Endoscopy, in full.

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.

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).

Scope: the guideline covers adults with IDA without dominant GI symptoms (its definition of 'asymptomatic'); in patients WITH GI symptoms, endoscopy is directed first at the symptomatic segment, and the uninvestigated side is examined if that is negative. (1) In patients with anemia, use a ferritin cutoff of 45 ng/mL rather than 15 ng/mL to diagnose iron deficiency (strong recommendation, high-certainty evidence); in inflammatory conditions or CKD, adjunct tests (CRP, transferrin saturation) may be needed. (2) In asymptomatic postmenopausal women and men with IDA, perform bidirectional endoscopy (EGD plus colonoscopy) rather than no endoscopy (strong recommendation, moderate certainty); when both procedures are needed they should be performed on the same day, a practical consideration stated in the guideline, not part of the graded recommendation. (3) In asymptomatic premenopausal women with IDA, the AGA suggests bidirectional endoscopy over iron replacement therapy alone (conditional recommendation, moderate certainty); shared decision-making applies, and a patient who places higher value on avoiding endoscopy may reasonably choose an initial trial of iron. (4) In IDA with no etiology identified after bidirectional endoscopy, the AGA suggests noninvasive H. pylori testing (urea breath test, stool antigen, or serology per the technical review), with treatment if positive, over no testing (conditional, low certainty), a post-endoscopy step. (5) The AGA suggests against routine gastric biopsies to diagnose atrophic gastritis (conditional, very low certainty). (6) In asymptomatic adults with IDA and plausible celiac disease, the AGA suggests initial serologic testing, with small-bowel biopsy only if serology is positive, over routine small-bowel biopsies (conditional, very low certainty). (7) In uncomplicated asymptomatic patients with IDA and negative bidirectional endoscopy, the AGA suggests an initial trial of iron supplementation over routine video capsule endoscopy (conditional, very low certainty); VCE is second-line, for persistent or recurrent IDA despite iron therapy. The guideline does, however, advise caution in patients with comorbid conditions in whom identifying small-bowel pathology would change management: in selected such patients, for example, those on ongoing anticoagulation or antiplatelet therapy, those who are transfusion-dependent, or those with refractory IDA, VCE may reasonably be considered earlier, even as a first-line investigative approach, because identifying a small-bowel bleeding lesion may change management. This is an individualized judgment for particular patients, not a categorical exception that exempts these groups from the iron-first approach.