Endoscopy, in full.

For suspected ICI colitis, exclude infectious causes of diarrhea (including C. difficile) before treating. In grade 2 or higher colitis/diarrhea, early stool inflammatory markers (lactoferrin, calprotectin) may help stratify patients for endoscopy, and endoscopic confirmation of the diagnosis and severity should be considered before starting high-dose systemic glucocorticoids; abdominal imaging is reserved for dominant pain, fever, or bleeding and should not be done routinely for diarrhea alone. The AGA cautions that no validated severity index for ICI colitis exists and that symptoms correlate poorly with endoscopic, radiologic, and treatment-response severity, and that rapid progression over days can occur, particularly with ipilimumab. ICI colitis typically responds to high-dose systemic glucocorticoids at 0.5-2 mg/kg prednisone-equivalent daily tapered over 4-6 weeks (the AGA explicitly notes these doses and schedules have not been rigorously examined). If there is no improvement after 2-3 days, add infliximab or vedolizumab while continuing glucocorticoids; both are reasonable options for glucocorticoid-refractory colitis. Budesonide is ineffective as prophylaxis and is not a standard treatment for ICI colitis, it is reserved for ICI-associated microscopic colitis. Retreatment with immunotherapy is possible under select conditions. For hepatitis, obtain baseline liver chemistries (total bilirubin, alkaline phosphatase, AST, ALT) and HBV serologies before ICI; grade by CTCAE and manage as follows: grade 1 (AST/ALT 1-3x ULN or bilirubin 1-1.5x ULN), monitor liver chemistries 1-2 times weekly; grade 2 (AST/ALT >3-5x ULN or bilirubin >1.5-3x ULN), hold ICI until resolution to grade 1, and if symptomatic give prednisone 0.5-1.0 mg/kg/d or equivalent; grade 3 (AST/ALT >5-20x ULN or bilirubin >3-10x ULN), discontinue ICI and start methylprednisolone 1-2 mg/kg/d or equivalent; grade 4 (AST/ALT >20x ULN or bilirubin >10x ULN or hepatic decompensation), permanently discontinue ICI and start methylprednisolone 2 mg/kg/d. For ICI hepatitis that does not adequately improve after 3-5 days of high-dose glucocorticoids, escalate to a second-line immunosuppressant, mycophenolate mofetil (with azathioprine as an accepted alternative), while continuing glucocorticoids; infliximab is not recommended for ICI hepatitis because of its potential for hepatotoxicity. Evaluate all ICI-related liver-chemistry elevations for alternate etiologies (consider liver biopsy), and obtain biliary imaging when alkaline phosphatase and/or bilirubin are elevated.

The CAPS Consortium recommends pancreatic surveillance for selected high-risk individuals to detect stage I (T1N0M0, margin-negative resectable) pancreatic cancer and high-grade precursors (PanIN-3, IPMN with high-grade dysplasia); it should ideally be performed in a research setting by a multidisciplinary team at a center with appropriate expertise. Candidate groups and their affected-relative requirements: Peutz-Jeghers/STK11 carriers regardless of family history; CDKN2A carriers regardless of family history (surveillance regardless of family history reached 77% agreement, still meeting the guideline's ≥75% consensus threshold as a Grade 1 'definitely do it' recommendation, while surveillance in those with at least one affected first-degree relative reached stronger 99% agreement); BRCA2 carriers with at least one affected FDR or at least two affected relatives of any degree; ATM, PALB2, and Lynch (MLH1/MSH2/MSH6) carriers only if at least one affected FDR; BRCA1 with an affected FDR did NOT reach consensus; hereditary pancreatitis was an area of disagreement (no consensus on whether or how to surveil); and familial pancreatic cancer kindreds, an individual with at least one affected FDR who in turn has an affected FDR, qualify on pedigree alone without an identified germline variant. Germline testing and genetic counseling should be considered for those eligible for surveillance but are not an absolute prerequisite. Start ages (exact age often did not reach consensus): CDKN2A at age 40; Peutz-Jeghers at least by age 40, or 10 years younger than the youngest affected relative; hereditary pancreatitis/PRSS1 at age 40 or 20 years after the first attack; BRCA2/ATM/PALB2/BRCA1/Lynch carriers at age 45 or 50, or 10 years younger than the youngest affected relative; familial pancreatic cancer kindreds at age 50 or 55, or 10 years younger than the youngest affected relative (experts split between 50 and 55). New-onset diabetes in a high-risk individual should trigger screening regardless of age. Modalities: both baseline and follow-up surveillance use EUS and MRI/MRCP, alternated (consensus that both are used, but NO consensus on if or how to alternate them); CT is reserved for individuals who cannot undergo MRI/EUS or when a solid lesion is detected; CA19-9 is an additional test only when imaging shows worrisome features; routine fasting glucose and/or HbA1c testing is advised. Interval: in the absence of pancreatic abnormalities, or with only low-risk findings such as pancreatic lobulation, cysts without worrisome features, or a <1 cm non-functioning neuroendocrine tumor, continue 12-monthly imaging. Concerning findings: a newly detected solid lesion of uncertain significance should be re-imaged at 3 months (3-6 months for CDKN2A carriers); EUS-FNA is indicated for solid lesions ≥5 mm, cystic lesions with worrisome features (mural nodule, solid component, duct dilation), or a main-pancreatic-duct stricture without a mass. Surgical resection, performed at a specialty center as an oncologic/radical resection, is indicated for a solid lesion (≥5 mm; resection regardless of size did not reach consensus), or an IPMN with a mural nodule, an enhancing solid component, symptoms (pancreatitis/jaundice/pain), or a main pancreatic duct ≥10 mm. Surveillance of average-risk individuals is not recommended.

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.

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.

For right upper quadrant pain, characterize the pattern (acute vs chronic, post-meal vs unrelated, with vs without fever/jaundice) and triage acute red-flag presentations (Murphy sign, Charcot's triad, painless jaundice with weight loss, pregnancy with LFT/coagulation derangement) to the ED. Obtain labs (CBC, CMP with LFTs, lipase, urinalysis, pregnancy test in reproductive-age women) and RUQ ultrasound as first imaging, then direct further workup by ultrasound findings, cholecystectomy for acute cholecystitis, MRCP for suspected choledocholithiasis based on risk stratification (e.g., high-risk criteria including CBD dilation >6 mm, bilirubin >4 mg/dL, or gallstone pancreatitis), CCK-HIDA/GBEF for acalculous functional gallbladder disorder, and cross-sectional imaging for liver masses or other pathology.