Endoscopy, in full.

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).

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).

All patients meeting clinical criteria for, or carrying a pathogenic germline variant of, a hereditary GI cancer syndrome should have pre- and post-test genetic counseling, and at-risk first-degree relatives should be offered genetic testing. Syndrome-specific surveillance: LYNCH SYNDROME, colonoscopy at least every 2 years (annual colonoscopy should be considered in confirmed mutation carriers), beginning at age 20-25 years, or 2-5 years before the earliest CRC diagnosis in the family if that was before age 25; baseline EGD with gastric biopsy and test-and-treat for H. pylori at age 30-35, with ongoing upper-GI surveillance every 3-5 years where family history of gastric/duodenal cancer exists; annual endometrial biopsy and transvaginal ultrasound from age 30-35, with prophylactic hysterectomy/bilateral salpingo-oophorectomy offered after childbearing; surveillance BEYOND population-based recommendations for the urinary tract, pancreas, breast and prostate is NOT recommended unless supported by family history. CLASSIC FAP, annual sigmoidoscopy or colonoscopy beginning at puberty; colectomy indicated for documented/suspected cancer or significant symptoms (absolute), or for relative indications such as multiple adenomas >6 mm or a significant increase in adenoma number that make endoscopic control unfeasible; upper-GI surveillance by EGD/duodenoscopy from age 25-30, repeated every 0.5-4 years by Spigelman stage, plus annual thyroid ultrasound. AFAP, surveillance by colonoscopy (not sigmoidoscopy, as polyps are right-sided) with polypectomy every 1-2 years, beginning in the late teens to early 20s; upper-GI surveillance by EGD/duodenoscopy from age 25-30, repeated every 0.5-4 years by Spigelman stage, plus annual thyroid ultrasound (as for classic FAP). MUTYH-ASSOCIATED POLYPOSIS (biallelic MUTYH), colonoscopy every 1-2 years beginning at age 25-30; upper-GI surveillance by EGD/duodenoscopy from age 25-30, repeated every 0.5-4 years by Spigelman stage, plus annual thyroid ultrasound (as for classic FAP). SERRATED POLYPOSIS SYNDROME, colonoscopy every 1-3 years with attempted removal of all polyps >5 mm.

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.

Triage suspected perforation with immediate IV access (2 large-bore IVs) and assessment of perfusion in parallel with diagnostics; obtain upright CXR and CT abdomen/pelvis (most sensitive/specific) plus labs and lactate, and start empiric broad-spectrum antibiotics. Fluid therapy is stratified by perfusion status, not given as a fixed protocol for all comers: in adults with sepsis-induced hypoperfusion or septic shock, give at least 30 mL/kg IV crystalloid within the first 3 hours (Surviving Sepsis Campaign 2026; conditional recommendation, low-certainty evidence), selecting the initial volume by individual patient characteristics and context (use adjusted or ideal body weight if BMI >30 kg/m²) with frequent, ongoing reassessment to avoid under- or over-resuscitation, alongside sepsis care: blood cultures as soon as possible and ideally before antimicrobials, lactate with serial measurement to guide resuscitation, and vasopressors if hypotension persists despite fluids. In patients without sepsis-induced hypoperfusion or shock, do not give protocolized volume resuscitation; use maintenance fluids or small individualized boluses guided by hemodynamic reassessment, and in fluid-sensitive patients (e.g., heart failure, end-stage renal disease) use smaller individualized boluses with close reassessment rather than a fixed weight-based volume. Obtain mandatory emergency surgical consultation for any confirmed perforation, hard peritoneal signs, free air, or hemodynamic instability, proceeding to exploratory laparotomy/laparoscopy or cause-specific surgery (Graham patch, Hartmann, colectomy). Selected contained post-procedural perforations that are small, clip-amenable, and hemodynamically stable may be managed conservatively with ICU monitoring, NPO, antibiotics, and serial imaging.

In patients with classic GERD symptoms (heartburn, regurgitation) and no alarm symptoms, give an 8-week trial of empiric PPI ONCE DAILY before a meal (strong, moderate evidence); administer PPI 30-60 minutes before a meal rather than at bedtime (strong, moderate). Endoscopy is the FIRST test in patients presenting with dysphagia or other alarm symptoms, the guideline names weight loss and GI bleeding, and also in patients with multiple risk factors for Barrett's esophagus (strong, low). If classic symptoms respond to the 8-week trial, attempt to discontinue the PPI (conditional, low); for patients without erosive esophagitis or Barrett's whose symptoms resolved, an attempt at discontinuation should be made; patients requiring maintenance should take the lowest effective dose. If symptoms do not respond adequately to the 8-week trial, or return on discontinuation, perform diagnostic endoscopy, ideally after PPIs are stopped for 2-4 weeks (strong, low). Where GERD is suspected but unclear and endoscopy shows no objective evidence, perform reflux monitoring OFF therapy to establish the diagnosis (strong, low); conversely, do NOT perform off-therapy reflux monitoring solely as a diagnostic test in patients already known to have LA grade C or D esophagitis or long-segment Barrett's, because the diagnosis is already established (strong, low). In refractory GERD, optimize PPI therapy first (strong, moderate); then pH monitoring OFF PPIs if GERD was not previously established by pH study, long-segment Barrett's, or LA grade C/D esophagitis, versus impedance-pH ON PPIs where GERD is already established but symptoms persist on twice-daily PPI (both conditional, low). Before antireflux surgery or endoscopic therapy, HRM is recommended to rule out achalasia and absent contractility, with provocative testing (e.g., multiple rapid swallows) to identify contractile reserve in ineffective esophageal motility; on-therapy reflux monitoring is suggested before intervention in patients with prior objective GERD findings who remain symptomatic. Antireflux surgery by an experienced surgeon is an option for patients with OBJECTIVE evidence of GERD, with severe esophagitis (LA C/D), large hiatal hernia, or persistent troublesome symptoms benefiting most; TIF is suggested only for troublesome regurgitation or heartburn in patients who do not wish to undergo antireflux surgery and who are WITHOUT severe esophagitis (LA C/D) or hiatal hernia >2 cm. For extraesophageal symptoms WITHOUT typical GERD symptoms, perform reflux testing BEFORE starting PPI therapy (strong, moderate); with concomitant typical symptoms, consider twice-daily PPI for 8-12 weeks before further testing (conditional, low). Lifestyle: weight loss in overweight/obese patients (strong, moderate); avoid meals within 2-3 hours of bedtime, avoid tobacco, avoid trigger foods, and elevate the head of the bed for nighttime symptoms (all conditional, low).

Confirm chronic pancreatitis on CROSS-SECTIONAL IMAGING, CT for late calcific disease, MRI/MRCP (with secretin where available) for earlier ductal and parenchymal change, EUS an acceptable alternative; per ACG 2020, "Diagnosis is made usually on cross-sectional imaging, with modalities such as endoscopic ultrasonography and pancreatic function tests playing a secondary role". Fecal elastase does NOT confirm chronic pancreatitis: it is a test of exocrine FUNCTION and is the appropriate initial test for the exocrine pancreatic insufficiency (EPI) that chronic pancreatitis causes, a consequence of the disease, not the diagnosis of it. A normal fecal elastase does not exclude chronic pancreatitis and a low one does not establish it. Per AGA 2023, fecal elastase must be run on a semi-solid or solid stool specimen; below 100 mcg/g is good evidence of EPI and 100-200 mcg/g is indeterminate (below 200 mcg/g is the cutoff commonly used to screen). Then manage with smoking and alcohol cessation, PERT for exocrine insufficiency titrated to symptoms, fat-soluble vitamin and bone surveillance, and individualized type 3c diabetes control, considering insulin early in patients with marked hyperglycemia or symptoms of insulin deficiency. Treat pain with a stepwise ladder from scheduled acetaminophen and neuromodulators to EUS-guided celiac plexus block and endoscopic/surgical intervention, referring early for surgery per ESCAPE 2020 in candidates with main pancreatic duct obstruction. Screen for PDAC per lifetime risk and pursue etiologic workup via TIGAR-O v2, including genetic testing and autoimmune pancreatitis evaluation.