Endoscopy, in full.

Diagnosis is unchanged and still follows the separate ESGE diagnostic guideline (Endoscopy 2025;57:166-185). Start with MRI/MRCP plus laboratory tests, read CA19-9 only after decompression, and check IgG4 when IgG4-related sclerosing cholangitis is suspected. For distal extrahepatic strictures with no pancreatic mass, do combined same-session EUS-guided tissue acquisition plus ERCP brushing and biopsy. For perihilar strictures, sample by ERCP first and move to cholangioscopy-guided biopsy if the result is indeterminate. Do not place an uncovered SEMS (USEMS) until malignancy is confirmed. Management now follows the 2026 ESGE biliary stricture management guideline, which replaces the 2018 stenting guideline and brings it into line with the 2022 therapeutic EUS guideline. Benign: post-cholecystectomy strictures get temporary multiple plastic stents (MPSs), exchanged every 3-4 months with as many stents as possible, for about 12 months. A fully covered SEMS (FCSEMS) is an option only if the stricture is more than 2 cm below the hepatic confluence or the patient will not comply with repeated ERCPs. Anastomotic strictures after liver transplant get MPSs, or a temporary FCSEMS if more than 2 cm below the confluence. Nonanastomotic post-transplant strictures that can be treated endoscopically get MPSs plus balloon dilation if needed. Chronic pancreatitis strictures get a temporary 8-10 mm FCSEMS for 6-12 months. High-grade PSC strictures get balloon dilation alone, with no stent, because stenting adds no benefit and may add adverse events. Endotherapy is indicated for a benign stricture with liver tests raised for more than 1 month and/or cholangitis. Malignant distal: drain before surgery only selectively (cholangitis, severe jaundice or pruritus, delayed surgery). When drainage is needed before surgery or neoadjuvant therapy, or for palliation, place a 10-mm SEMS endoscopically. Endoscopic drainage is preferred over surgery or PTBD for inoperable obstruction. Malignant hilar: manage in high-volume centres with a hepatobiliary multidisciplinary team (MDT). ERCP is preferred over PTBD for preoperative drainage. Palliate Bismuth I-II with ERCP. For Bismuth III-IV, ERCP or ERCP combined with EUS-guided drainage (EUS-BD) is preferred over primary PTBD, with PTBD as a complement if needed. For proven Bismuth II-IV, aim to drain more than 50%, ideally 70% or more, of the viable nonatrophic liver volume using several routes as needed. Use plastic stents when the drainage strategy is undefined or the centre is not expert. USEMS are for expert centres when the diagnosis is proven, the tumour is unresectable, and complete drainage is predicted. After failed or unfeasible ERCP, EUS-BD is recommended over PTBD. Use hepaticogastrostomy (EUS-HGS) if there is a duodenal stricture, and EUS-HGS or choledochoduodenostomy (EUS-CDS) if there is not. PTBD is used if EUS-BD fails. In surgically altered anatomy, benign disease gets enteroscopy-assisted ERCP first; malignant disease gets enteroscopy-assisted ERCP or EUS-BD. Give antibiotics before ERCP in selected cases: predicted incomplete drainage, hilar strictures, immunocompromised patients, PSC, cholangioscopy. This follows the ESGE ERCP-adverse-events guideline. Etiology-specific care (Strasberg injuries, IgG4-SC, Mirizzi, choledochal cysts) is unchanged.

Manage diabetes in GI/hepatology patients by individualizing the A1c target to the population, in cirrhosis, A1c is unreliable because altered red blood cell turnover typically underestimates glycemia, so set glycemic goals using blood glucose monitoring and/or CGM rather than a fixed A1c cutoff, and in diabetic gastroparesis individualize the target rather than applying a universal cutoff; ≤7% pre-bariatric, <6.5% pre-conception, while screening all T2DM for MASLD with FIB-4, screening T1DM for concurrent celiac disease, and screening for diabetic gastroparesis when chronic nausea, early satiety, or postprandial fullness are present. Evaluate new-onset DM after age 50 without obesity for a pancreatic cancer differential, and coordinate peri-procedural medication holds and multidisciplinary endocrinology involvement.

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).