Shaping surgical decisions in IBD - Unveiling the power of intestinal ultrasound across the perioperative pathway.

Intestinal ultrasound (IUS) is an increasingly utilized, non-invasive imaging modality in the management of inflammatory bowel disease (IBD). While its application in monitoring medical therapy is well recognized, its potential to support surgical decision-making remains underappreciated. This narrative review examines the role of IUS across the perioperative continuum in Crohn's disease (CD) and ulcerative colitis (UC), with a focus on practical surgical relevance. In CD, IUS might contribute to the differentiation between inflammatory and fibrotic strictures, assessment of penetrating disease, and identification of real-time functional signs such as prestenotic dilation and swirling luminal contents. These findings guide early surgical referral and avoid unnecessary delays. Postoperatively, IUS allows for dynamic surveillance, with bowel wall thickness and Doppler flow serving as early markers of recurrence in CD. Assessments at 3, 6, and 12 months can guide therapeutic escalation or confirm remission without requiring invasive endoscopy. In acute severe UC, IUS can predict steroid non-response within 48 h and help define disease extent which might directly influences surgical strategy. Adjunct techniques such as contrast-enhanced ultrasound (CEUS), small intestinal contrast ultrasound (SICUS), and shear wave elastography (SWE) enhance diagnostic accuracy in specific settings. Moreover, muscle ultrasound provides a practical bedside tool to evaluate nutritional status and support preoperative risk stratification. IUS offers surgeons a repeatable, accessible, and real-time diagnostic approach that bridges medical and surgical care. As evidence grows and standardization improves, IUS is poised to become a cornerstone in multidisciplinary IBD surgery, supporting precision, shared decision-making, and better outcomes.