Clinical appraisal of handheld intestinal ultrasound in inflammatory bowel disease: Where are we now?

Gastroenterologist-performed intestinal ultrasound (IUS) is increasingly used to monitor inflammatory bowel disease (IBD) due to its noninvasive, real-time, and cost-effective attributes, alongside high diagnostic accuracy. However, wider adoption remains limited by the cost, size, and workflow demands of cart-based or high-end ultrasound platforms. Handheld ultrasound has emerged as a miniaturized alternative that can be and applied at the bedside. Early studies of handheld intestinal ultrasound (HHIUS) in IBD have demonstrated reproducibility and diagnostic performance comparable to conventional IUS for selected applications, particularly bowel wall thickness assessment, with limitations in assessing deep pelvic lesion and complications. Whereas interdevice comparisons specific to IBD are lacking, data from general medicine suggest rapid improvements in image quality and usability of handheld devices. However, most comparative studies have not evaluated color Doppler, a core IUS parameter. In ulcerative colitis, Doppler-inclusive assessment using the Milan Ultrasound Criteria appears feasible with HHIUS, whereas color Doppler performance in Crohn's disease remains insufficiently validated. Hardware accessibility alone does not ensure IUS competency. Safe implementation requires structured training, including supervised practice, image quality review, and feedback, which may be supplemented by real-time telementoring and artificial intelligence. Taken together, HHIUS may be best positioned as a complementary bedside adjunct for triage, focused assessment, selected monitoring, resource-limited settings, and education, with predefined escalation to conventional IUS, magnetic resonance enterography/computed tomography, or endoscopic reassessment when appropriate. Future studies are needed to evaluate color Doppler performance, interdevice reproducibility, and safe integration of HHIUS into clinical workflows and training programs.