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).

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).

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).

Diagnose PSC with high-quality MRCP as the reference-standard imaging (avoid ERCP for diagnostic purposes; if MRCP findings are equivocal, repeat MRCP rather than proceeding to ERCP), reserving ERCP for therapeutic intervention, and exclude secondary sclerosing cholangitis/IgG4-related disease. No disease-modifying therapy is proven to alter transplant-free survival, but moderate-dose UDCA (13-23 mg/kg/day) may now be considered and continued in patients not enrolled in or eligible for a clinical trial if it produces a meaningful improvement in alkaline phosphatase (GGT in children) and/or symptoms by 12 months, discontinuing if no response; high-dose UDCA remains contraindicated. Perform annual abdominal MRI/MRCP with or without serum CA19-9 for cholangiocarcinoma/gallbladder-cancer surveillance in adults with large-duct PSC (not recommended under age 18 or in small-duct PSC). Manage gallbladder polyps by size, cholecystectomy for polyps >8 mm, ultrasound surveillance every 6 months for polyps ≤8 mm, rather than referring every polyp. For colorectal surveillance, begin surveillance colonoscopy at the time of PSC-IBD diagnosis (or at age 15 for childhood-onset disease) and repeat at 1-2 year intervals; in PSC without IBD, perform a diagnostic colonoscopy at PSC diagnosis and repeat every 5 years if IBD is not found. Evaluate dominant strictures with brush cytology plus FISH (± cholangioscopy) before/at balloon dilation, repeating ERCP with sampling in 3 months if cytology is suspicious regardless of FISH result. Treat recurrent cholangitis and cholestatic pruritus, maintain bone health, and refer for transplant evaluation for decompensation, intractable pruritus, recurrent bacterial cholangitis, or early-stage CCA per Mayo protocol.

The thresholds on file still hold, and the 2026 AGA Clinical Practice Update (Calderwood, Yoshida, Das, Falk; Clin Gastroenterol Hepatol, online 2026-08-03) agrees with them while adding to them. Average-risk adults are screened routinely from age 45 to 75 (USPSTF 2021: Grade B for 45-49, Grade A for 50-75; USMSTF and ACS agree). For ages 76-85 the decision is individualized (USPSTF Grade C). Under USMSTF, people who are up to date with negative prior screening, especially a high-quality colonoscopy, should consider stopping at 75 or when life expectancy falls below 10 years. People who were never adequately screened may be screened up to 85, depending on age and comorbidity. Screening is not recommended at 86 or older. The 2026 AGA update adds four things. (1) After age 75, the decision to continue screening (BPA 6) or polyp surveillance (BPA 7) should be individualized by weighing benefit, screening or polyp history, comorbidities and risks; this now explicitly covers post-polypectomy surveillance, not only screening. (2) Formal comorbidity assessment and life-expectancy tools may help separate older adults likely to benefit from those likely to be harmed (BPA 1). (3) Colonoscopy adverse events rise with age whatever the indication, so the reasoning behind any colonoscopy decision in someone over 75 should be documented in the EHR (BPA 8). (4) For Barrett's esophagus, continuing surveillance is a shared decision, and a patient who could not tolerate endoscopic, surgical or oncologic treatment should stop surveillance at any age (BPA 3 and 5). The AGA statements are expert-opinion Best Practice Advice without formal evidence grades, and they set no new numeric age or life-expectancy cutoffs. New alarm features (iron-deficiency anemia, GI bleeding, change in bowel habit, weight loss) still warrant diagnostic workup at any age; this is general practice, not a guideline statement.

Two current documents govern ampullary adenoma: the AGA Clinical Practice Update expert review (Barakat, Maranki, Irani, Chahal; Clin Gastroenterol Hepatol, online 2026-09-09; ungraded Best Practice Advice from literature review plus expert opinion, no systematic review) and the ESGE 2021 graded guideline (Vanbiervliet et al., Endoscopy 2021;53:429-448), which it does not replace. DIAGNOSIS: both use a side-viewing duodenoscope. AGA adds that biopsies should avoid the pancreatic orifice to limit post-procedure pancreatitis. Because 20-40% of ampullary adenomas harbor malignancy, AGA advises AT LEAST 6 biopsies, targeting ulcerated or indurated areas. ESGE requires proven adenoma before papillectomy and recommends against diagnostic papillectomy. STAGING: AGA says to consider EUS for every adenoma potentially amenable to endoscopic resection, EXCEPT lesions <1 cm with no worrisome clinical or endoscopic features. ESGE recommends EUS plus MRCP (IDUS in selected patients) and advises against routine molecular testing of biopsies. SELECTION: AGA describes the lesion most amenable to papillectomy as having well-defined margins, size <4-5 cm, nonfriable tissue, softness to probing, and intraductal extension <=1 cm. AGA sets 3 absolute contraindications: metastatic spread; invasive cancer beyond the mucosa; and >1 cm intraductal extension in a surgically fit patient. Relative contraindications are size >5 cm, early-stage/T1 cancer, and likely poor follow-up adherence. For >1 cm intraductal extension, AGA suggests surgical consultation; <1 cm may be treated endoscopically with close surveillance. This is a stricter intraductal threshold than ESGE's, which suggests surgery only for intraductal involvement >20 mm and adjunct RFA or cystotome ablation with temporary biliary stenting for <=20 mm in expert centers. ESGE also gates en bloc resection at adenomas up to 20-30 mm and lists >4 cm or a periampullary diverticulum as technical reasons to consider surgery. TECHNIQUE: both say to avoid biliary or pancreatic sphincterotomy before papillectomy (AGA's reasons: cautery artifact and bleeding) and to use en bloc snare resection when feasible. Submucosal injection is generally not needed, except for a laterally spreading duodenal-wall component. ESGE also suggests endocut current. PANCREATITIS PROPHYLAXIS: AGA advises using ALL THREE together: prophylactic pancreatic duct stent, rectal NSAID, and high-volume lactated Ringer's. ESGE recommends the PD stent and rectal diclofenac or indomethacin 100 mg, with lactated Ringer's suggested mainly when stenting is not possible. BLEEDING: standard hemostasis methods (epinephrine, electrocoagulation, clips, APC, hemostatic sprays); ESGE says prophylactic hemostasis is individualized. BILIARY DRAINAGE when resection is not feasible: AGA allows drainage with or without sphincterotomy and SEMS for significant jaundice or cholangitis, at the surgeon's discretion. ESGE recommends against routine preoperative drainage, reserving it for cholangitis, severe jaundice, delayed surgery, or neoadjuvant therapy, with SEMS when drainage is needed. ADJUNCT/RESIDUAL: for adenomas >3 cm resected piecemeal or with positive margins, AGA advises considering adjunct thermal ablation plus ductography, repeated every 2-3 months until biopsy confirms eradication. ESGE allows APC and EMR for benign residual or recurrent lesions. SURVEILLANCE: both use the same schedule: side-viewing duodenoscopy with biopsy of the scar and any abnormal area at 3 months, then at 6 and 12 months, then yearly for at least 5 years. AGA says surveillance beyond 5 years should be individualized (recurrence risk, comorbidity, life expectancy) but is required if high-risk features are present. In FAP, AGA individualizes intervals by ampullary, gastric and duodenal disease burden. MALIGNANCY: AGA advises multidisciplinary discussion (GI, surgery, oncology) for high-grade dysplasia, incomplete resection, or suspected malignancy. ESGE recommends pancreaticoduodenectomy with lymphadenectomy for T1 or higher, and accepts local resection for Tis when final pathology shows no residual disease.

Suspected small-bowel bleeding (SSBB), bleeding between the ampulla of Vater and the ileocecal valve, suspected when GI bleeding persists after negative upper and lower endoscopy. Small-bowel capsule endoscopy (SBCE) is recommended as the FIRST-LINE examination, before other endoscopic and radiological tests (strong, moderate). ESGE does NOT recommend routine second-look endoscopy prior to SBCE in suspected small-bowel bleeding or iron-deficiency anemia (strong, low). In OVERT suspected small-bowel bleeding, perform SBCE as soon as possible after the bleeding episode, ideally within 48 hours, to maximize diagnostic and therapeutic yield (strong, high). Device-assisted enteroscopy (DAE) is recommended to confirm and possibly treat lesions identified by SBCE (strong, high); in overt suspected small-bowel bleeding, DAE should optimally be performed within 48-72 hours of the bleeding episode (strong, high). Where SBCE is unavailable or contraindicated, DAE and/or dedicated small-bowel cross-sectional imaging may be considered first, depending on availability, expertise and clinical suspicion (weak, low). After a HIGH-QUALITY NEGATIVE SBCE, ESGE recommends conservative management (strong, moderate), the 2015 wording qualified this as patients without ongoing bleeding evidenced by overt bleeding or continued transfusion requirement, and the 2022 update carries this qualifier as a separate companion recommendation: for patients with a high-quality negative SBCE who have ONGOING overt bleeding or a continued need for blood transfusions, ESGE recommends further investigation using repeat SBCE, DAE, or dedicated small-bowel cross-sectional imaging (strong, moderate). SBCE is also recommended first-line in iron-deficiency anemia when small-bowel evaluation is indicated (strong, high), and after unremarkable or nondiagnostic dedicated small-bowel cross-sectional imaging if likely to influence management (strong, low). CROHN'S DISEASE: in SUSPECTED Crohn's with negative ileocolonoscopy, SBCE is the initial small-bowel modality ONLY in the absence of obstructive symptoms or known bowel stenosis (strong, high); in that group ESGE explicitly does NOT recommend routine cross-sectional imaging or a patency capsule before SBCE (strong, HIGH quality). With obstructive symptoms or known stenosis, dedicated cross-sectional imaging (MRE/MR-enteroclysis or CTE/CT-enteroclysis) is used FIRST (strong, moderate), and a patency capsule is recommended before SBCE in suspected Crohn's with obstructive symptoms (strong, low), even when cross-sectional imaging is negative. In ESTABLISHED Crohn's, a patency capsule before SBCE is recommended to decrease the retention rate (strong, moderate). SMALL-BOWEL TUMORS: SBCE is recommended where there is increased risk of a small-bowel tumor (strong, moderate); ESGE does NOT recommend specific investigations before SBCE in suspected small-bowel tumor UNLESS the patient is considered at risk of capsule retention (strong, low). If imaging has ALREADY demonstrated a suspected small-bowel tumor, DAE is preferred over SBCE (strong, low). Cross-sectional imaging is recommended for staging and operability when SBCE shows a tumor with high diagnostic certainty (strong, low); where the capsule diagnosis is uncertain, biopsy sampling AND tattooing of the location by DAE is recommended (strong, low); for a subepithelial mass, confirm by DAE and/or cross-sectional imaging per local availability/expertise (strong, low). SBCE is NOT recommended for follow-up of treated small-bowel tumors, for lack of data (strong, low). PATENCY/RETENTION generally: GI obstruction is an absolute contraindication to SBCE. If the patency capsule is egested intact, retention of a real capsule is unlikely; if not egested within 30 hours, cross-sectional imaging (not plain abdominal radiography) is favored to localize it. In Peutz-Jeghers syndrome, routine patency capsule use is NOT recommended and should be considered case-by-case.

Diagnose and manage GI complications by bariatric procedure type: post-sleeve GERD with PPI, lifestyle, and conversion to RYGB if refractory; marginal ulcer with high-dose PPI BID plus sucralfate, NSAID avoidance, smoking cessation, and H. pylori test/treat; suspected internal hernia with acute post-RYGB SBO with urgent surgical exploration, using CT to support the diagnosis when it will not delay surgery, a normal CT does not exclude internal hernia, and exploration should proceed when clinical suspicion remains high despite negative imaging; and dumping syndrome with dietary modification (plus acarbose or octreotide for refractory late hypoglycemia). Maintain lifelong nutritional surveillance with annual labs and periodic bone density, and evaluate weight regain multidisciplinarily with endoscopic or surgical revision options.

U.S. Multi-Society Task Force (2017 guideline, revised by the 2022 focused update on age to start and stop): offer average-risk colorectal cancer screening to everyone aged 45-75. Screening at 45-49 is a weaker recommendation than at 50-75. Colonoscopy every 10 years and annual FIT are the Tier 1 cornerstones. Tier 2 alternatives are multi-target stool DNA every 3 years, CT colonography every 5 years, and flexible sigmoidoscopy every 5-10 years. Capsule colonoscopy every 5 years is Tier 3. Any abnormal non-colonoscopy test requires a diagnostic colonoscopy, and a stool test should not be offered to a patient who would decline follow-up colonoscopy. Patients who are up to date with negative prior screening, particularly a high-quality colonoscopy, may consider stopping at 75 or when life expectancy is under 10 years. Decisions at 76-85 are individualized by health and prior screening, and screening after 85 is not recommended. The American Cancer Society's May 2026 guideline agrees on the 45-75 range, no screening after 85, and colonoscopy as the preferred option. It adds the next-generation mt-sDNA test and the multitarget stool RNA test (ColoSense), both every 3 years, and it adds an FDA-approved blood-based cfDNA test (Shield) only for people who decline or do not complete visual or stool screening. ACS says a positive stool or blood test should be followed by colonoscopy, preferably within 6 months. The 2026 ASGE paper on follow-up after an abnormal stool test is an implementation review (navigation, tracking, direct-access colonoscopy), not a new screening guideline.

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.

ACG 2021 (statement numbers are the guideline's own): Endoscopic therapy is RECOMMENDED for UGIB due to ulcers with active spurting, active oozing, or a nonbleeding visible vessel (strong, moderate-quality) [#6]. For ulcers with an adherent clot resistant to vigorous irrigation the panel COULD NOT REACH a recommendation for or against endoscopic therapy [#7]. Recommended hemostatic modalities are bipolar electrocoagulation, heater probe, or injection of absolute ethanol (strong, moderate-quality) [#8]; clips, argon plasma coagulation, and soft monopolar electrocoagulation are only SUGGESTED (conditional, very-low- to low-quality) [#9]. Epinephrine injection must NOT be used alone, but in combination with another hemostatic modality (strong, very-low- to moderate-quality) [#10], note the guideline does not require that epinephrine be part of therapy; the three strongly recommended modalities are effective as monotherapy. TC-325 hemostatic powder spray is suggested for actively bleeding ulcers (conditional, very-low-quality) [#11]. Over-the-scope clips are suggested for RECURRENT ulcer bleeding after previous successful endoscopic hemostasis (conditional, low-quality) [#12]. After successful endoscopic hemostasis, high-dose PPI given continuously OR intermittently for 3 days is recommended (strong, moderate- to high-quality) [#13]; high-risk patients then continue twice-daily PPI until 2 weeks after the index endoscopy (conditional, low-quality) [#14]. Peri-procedural care: restrictive RBC transfusion at a threshold of hemoglobin 7 g/dL (conditional, low-quality) [#2]; erythromycin infusion (250 mg IV) before endoscopy (conditional, very-low-quality) [#3]; no recommendation for or against pre-endoscopic PPI [#4]; endoscopy within 24 hours of presentation for patients admitted or under observation (conditional, very-low-quality) [#5], the 2021 panel explicitly DECLINED to carry forward the 2012 ACG suggestion that endoscopy within 12 hours 'may be considered' in high-risk patients, and an RCT of endoscopy <6 h vs 6-24 h after consultation in patients with GBS ≥12 showed no reduction in further bleeding or mortality; resuscitation and attention to active comorbidities should be undertaken before endoscopy. Rebleeding pathway is ordered: recurrent bleeding after endoscopic therapy → REPEAT endoscopy with endoscopic therapy rather than surgery or transcatheter arterial embolization (conditional, low-quality) [#15]; only if endoscopic therapy FAILS → transcatheter arterial embolization (conditional, very-low-quality) [#16]. Very-low-risk patients (Glasgow-Blatchford score 0-1) may be discharged from the ED with outpatient follow-up (conditional, very-low-quality) [#1]. For nonpeptic-ulcer causes, the Canadian Association of Gastroenterology (CAG) Clinical Practice Guideline for the Endoscopic Management of Nonvariceal Nonpeptic Ulcer Upper Gastrointestinal Bleeding (Barkun AN et al., Gastroenterology 2025;169(5); DOI 10.1053/j.gastro.2025.04.041; ASGE/ESGE/SIED/WEO- and AGA-endorsed) (all recommendations conditional, very low certainty): active bleeding malignant UGI tumors, conventional hemostatic therapy over none [1A], topical hemostatic agents (THAs) over none [1B], no recommendation among conventional modalities [2], THAs suggested OVER conventional hemostatic therapy [3], oncologic therapy after endoscopic hemostasis [4]; Mallory-Weiss tears, hemostatic therapy for ACTIVE bleeding (spurting/oozing) over none [5], EBL or through-the-scope clip over epinephrine injection alone [6A/6B], and suggested AGAINST endoscopic hemostatic therapy for MWTs with nonbleeding visible vessels [7A], nonbleeding adherent clots [7B], or nonbleeding clean-based ulcers/flat pigmented spots [7C]; Dieulafoy lesions, EBL or TTSC (each ± epinephrine), or contact thermal devices ± epinephrine, or sclerosant injection ± epinephrine [8A/8B/8D], no recommendation on cap-mounted clips [8C], suggested against epinephrine injection alone versus mechanical [9A] or thermal [9B] devices; GAVE, suggested against RFA relative to APC [10], and EBL suggested over APC [11].