Endoscopy, in full.

Stage cholangiocarcinoma with multiphasic MRI/MRCP plus CT chest/abdomen/pelvis, obtain tissue via ERCP brush cytology with FISH, cholangioscopy-directed biopsy, or EUS-FNA (avoiding primary perihilar tumor sampling if liver transplant is being considered due to theoretical seeding risk), and manage through a multidisciplinary tumor board with treatment stratified by tumor location: resect (anatomic hepatectomy for intrahepatic, hemihepatectomy with bile duct resection for perihilar, Whipple for distal) with adjuvant capecitabine (category 1, per BILCAP) when resectable. For unresectable or metastatic disease, first-line systemic therapy is gemcitabine plus cisplatin combined with a PD-L1/PD-1 checkpoint inhibitor, either durvalumab (TOPAZ-1) or pembrolizumab (KEYNOTE-966), both listed as category 1 preferred options by NCCN; comprehensive molecular/genomic profiling is recommended for all unresectable/metastatic candidates for systemic therapy to identify actionable targets (e.g., FGFR2 fusions, IDH1 mutations, HER2 amplification) for later-line therapy. Selected unresectable early-stage perihilar tumors may undergo neoadjuvant chemoradiation and liver transplant per the Mayo Clinic protocol at experienced centers, and jaundice or cholangitis is managed with biliary drainage (ERCP preferred over PTC).

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.

Confirm unintentional weight loss (≥5% body weight over 6-12 months, office-weighed) and triage into a three-bucket framework, decreased intake, malabsorption, or hypermetabolic, to direct the evaluation. Obtain first-tier labs (CBC, CMP with LFTs, TSH, glucose/A1c, lipase, CRP/ESR, nutritional and iron studies, HIV, and a universal celiac panel) plus mechanism-directed imaging and endoscopy, prioritizing urgent EGD, colonoscopy, or pancreas-protocol CT when malignancy red flags are present. Assess for malnutrition early and initiate nutritional support concurrently with the diagnostic workup, as clinically indicated. Reserve multidisciplinary/PET-CT review for refractory undiagnosed cases.

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

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.

PRIMARY, AGA 2022 (pharmacotherapy, the GI-society spine): Manage obesity as a chronic disease with lifestyle intervention as the foundation. In adults with BMI ≥30 kg/m², OR BMI ≥27 kg/m² with a weight-related complication, who have an inadequate response to lifestyle intervention alone, the AGA STRONGLY recommends ADDING long-term pharmacotherapy to (not replacing) continued lifestyle intervention. Among agents the AGA suggests semaglutide 2.4 mg, liraglutide 3.0 mg, phentermine-topiramate ER, and naltrexone-bupropion ER (all moderate-certainty evidence), and, as lower-certainty options, e.g., where cost is a barrier, phentermine and diethylpropion (low-certainty evidence); when prioritizing for greatest weight loss the panel favored semaglutide 2.4 mg. The AGA suggests AGAINST orlistat and made no recommendation on Gelesis100 (identified as a knowledge gap). Agent choice should be individualized to comorbidities, contraindications, patient preference, and cost/access. COMORBIDITY BRANCHES (attributed separately, NOT part of the AGA document): For obesity-associated MASH, AASLD Practice Guidance supports selecting patients with stage F2-F3 fibrosis by non-invasive tests (VCTE ~8-15 kPa, MRE 3.1-4.4 kPa, or ELF 9.2-10.5) rather than mandatory biopsy, and endorses resmetirom (thyroid hormone receptor-β agonist; FDA-approved March 2024) as the only currently approved pharmacotherapy for MASH (not indicated for MASH cirrhosis). For metabolic/bariatric surgery, the 2022 ASMBS/IFSO indications recommend surgery at BMI ≥35 kg/m² regardless of comorbidity and consideration at BMI 30-34.9 kg/m² with metabolic disease (lower Asian-population thresholds: offer surgery at BMI >27.5, clinical obesity from >25), with multidisciplinary pre-operative evaluation. Concurrently screen for and manage the GI/hepatology comorbidities of obesity (MASLD/MASH, GERD, cholelithiasis).

Match the pre-sedation assessment, the drug regimen and the monitoring to the patient's risk and the complexity of the procedure. Before every sedated procedure, check ASA class, Mallampati score, BMI, OSA risk and fasting status. Propofol and midazolam-with-opiate are both strongly recommended. Using propofol as first line depends on national legislation and staffing, not on proof that it works better. Remimazolam is an ultra-short-acting benzodiazepine, FDA-approved for procedural sedation in July 2020, with fast onset, short duration, organ-independent metabolism and flumazenil reversibility. It is an accepted alternative to midazolam and propofol. Consider it especially in high-risk patients: the elderly and those with cardiorespiratory comorbidity. ESGE/ESGENA 2026 says this, and the ASGE 2026 clinical practice update now covers it, the first ASGE document to address remimazolam (the ASGE 2018 sedation guideline covered only midazolam and propofol). Whoever gives the sedation must be able to rescue a patient one level deeper than intended. Involve an anesthesiology specialist for emergency endoscopy with raised aspiration risk, hemodynamic instability or significant comorbidities. Do the same electively for ASA >=3, Mallampati >=3, severe OSA or an expected difficult airway. Manage GLP-1 receptor agonists case by case rather than stopping them by default. Discharge the patient against a scoring system, with an adult accompanying them and 24-hour restrictions.

Perform individual gastric risk assessment and staging of precancerous conditions at first-time gastroscopy, irrespective of the patient's country of origin. Use high quality endoscopy with virtual chromoendoscopy (VCE), after proper training, for screening, diagnosis and staging of atrophy and intestinal metaplasia and after endoscopic therapy; VCE guides the biopsy site, with random biopsies taken only when there are no endoscopically suspected changes. Take biopsies from at least two topographic sites, 2 from the antrum/incisura and 2 from the corpus, VCE-guided, in two separate, clearly labeled vials; an additional incisura biopsy is optional, not required. Stage with validated endoscopic classifications of atrophy (e.g. Kimura-Takemoto) or intestinal metaplasia (e.g. EGGIM) to stratify gastric cancer risk (suggestion, weaker than the biopsy recommendation). Follow up patients with extensive endoscopic changes (Kimura C3+ or EGGIM 5+) OR an advanced histological stage that reaches OLGA/OLGIM III/IV, severe atrophy or intestinal metaplasia and/or significant changes in both antrum and corpus rising to stage III/IV, not any intestinal metaplasia or any antrum-plus-corpus involvement on its own, with high quality endoscopy every 3 years, irrespective of country of origin (strong recommendation, moderate quality). Propose NO surveillance for patients with mild to moderate atrophy or intestinal metaplasia restricted to the antrum, in the absence of endoscopic signs of extensive lesions or other risk factors (family history of gastric cancer, incomplete intestinal metaplasia, persistent H. pylori infection), the guideline states this group constitutes most individuals found in clinical practice. Eradicate H. pylori in all patients with precancerous conditions and after endoscopic or surgical therapy. Discontinue or do not start gastric cancer screening or surveillance in asymptomatic individuals over 80, and weigh comorbidities when planning treatment of superficial lesions. Advise smoking cessation; low-dose daily aspirin may be considered for gastric cancer prevention only in selected individuals already at high cardiovascular risk. For visible neoplasia, use ESD for differentiated lesions clinically staged as dysplastic (low or high grade) or intramucosal carcinoma (any size if not ulcerated, or ≤30 mm if ulcerated), with EMR an alternative for Paris 0-IIa lesions ≤10 mm with low likelihood of malignancy. At the population level, endoscopic screening is suggested every 2-3 years in high-risk regions (age-standardized rate >20 per 100,000 person-years), every 5 years in intermediate-risk regions (ASR 10-20) only if cost-effectiveness has been proven, and not at all in low-risk regions (ASR <10).

For ALL patients undergoing ERCP (average-risk and high-risk alike), give periprocedural rectal NSAID prophylaxis (100 mg indomethacin or diclofenac) unless contraindicated (e.g., recent PUD, renal insufficiency), this is now a strong recommendation for unselected patients, not just high-risk ones. For high-risk patients undergoing repeated or deep pancreatic-duct access or ampullectomy, add a prophylactic small-caliber pancreatic duct stent (3-5Fr, preferably 5Fr, 3-7cm, removed within 5-10 days), strong recommendation; for other high-risk scenarios (difficult cannulation, prior PEP, precut sphincterotomy without fistulotomy), PD stenting is a conditional recommendation when PD access is easily achieved. Aggressive periprocedural/postprocedural IV hydration with lactated Ringer's (20 mL/kg bolus, then 3 mL/kg/h for 8h) is a conditional suggestion for unselected patients (most practical for inpatients), and wire-guided cannulation is conditionally favored over contrast-guided to reduce PEP risk. The SVI trial (Elmunzer, Lancet 2024) found rectal indomethacin alone did NOT meet non-inferiority versus indomethacin+stent in high-risk patients (PEP 14.9% vs 11.3%), supporting continued use of the combination bundle in high-risk cases rather than dropping the stent. Post-procedure, monitor for the major complications (pancreatitis, sphincterotomy bleeding, perforation, cholangitis) and manage by type, PEP by Cotton criteria with fluids/analgesia, bleeding with repeat endoscopic hemostasis, perforation by Stapfer classification with surgical consult for Type I, and cholangitis with empiric antibiotics (Tokyo Guidelines TG18) plus biliary drainage; these complication-management elements are unchanged from ESGE 2020.

Resuscitate and risk-stratify first. ACG 2023 SUGGESTS (conditional, low-quality evidence) using a risk-stratification tool such as the Oakland score to identify low-risk patients with acute LGIB who are appropriate for early discharge and outpatient evaluation, supplementing, not replacing, clinical judgment. Use a restrictive RBC transfusion strategy with a transfusion threshold of hemoglobin 7 g/dL in hemodynamically stable patients (conditional, low-quality); a higher threshold (~8 g/dL) may be considered in known/active cardiovascular disease. For patients with ONGOING HEMODYNAMICALLY SIGNIFICANT hematochezia, ACG SUGGESTS CT angiography as the initial diagnostic test (conditional, low-quality; ~90% sensitivity for source localization, low yield once bleeding is minor or has stopped); if CTA shows extravasation, promptly refer to interventional radiology for transcatheter arteriography and possible embolization (STRONG, moderate-quality). For patients hospitalized with acute LGIB who REQUIRE inpatient colonoscopy, ACG RECOMMENDS a NONEMERGENT inpatient colonoscopy rather than urgent colonoscopy within 24 hours, because urgent colonoscopy within 24h has not been shown to improve rebleeding or mortality (STRONG, moderate-quality); no specific bowel-prep regimen is superior. Reserve reversal agents for LIFE-THREATENING bleeding that does not respond to initial resuscitation (conditional, very-low-quality): for VKA with an INR substantially above therapeutic range, 4-factor PCC is preferred over FFP; for a DOAC taken within the prior 24 hours, use targeted agents (idarucizumab for dabigatran; andexanet alfa for apixaban/rivaroxaban) when available. After cessation of bleeding, ACG RECOMMENDS resuming anticoagulation, since resumption lowers postbleeding thromboembolism and mortality (STRONG, moderate-quality). For antiplatelet therapy after diverticular hemorrhage: CONTINUE aspirin in patients with established cardiovascular disease (secondary prevention; conditional, low-quality), but DISCONTINUE aspirin used for primary cardiovascular prevention (conditional, low-quality).