Four reasons to add intestinal ultrasound to your practice
“It's really made its way already into the mainstream of IBD care,” Dr. Rishika Chugh said.
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01/27/2026
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by Doug Brunk
In the clinical opinion of Rishika Chugh, MD, there are at least four reasons why clinicians who care for patients with inflammatory bowel disease should consider using ultrasound to help guide treatment and management.
First, it’s patient-centric, she said at the during the 2026 Crohn’s & Colitis Congress®, a partnership of AGA and the Crohn's & Colitis Foundation, held in Las Vegas. Dr. Chugh, a gastroenterologist at the University of California, San Francisco, shared the story of a young woman with Crohn’s disease whose journey through treatment had been long and frustrating. Medications had failed her one by one, and when she arrived at Dr. Chugh’s office for another opinion, her symptoms were unclear and her diagnostic workup was delayed by the realities of life: busy schedules, long waiting times, and slow authorizations.
In the past, getting answers often took months. But on that very first visit, Dr. Chugh performed an intestinal ultrasound. In real time, she saw the problem clearly: active disease in the terminal ileum with pre-stenotic bowel dilation.
“I was able to confirm that she had active TI disease, started the authorization process for risankizumab right away, and therefore, even before her labs came back, I was able to get her started on risankizumab in this case,” she said. “This case highlights how intestinal ultrasound accelerates IBD care.”
Dr. Chugh, who is also education committee chair of the Intestinal Ultrasound Group of the United States and Canada (iUSCAN), added that patients prefer intestinal ultrasound because it doesn’t require bowel prep, fasting, diet changes, contrast, or sedation, and it takes only 5-20 to perform, often providing results in real time. “Over and over, patients say they feel more supported, better informed, and more confident in their care,” she said.
Other reasons to embrace intestinal ultrasound include the following:
It saves costs. She cited a prospective observational study by Australian researchers in which an IBD nurse used a symptom severity-based protocol to triage 211 episodes of care over the course of 30 weeks. Based on clinical urgency, patients were discussed with their specialist, referred for rapid access intestinal ultrasound, or planned for hospitalization. The study authors estimated that the protocol avoided 20 hospitalizations, 123 urgent IBD clinic reviews, and saved more than $146,000 Australian dollars in health care costs.
It’s accurate. According to a review that Dr. Chugh and colleagues published in Current Gastroenterology Reports, ultrasound correlates strongly with endoscopy, biomarkers, and MRI. It detects inflammation, tracks response to therapy within weeks, and reliably excludes active disease when findings are normal. For example, in a prospective study of 407 Crohn’s disease patients who underwent intestinal ultrasound or small intestinal contrast ultrasound followed by computer tomography enterography or magnetic resonance enterography, ultrasound showed sensitivity/specificity of 95.3%/93.0% for disease activity and 90.7%/90.5% for extent.
It's the future. For example, the STARDUST substudy used intestinal ultrasound to examine the most affected part of the bowel at the start of treatment, with experts centrally reviewing key measurements in patients treated with ustekinumab. REASON is a phase 3b study focused on healing through the full bowel wall and uses intestinal ultrasound and magnetic enterography to measure how patients respond to guselkumab. VECTORS is a phase 4 randomized study that takes a treat-to-target approach and includes intestinal ultrasound results as part of how response to vedolizumab is assessed.
Intestinal ultrasound as a method of disease monitoring has also made its way into standard of care documents, including a clinical practice update from AGA and a guideline from the European Crohn’s and Colitis Organization (ECCP), the European Society of Gastrointestinal and Abdominal Radiology (ESGAR), the European Society of Pathology (ESP), and the International Bowel Ultrasonography Group (IBUS).
“Intestinal ultrasound is the present; it's here,” Dr. Chugh concluded. “If you are not incorporating ultrasound into your practice, you may find yourself left behind, because it's really made its way already into the mainstream of IBD care.”
She reported having no relevant disclosures.
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The guidelines emphasize four-hour gastric emptying studies over two-hour testing. How do you see this affecting diagnostic workflows in practice?
Dr. Staller: Moving to a four-hour solid-meal scintigraphy will actually simplify decision-making. The two-hour reads miss a meaningful proportion of delayed emptying; standardizing on four hours reduces false negatives and the “maybe gastroparesis” purgatory that leads to repeat testing. Practically, it means closer coordination with nuclear medicine (longer slots, consistent standardized meal), updating order sets to default to a four-hour protocol, and educating front-line teams so patients arrive appropriately prepped. The payoff is fewer equivocal studies and more confident treatment plans.
Metoclopramide and erythromycin are the only agents conditionally recommended for initial therapy. How does this align with what is being currently prescribed?
Dr. Staller: This largely mirrors real-world practice. Metoclopramide remains the only FDA-approved prokinetic for gastroparesis, and short “pulsed” erythromycin courses are familiar to many of us—recognizing tachyphylaxis limits durability. Our recommendation is “conditional” because the underlying evidence is modest and patient responses are heterogeneous, but it formalizes what many clinicians already do: start with metoclopramide (lowest effective dose, limited duration, counsel on neurologic adverse effects) and reserve erythromycin for targeted use (exacerbations, bridging).
Several agents, including domperidone and prucalopride, received recommendations against first-line use. How will that influence discussions with patients who ask about these therapies?
Dr. Staller: Two points I share with patients: evidence and access/safety. For domperidone, the data quality is mixed, and US access is through an FDA IND mechanism; you’re committing patients to EKG monitoring and a non-trivial administrative lift. For prucalopride, the gastroparesis-specific evidence isn’t strong enough yet to justify first-line use. So, our stance is not “never,” it’s just “not first.” If someone fails or cannot tolerate initial therapy, we can revisit these options through shared decision-making, setting expectations about benefit, monitoring, and off-label use. The guideline language helps clinicians have a transparent, evidence-based conversation at the first visit.
The guidelines suggest reserving procedures like G-POEM and gastric electrical stimulation for refractory cases. In your practice, how do you decide when a patient is “refractory” to medical therapy?
Dr. Staller: I define “refractory” with three anchors.
1. Adequate trials of foundational care: dietary optimization and glycemic control; an antiemetic; and at least one prokinetic at appropriate dose/duration (with intolerance documented if stopped early).
2. Persistent, function-limiting symptoms: ongoing nausea/vomiting, weight loss, dehydration, ER visits/hospitalizations, or malnutrition despite the above—ideally tracked with a validated instrument (e.g., GCSI) plus nutritional metrics.
3. Objective correlation: delayed emptying on a standardized 4-hour solid-meal study that aligns with the clinical picture (and medications that slow emptying addressed).
At that point, referral to a center with procedural expertise for G-POEM or consideration of gastric electrical stimulation becomes appropriate, with multidisciplinary evaluation (GI, nutrition, psychology, and, when needed, surgery).
What role do you see dietary modification and glycemic control playing alongside pharmacologic therapy in light of these recommendations?
Dr. Staller: They’re the bedrock. A small-particle, lower-fat, calorie-dense diet—often leaning on nutrient-rich liquids—can meaningfully reduce symptom burden. Partnering with dietitians early pays dividends. For diabetes, tighter glycemic control can improve gastric emptying and symptoms; I explicitly review medications that can slow emptying (e.g., opioids; consider timing/necessity of GLP-1 receptor agonists) and encourage continuous glucose monitor-informed adjustments. Pharmacotherapy sits on top of those pillars; without them, medications will likely underperform.
The guideline notes “considerable unmet need” in gastroparesis treatment. Where do you think future therapies or research are most urgently needed?
Dr. Staller: I see three major areas.
1. Truly durable prokinetics: agents that improve emptying and symptoms over months, with better safety than legacy options (e.g., next-gen motilin/ghrelin agonists, better-studied 5-HT4 strategies).
2. Endotyping and biomarkers: we need to stop treating all gastroparesis as one disease. Clinical, physiologic, and microbiome/omic signatures that predict who benefits from which therapy (drug vs G-POEM vs GES) would transform care.
3. Patient-centered trials: larger, longer RCTs that prioritize validated symptom and quality-of-life outcomes, include nutritional endpoints, and reflect real-world medication confounders.
Our guideline intentionally highlights these gaps to hopefully catalyze better trials and smarter referral pathways.
Dr. Staller is with the Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston.