Inflammatory bowel diseases (IBD), encompassing ulcerative colitis (UC) and Crohn's disease (CD), are chronic, immune-mediated disorders of the gastrointestinal tract driven by complex interactions between genetic, environmental, microbial, and immunological factors [1, 2, 3]. While UC has traditionally been regarded as a mucosal disease, increasing evidence supports the presence of transmural inflammation in select cases, aligning it more closely with the pathophysiology of CD [4, 5, 6]. Globally, the incidence of IBD continues to rise—particularly in newly industrialized regions—accompanied by escalating use of high-cost therapies, expanded surgical indications, and more intensive surveillance strategies. Together, these trends have contributed to IBD becoming a significant and growing global healthcare burden [3].

Although the therapeutic landscape has been transformed by biologics and small molecules, direct comparative data remain limited, and therapeutic positioning continues to evolve [7]. Despite medical advances, surgical intervention remains necessary in up to 50 % of patients with CD and 30 % with UC, primarily due to complications such as strictures, fistulae, dysplasia, or colorectal cancer [8, 9, 10]. Importantly, surgery is increasingly viewed not merely as a last resort, but as a proactive strategy to achieve deep remission and long-term disease control. Trials such as LIR!C have demonstrated that early surgical intervention—such as laparoscopic ileocecal resection—can offer outcomes comparable to or better than anti-TNF therapy, including reduced recurrence and medication burden [11,12]. Similarly, early colectomy in acute severe UC (ASUC) has been associated with improved morbidity and mortality outcomes, while also the role of appendectomy is being further explored in moderate-to-severe active and quiescent disease [13, ∗14, ∗∗15]. Collectively, this underscores the evolving role of surgery as a potential disease-modifying treatment.

As surgical strategies evolve, so too must perioperative monitoring. Accurate assessment of disease activity and postoperative recurrence is critical to guide timing, optimize surgical outcomes, and support postoperative management. However, traditional tools such as endoscopy and magnetic resonance enterography (MRE) have limitations—endoscopy is invasive and inadequate for assessing transmural and post-surgical disease; MRE and computed tomography (CT), though informative, are costly and less feasible for repeated assessments [16].

In this setting, intestinal ultrasound (IUS) has emerged as a practical, non-invasive, cost-effective, and radiation-free imaging modality that provides real-time, bedside assessment of both pre- and post-surgical disease activity and bowel damage [1,17,18]. IUS allows evaluation of bowel wall thickness (BWT), bowel wall vascularity, mesenteric fat (iFat), lymph nodes, and complications such as strictures, fistulas, and abscesses [1,17,19]. Its correlation with cross-sectional imaging, excellent safety profile, and reproducibility make it an ideal tool for repeated use, including in perioperative decision-making and postoperative surveillance [16,20]. Furthermore, IUS enhances shared decision-making by providing immediate visual feedback and supporting multidisciplinary discussions in a point-of-care setting on surgical timing and strategy [1,20]. Previous reviews of IUS in IBD have largely focused on diagnostic accuracy and treatment monitoring. Its role in the perioperative setting, however, remains unexplored. By concentrating specifically on pre- and postoperative contexts, this narrative review offers a novel synthesis of how IUS can inform surgical decision-making in both Crohn's disease and ulcerative colitis.