Endoscopy, in full.

After polyp removal, assign the next colonoscopy surveillance interval using USMSTF 2020 based on polyp number, size, and histology (e.g., 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 adenoma with tubulovillous/villous histology or high-grade dysplasia 3 years; >10 adenomas 1 year with polyposis evaluation; and for serrated polyps, 1-2 sessile serrated lesions <10 mm 5-10 years, 3-4 sessile serrated lesions <10 mm or a hyperplastic polyp ≥10 mm 3-5 years, and a sessile serrated lesion ≥10 mm or with dysplasia or a traditional serrated adenoma 3 years), and apply the shortest interval indicated when findings are mixed. Confirm complete resection and adequate prep before applying an interval, and use site-check/tumor-board pathways for piecemeal resection and malignant (T1) polyps. Refer for genetic evaluation when Lynch, FAP/AFAP/MAP, or serrated polyposis syndrome criteria are met.

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.

Confirm ulcerative colitis with endoscopy showing continuous colonic inflammation from the rectum plus histology, after excluding infection with two-step CDI testing. Treat mild-moderate disease with 5-ASA by route and extent (suppository for proctitis, enema for left-sided, oral plus rectal for extensive); 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 - S1P modulators are weakest in exactly this group. Do not cycle within the anti-TNF class after primary non-response; switch mechanism. Apply treat-to-target (STRIDE-II) to endoscopic improvement (MES 0-1). Screen for acute severe UC by Truelove-Witts and admit for IV steroids. Begin CRC surveillance 8-10 years after DIAGNOSIS for extensive or left-sided disease; isolated proctitis follows average-risk screening.

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).