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.

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.

ESGE 2021 gates everything on proven adenoma. ESGE recommends AGAINST diagnostic/therapeutic papillectomy when adenoma has not been proven (strong, low), and recommends histological confirmation by endoscopic biopsies in the case of low-grade-dysplasia adenoma before initiating any treatment (strong, low). Assessment uses a side-viewing endoscope when an ampullary tumor is suspected (strong, moderate); the cap-assisted method is suggested only when the papilla is not seen on forward-viewing endoscopy (weak, moderate); high-resolution virtual chromoendoscopy is suggested for diagnosis and staging (weak, low). Staging is EUS plus abdominal MRCP (strong, low); IDUS is suggested only in selected patients, with routine use balanced against training, cost and pancreatitis risk (weak, low). ESGE suggests that IHC, K-ras and p53 evaluation, PCR, and microsatellite instability testing should NOT routinely be applied to ampullary tumor biopsies to inform prognosis or potential treatment response (weak, low). TREATMENT: ESGE recommends endoscopic papillectomy for ampullary adenoma without intraductal extension (strong, moderate), and en bloc resection of adenomas up to 20-30 mm to achieve R0 (strong, low). Technique is direct snare resection WITHOUT submucosal injection (strong, moderate) - but submucosal injection IS recommended before EMR of the extrapapillary duodenal-wall component of a laterally spreading ampullary tumor (strong, moderate); LST-p can be managed endoscopically, accepting higher intraprocedural and delayed bleeding risk (strong, low). ESGE suggests avoiding any biliary, pancreatic or biductal sphincterotomy prior to papillectomy (weak, very low) and suggests endocut current (weak, low). PROPHYLAXIS: prophylactic pancreatic duct stenting is recommended to reduce post-papillectomy pancreatitis (strong, moderate); ESGE suggests routine rectal administration of 100 mg diclofenac or indomethacin immediately before papillectomy in all patients without NSAID contraindication (weak, low); if PD stenting is not possible, high-volume lactated Ringer's hydration is suggested (weak, low). Prophylactic hemostasis is individualized (strong, very low). SURGERY: ESGE only SUGGESTS considering surgical treatment when endoscopic resection is not feasible for technical reasons (e.g. periampullary diverticulum, size >4 cm) and in the case of intraductal involvement of >20 mm - and surveillance thereafter is still mandatory (weak, low). For adenoma with intraductal extension of 20 mm or less, ESGE suggests complementary techniques in expert centers (thermal ablation by cystotome, or RFA) with temporary biliary stenting (weak, low). For malignancy, ESGE recommends pancreaticoduodenectomy including lymphadenectomy for ampullary lesions of stage T1 or higher, including when pathology after endoscopic papillectomy or surgical ampullectomy reveals T1 adenocarcinoma (strong, low); for Tis ampullary cancer, transduodenal ampullectomy or endoscopic papillectomy may be considered sufficient when final pathology shows no residual disease (strong, low). BILIARY DRAINAGE: ESGE recommends against routine preoperative biliary drainage in surgically eligible ampullary cancer, reserving it for cholangitis, severe symptomatic jaundice (e.g. intense pruritus), delayed surgery, or before neoadjuvant chemotherapy in jaundiced patients (strong, moderate); when required, endoscopic SEMS insertion (strong, moderate); ERCP with SEMS in palliative settings (strong, high). FOLLOW-UP: long-term monitoring after endoscopic papillectomy or surgical ampullectomy by duodenoscopy with biopsies of the scar and of any abnormal area, within the first 3 months, at 6 and 12 months, and yearly thereafter for at least 5 years (strong, low). On recurrence, assess local extent with endoscopy plus biopsies, EUS and MRCP before any treatment (strong, low); benign residual or recurrent lesions may be managed endoscopically including APC and EMR (weak, low).

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.

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.

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].