AGA Clinical Practice Update on Nonampullary Duodenal Lesions: Expert Review.

Nonampullary duodenal polyps are found in up to 5% of all upper endoscopies; the vast majority are identified incidentally in asymptomatic patients. Although most are benign, adenomas are estimated to account for 10%-20% of these lesions. Most international guidelines recommend that all duodenal adenomas should be considered for endoscopic resection; this may be associated with a near 15% adverse event rate (predominantly bleeding and perforation) in prospective studies, with substantial local recurrence on surveillance. The aim of this American Gastroenterological Association (AGA) Clinical Practice Update Expert Review was to describe how individuals should be evaluated and risk-stratified for duodenal polyps, the best approaches to endoscopic resection and surveillance, and management of complications, highlighting opportunities for future research to fill gaps in the existing literature. This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology. These Best Practice Advice statements were drawn from a review of the published literature and from expert opinion. Because systematic reviews were not performed, these Best Practice Advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. Best Practice Advice Statements BEST PRACTICE ADVICE 1: Non-neoplastic duodenal lesions (eg, metaplastic foveolar epithelium and gastric heterotopia) may mimic neoplastic adenomatous pathology. Careful optical evaluation and pathologic correlation may be necessary to exclude dysplasia. Nondysplastic lesions do not require endoscopic resection unless they are symptomatic or bleeding. BEST PRACTICE ADVICE 2: Ideal duodenal endoscopic inspection includes identification of the major and minor papilla with photodocumentation to ensure no involvement by the lesion. Adding a clear distal attachment device to a forward-viewing gastroscope improves visualization of the papilla and the medial wall. A side-viewing duodenoscope should be used when the major and minor papilla are not visible with the gastroscope and for most lesions on the medial wall of the duodenum within 5 cm of the ampulla. BEST PRACTICE ADVICE 3: All duodenal polyps should be described according to their size, Paris morphology, suspected histologic layer of origin (mucosal lesion or subepithelial lesion), duodenal location (D1-4) and orientation (anterior, posterior, medial, or lateral wall), and proximity/relationship to the major papilla to facilitate therapeutic planning and subsequent surveillance. BEST PRACTICE ADVICE 4: Given the high frequency of concomitant colonic adenomas in patients with duodenal adenomas, on identification of a duodenal adenoma, a colonoscopy should be performed if a high-quality examination has not been performed in the last 3 years. BEST PRACTICE ADVICE 5: Routine small bowel investigation (ie, capsule endoscopy) is not advised in patients with sporadic and nonsporadic duodenal adenomas. Periodic small bowel inspection with capsule endoscopy may be of benefit in patients with Peutz-Jeghers syndrome. BEST PRACTICE ADVICE 6: Definitive treatment of duodenal adenomas by endoscopic resection is less morbid, resource-intensive, and expensive than surgery and is therefore the preferred treatment option. BEST PRACTICE ADVICE 7: Due to the risk of malignant transformation, all sporadic duodenal adenomas should be considered for endoscopic resection. However, in comparison with colonic adenomas, the time course to malignant transformation may be more prolonged, and the risk of resection-related morbidity much greater. Therefore, the comorbidities and anticipated longevity of the patient must be carefully factored into the decision-making process. BEST PRACTICE ADVICE 8: The approach to endoscopic duodenal resection (ie, hot vs cold and conventional vs underwater endoscopic mucosal resection) should be individualized to reduce bleeding risk, based on lesion size, morphology, patient comorbidities, and endoscopist comfort level with specific techniques. Piecemeal cold snare resection for flat duodenal adenomas mitigates postprocedural bleeding risk and, for lesions <20 mm, is effective and carries a minimal risk of recurrence. In patients with comorbidities with flat nonbulky lesions measuring < 20 mm, cold snare resection can be considered. BEST PRACTICE ADVICE 9: Currently, duodenal adenomas >20 mm or with large Paris subtype Is components should be removed by conventional hot snare endoscopic mucosal resection. Thermal ablation of the post-endoscopic mucosal resection margin to mitigate the risk of recurrence to <2%-5% is safe and effective and should be considered. BEST PRACTICE ADVICE 10: Endoscopists performing duodenal polyp resection should be aware of the increased risk of postprocedural bleeding (compared with elsewhere in the gastrointestinal tract), which usually occurs in the first 48 hours after the procedure, with the risk proportional to the lesion size. For lesions >3 cm, bleeding risk is >25% and may be life-threatening and associated with hemodynamic compromise; however, after resuscitation, endoscopic hemostasis is generally effective. BEST PRACTICE ADVICE 11: Evaluation of the postpolypectomy/endoscopic mucosal resection defect is critical to identify concerns for postprocedural duodenal perforation, which, if unrecognized and left untreated, may be life-threatening and often mandates surgery. BEST PRACTICE ADVICE 12: Initial endoscopic surveillance for a completely resected duodenal adenoma should be undertaken at an interval of 6 months. Although usually diminutive, recurrence is often scarred and not amenable to conventional snare resection and may require avulsion techniques to achieve cure. BEST PRACTICE ADVICE 13: Nonampullary duodenal adenomas associated with familial adenomatous polyposis should be considered for endoscopic resection based on size (≥1 cm), morphologic characteristics, advanced histology (ie, high-grade dysplasia), and/or based on Spiegelman criteria.

Bourke MJ ，Lo SK ，Buerlein RCD ，Das KK ... -  《-》

AGA Clinical Practice Update on Screening and Surveillance in Individuals at Increased Risk for Gastric Cancer in the United States: Expert Review.

Gastric cancer (GC) is a leading cause of preventable cancer and mortality in certain US populations. The most impactful way to reduce GC mortality is via primary prevention, namely Helicobacter pylori eradication, and secondary prevention, namely endoscopic screening and surveillance of precancerous conditions, such as gastric intestinal metaplasia (GIM). An emerging body of evidence supports the possible impact of these strategies on GC incidence and mortality in identifiable high-risk populations in the United States. Accordingly, the primary objective of this American Gastroenterological Association (AGA) Clinical Practice Update (CPU) Expert Review is to provide best practice advice for primary and secondary prevention of GC in the context of current clinical practice and evidence in the United States. This CPU Expert Review was commissioned and approved by the AGA Institute CPU Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Gastroenterology. These best practice advice statements were drawn from a review of the published literature and expert opinion. Because systematic reviews were not performed, these best practice advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. Best Practice Advice Statements BEST PRACTICE ADVICE 1: There are identifiable high-risk groups in the United States who should be considered for GC screening. These include first-generation immigrants from high-incidence GC regions and possibly other non-White racial and ethnic groups, those with a family history of GC in a first-degree relative, and individuals with certain hereditary gastrointestinal polyposis or hereditary cancer syndromes. BEST PRACTICE ADVICE 2: Endoscopy is the best test for screening or surveillance in individuals at increased risk for GC. Endoscopy enables direct visualization to endoscopically stage the mucosa and identify areas concerning for neoplasia, as well as enables biopsies for further histologic examination and mucosal staging. Both endoscopic and histologic staging are key for risk stratification and determining whether ongoing surveillance is indicated and at what interval. BEST PRACTICE ADVICE 3: High-quality upper endoscopy for the detection of premalignant and malignant gastric lesions should include the use of a high-definition white-light endoscopy system with image enhancement, gastric mucosal cleansing, and insufflation to achieve optimal mucosal visualization, in addition to adequate visual inspection time, photodocumentation, and use of a systematic biopsy protocol for mucosal staging when appropriate. BEST PRACTICE ADVICE 4: H pylori eradication is essential and serves as an adjunct to endoscopic screening and surveillance for primary and secondary prevention of GC. Opportunistic screening for H pylori infection should be considered in individuals deemed to be at increased risk for GC (refer to Best Practice Advice 1). Screening for H pylori infection in adult household members of individuals who test positive for H pylori (so-called "familial-based testing") should also be considered. BEST PRACTICE ADVICE 5: In individuals with suspected gastric atrophy with or without intestinal metaplasia, gastric biopsies should be obtained according to a systematic protocol (eg, updated Sydney System) to enable histologic confirmation and staging. A minimum of 5 total biopsies should be obtained, with samples from the antrum/incisura and corpus placed in separately labeled jars (eg, jar 1, "antrum/incisura" and jar 2, "corpus"). Any suspicious areas should be described and biopsied separately. BEST PRACTICE ADVICE 6: GIM and dysplasia are endoscopically detectable. However, these findings often go undiagnosed when endoscopists are unfamiliar with the characteristic visual features; accordingly, there is an unmet need for improved training, especially in the United States. Artificial intelligence tools appear promising for the detection of early gastric neoplasia in the adequately visualized stomach, but data are too preliminary to recommend routine use. BEST PRACTICE ADVICE 7: Endoscopists should work with their local pathologists to achieve consensus for consistent documentation of histologic risk-stratification parameters when atrophic gastritis with or without metaplasia is diagnosed. At a minimum, the presence or absence of H pylori infection, severity of atrophy and/or metaplasia, and histologic subtyping of GIM, if applicable, should be documented to inform clinical decision making. BEST PRACTICE ADVICE 8: If the index screening endoscopy performed in an individual at increased risk for GC (refer to Best Practice Advice 1) does not identify atrophy, GIM, or neoplasia, then the decision to continue screening should be based on that individual's risk factors and preferences. If the individual has a family history of GC or multiple risk factors for GC, then ongoing screening should be considered. The optimal screening intervals in such scenarios are not well defined. BEST PRACTICE ADVICE 9: Endoscopists should ensure that all individuals with confirmed gastric atrophy with or without GIM undergo risk stratification. Individuals with severe atrophic gastritis and/or multifocal or incomplete GIM are likely to benefit from endoscopic surveillance, particularly if they have other risk factors for GC (eg, family history). Endoscopic surveillance should be considered every 3 years; however, intervals are not well defined and shorter intervals may be advisable in those with multiple risk factors, such as severe GIM that is anatomically extensive. BEST PRACTICE ADVICE 10: Indefinite and low-grade dysplasia can be difficult to reproducibly identify by endoscopy and accurately diagnose on histopathology. Accordingly, all dysplasia should be confirmed by an experienced gastrointestinal pathologist, and clinicians should refer patients with visible or nonvisible dysplasia to an endoscopist or center with expertise in the diagnosis and management of gastric neoplasia. Individuals with indefinite or low-grade dysplasia who are infected with H pylori should be treated and have eradication confirmed, followed by repeat endoscopy and biopsies by an experienced endoscopist, as visual and histologic discernment may improve once inflammation subsides. BEST PRACTICE ADVICE 11: Individuals with suspected high-grade dysplasia or early GC should undergo endoscopic submucosal dissection with the goal of en bloc, R0 resection to enable accurate pathologic staging with curative intent. Eradication of active H pylori infection is essential, but should not delay endoscopic intervention. Endoscopic submucosal dissection should be performed at a center with endoscopic and pathologic expertise. BEST PRACTICE ADVICE 12: Individuals with a history of successfully resected gastric dysplasia or cancer require ongoing endoscopic surveillance. Suggested surveillance intervals exist, but additional data are required to refine surveillance recommendations, particularly in the United States. BEST PRACTICE ADVICE 13: Type I gastric carcinoids in individuals with atrophic gastritis are typically indolent, especially if <1 cm. Endoscopists may consider resecting gastric carcinoids <1 cm and should endoscopically resect lesions measuring 1-2 cm. Individuals with type I gastric carcinoids >2 cm should undergo cross-sectional imaging and be referred for surgical resection, given the risk of metastasis. Individuals with type I gastric carcinoids should undergo surveillance, but the intervals are not well defined. BEST PRACTICE ADVICE 14: In general, only individuals who are fit for endoscopic or potentially surgical treatment should be screened for GC and continued surveillance of premalignant gastric conditions. If a person is no longer fit for endoscopic or surgical treatment, then screening and surveillance should be stopped. BEST PRACTICE ADVICE 15: To achieve health equity, a personalized approach should be taken to assess an individual's risk for GC to determine whether screening and surveillance should be pursued. In conjunction, modifiable risk factors for GC should be distinctly addressed, as most of these risk factors disproportionately impact people at high risk for GC and represent health care disparities.

Shah SC ，Wang AY ，Wallace MB ，Hwang JH ... -  《-》

AGA Clinical Practice Update on Advances in Per-Oral Endoscopic Myotomy (POEM) and Remaining Questions-What We Have Learned in the Past Decade: Expert Review.

This American Gastroenterological Association (AGA) Institute Clinical Practice Update (CPU) aims to review the available evidence and provide expert advice regarding advances in per-oral endoscopic myotomy (POEM). This CPU was commissioned and approved by the AGA Institute CPU Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Gastroenterology. This review is framed around best practice advice points agreed upon by the authors, based on the current available evidence and expert opinion in this field. Because systematic reviews were not performed, these best practice advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. Best Practice Advice Statements BEST PRACTICE ADVICE 1: Patients evaluated for POEM should undergo a comprehensive diagnostic workup, which includes clinical history and review of medications, upper endoscopy, timed barium esophagram, and high-resolution manometry. Endoscopic functional luminal impedance planimetry can be a useful adjunct test, particularly in cases when diagnosis is equivocal. BEST PRACTICE ADVICE 2: POEM, laparoscopic Heller myotomy, and pneumatic dilation are effective therapies for type I and type II achalasia; the decision between these treatment modalities should be based on shared decision making, taking into account patient and disease characteristics, patient preferences, and local expertise. POEM should be considered the preferred treatment for type III achalasia. BEST PRACTICE ADVICE 3: Patients with esophagogastric outflow obstruction alone and/or nonachalasia spastic disorders on manometry should undergo a comprehensive evaluation with correlation of symptoms. Evidence for POEM for these manometric findings are limited and should only be considered on a case-by-case basis after other less invasive approaches have been exhausted. BEST PRACTICE ADVICE 4: A single dose of antibiotics at the time of POEM may be sufficient for antibiotic prophylaxis. BEST PRACTICE ADVICE 5: POEM can be performed via either an anterior or posterior tunnel orientation, with comparable efficacy, safety, and rate of postprocedure reflux between these 2 approaches. Endoscopist's preferences and patient's surgical history, including prior laparoscopic Heller myotomy and/or POEM, should be considered when determining tunnel orientation. BEST PRACTICE ADVICE 6: The optimal length of the myotomy in the esophagus and cardia, as it pertains to treatment efficacy and risk for postprocedure reflux, remains to be determined. Adjunct techniques, including real-time intraprocedure functional luminal impedance planimetry, may be considered to tailor or confirm the adequacy of the myotomy. BEST PRACTICE ADVICE 7: The clinical impact of routine esophagram or endoscopy immediately post-POEM remains unclear. Testing can be considered based on local practice preferences, and in cases in which intraprocedural events or postprocedural findings warrant further evaluation. BEST PRACTICE ADVICE 8: Same-day discharge after POEM can be considered in select patients who meet discharge criteria. Patients with advanced age, significant comorbidities, poor social support, and/or access to specialized care should be considered for hospital admission, irrespective of symptoms. BEST PRACTICE ADVICE 9: Pharmacologic acid suppression should be strongly considered in the immediate post-POEM setting, given the increased risk of postprocedure reflux and esophagitis. BEST PRACTICE ADVICE 10: All patients should undergo monitoring for gastroesophageal reflux disease after POEM. Patients with persistent esophagitis and/or reflux-like symptoms despite proton pump inhibitor use, should undergo additional testing to evaluate for other etiologies besides pathologic acid exposure and management to optimize and achieve reflux control. BEST PRACTICE ADVICE 11: Long-term postprocedure surveillance is encouraged to monitor for progression of disease and complications of gastroesophageal reflux disease. BEST PRACTICE ADVICE 12: POEM may be superior to pneumatic dilation for patients with failed initial POEM or laparoscopic Heller myotomy; however, the decision among treatment modalities should be based on shared decision making between the patient and physician, taking into account risk of postprocedural reflux, need for repeat interventions, patient preferences, and local expertise.

Yang D ，Bechara R ，Dunst CM ，Konda VJA ... -  《-》

AGA Clinical Practice Update on Management of Portal Vein Thrombosis in Patients With Cirrhosis: Expert Review.

Portal vein thromboses (PVTs) are common in patients with cirrhosis and are associated with advanced portal hypertension and mortality. The treatment of PVTs remains a clinical challenge due to limited evidence and competing risks of PVT-associated complications vs bleeding risk of anticoagulation. Significant heterogeneity in PVT phenotype based on anatomic, host, and disease characteristics, and an emerging spectrum of therapeutic options further complicate PVT management. This Clinical Practice Update (CPU) aims to provide best practice advice for the evaluation and management of PVT in cirrhosis, including the role of direct oral anticoagulants and endovascular interventions. This expert review was commissioned and approved by the American Gastroenterological Association (AGA) Institute CPU Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Gastroenterology. These Best Practice Advice statements were drawn from a review of the published literature and from expert opinion. Because systematic reviews were not performed, these Best Practice Advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. Best Practice Advice Statements BEST PRACTICE ADVICE 1: Asymptomatic patients with compensated cirrhosis do not require routine screening for PVT. BEST PRACTICE ADVICE 2: Patients with cirrhosis with PVTs identified on Doppler ultrasound should undergo cross-sectional imaging with computed tomography or magnetic resonance imaging to confirm the diagnosis, evaluate for malignancy, and document the degree of lumen occlusion, clot extent, and chronicity. BEST PRACTICE ADVICE 3: Patients with cirrhosis and PVT do not require a hypercoagulable workup in the absence of additional thromboemboli or laboratory abnormalities or family history suggestive of thrombophilia. BEST PRACTICE ADVICE 4: Patients with cirrhosis and PVT with evidence of intestinal ischemia require urgent anticoagulation to minimize ischemic injury. If available, these patients should be managed by a multidisciplinary team, including gastroenterology and hepatology, interventional radiology, hematology, and surgery. BEST PRACTICE ADVICE 5: Consider observation, with repeat imaging every 3 months until clot regression, in patients with cirrhosis without intestinal ischemia and recent (<6 months) thrombosis involving the intrahepatic portal vein branches or when there is <50% occlusion of the main portal vein, splenic vein, or mesenteric veins. BEST PRACTICE ADVICE 6: Anticoagulation should be considered in patients with cirrhosis without intestinal ischemia who develop recent (<6 months) PVT that is >50% occlusive or involves the main portal vein or mesenteric vessels. Patients who have increased benefit of recanalization include those with involvement of more than 1 vascular bed, those with thrombus progression, potential liver transplantation candidates, and those with inherited thrombophilia. BEST PRACTICE ADVICE 7: Anticoagulation is not advised for patients with cirrhosis with chronic (>6 months) PVT with complete occlusion with collateralization (cavernous transformation). BEST PRACTICE ADVICE 8: Patients with cirrhosis and PVT warrant endoscopic variceal screening if they are not already on nonselective beta-blocker therapy for bleeding prophylaxis. Avoid delays in the initiation of anticoagulation for PVT, as this decreases the odds of portal vein recanalization. BEST PRACTICE ADVICE 9: Vitamin K antagonists, low-molecular-weight heparin, and direct oral anticoagulants are all reasonable anticoagulant options for patients with cirrhosis and PVT. Decision making should be individualized and informed by patient preference and Child-Turcotte-Pugh class. Direct oral anticoagulants may be considered in patients with compensated Child-Turcotte-Pugh class A and Child-Turcotte-Pugh class B cirrhosis and offer convenience as their dosages are independent of international normalized ratio monitoring. BEST PRACTICE ADVICE 10: Patients with cirrhosis on anticoagulation for PVT should have cross-sectional imaging every 3 months to assess response to treatment. If clot regresses, anticoagulation should be continued until transplantation or at least clot resolution in nontransplantation patients. BEST PRACTICE ADVICE 11: Portal vein revascularization with transjugular intrahepatic portosystemic shunting may be considered for selected patients with cirrhosis and PVT who have additional indications for transjugular intrahepatic portosystemic shunting, such as those with refractory ascites or variceal bleeding. Portal vein revascularization with transjugular intrahepatic portosystemic shunting may also be considered for transplantation candidates if recanalization can facilitate the technical feasibility of transplantation.

Davis JPE ，Lim JK ，Francis FF ，Ahn J ... -  《-》

Defining the optimum strategy for identifying adults and children with coeliac disease: systematic review and economic modelling.

Elwenspoek MM ，Thom H ，Sheppard AL ，Keeney E ，O'Donnell R ，Jackson J ，Roadevin C ，Dawson S ，Lane D ，Stubbs J ，Everitt H ，Watson JC ，Hay AD ，Gillett P ，Robins G ，Jones HE ，Mallett S ，Whiting PF ... -  《-》