Imaging in inflammatory bowel disease 2025: ECCO-ESGAR-ESP-IBUS diagnostic and monitoring recommendations with MRI and intestinal ultrasound in treat-to-target strategies

The 2025 ECCO-ESGAR-ESP-IBUS multisociety guidelines mark a paradigm shift in IBD management, positioning imaging as a central element of the treat-to-target strategy. This critical review analyzes these updates from a radiological perspective. Magnetic resonance enterography (MRE) and intestinal ultrasound (IUS) are now established as co-first-line modalities for diagnosis and monitoring, reflecting their proven accuracy and safety. Evidence from trials such as METRIC, TRUST-UC, and PISA-II demonstrates that cross-sectional imaging reliably detects disease activity, complications, and therapeutic response, enabling proactive, non-invasive disease control. The guidelines promote early imaging-based assessment and incorporate transmural healing as an achievable therapeutic target. However, practical barriers remain, including limited access to MRE, operator dependence on IUS, and heterogeneity in the definition of transmural healing and fibrosis. Implementing standardized protocols and structured training is essential to realize the guidelines' vision. By positioning imaging at the core of IBD care, the 2025 guidelines transform radiology from a diagnostic adjunct to a strategic driver of precision therapy. CRITICAL RELEVANCE STATEMENT: Cross-sectional imaging, particularly MRE and IUS, has become indispensable for comprehensive IBD assessment. The 2025 ECCO-ESGAR-ESP-IBUS guidelines integrate imaging into every phase of patient management, underscoring its value for diagnosis, monitoring, and achieving transmural remission. This shift requires structured training and harmonization across Europe. KEY POINTS: MRE and IUS have become co-first-line modalities for IBD diagnosis and follow-up with imaging now embedded within the treat-to-target framework, emphasizing early response and transmural healing. MRE is preferred for baseline staging and complex complications; IUS excels in dynamic, point-of-care monitoring. Standardization and training remain major barriers to implementation.