Background: Endoscopic assessment is central to the management of inflammatory bowel disease (IBD), particularly within treat-to-target strategies. However, conventional high-definition white-light endoscopy (HD-WLE) is limited by interobserver variability and its inability to reliably reflect microscopic inflammation or predict long-term outcomes. Over the last decade, multiple technological innovations have reshaped the role of endoscopy in both disease activity monitoring and dysplasia surveillance. Methods: This narrative review provides a comprehensive and clinically oriented overview of emerging endoscopic technologies in IBD, including image-enhanced endoscopy, ultra-high-magnification techniques, artificial intelligence (AI), and molecular imaging. We discuss their diagnostic performance, prognostic implications, and potential integration into clinical practice. Results: Image-enhanced endoscopy improves visualization of subtle mucosal and vascular alterations and demonstrates stronger correlation with histological activity compared with HD-WLE alone. Confocal laser endomicroscopy and endocytoscopy enable in vivo microscopic assessment of epithelial architecture and barrier integrity, redefining remission beyond macroscopic healing. AI systems have shown expert-level performance in grading inflammatory severity in ulcerative colitis and high sensitivity in capsule endoscopy for Crohn’s disease, supporting objective and reproducible assessment. In surveillance, targeted high-definition inspection has replaced random biopsies, while adjunctive optical and AI-based tools enhance lesion detection and characterization. Molecular imaging introduces a predictive dimension by enabling visualization of drug–target engagement and dysplasia-specific pathways. Conclusions: Endoscopy in IBD is evolving from a descriptive modality toward a multimodal precision tool integrating enhanced imaging, AI-driven standardization, and molecular profiling. Although further validation and cost-effectiveness studies are required, these innovations have the potential to improve therapeutic stratification, surveillance strategies, and long-term patient outcomes.