Endoscopy, in full.

General post-polypectomy surveillance still follows USMSTF 2020 (Gupta et al.), which has not been replaced: 1-2 tubular adenomas <10 mm, 7-10 years; 3-4 tubular adenomas <10 mm, 3-5 years; 5-10 tubular adenomas <10 mm, any adenoma ≥10 mm, or an adenoma with tubulovillous/villous histology or high-grade dysplasia, 3 years; >10 adenomas, 1 year with polyposis evaluation. For serrated polyps: 1-2 SSLs <10 mm, 5-10 years; 3-4 SSLs <10 mm or a hyperplastic polyp ≥10 mm, 3-5 years; an SSL ≥10 mm, an SSL with dysplasia, or a traditional serrated adenoma, 3 years. When findings are mixed, use the shortest interval indicated. Before applying an interval, confirm complete resection and adequate prep. Piecemeal resections get a site check, and malignant (T1) polyps go to a tumor-board pathway. Serrated polyposis syndrome (SPS) is now governed by a separate USMSTF consensus statement (Rex et al., published simultaneously in Gastroenterology, Am J Gastroenterol and GIE on 2026-09-30). It has 11 recommendations. Diagnose SPS with the 2019 WHO criteria, which count the size, cumulative lifetime number and location of serrated polyps. Until SPS is diagnosed, record the number, size and location of serrated polyps in every colonoscopy report. SPS colonoscopy should be done by endoscopists with documented adequate SSL detection, using high-definition white light with or without chromoendoscopy. Without concurrent CRC, endoscopy is preferred over surgery for primary management. If the polyp burden cannot be managed endoscopically, refer to an advanced endoscopic resection expert before surgery. Resect SSLs and hyperplastic polyps by cold snare, with submucosal injection for larger lesions. Do clearance colonoscopy at 3-6 months, then surveil every 1-2 years. Consider 3-year intervals if the burden is greatly reduced at surveillance. First-degree relatives start colonoscopy at age 40, or 10 years before the youngest CRC diagnosis in the family, or 5 years before the youngest SPS diagnosis, whichever comes first. SPS has no established genetic basis, so germline testing is recommended only when concurrent non-serrated polyps suggest a heritable syndrome. Lynch, FAP/AFAP and MAP criteria still trigger genetic evaluation.

Evaluate for achalasia any patient with dysphagia to solids and liquids, regurgitation, or chest pain, and specifically consider it in patients presumed to have GERD who do not respond to acid suppression (strong recommendation, very low quality). Diagnose with high-resolution manometry using esophageal pressure topography rather than conventional line tracings (strong, high). Subtype by Chicago Classification (I, II, III), this is a conditional recommendation (low quality): subtyping may inform prognosis and treatment choice, with type II having the most favorable outcomes and type III requiring a longer/tailored myotomy; ACG does not make subtyping mandatory for diagnosis. Always perform upper endoscopy in suspected achalasia to exclude pseudoachalasia from an obstructing mass; use cross-sectional imaging and/or endoscopic ultrasound in difficult cases (ACG states this as narrative guidance, not a numbered recommendation, and specifies no biopsy protocol). FLIP is described as complementary, useful in patients who cannot tolerate manometry and as an arbiter in difficult cases where manometry fails to diagnose achalasia despite high clinical suspicion, not as a required confirmatory test. TREATMENT: pneumatic dilation is superior to medical therapy for symptom relief and esophageal emptying (strong, very low). PD and laparoscopic Heller myotomy are both effective and equivalent short- and long-term for patients who are candidates for definitive therapy (strong, high). POEM and LHM give comparable symptomatic improvement (strong, moderate). POEM and PD give comparable symptomatic improvement in type I or II (conditional, low). For type III, tailored POEM or LHM is recommended as a more efficacious disruptive LES therapy than PD (strong, moderate), ACG does NOT single out POEM over LHM for type III. When surgical myotomy is performed, add fundoplication: myotomy with fundoplication is superior to myotomy alone for controlling distal esophageal acid exposure (strong, moderate), using either Dor or Toupet (conditional, moderate). Botulinum toxin injection is first-line therapy for patients unfit for definitive therapy (strong, moderate), and prior botulinum toxin does not significantly compromise subsequent myotomy performance or outcomes (strong, low). POEM carries a higher incidence of GERD than LHM with fundoplication or PD (strong, moderate). Do not place stents for long-term dysphagia (strong, low). Reserve esophagectomy for surgically fit patients with megaesophagus who have failed other interventions (strong, low), and consider Heller myotomy before esophagectomy in patients who failed PD and POEM when the anatomy is conducive and there is evidence of incomplete myotomy (strong, very low). FOLLOW-UP: use timed barium esophagram as the first-line test to evaluate continued or recurrent symptoms after definitive therapy (strong, very low); the Eckardt score alone or HRM alone should not be used to define treatment failure. Do not obtain routine gastrografin esophagram after dilation, reserve it for clinical suspicion of perforation (strong, low). RETREATMENT: PD is appropriate and safe after failed surgical myotomy or POEM (strong, moderate), and POEM is safe in patients who previously underwent PD or LHM (strong, low). SURVEILLANCE: ACG recommends AGAINST routine endoscopic surveillance for esophageal carcinoma in patients with achalasia (strong, low), although risk is elevated (~1 cancer per 300 patient-years), absolute numbers are low, an estimated >400 endoscopies would be needed to detect one cancer, and surveillance has not demonstrated improved survival.

Outpatient positioning is unchanged from the ACG 2025 UC guideline and the AGA living guideline for moderate-to-severe UC. Confirm UC with endoscopy showing continuous colonic inflammation from the rectum plus histology, after excluding infection with two-step C. difficile testing. Treat mild-moderate disease with 5-ASA chosen by route and extent: suppository for proctitis, enema for left-sided disease, oral plus rectal for extensive disease. If 5-ASA fails, treat as moderate-to-severe rather than stepping up gradually. Position advanced therapy by efficacy tier, not by an anti-TNF-first rule. Advanced-therapy-naive, higher efficacy: infliximab, vedolizumab, ozanimod, etrasimod, upadacitinib, risankizumab, guselkumab. Intermediate: golimumab, ustekinumab, tofacitinib, filgotinib, mirikizumab. Lower: adalimumab. Previously TNF-exposed, higher efficacy: tofacitinib, upadacitinib, ustekinumab. Lower: adalimumab, vedolizumab, ozanimod, etrasimod. After anti-TNF primary non-response, switch mechanism rather than cycling within the class. Treat to target (STRIDE-II): endoscopic improvement, Mayo endoscopic subscore 0-1. Begin CRC surveillance 8-10 years after diagnosis for extensive or left-sided disease; isolated proctitis follows average-risk screening. Inpatient care now follows the 2026 AGA Clinical Practice Update (13 best-practice statements). Admit for severe symptoms refractory to outpatient therapy, suspected complications (obstruction, abscess, toxic megacolon) or significant malnutrition, and identify acute severe UC by Truelove-Witts. Give every patient admitted with diarrhea two-step C. difficile testing. Test for CMV, with early endoscopy, if symptoms worsen, the patient is systemically toxic or disease is steroid-refractory. Give routine VTE prophylaxis with LMWH or fondaparinux unless contraindicated, and individualize post-discharge extension. Give IV methylprednisolone 60 mg/day or equivalent; the AGA living guideline says 40-60 mg/day, and higher doses add no benefit. Do not give adjunctive antibiotics without infection. Involve surgery early. Assess response by day 3 (72 h) using stool frequency and CRP (Oxford criteria); do not continue IV steroids beyond about 7 days without response. Rescue steroid non-responders with infliximab (accelerated or intensified dosing in selected patients with high inflammatory burden or protein-losing colopathy), cyclosporine, or a JAK inhibitor at standard or intensified dosing, or with colectomy. Before discharge, the response should be stable and a transition plan should be in place.

Per NCCN Neuroendocrine and Adrenal Tumors v2.2025: Work up a suspected pancreatic NET with multiphasic pancreatic-protocol contrast CT and/or MRI; consider EUS with biopsy (FNB) for tissue; use somatostatin-receptor imaging with 68Ga- or 64Cu-DOTATATE PET/CT when it will change management. Obtain biochemical/hormonal evaluation only when a functional syndrome is clinically suspected (not routine for nonfunctioning tumors). Grade by mitotic count and Ki-67 under the WHO classification of neuroendocrine neoplasms (G1 <3%, G2 3-20%, G3 >20%). Consider genetics referral/germline testing for inherited syndromes, principally MEN1 and VHL (less commonly NF1, TSC). LOCALIZED well-differentiated G1/G2: for an incidentally found sporadic nonfunctioning tumor <=2 cm without high-risk features, that is, none of the worrisome imaging/pathologic features that favor resection: main pancreatic-duct dilation (>3 mm) or biliary-duct obstruction, pathologic regional lymphadenopathy on cross-sectional imaging, or vascular encasement/invasion of adjacent structures (grade, functional/symptomatic status, size >2 cm, and interval growth are addressed separately below), NCCN lists BOTH observation and surgery as options; observed lesions are followed with multiphasic CT/MRI (± SSTR-PET as indicated) at 3-12 months, then every 6-12 months if stable. For tumors >2 cm, functional/symptomatic, higher-grade, or enlarging on surveillance, surgical resection (enucleation, distal pancreatectomy, or pancreaticoduodenectomy by location) is recommended and can be curative. ADVANCED/METASTATIC well-differentiated: somatostatin analogs (octreotide LAR or lanreotide) are a preferred first-line option for SSTR-positive, lower-grade/lower-proliferation tumors. 177Lu-DOTATATE PRRT is now also a first-line option for SSTR-positive disease on the strength of NETTER-2, whose population was newly diagnosed grade 2/3 GEP-NET with Ki-67 10-55% (median PFS 22.8 vs 8.5 months), keep the Ki-67 10-55% window and SSTR-positivity as the qualifiers, not an open-ended 'Ki-67 >=10%.' Subsequent-line options for progressive disease include everolimus, sunitinib (pancreatic primary), CAPTEM (capecitabine + temozolomide), PRRT if not already used, and cabozantinib, FDA-approved March 26, 2025 and included by NCCN as a category 1 option for previously treated, unresectable/locally advanced/metastatic well-differentiated pancreatic NET (the FDA label specifies only 'previously treated,' without a required prior-drug sequence).