—relying on clinical symptoms, biomarkers, and endoscopic evaluation—provide incomplete assessment of transmural disease activity, the hallmark of CD pathophysiology. Endoscopy, while remaining the gold standard for mucosal assessment, fails to evaluate transmural and extramural disease manifestations, missing subclinical inflammation that drives long-term complications and contributing to the well-recognized transmural–endoscopic discordance [2]. This discordance—present in 40–60 % of patients in apparent clinical remission—represents a critical blind spot that highlights the need for imaging modalities uniquely capable of assessing transmural and extramural disease activity [3,4].

Intestinal ultrasound (IUS) addresses these limitations by providing real-time, non-invasive assessment of full bowel wall thickness and associated complications, enabling earlier detection of treatment response and more accurate prognostic assessment than conventional endpoints alone [5]. The clinical implementation of IUS faces practical barriers including limited training opportunities, equipment requirements, and standardized protocols for clinical decision-making. However, the recently published ECCO-ESGAR-ESP-IBUS multi-society guidelines propose a structured approach and, for the first time, formally endorse IUS as an essential tool in standard CD care pathways: baseline assessment should be obtained in newly diagnosed CD patients with IUS, MRE or both, and at treatment initiation or optimization [6,7]. Early response assessment using IUS is recommended within 12 weeks of treatment changes, followed by regular monitoring every 3–6 months in remitted patients. The development of validated scoring systems, such as IBUS-SAS, standardized assessment protocols, and advanced modalities such as contrast-enhanced ultrasound (CEUS) has positioned IUS as a cornerstone of precision medicine in CD management. As anti-fibrotic therapies emerge, the ability to differentiate inflammatory from fibrotic tissue components becomes increasingly critical for optimal patient stratification and treatment selection.

As IUS technology matures from research applications to clinical implementation, the field has reached a critical juncture where individual technique validation must evolve into comprehensive care pathways. This review not only summarizes current evidence but also provides clinicians with a pragmatic framework to integrate IUS into everyday practice, bridging the gap between technological validation and real-world implementation.