Endoscopy, in full.

Risk-stratify suspected choledocholithiasis (high >50%, intermediate 10-50%, low <10% probability). HIGH-risk criteria, any of which should directly prompt ERCP: (1) CBD stone on ultrasound or cross-sectional imaging; (2) ascending cholangitis; (3) total bilirubin >4 mg/dL AND dilated CBD (>6 mm in adults with gallbladder in situ, >8 mm after cholecystectomy). Gallstone pancreatitis was deliberately REMOVED as a high-risk criterion in the 2019 revision. INTERMEDIATE risk (abnormal liver biochemical tests, age >55 y, or bile-duct dilation on imaging): the panel suggests confirmation with either EUS or MRCP (conditional recommendation, low-quality evidence; choice by patient preference, local expertise, availability), laparoscopic intraoperative cholangiography (IOC) or intraoperative US are equally sanctioned alternatives. LOW risk: cholecystectomy with or without IOC/intraoperative US if indicated for symptomatic cholelithiasis; no ERCP and no mandatory advanced biliary imaging. In gallstone pancreatitis WITHOUT cholangitis or biliary obstruction/choledocholithiasis, the panel recommends AGAINST urgent (<48 h) ERCP (strong recommendation, low-quality evidence). Same-admission cholecystectomy is recommended for patients with MILD gallstone pancreatitis (consensus, PONCHO-based); ERCP with prophylactic sphincterotomy should not be used as an alternative to cholecystectomy unless surgery is absolutely contraindicated (e.g., recurrent pancreatitis in end-stage liver disease). For large bile-duct stones, the panel suggests endoscopic sphincterotomy followed by large-balloon dilation (ES-LBD) rather than sphincterotomy alone (conditional, moderate); for large AND difficult stones, it suggests intraductal therapy (cholangioscopy-guided EHL or laser lithotripsy) or conventional therapy with papillary dilation, chosen by local expertise, cost, and patient/physician preference (conditional, very low). Timing versus cholecystectomy: pre- or postoperative ERCP or laparoscopic bile-duct clearance for patients at high risk or with positive IOC, depending on local surgical and endoscopic expertise (consensus).

Evaluate suspected pancreatic adenocarcinoma with a dedicated pancreatic-protocol (multiphasic, contrast-enhanced) CT of the abdomen as the preferred imaging for diagnosis and staging (MRI/MRCP is an acceptable alternative); PET/CT may be added after, never as a substitute for, protocol CT/MRI in higher-risk situations. Obtain tissue confirmation, preferably by EUS-guided FNA/FNB with core biopsy where feasible; biopsy is generally required before neoadjuvant or palliative therapy, whereas patients with clearly resectable disease may proceed to surgery without preoperative biopsy. Measure baseline CA 19-9 (interpret after biliary decompression / with normal bilirubin; it can be falsely low in Lewis-antigen-negative patients and falsely elevated with cholestasis). Offer GERMLINE testing for inherited susceptibility to EVERY patient with confirmed pancreatic adenocarcinoma regardless of family history, using a comprehensive multi-gene panel; separately, for patients with locally advanced or metastatic disease who are candidates for anti-cancer therapy, obtain TUMOR/SOMATIC molecular profiling (broad NGS; RNA-based assays improve fusion detection; cell-free/liquid biopsy if tissue is insufficient). Assign resectability, resectable, borderline resectable, locally advanced (unresectable), or metastatic, by multidisciplinary review, ideally at a high-volume center. RESECTABLE disease: upfront resection (pancreaticoduodenectomy for head/uncinate; distal pancreatectomy ± splenectomy for body/tail) followed by adjuvant therapy, or neoadjuvant therapy in selected high-risk patients; preferred adjuvant regimen is modified FOLFIRINOX in patients able to tolerate it, ideally begun within 12 weeks of surgery, for a total of ~6 months of perioperative systemic therapy. BORDERLINE RESECTABLE and LOCALLY ADVANCED disease: neoadjuvant systemic therapy, with or without subsequent chemoradiation/RT, then restaging and reassessment for resection. METASTATIC disease by performance status: good PS (ECOG 0-1, adequate organ function), first-line FOLFIRINOX/modified FOLFIRINOX, NALIRIFOX, or gemcitabine + nab-paclitaxel, with clinical trial preferred; after ~4-6 months without progression, transition to a maintenance strategy (including olaparib for germline BRCA1/2 carriers who have NOT progressed on first-line platinum-based therapy), a clinical trial, or a treatment break; intermediate PS (ECOG 2), clinical trial preferred, otherwise less-intensive first-line therapy (preferred gemcitabine + nab-paclitaxel [category 1], or single-agent gemcitabine or capecitabine, or FOLFOX/FOLFIRI/CapeOx), since the intensive triplets (FOLFIRINOX/modified FOLFIRINOX and NALIRIFOX) are limited to ECOG 0-1 and are generally not appropriate at ECOG 2, with the same maintenance-versus-progression reassessment applied after ~4-6 months without progression; poor PS (ECOG 3-4), palliative/best supportive care, with single-agent chemotherapy or a biomarker-directed agent only if clinically appropriate. Treat by molecular target wherever an actionable alteration is present, across lines: pembrolizumab (or dostarlimab) for MSI-H/dMMR and pembrolizumab for TMB-H, olaparib for germline BRCA1/2 (maintenance after platinum), larotrectinib/entrectinib for NTRK fusions, selpercatinib for RET fusions, dabrafenib + trametinib for BRAF V600E, erdafitinib for FGFR2 alterations, fam-trastuzumab deruxtecan for HER2-positive disease, zenocutuzumab for NRG1 fusion-positive disease, and (in recent NCCN versions) KRAS G12C inhibitors (adagrasib/sotorasib), several of these after prior systemic therapy. Integrate supportive care throughout: relieve obstructive jaundice with an endoscopic self-expanding metal stent in non-operative or neoadjuvant pathways, but do NOT perform routine preoperative biliary drainage before planned upfront resection; treat exocrine insufficiency with pancreatic enzyme replacement titrated to symptoms (common starting dose ~40,000-50,000 units of lipase with main meals, roughly half with snacks, increased as needed); manage refractory pain with celiac plexus neurolysis or palliative RT; relieve gastric outlet obstruction with surgical or EUS-guided gastrojejunostomy (or enteral stenting); and provide VTE prophylaxis, nutritional support, and early palliative care.

For acute variceal hemorrhage in cirrhosis, resuscitate conservatively with a restrictive RBC transfusion strategy targeting hemoglobin 7-8 g/dL, start a vasoactive agent as soon as bleeding is suspected and before endoscopy (terlipressin, somatostatin, or octreotide; octreotide is the agent available for this indication in US practice) and continue it 2-5 days, and give empiric IV ceftriaxone 1 g every 24 hours in patients with advanced cirrhosis. Perform upper endoscopy within 12 hours of presentation once resuscitated, or as soon as safely possible if the patient is unstable, with band ligation for esophageal varices and for GOV1 (which is treated as an esophageal varix); cardiofundal varices (GOV2 and IGV1) are treated with cyanoacrylate injection, with EUS-guided coil placement with or without cyanoacrylate increasingly used as first-line where expertise exists, and TIPS or BRTO as alternatives or salvage. PPIs started empirically should be stopped immediately after endoscopy unless there is a separate strict indication. Evaluate every patient at presentation for pre-emptive (early) TIPS with a PTFE-covered stent, placed within 72 hours and ideally within 24 hours, in high-risk patients defined as Child-Pugh class C with score under 14 (that is, 10-13) or Child-Pugh class B with score above 7 who have active bleeding at initial endoscopy despite vasoactive drugs; the decision is individualized and multidisciplinary, weighing age, frailty, comorbidity, heart failure, HCC, portal vein thrombosis, and transplant candidacy. For uncontrolled bleeding, a self-expanding covered esophageal metal stent is as effective as balloon tamponade and is the safer option; both are a bridge to definitive therapy (PTFE-covered TIPS) and neither is definitive therapy. Balloon tamponade must NOT be left in place for more than 24 hours, 24 hours is the ceiling, not a range: Baveno VI states it "should only be used in refractory oesophageal bleeding, as a temporary bridge (for a maximum of 24 h) with intensive care monitoring and considering intubation, until definitive treatment can be instituted", because severe esophageal injury/necrosis, perforation and aspiration rise sharply beyond that point. The 72-hour figure in this standard belongs to the pre-emptive TIPS window and must not be read as a permissible tamponade duration. Secondary prophylaxis is mandatory in all survivors and is combination therapy: a nonselective beta-blocker, either a traditional NSBB (propranolol or nadolol) or carvedilol, which Baveno VII endorses as an equivalent rather than clearly superior option in this specific indication, plus serial EVL every 2 to 8 weeks until variceal eradication, with surveillance endoscopy thereafter. TIPS is the treatment of choice for patients who rebleed despite NSBB plus EVL.

Diagnose acute pancreatitis (AP) by the Atlanta criteria (2 of 3: characteristic epigastric/LUQ pain, lipase or amylase >3x ULN [lipase preferred for specificity/duration], or characteristic imaging). ACG 2024 stratifies severity risk using SIRS on admission plus bedside risk factors, rising/elevated BUN, rising/elevated hematocrit (>44), obesity (BMI>30), extrapancreatic fluid collections/pleural effusion/infiltrates, altered mental status, and older age/comorbidities, rather than mandating a formal BISAP or APACHE II composite score. Give moderately aggressive lactated Ringer's, most important in the first 6-12 hours, reassessing volume status/BUN/HCT at 6 hours (further aggressive hydration has little added benefit after 24-48h). Start oral low-fat solid food within 24-48h as tolerated in mild disease; if enteral feeding is needed for moderately severe/severe disease, prefer nasogastric over nasojejunal with small-peptide/medium-chain-triglyceride formula and continuous (not bolus/cyclic) feeding; avoid parenteral nutrition if possible. Do not give prophylactic antibiotics, even in severe disease or sterile necrosis; reserve antibiotics for suspected infected necrosis (typically arising 10-14 days in), and choose agents that penetrate pancreatic necrosis while together covering both gut-derived gram-negative enterics and anaerobes, a carbapenem supplies this as monotherapy, whereas a fluoroquinolone or a third-or-higher-generation cephalosporin must be combined with metronidazole; metronidazole alone (anaerobic cover only), or a cephalosporin or a quinolone alone, does not adequately treat infected necrosis. Perform cholecystectomy preferably before discharge for mild acute biliary pancreatitis, and after a second unexplained AP episode even without identified gallstones; reserve ERCP within 24h for AP complicated by cholangitis, with rectal indomethacin +/- pancreatic duct stent and periprocedural hydration to reduce post-ERCP pancreatitis risk. Check triglycerides when gallstones/alcohol are absent (>1000 mg/dL supports a hypertriglyceridemia etiology). For stable pancreatic necrosis, defer surgical, radiological, or endoscopic intervention 4-6 weeks to allow walling-off (step-up approach).

For average-risk adults, colorectal cancer screening is routine from age 45-75 (2021 update lowered the start age from 50 to 45; USPSTF/USMSTF/ACS concordant). For ages 76-85, the decision to start or continue is individualized, based on shared decision-making that weighs prior screening history, comorbidity, life expectancy, CRC risk, and patient preference (USPSTF Grade C). Screening is not recommended/offered at age 86 or older. The specific USMSTF criterion for stopping in previously well-screened patients is: individuals up to date with screening who have negative prior screening (particularly high-quality colonoscopy) should consider stopping at age 75 OR when life expectancy is less than 10 years, not 5 years. Individuals without adequate prior screening may be considered for screening up to age 85 depending on age and comorbidities. New alarm symptoms (iron deficiency anemia, GI bleeding, change in bowel habits, weight loss) always warrant workup regardless of age or screening status; this remains sound general practice though it is not a specific guideline citation.

DIAGNOSIS: Diagnosis of BE requires intestinal metaplasia in the tubular esophagus (conditional, very-low certainty) AND columnar mucosa of at least 1 cm (conditional, low). Patients with a normal-appearing Z line, or a Z line with <1 cm proximal displacement from the top of the gastric folds and no visible lesion, should NOT undergo routine biopsy. At screening endoscopy with findings consistent with possible BE, obtain at least 8 biopsies, following the Seattle protocol (4-quadrant biopsies every 1-2 cm plus targeted sampling of any visible lesion) for segments longer than 4 cm (conditional, low). The at-least-8-biopsy minimum applies to all screening exams regardless of segment length and is NOT waived for shorter (<=4 cm) segments; when a short segment - typically 1-2 cm, e.g. a single tongue - will not physically support 8 biopsies, obtain at least 4 biopsies per cm of circumferential BE and 1 biopsy per cm of tongues of BE, so that short segments are still adequately sampled and dysplasia or cancer is not missed. Dysplasia of any grade must be confirmed by a SECOND pathologist with expertise in GI pathology (STRONG, low). SURVEILLANCE: Use both high-definition white-light endoscopy AND chromoendoscopy (STRONG, moderate) with a structured biopsy protocol (STRONG, low). Intervals are dictated by degree of dysplasia (conditional, very-low) and by segment length (STRONG, moderate): nondysplastic BE <3 cm - EGD every 5 years; nondysplastic BE >=3 cm - EGD every 3 years. Indefinite for dysplasia (confirmed by a second pathologist), any length - escalate to twice-daily PPI and repeat EGD within 6 months; if still indefinite, EGD annually; if downgraded/upgraded, follow the NDBE or LGD algorithm. Confirmed LGD opting for surveillance - EGD at 6 months, at 12 months from diagnosis, then annually, sampling with 4-quadrant biopsies every 1 cm. MEDICAL: At least once-daily PPI in patients with BE without allergy or other contraindication to PPI use (conditional, VERY-LOW certainty); higher/twice-daily dosing is reserved for those who need it for symptom control, as the incremental antineoplastic benefit of dose escalation is unclear. Suggest AGAINST antireflux surgery as an antineoplastic measure (conditional, low). No recommendation could be made on aspirin plus PPI chemoprevention, on WATS-3D, or on p53 IHC/TissueCypher. ENDOSCOPIC THERAPY: For BE with HGD or intramucosal carcinoma (T1a), EET is recommended over ESOPHAGECTOMY (STRONG, moderate). For confirmed LGD, endoscopic therapy is SUGGESTED to reduce progression to HGD/EAC, with endoscopic surveillance of confirmed LGD explicitly retained as an ACCEPTABLE ALTERNATIVE (conditional, moderate) - this is a shared-decision-making choice, not a mandate. Resect all visible lesions endoscopically BEFORE ablation of the residual segment (conditional, very-low); RFA is the preferred ablative modality; goal is complete eradication of intestinal metaplasia. EET should be performed at high-volume centers (conditional, very-low). T1b (submucosal) cancer: the default is surgical referral for esophagectomy, BUT EET may be considered for sm1 disease (invasion into the upper third of the submucosa, depth <500 micrometers) with low-risk features - well differentiated, <2 cm, no lymphovascular invasion, negative deep margin. Patients with high-risk histology are best treated with esophagectomy unless they are poor surgical candidates, for whom multidisciplinary discussion of alternatives such as ADJUVANT chemoradiation may be appropriate. POST-EET: An endoscopic surveillance program is recommended after successful EET (STRONG, moderate), with intervals set by the BASELINE degree of dysplasia: baseline LGD - 1 year, 3 years, then every 2 years; baseline HGD or T1a - 3, 6, and 12 months, then annually.

Diagnose acute pancreatitis (AP) by the Atlanta criteria (2 of 3: characteristic epigastric/LUQ pain, lipase or amylase >3x ULN [lipase preferred for specificity/duration], or characteristic imaging). ACG 2024 stratifies severity risk using SIRS on admission plus bedside risk factors, rising/elevated BUN, rising/elevated hematocrit (>44), obesity (BMI>30), extrapancreatic fluid collections/pleural effusion/infiltrates, altered mental status, and older age/comorbidities, rather than mandating a formal BISAP or APACHE II composite score. Give moderately aggressive lactated Ringer's, most important in the first 6-12 hours, reassessing volume status/BUN/HCT at 6 hours (further aggressive hydration has little added benefit after 24-48h). Start oral low-fat solid food within 24-48h as tolerated in mild disease; if enteral feeding is needed for moderately severe/severe disease, prefer nasogastric over nasojejunal with small-peptide/medium-chain-triglyceride formula and continuous (not bolus/cyclic) feeding; avoid parenteral nutrition if possible. Do not give prophylactic antibiotics, even in severe disease or sterile necrosis; reserve antibiotics for suspected infected necrosis (typically arising 10-14 days in), and choose agents that penetrate pancreatic necrosis while together covering both gut-derived gram-negative enterics and anaerobes, a carbapenem supplies this as monotherapy, whereas a fluoroquinolone or a third-or-higher-generation cephalosporin must be combined with metronidazole; metronidazole alone (anaerobic cover only), or a cephalosporin or a quinolone alone, does not adequately treat infected necrosis. Perform cholecystectomy preferably before discharge for mild acute biliary pancreatitis, and after a second unexplained AP episode even without identified gallstones; reserve ERCP within 24h for AP complicated by cholangitis, with rectal indomethacin +/- pancreatic duct stent and periprocedural hydration to reduce post-ERCP pancreatitis risk. Check triglycerides when gallstones/alcohol are absent (>1000 mg/dL supports a hypertriglyceridemia etiology). For stable pancreatic necrosis, defer surgical, radiological, or endoscopic intervention 4-6 weeks to allow walling-off (step-up approach).

Distinguish benign from malignant biliary strictures using cross-sectional imaging (MRI/MRCP preferred over contrast-enhanced CT) plus laboratory tests, interpreting CA19-9 after biliary decompression and never relying on tumor markers alone; check serum IgG4 when IgG4-related sclerosing cholangitis is suspected (HISORt criteria). Per the ESGE 2024 diagnostic work-up guideline, tissue-acquisition strategy now branches by stricture location rather than following one linear sequence: for DISTAL extrahepatic strictures with jaundice and no pancreatic mass, combined same-session EUS-guided tissue acquisition (EUS-TA, end-cutting FNB needle) plus ERCP-based tissue acquisition (standard brush cytology plus fluoroscopy-guided biopsy) is the strongly preferred first-line approach; for PERIHILAR strictures, obtain brush cytology plus fluoroscopy-guided biopsy at index ERCP, escalate indeterminate strictures to cholangioscopy-guided biopsy (with intraductal ultrasound/confocal laser endomicroscopy selectively), and reserve EUS-TA for cases where ERCP-based sampling is insufficient and curative resection is not feasible and/or extraluminal disease is accessible; escalate any positive or indeterminate feature to multidisciplinary tumor board. Manage benign anastomotic and chronic-pancreatitis strictures with a fully-covered self-expanding metal stent for 6-12 months (multiple plastic stents when FCSEMS is contraindicated, hepaticojejunostomy if refractory). Treat cholangitis with biliary obstruction as an indication for urgent biliary drainage, but do not instrument every obstructed sector: for hilar or multisegmental strictures (Bismuth II-IV), ESGE suggests draining ≥50% of the liver volume and avoiding opacification of biliary ducts that will not be drained (weak recommendation, low-quality evidence), because post-ERCP cholangitis frequently complicates injection of obstructed ducts that are not subsequently drained, whereas drainage of >50% of liver volume is associated with less cholangitis and longer survival; ESGE suggests antibiotic prophylaxis before biliary stenting in selected patients (e.g., immunocompromised patients, expected incomplete biliary drainage; weak recommendation, moderate-quality evidence), with a full antibiotic course if adequate drainage is not achieved during the procedure. Direct etiology-specific care for Strasberg bile-duct injuries, post-transplant strictures (ASGE 2023: ERCP preferred over PTBD, covered SEMS preferred over multiple plastic stents), IgG4-sclerosing cholangitis, Mirizzi syndrome, and choledochal cysts.

Abdominal ultrasound should be performed in a patient with a recent history of biliary pain (high quality evidence; strong recommendation); in case of strong clinical suspicion of gallbladder stones and negative abdominal ultrasound, EUS (or magnetic resonance imaging) may be performed (low quality; weak). Cholecystectomy is the preferred treatment for symptomatic gallbladder stones (moderate quality; strong recommendation), and laparoscopic cholecystectomy is the standard method, including for acute calculous cholecystitis (high quality; strong), although mini-laparotomy cholecystectomy (laparotomy <8 cm) is an equally acceptable alternative (high quality; strong). For uncomplicated biliary colic, cholecystectomy should be performed as early as possible (low quality; weak recommendation); EASL qualifies that cholecystectomy may not be necessary if biliary colic has not occurred within the last 5 years or after just one episode of colic (~50% chance of another colic within 1 year). For acute cholecystitis, early laparoscopic cholecystectomy preferably within 72 h of admission should be performed by surgeons with adequate expertise (high quality; strong recommendation). Antibiotics are NOT recommended at all times in mild acute cholecystitis, i.e. without cholangitis, bacteremia/sepsis, abscess or perforation (very low quality; weak recommendation). Biliary colic should be treated with NSAIDs, e.g. diclofenac 50-75 mg IM, ketoprofen 200 mg IV, or indomethacin 50 mg IV / 2 × 75 mg suppositories (moderate quality; weak), with spasmolytics and, for severe symptoms, opioids such as buprenorphine (low quality; strong). In severe acute cholecystitis or difficult biliary anatomy, subtotal cholecystectomy (laparoscopic or open) or percutaneous cholecystostomy followed by later cholecystectomy are options; percutaneous cholecystostomy is a treatment alternative in high-risk patients, but whether definitive cholecystectomy is still needed afterwards is explicitly unsolved (no RCTs) and cholecystectomy should be considered, since patients who improve after cholecystostomy may worsen during follow-up. In the elderly and those with high anaesthetic risk, cholecystectomy should be performed for gallstone complications (acute cholecystitis, gallstone pancreatitis, obstructive jaundice) as soon as general status allows (low quality; weak), and laparoscopic cholecystectomy should not be withheld on the basis of chronological age alone (very low quality; weak). Routine treatment is NOT recommended for asymptomatic gallbladder stones (very low quality; weak recommendation). Oral bile-acid litholysis, alone or with ESWL, is not recommended (moderate quality; strong). In patients with simultaneous gallbladder and bile duct stones, early laparoscopic cholecystectomy should be performed within 72 h after preoperative ERCP for choledocholithiasis (moderate quality; strong); same-day but separate ERCP and cholecystectomy are not recommended. Before elective cholecystectomy, abdominal ultrasound confirming stones is required (moderate quality; strong) and no other routine tests are necessary; liver biochemical tests in individually selected cases (very low quality; weak). Routine intraoperative cholangiography is not supported by current evidence.

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 chronic pancreatitis on CROSS-SECTIONAL IMAGING, CT for late calcific disease, MRI/MRCP (with secretin where available) for earlier ductal and parenchymal change, EUS an acceptable alternative; per ACG 2020, "Diagnosis is made usually on cross-sectional imaging, with modalities such as endoscopic ultrasonography and pancreatic function tests playing a secondary role". Fecal elastase does NOT confirm chronic pancreatitis: it is a test of exocrine FUNCTION and is the appropriate initial test for the exocrine pancreatic insufficiency (EPI) that chronic pancreatitis causes, a consequence of the disease, not the diagnosis of it. A normal fecal elastase does not exclude chronic pancreatitis and a low one does not establish it. Per AGA 2023, fecal elastase must be run on a semi-solid or solid stool specimen; below 100 mcg/g is good evidence of EPI and 100-200 mcg/g is indeterminate (below 200 mcg/g is the cutoff commonly used to screen). Then manage with smoking and alcohol cessation, PERT for exocrine insufficiency titrated to symptoms, fat-soluble vitamin and bone surveillance, and individualized type 3c diabetes control, considering insulin early in patients with marked hyperglycemia or symptoms of insulin deficiency. Treat pain with a stepwise ladder from scheduled acetaminophen and neuromodulators to EUS-guided celiac plexus block and endoscopic/surgical intervention, referring early for surgery per ESCAPE 2020 in candidates with main pancreatic duct obstruction. Screen for PDAC per lifetime risk and pursue etiologic workup via TIGAR-O v2, including genetic testing and autoimmune pancreatitis evaluation.

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.

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).