Beyond the mucosa: intestinal ultrasound for post-endoscopic healing risk stratification in ulcerative colitis

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We congratulate the authors for demonstrating that transmural healing (TH), assessed by intestinal ultrasound (IUS), more accurately predicts relapse in ulcerative colitis (UC) than endoscopic healing (EH).1 IUS provides a practical, non-invasive way to interrogate the bowel wall beyond the mucosa and to bring imaging to the bedside. The observation that TH, defined as bowel wall thickness (BWT) in <3 mm, identifies a subgroup with more durable remission underscores the promise of ultrasound-guided care in the maintenance phase. Importantly, the benefit of TH was independent of Mayo endoscopic subscore (MES) status, highlighting its additive prognostic value beyond EH alone. This should be seen as complementary, not antithetical, to EH. In clinical practice, EH and TH frequently co-occur but are not synonymous. The most clinically salient population may be patients with MES of 1, where residual submucosal activity is plausible and therapeutic decisions are nuanced. In this setting, a “TH-positive” result may reassure clinicians continuing the current treatment or even considering treatment de-escalation, whereas a “TH-negative” result may prompt treatment intensification or closer monitoring. Positioning IUS as additive to endoscopy aligns with contemporary multimodal treat-to-target principles.

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