The week in GI, filtered to what is worth knowing.

Scope: this primary document covers portal hypertension and varices in cirrhosis ONLY. Everything else in the current entry (HCC surveillance, transplant referral, nutrition, vaccination, ascites/SBP/HE/HRS/ACLF management) belongs to the separate documents listed as supporting sources and must not be attributed to this guidance. Risk-stratify compensated advanced chronic liver disease (cACLD) with non-invasive tests before defaulting to endoscopy. By vibration-controlled transient elastography, liver stiffness (LSM) under 10 kPa excludes cACLD, 10 to 14.9 kPa is suggestive and warrants further testing, and 15 kPa or above rules cACLD in. Clinically significant portal hypertension (CSPH, i.e. HVPG above 10 mm Hg) is ruled in non-invasively by LSM at or above 25 kPa alone, or LSM 20 to 24.9 kPa with platelets below 150 x 10^9/L, or LSM 15 to 19.9 kPa with platelets below 110 x 10^9/L. Where spleen stiffness measurement is available, values below 21 kPa argue against CSPH and above 50 kPa argue for it. These non-invasive cutoffs are conditional probability thresholds, not universal diagnostic rules, and hold only when their derivation conditions are met. They were established in compensated advanced chronic liver disease of viral (treated or untreated HBV/HCV), alcohol-related, or non-obese (BMI under 30) MASLD etiology, and are not validated for and should not be applied to cholestatic (e.g. PBC, PSC), vascular, or other etiologies, in which different cutoffs apply. They also require a technically reliable liver stiffness measurement by vibration-controlled transient elastography, fasting, at least 10 valid acquisitions, and an IQR/median ratio below 30 percent, and are confounded by factors that raise liver stiffness independently of fibrosis, including ALT flares or acute hepatitis, extrahepatic cholestasis, hepatic congestion (right heart failure), and recent food intake; Baveno VII recommends confirming an LSM-based rule-in on a repeat measurement obtained on a separate day. The spleen stiffness cutoffs apply only to a dedicated 100 Hz spleen module, carry a higher technical failure rate, are machine-dependent, and are not interchangeable with values obtained using the standard 50 Hz liver probe. Where these population or acquisition conditions are not met, the numeric thresholds do not reliably classify CSPH, and HVPG measurement or endoscopy is required rather than a non-invasive determination. Preserve the gray zone: LSM 15 to 25 kPa without a qualifying platelet count is explicitly indeterminate (roughly 40 to 60 percent of cACLD patients) and calls for HVPG and/or endoscopy rather than assumption in either direction. Once CSPH is established, offer a non-selective beta-blocker, carvedilol preferred at 12.5 mg/day, to lower portal pressure and prevent FIRST decompensation, on the strength of PREDESCI. This is a treat-the-pressure strategy rather than a treat-the-varices one: because a patient already on NSBB for CSPH would not have management changed by the finding, screening endoscopy becomes unnecessary for most such patients. Screening EGD is still indicated where elastography is unavailable, technically difficult, or gives discordant results, and for patients who do not meet non-invasive criteria. Standard beta-blocker contraindications (severe asthma, advanced heart block, bradyarrhythmias) continue to apply. For varices needing treatment managed endoscopically, band ligation is repeated every 2 to 4 weeks until obliteration, with surveillance endoscopy at 6 months and annually thereafter. Gastric/cardiofundal varices are treated with cyanoacrylate injection or EUS-guided coil embolization rather than banding, with hepatology involvement. In acute variceal hemorrhage, consider preemptive (early) TIPS within 24 to 72 hours in high-risk patients: Child-Turcotte-Pugh class B with score above 7 and active bleeding at endoscopy despite vasoactive therapy, or CTP class C with score 10 to 13. Keep the document's own qualifier: there is no established universal MELD or CTP cutoff at which TIPS is mandatory, and the decision is case-by-case with hepatology consultation. Statin use in compensated cirrhosis is NOT a recommendation traceable to this document; the current entry's statin sentence needs its own source or removal. Verification note: the Hepatology full text is paywalled (402/403 on direct fetch). Document identity, title, year, volume, pages and authorship were confirmed via Crossref and PubMed metadata; the numeric thresholds above were corroborated from two independent peer-reviewed commentaries on this specific guidance and match the Baveno VII rule-of-five, but were not read verbatim from the primary PDF. A human should confirm the exact guidance-statement wording against the full text before this entry is treated as quotation-grade.

Diagnose MASLD by hepatic steatosis on imaging (or biopsy) plus at least one cardiometabolic criterion and exclusion of competing etiologies (significant alcohol use, other liver disease), then risk-stratify fibrosis using a sequential non-invasive approach: FIB-4 first, followed by a second-line imaging-based test (VCTE, MRE, or ELF) for indeterminate/high-risk FIB-4, with liver biopsy reserved for discordant or unclear cases. Lifestyle modification (≥7-10% weight loss, Mediterranean diet, exercise) remains the foundation for all patients. For adults with MASH and F2-F3 fibrosis identified by non-invasive tests (VCTE 8-15 kPa, MRE 3.1-4.4 kPa, or ELF 9.2-10.5) rather than biopsy, AASLD now gives dedicated, updated practice guidance on both FDA-approved pharmacotherapies: resmetirom (Oct 2024 update) and semaglutide 2.4mg/week subcutaneous (Nov 2025 update, following August 2025 accelerated FDA approval based on ESSENCE trial data: 62.9% vs 34.3% MASH resolution without fibrosis worsening; 36.8% vs 22.4% ≥1-stage fibrosis improvement). Pioglitazone or vitamin E remain options per the 2023 base guidance. Manage cardiometabolic risk with statins for ASCVD reduction plus glycemic and blood-pressure control; for semaglutide specifically, routine hepatic panels are recommended only as clinically indicated (no discontinuations for LFT elevation in ESSENCE), with monitoring for GI adverse effects and rare risks (AKI, gallbladder disease, pancreatitis, thyroid C-cell tumors, retinopathy progression, lean mass loss). HCC surveillance with ultrasound and AFP every 6 months remains indicated only if cirrhosis is present.

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.

WORKUP (NCCN ESOPH-1): H&P; EGD with biopsy; chest/abdomen CT with oral and IV contrast; pelvis CT with contrast ONLY as clinically indicated; FDG-PET/CT (skull base to mid-thigh) if no evidence of M1 disease; CBC and comprehensive chemistry; EUS if no evidence of M1 or unresectable disease; endoscopic resection (ER) is recommended for accurate staging of early-stage cancers (Tis, T1a, or T1b) and may also be therapeutic; bronchoscopy if the tumor is at or above the carina with no evidence of M1; biopsy of metastatic disease as clinically indicated; assign Siewert category; nutritional assessment and counseling; smoking-cessation counseling; screen for family history. BIOMARKERS: universal MSI (PCR/NGS) or MMR (IHC) testing AND universal PD-L1 testing in ALL newly diagnosed patients; HER2 and CLDN18.2 testing if advanced/metastatic adenocarcinoma is documented or suspected; NGS should be considered. Multidisciplinary evaluation is recommended for stage I-IVA (locoregional) disease (ESOPH-E). ENDOSCOPIC THERAPY (ESOPH-A): the goal of endoscopic therapy (EMR, ESD, and/or ablation) is complete removal or eradication of early-stage disease, pTis, pT1a, and SELECTED superficial pT1b without LVI, plus the pre-neoplastic Barrett's segment. Tis/HGD must first be fully characterized for nodularity, lateral spread and multifocality, with EUS to rule out nodal metastases in select higher-risk cases. Areas of nodularity or ulceration must be RESECTED, not ablated. Completely flat lesions ≤2 cm (squamous HGD/Tis, and BE with flat HGD) should be treated by ER because it gives more accurate histologic assessment; flat lesions >2 cm can be treated by ER but with greater complication risk, and may be treated by ablation alone (data for ablation-alone in squamous HGD are very limited). Lesions pathologically limited to lamina propria/muscularis mucosae (pT1a) or superficial submucosa (pT1b), in the absence of nodal metastases, LVI, or poor differentiation, can be treated with full ER, HOWEVER a thorough patient-and-surgeon discussion of esophagectomy versus the risk of concurrent nodal disease should be undertaken, especially for larger tumors or deeper invasion. Ablation of residual Barrett's should follow ER; complete BE eradication may also be achieved by widefield EMR or ESD at the initial intervention when needed to resect superficial tumor or nodularity ≤2 cm. For SCC, the level of evidence for ablation after ER is LOW; additional ablation may be needed only for multifocal HGD/CIS elsewhere, and may not be needed for completely excised lesions. Endoscopic therapy is 'PREFERRED' for limited early-stage disease: Tis and T1a, ≤2 cm, well or moderately differentiated. Esophagectomy is indicated for extensive carcinoma in situ (pTis/HGD), pT1a, or superficial pT1b, especially nodular disease not adequately controlled endoscopically. PRIMARY TREATMENT, MEDICALLY FIT PATIENTS, ADENOCARCINOMA (ESOPH-13): cT1b-cT2, N0 LOW-RISK (<3 cm, well differentiated) → esophagectomy. cT2 N0 HIGH-RISK (LVI, ≥3 cm, or poorly differentiated), cT1b-cT2 N+, or cT3-cT4a any N → perioperative systemic therapy is PREFERRED (FLOT: 5-FU 2600 mg/m2 IV over 24 h day 1, leucovorin 200 mg/m2, oxaliplatin 85 mg/m2, docetaxel 50 mg/m2, every 14 days, 4 cycles pre- and 4 cycles postoperatively; or FLOT + durvalumab 1500 mg for PD-L1 CPS ≥1 or TAP ≥1%, category 1 for EGJ, category 2A for esophageal adenocarcinoma; note MATTERHORN showed no EFS advantage for durvalumab in diffuse-type disease), QUALIFIER: perioperative therapy is preferred for patients medically fit and with access to frequent toxicity evaluation; preoperative chemoradiation for planned esophagectomy remains an option and may be considered for borderline-resectable patients or patients who are not FLOT candidates (perioperative FOLFOX/CAPOX is another alternative). Consider neoadjuvant or perioperative immune checkpoint inhibitor if the tumor is MSI-H/dMMR (in multidisciplinary consultation; the role of surgery after complete response is unclear). Definitive chemoradiation for patients who are medically unfit/inoperable for surgery or who decline surgery. cT4b → definitive chemoradiation, or chemotherapy alone with invasion of trachea, great vessels, vertebral body, or heart. SQUAMOUS CELL CARCINOMA (ESOPH-2): cT1b-cT2, N0 LOW-RISK (<3 cm, well differentiated) → esophagectomy (non-cervical esophagus). cT2 N0 high-risk (LVI, ≥3 cm, poorly differentiated), cT1b-cT2 N+, or cT3-cT4a any N → PREOPERATIVE CHEMORADIATION is preferred (or definitive chemoradiation). cT4b → definitive chemoradiation, or chemotherapy alone for trachea/great-vessel/vertebral/cardiac invasion. NCCN states explicitly: 'Preoperative chemoradiation is preferred for esophageal SCC.' Preoperative RT dose 41.4-50.4 Gy at 1.8-2.0 Gy/day (23-28 fractions); preferred concurrent regimens include weekly paclitaxel 50 mg/m2 + carboplatin AUC 2 (CROSS, category 1) and fluorouracil + oxaliplatin (category 1). POSTOPERATIVE (ESOPH-F): nivolumab is the preferred postoperative regimen ONLY after PREOPERATIVE CHEMORADIATION with R0 resection and residual pathologic disease (category 1), 240 mg IV every 14 days for 16 weeks, then 480 mg IV every 28 days, maximum treatment duration 1 year. PALLIATION (ESOPH-A/H): esophageal dilation with balloons or bougies for temporary relief of malignant or treatment-related obstruction (avoid overdilation, perforation risk); long-term dysphagia palliation by endoscopic tumor ablation (Nd:YAG laser, PDT, cryoablation) or expandable metal/plastic stents; feeding gastrostomy or jejunostomy for anorexia/dysphagia/malnutrition, but placement of a GASTROSTOMY preoperatively may compromise the gastric vasculature and interfere with gastric-conduit reconstruction and SHOULD BE AVOIDED (feeding jejunostomy is generally preferred for postoperative nutritional support; multidisciplinary expertise is recommended before percutaneous gastrostomy).