Ulcerative colitis (UC) is a chronic inflammatory bowel disease (IBD) with a heterogeneous clinical presentation, ranging from proctitis to pancolitis, depending on the extent of colonic involvement [1,2]. UC follows a relapsing-remitting course, significantly impairs quality of life, and increases the lifetime risk of colorectal cancer. Its management is primarily medical and requires close, accurate monitoring over time [3, 4, 5].

Due to the progressive course of UC, early intervention is crucial. Detecting the disease at an early stage allows for the prompt start of therapy, which enhances the chances of remission [6]. In this context, accurate and timely assessment of disease activity plays a central role in guiding therapy, evaluating treatment response and preventing complications [7, 8, 9, 10].

Historically, endoscopy has been the gold standard for monitoring UC, offering direct visualization of mucosal inflammation and the possibility of histological assessment [11,12]. However, its invasive nature, high cost and limited feasibility for repeated use restrict its practicality in routine care [13]. Biomarkers such as C-reactive protein (CRP) and fecal calprotectin (FC) provide useful supplementary information, though their correlation with mucosal healing is imperfect and their specificity limited [14].

Furthermore, the evolving recognition of UC as a condition that extends beyond the mucosa toward a more transmural pattern [15,16] challenges traditional paradigms and calls for a deeper understanding of pathophysiological mechanisms, diagnostic strategies and therapeutic targets [9]. In recent years, intestinal ultrasound (IUS) has emerged as a promising, non-invasive, and increasingly accessible imaging modality for UC monitoring. IUS has shown a strong correlation with both endoscopic and clinical indices of disease activity [17,18]. Beyond this, IUS can offer the possibility of capturing transmural and peri-intestinal changes in real time, providing complementary information that may shift UC management toward a more comprehensive approach targeting deeper levels of healing [19, 20, 21].

As expertise and evidence continue to grow, IUS has become a pivotal tool in the personalized, dynamic management of UC, revolutionizing traditional monitoring paradigms and enhancing long-term patient outcomes [22].