Computer-aided diagnosis (CAD) offers a promising solution to reduce variation in colonoscopy performance. Pooled miss rates as high as 22% for polyps and associated interval colorectal cancers following colonoscopy are concerning. Meanwhile, the concept of 'optical biopsy' where in vivo classification of polyps based on enhanced imaging replaces histopathology has not been incorporated into routine practice, largely limited by inter-observer variability and generally meeting accepted standards only in expert settings. Real-time decision support software has been developed to detect and characterise polyps, whilst also offering feedback on the technical quality of inspection. Some of the current algorithms, particularly with recent advances in artificial intelligence techniques, now match human expert performance for optical biopsy. This article will review the current evidence in relation to the clinical applications of CAD and artificial intelligence in colonoscopy.