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Abstract

Introduction:

Intestinal ultrasound (IUS) is a non-invasive, accurate, and increasingly utilized tool for the assessment and monitoring of inflammatory bowel disease (IBD).

Objectives:

This Australian survey, endorsed by the Gastroenterology Network of Intestinal Ultrasound (GENIUS), aimed to evaluate clinician attitudes toward IUS and identify barriers to its broader national implementation.

Design:

National cross-sectional observational study.

Methods:

An online survey was distributed to adult and pediatric gastroenterologists and trainees across Australia, with data collected between September and December 2024.

Results:

One hundred twenty-two respondents participated, comprising adult (52%), pediatric (25%), and trainee (23%) gastroenterologists, with two-thirds reporting a subspecialty interest in IBD. Nearly all agreed that IUS has clinical utility in Crohn’s disease (99%) and ulcerative colitis (96%), with 96% considering IUS standard of care in IBD. Clinical confidence in IUS was high (84%), particularly among IBD specialists (95% vs 73%; p < 0.01), though lower than for colonoscopy (98%) and magnetic resonance enterography (MRE; 97%). IUS was also perceived as more resource-efficient than colonoscopy (96%) and MRE (88%). While 82% of respondents had access to IUS, mainly in an outpatient capacity, availability was lower in non-metropolitan locations. Among clinicians without access, almost all agreed that IUS access would improve IBD care; with scarcity of IUS funding and trained personnel cited as barriers. Almost half of the respondents had completed or were undertaking IUS training, with 40% of remaining respondents interested in future training.

Conclusion:

Australian gastroenterologists widely support IUS in IBD care. Expanding access to IUS requires renewed focus on service development and training initiatives, particularly in underserved areas, and cost-effectiveness studies to support these efforts.

Plain language summary

How Australian gastroenterologists view and use intestinal ultrasound in inflammatory bowel disease

Patients with inflammatory bowel disease (IBD), including Crohn’s disease and ulcerative colitis, need close monitoring to assess disease activity and guide treatment decisions. Intestinal ultrasound (IUS) is a safe, accurate, and non-invasive imaging tool that allows clinicians to assess bowel inflammation without invasive and uncomfortable procedures such as colonoscopy and MRI. In this Australian survey, supported by the Gastroenterology Network of Intestinal Ultrasound (GENIUS), we asked gastroenterologists about their views on IUS. We received 122 responses from adult and pediatric gastroenterologists and trainees across Australia. Almost all respondents believed IUS is useful for managing IBD, and that access to IUS should be part of standard IBD care. Most felt confident using IUS to guide clinical decisions, and considered it more resource efficient than both colonoscopy and MRI. Although most respondents had access to IUS, availability was more limited in non metropolitan locations. Among respondents without access, almost all agreed that access to IUS would enhance the care of IBD patients. The main barriers identified were a lack of trained staff and funding to establish and support IUS service development. Encouragingly, nearly half of respondents had completed or were currently undertaking IUS training, and many others were interested in future training. Overall, there is strong support for the use of IUS in IBD care in Australia. Expanding access will require further investment in IUS training and service development.

Keywords

access gastrointestinal ultrasound health care quality inflammatory bowel disease

Introduction

Inflammatory bowel diseases (IBD), including Crohn’s disease and ulcerative colitis, are chronic, incurable conditions affecting an estimated 179,420 Australians.¹ The economic burden of IBD remains substantial, with diagnostic investigations accounting for up to 26% of healthcare costs in the first year following diagnosis, and 8%–12% annually thereafter.² Monitoring disease activity often requires repeated visualization of the bowel using colonoscopy and/or magnetic resonance enterography (MRE); although effective, these methods are invasive, resource-intensive, and poorly suited for timely, frequent monitoring recommended in current guidelines.^3–7

Intestinal ultrasound (IUS) has emerged as an accurate, non-invasive, and repeatable tool for the assessment and monitoring of IBD.^8,9 Patients prefer IUS over MRE and colonoscopy, and its use has been associated with improved disease-specific patient knowledge.^10,11 Furthermore, centers that have adopted IUS have reported clinical workflow efficiencies and shorter wait times for patients presenting with mild or moderate disease.¹² Despite these advantages, access and expertise in IUS are not yet universal.¹³ A 2022 survey of 106 UK-based gastroenterologists found that fewer than one-third had access to IUS, and confidence in IUS-based decision-making was markedly lower than for MRE. Notably, 37.7% of respondents reported little to no confidence in using IUS to guide clinical decisions, compared to just 1.9% for MRE.¹⁴ These findings highlight the need to better understand clinician attitudes toward IUS, and examine factors influencing its accessibility, including access and demand for future training.

In response to growing interest in IUS in clinical practice, several organizations have emerged to promote its integration into routine IBD care. In Australia, the Gastroenterology Network of Intestinal Ultrasound (GENIUS) has led national efforts to integrate IUS into IBD care and standardize training pathways. This nationwide survey of adult and pediatric gastroenterologists, as well as gastroenterology trainees, aims to evaluate clinician attitudes toward IUS and identify potential barriers to its broader implementation in an Australian IBD context.

Methods

Study design

This prospective cross-sectional observational study utilized a Research Electronic Data Capture (REDCap) survey developed and distributed to adult and pediatric gastroenterologists and trainees across Australia (Supplemental Appendix A).^15,16 Survey themes and questions were developed by consensus, with three key themes related to IUS identified: clinician attitudes, access, and training. The final survey was organized into four sections, designed to capture perspectives across identified themes. Survey questions included a combination of multiple-choice items (single and multiple answers) and responses measured using a 5-point Likert scale. Agreement was defined as responses of “Agree” or “Strongly Agree,” while “Disagree” and “Strongly Disagree” were categorized as disagreement. Responses of “Neutral” or “Unsure” were excluded from both categories in the analysis. The reporting of this study conforms to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) statement.¹⁷

Data collection

The survey was distributed between September and December 2024 using multiple methods. Initial dissemination occurred during the Australian Gastroenterology Week (AGW) national conference, held in Adelaide in September 2024. Following the conference, the survey link was circulated via email through established Australian adult and pediatric gastroenterology networks. To minimize duplicate responses, participants were explicitly instructed at the beginning of the survey not to complete it if they had already done so.

Statistics

Descriptive statistics were used to summarize survey findings. Categorical data were reported as proportions (percentages) and analyzed through cross-tabulation statistics using either the chi-square or Fisher’s exact tests, as appropriate. Statistical analyses were undertaken using R statistical software (version 4.2.2, R Core Team 2025).

Ethics approval

The study was approved by the Human Research Ethics Committee at Austin Health (HREC/111182/Austin) and conducted in accordance with the Declaration of Helsinki.

Results

A total of 122 clinicians from across Australia participated in the survey, representing all states and territories except the Northern Territory. Respondents comprised adult (52%), pediatric (25%), and trainee (23%) gastroenterologists (Table 1), with approximately two-thirds self- identifying as IBD subspecialists. Among gastroenterologists, years since fellowship (1–5 years: 37%; 6–10 years: 26%; ⩾11 years: 37%) were evenly distributed and almost half (49%) of respondents were involved in the care of gastroenterology patients in rural or regional locations.

Table 1.

Overview of respondent demographics.

	All (n = 122)	Adult gastroenterologist (n = 64)	Pediatric gastroenterologist (n = 30)	Trainees gastroenterologist^a (n = 28)
IBD specialists	64 (52.5)	46 (71.9)	18 (60)	−
Clinical experience
Trainee/Fellow	28 (22.9)
Consultant: 1–5 years	35 (28.7)	28 (43.8)	7 (23.3)	−
Consultant: 6–10 years	24 (19.7)	18 (28.1)	6 (20.0)	−
Consultant: >11 years	35 (28.7)	18 (28.1)	17 (56.7)	−
Clinical practice setting
Public healthcare only	47 (38.5)	9 (14.1)	11 (36.7)	27 (96.4)
Public and private healthcare	74 (60.7)	55 (85.9)	18 (60.0)	1 (3.6)
Private only	1 (0.8)	0 (0)	1 (3.3)	0 (0)
Clinical practice location
Metropolitan only	62 (50.8)	29 (45.3)	15 (50)	18 (64.3)
Both metropolitan and rural	45 (36.9)	24 (37.5)	15 (50)	6 (21.4)
Regional and rural only	15 (12.3)	11 (17.2)	0 (0)	4 (14.3)
IUS expertise
Completed training	36 (29.5)	30 (46.9)	3 (10)	3 (10.7)
Currently training	23 (18.9)	8 (12.5)	3 (10)	12 (42.9)
Interested in future training	25 (20.5)	9 (14.1)	8 (26.7)	8 (28.6)
Not interested in training	38 (31.1)	17 (26.6)	16 (53.3)	5 (17.9)

Trainee participants did not specify adult or pediatric stream.

IBD, inflammatory bowel disease; IUS, intestinal ultrasound.

Clinician attitudes toward IUS

Nearly all respondents agreed that IUS has clinical utility in the management of Crohn’s disease (99%) and ulcerative colitis (96%; Figure 1(a)), with 96% considering the application of IUS to now be standard of care in IBD. Three-quarters of respondents cited healthcare costs as an influential factor in their choice of IBD investigation, with most perceiving IUS as requiring fewer healthcare resources than colonoscopy (96%) and MRE (88%). Wait times for IUS, MRE, and colonoscopy were cited by 87% of clinicians as an influential factor when choosing an IBD investigation.

Figure 1.

Clinician attitudes toward IUS in inflammatory bowel disease (n = 122). (a) Perceived utility of IUS in Crohn’s disease and ulcerative colitis. (b) Clinician comfort in managing inflammatory bowel disease across diagnostic modalities (n = 122).

Overall, 84% of clinicians felt comfortable using IUS to guide IBD management, although this was significantly lower than for colonoscopy (98%) and MRE (97%; p < 0.001; Figure 1(b)). Comfort with IUS was higher among IBD subspecialists compared to non-specialists (95% vs 73%; p = 0.006). IUS was perceived as comparable to MRE for the assessment of ileal Crohn’s disease by 81% of clinicians and was also favored by 81% as a monitoring tool in pregnant IBD patients. IUS was also perceived to be useful in distinguishing symptoms due to active and inactive IBD, from those attributable to co-existing functional gastrointestinal disorders by 95% of respondents.

Access to IUS and MRE

Clinicians reported managing IBD patients across metropolitan (51%), regional/rural (12%), and mixed (37%) healthcare settings. Overall, 82% of respondents had access to IUS as an imaging modality, compared to universal (100%) access to MRE. Adult gastroenterologists had greater access to IUS compared to pediatric gastroenterologists (84% vs 64%; p = 0.08). Notably, IUS was available in almost all Australian states (Figure 2), with service provision via outpatient (72%), point-of-care (38%), and inpatient (29%) settings. Among respondents with access to IUS, over two-thirds (69%) could access IUS imaging within 6 weeks and 91% within 3 months, compared to 27% and 72%, respectively, at the same timepoints for MRE (Figure 3). Most clinicians (88%) agreed that access to IUS improved the care of their IBD patients and reduced reliance on MRE (70%) and colonoscopy (73%).

Figure 2.

A national snapshot of IUS access in Australia based on survey responses (n = 122).

Figure 3.

Average wait times for the assessment of inflammatory bowel disease using IUS compared to MR enterography.

Among respondents who did not have access to IUS (n = 22), 21 (96%) believed that having access to IUS would improve patient care and 1 (4.5%) was neutral. The primary service level barriers to IUS were a lack of funding for ultrasound equipment and a shortage of trained personnel. Notably, 85% of clinicians working across mixed healthcare settings (metropolitan and regional/rural) reported poorer IUS access in non-metropolitan areas.

IUS training

Half of the respondents had either completed (30%) or were currently undertaking (19%) IUS training. A greater proportion of adult gastroenterologists had completed or were undertaking IUS training compared to pediatric gastroenterologists (59% vs 20%; p < 0.001). Of those who had completed IUS training, two-thirds reported performing up to 400 scans annually, and 26 of the 36 trained clinicians were actively involved in IUS training. Most respondents (53%) considered a minimum of 150 supervised scans, including at least 75 abnormal IBD cases, as sufficient for competency. Twenty-nine percent of respondents considered 150–200 scans sufficient for competency, while 19% believed that more than 200 scans were required. Among the 63 remaining respondents not performing IUS, 40% expressed interest in pursuing IUS training in the future; with a greater proportion of trainee (62%) gastroenterologists reporting interest compared to adult (35%) and pediatric (33%) gastroenterologists.

Discussion

This survey is the first to characterize the current landscape of IUS use and clinician perceptions among adult and pediatric gastroenterologists and trainees in an Australian context. There was strong consensus on the clinical utility of IUS in both Crohn’s disease and ulcerative colitis, with nearly all respondents considering the use of IUS in IBD as standard of care. These findings also reflect a broader trend toward the first-line use of non-invasive, patient-centered approaches for IBD monitoring.^8,18,19

Clinician confidence in IUS-based decision-making was high (84%), albeit lower than both colonoscopy (98%) and MRE (97%). These findings show higher confidence in IUS than the 2022 survey findings of UK gastroenterologists, in which only 6% reported a high degree of confidence in IUS-directed clinical decision-making, which may be reflective of accelerated uptake of IUS over the intervening period.¹⁴ A 2014 review highlighted that IUS was significantly underutilized in the Asia-Pacific region, particularly in Australia, where at the time only one hospital routinely offered IUS services for IBD.²⁰ This contrasted with extensive adoption across several European countries, including Italy and Germany, where integration of IUS into IBD care and gastroenterology training has been entrenched for decades.^20,21 Over the past decade, increased access and exposure to IUS at several leading Australian IBD centers have contributed to its widespread uptake and nationwide acceptance, potentially explaining the observed improvements in access and clinician confidence in Australia.

Most clinicians viewed healthcare costs and resource use as important factors in selecting IBD investigations, with IUS perceived by respondents as more resource-efficient than colonoscopy and MRE. These perceptions are supported by UK health-economic modeling, indicating that up to 55% of MREs and 28% of colonoscopies could potentially be replaced by IUS, resulting in substantial healthcare cost savings.²² Similar findings were reported in an Australian IBD context, suggesting that integration of IUS into IBD care can reduce the use of MRE and colonoscopy to deliver substantial cost savings.²³ Another retrospective Australian study found that the number of endoscopies performed for the evaluation of IBD per patient was halved in the IUS era (14 per 100 patients), compared to the pre-IUS era (29 per 100 patients).²⁴ Furthermore, a recent Australian study evaluated the impact of point-of-care IUS on clinical decision-making, illustrating that it supported patient management decisions and reduced the need for additional investigations.⁹

Respondents identified wait times as influencing their choice of disease monitoring modality, reflecting the well-established association between diagnostic delays and adverse disease outcomes in IBD.^4,25,26 The reported median wait time for IUS was less than 6 weeks, which was lower than the wait time for MRE. While 82% of all respondents reported access to IUS, access was notably more limited in regional and rural areas compared to metropolitan areas. Nevertheless, access to IUS in Australia compares favorably to a UK-based survey in which only 30% of gastroenterologists reported access to an IUS service.¹⁴ An earlier UK-based questionnaire conducted in 2011 reported that 46% of departments performed small bowel ultrasound, with greater uptake among radiologists than gastroenterologists.²⁷ This proportion remained unchanged (19/41 centers offering IUS) in a 2022 radiologist-led multi-center audit of abdominal imaging in IBD. Notably, the audit found IUS to be the least utilized abdominal imaging modality, with significant regional variation, as five centers accounted for 81% of all IUS performed.²⁸ A qualitative semi-structured interview study of 14 participants conducted in the United Kingdom in 2021 identified behavioral and cultural barriers to IUS adoption, including a perceived reluctance to change practice and limited availability of formal training pathways.²⁹ Among Australian clinicians without access, key barriers included a lack of trained personnel, limited equipment availability and funding, and inadequate institutional support. These findings offer valuable and actionable insights for IUS-focused organizations, such as GENIUS, to help drive the expansion and integration of IUS through targeted workforce training and service development in underserved areas.

Non-invasive investigations such as IUS are particularly valuable in the diagnosis and monitoring of pediatric IBD.³⁰ In our cohort, almost two-thirds of pediatric gastroenterologists reported access to IUS, a notably lower proportion compared to 84% of adult gastroenterologists. Similarly, fewer pediatric clinicians had completed IUS training, although the proportion of pediatric gastroenterologists interested in future IUS training was higher than that of adult specialists. These findings highlight a need for targeted support to facilitate the integration of IUS into pediatric IBD care in Australia, including consideration of pediatric-specific service models, credentialing pathways, and how adult-focused training frameworks translate to pediatric practice.

High-quality training is essential to support the wider adoption of IUS. In this survey, 49% of clinicians had completed or were currently undertaking IUS training, while 40% of untrained respondents expressed interest in future training reflective of future demand. This was pronounced among trainee gastroenterologists, who were almost twice as likely to be interested in future training compared to adult gastroenterologists. Among clinicians who had completed IUS training, two-thirds reported performing up to 400 scans per year, and most were also involved in training others. While opinions on training requirements varied, the majority agreed that at least 150 supervised scans, including 75 abnormal IBD cases, were sufficient for competency. This remains comparable with GENIUS’ clinical training recommendations of 150 supervised scans, including 100 with IBD and 50 with pathology. Collectively, these findings highlight the need for structured and scalable training programs to meet growing interest in IUS.

This survey is one of the largest and most comprehensive to examine attitudes toward the use of IUS in IBD care, with strong participation from adult and pediatric gastroenterologists and trainees. This broad representation offers valuable insights into the current access, training, and use of IUS in an Australian IBD context. Nevertheless, several limitations must also be acknowledged. As with all voluntary surveys, there is a risk of participation bias, with potential over-representation of clinicians already engaged or interested in IUS, with a high proportion of respondents identifying as IBD subspecialists and limited private-only general gastroenterologists. This may overestimate the provision of IUS and positive attitudes relative to the broader Australian gastroenterology workforce, particularly in non-hospital-based settings, where implementation barriers may differ. Additionally, responses were self-reported and therefore reflect perceptions, rather than independently verified patient outcomes or utilization rates. The survey was disseminated widely through conference-based distribution and national professional networks. As such, the total number of clinicians who received the invitation could not be reliably determined to calculate a response rate. This limits the ability to quantify non-response bias and constrains national generalizability. Survey questions were generated under consensus opinion, without formal validation, with the aim of encouraging greater participation by limiting survey length and question complexity.

Conclusion

This national survey demonstrates overwhelmingly positive perceptions of IUS among Australian gastroenterologists, with high levels of clinician interest, confidence, and recognition of its clinical value. These findings underscore a clear need for healthcare systems to prioritize coordinated investment in IUS training, infrastructure, and service development, particularly in rural and regional settings where access remains limited. Integration of IUS into standard IBD care pathways represents a practical, cost-effective, and patient-centered strategy to enhance disease monitoring and support timely therapeutic decision-making. However, realizing these benefits at scale will require targeted workforce training, particularly amongst pediatric gastroenterologists and trainees, and service expansion initiatives. Future research should evaluate the health-economic impact of IUS, including potential reductions in colonoscopy use, cross-sectional imaging, hospitalization, and delays to treatment escalation.

Supplemental Material

sj-docx-1-tag-10.1177_17562848261432538 – Supplemental material for Examining attitudes to intestinal ultrasound in inflammatory bowel disease: a national survey of Australian gastroenterologists

Supplemental material, sj-docx-1-tag-10.1177_17562848261432538 for Examining attitudes to intestinal ultrasound in inflammatory bowel disease: a national survey of Australian gastroenterologists by Lynna Chen, Leonie Ruddick-Collins, Yoon-Kyo An, Brandon Baraty, Jakob Begun, Ray K. Boyapati, Robert V. Bryant, Rebecca L. Smith and Ashish R. Srinivasan in Therapeutic Advances in Gastroenterology

Footnotes

Acknowledgements

None.

Declarations

ORCID iDs

Lynna Chen

Ashish R. Srinivasan

Supplemental material

Supplemental material for this article is available online.

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