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Atrophic gastritis, intestinal metaplasia, and epithelial dysplasia of the stomach are common and are associated with an increased risk for gastric cancer. In the absence of guidelines, there is wide disparity in the management of patients with these premalignant conditions. The European Society of Gastrointestinal Endoscopy (ESGE), the European Helicobacter Study Group (EHSG), the European Society of Pathology (ESP) and the Sociedade Portuguesa de Endoscopia Digestiva (SPED) have therefore combined efforts to develop evidence-based guidelines on the management of patients with precancerous conditions and lesions of the stomach (termed MAPS). A multidisciplinary group of 63 experts from 24 countries developed these recommendations by means of repeat online voting and a meeting in June 2011 in Porto, Portugal. The recommendations emphasize the increased cancer risk in patients with gastric atrophy and metaplasia, and the need for adequate staging in the case of high grade dysplasia, and they focus on treatment and surveillance indications and methods. [ABSTRACT FROM AUTHOR]

Endoscopy has evolved from a purely diagnostic technique to a therapeutic procedure. This is possible in many cases thanks to the use of fluoroscopy, which entails exposure to ionizing radiation for both patients and the personnel involved. Endoscopic retrograde cholangiopancreatography (ERCP), which necessarily requires fluoroscopy, is classified by the Food and Drug Administration as an examination with a potential risk of triggering radiation induced injuries. This article reviews the biological effects of radiation, the types of radiological equipment used in ERCP, as well as the magnitudes and dosimetric units, to finally address the radio protection elements in the endoscopy room. The objective is to provide the reader with the information to be able to perform these procedures with the greatest radiological safety for both patients and occupationally exposed personnel.

This is a collaboration between the British Society of Gastroenterology (BSG) and the European Society of Gastrointestinal Endoscopy (ESGE), and is a scheduled update of their 2016 guideline on endoscopy in patients on antiplatelet or anticoagulant therapy. The guideline development committee included representatives from the British Society of Haematology, the British Cardiovascular Intervention Society, and two patient representatives from the charities Anticoagulation UK and Thrombosis UK, as well as gastroenterologists. The process conformed to AGREE II principles, and the quality of evidence and strength of recommendations were derived using GRADE methodology. Prior to submission for publication, consultation was made with all member societies of ESGE, including BSG. Evidence-based revisions have been made to the risk categories for endoscopic procedures, and to the categories for risks of thrombosis. In particular a more detailed risk analysis for atrial fibrillation has been employed, and the recommendations for direct oral anticoagulants have been strengthened in light of trial data published since the previous version. A section has been added on the management of patients presenting with acute GI haemorrhage. Important patient considerations are highlighted. Recommendations are based on the risk balance between thrombosis and haemorrhage in given situations., Competing Interests: Dr Radaelli has received speaker fees from Bristol-Meyers Squibb, Pfizer and Boehringer Ingelheim. Dr Alikhan has received fees from Alexion, Bayer, Boehringer Ingelheim, Bristol-Meyers Squibb, Daiichi, Pfizer and Portola. Dr Lester has received speaker fees from Sanofi Aventis and Leo Pharma, speaker fees and advisory board fees from Bayer, Daichii Sankyo, Pfizer, and Boehringer Ingelheim, and support to attend a scientific meeting from Boehringer Ingelheim. Prof Van- Hooft has received departmental research grant support from Cook Medical and Abbott, lecture fees from Medtronics and Cook Medical, and consultancy fees from Boston Scientific and Olympus. None of the remaining authors have competing interests to declare., (European Society of Gastrointestinal Endoscopy, British Society of Gastroenterology, the Author(s) or their employer(s). This is an open access article published by Thieme and BMJ Publishing Group Ltd under the terms of the Creative Commons Attribution Non Commercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes. (https://creativecommons.org/licenses/by-nc/4.0/).)

Background and study aim  Cold resection is becoming the standard of care for the resection of nonpedunculated colon lesions up to 10 mm in diameter. Sessile serrated adenomas/polyps (SSA/Ps), including those ≥ 10 mm, present various characteristics that make them ideal candidates for cold snare polypectomy (CSP). Patients and methods  A prospectively maintained database was searched retrospectively for consecutive patients with lesions ≥ 10 mm resected between March 2013 and March 2018. During that period, all SSA/P-appearing lesions were resected using CSP without submucosal injection, except for lesions with endoscopic suspicion of dysplasia or submucosal invasion. Patients with a pathological diagnosis of SSA/P were included in the analysis. Adverse events were recorded up to 21 days following colonoscopy. Results  615 SSA/Ps ≥ 10 mm were resected during 452 colonoscopy procedures in 379 patients (mean age 54.1 years; standard deviation [SD] 11.9 years). Mean polyp size was 13.7 (SD 5.2) mm; 122 lesions (19.8 %) were ≥ 20 mm and 479 lesions (77.9 %) underwent piecemeal resection. Immediate adverse events included persistent abdominal pain that resolved spontaneously within 2 hours in three patients (0.8 %; 95 % confidence interval [CI] 0.2 %-2.3 %). One patient with persistent intraprocedural bleeding was successfully treated with a hemostatic clip. No late adverse events were detected. Surveillance colonoscopy was performed in 293 patients (77.3 %) at 23.4 (SD 11.6) months following index colonoscopy; residual/recurrent lesions were diagnosed in 23 patients (7.8 %; 95 %CI 5.0 %-11.6 %). Conclusion  CSP without submucosal injection appeared to be safe and effective for the resection of large SSA/Ps., Competing Interests: Competing interests The authors declare that they have no conflict of interest., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Objectives: Rapid on-site evaluation (ROSE) by cytopathologists during endoscopic ultrasound-fine-needle aspiration (EUS-FNA) of solid pancreatic lesions (SPLs) improves adequacy and diagnostic accuracy while reducing the number of needle passes. We evaluated the usefulness of ROSE performed by the endosonographer., Methods: Patients with an SPL were randomly assigned to EUS-FNA with ROSE or non-ROSE. Procedure duration, number of needle passes, specimen adequacy, and adverse event rates were compared., Results: Sixty-five patients were enrolled (33 in the ROSE vs 32 in the non-ROSE group). Both groups were similar in terms of age, sex, size, and location of the lesion. Specimen adequacy rates were high and similar between groups. Mean (standard deviation) procedure duration was shorter in the ROSE versus non-ROSE group (30.0 [11.3] vs 37.0 [7.2] minutes, P < 0.005), as well as the mean (standard deviation) number of needle passes (2.6 [0.8] vs 3.5 [0.8], P < 0.005). Accuracy parameters as sensitivity and accuracy of ROSE by the endosonographer for malignancy were 93% and 88%, respectively., Conclusions: After specific training, the endosonographer can accurately evaluate samples during EUS-FNA of SPL, allowing for a shorter procedure duration and a lower number of needle passes., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Bile holds biomarkers of malignant biliary strictures (MBS) but is unsuited for automated analyzers used in routine diagnostic laboratories. Selected reaction monitoring (SRM) is a flexible high-throughput analytical approach based on targeted mass spectrometry (MS) already implemented in clinical settings. We tested the hypothesis that SRM could be used to quantify cancer biomarkers in human bile. An SRM-based assay was developed to simultaneously quantify up to 37 peptides from 13 bile proteins in a developmental cohort of 15 patients (MBS, n = 8; benign biliary stricture or obstruction (BBS), n = 7). The most reliable biomarkers were then absolutely quantified by SRM in a verification cohort of 67 patients (MBS, n = 37; BBS, n = 30). The diagnostic performances of single and combined biomarkers were assessed. In the developmental cohort, SRM-based analysis revealed six protein biomarkers with significantly higher peptide ratios (endogenous vs. standard) in bile from MBS vs. BBS. In the verification cohort, five of these biomarkers proved good diagnostic ability (individual receiver operating characteristic-area under the receiver operating characteristic curve (ROC-AUC) up to 0.889, accuracies from 67.8% to 83.1%). Combining bile biomarkers and serum CA19-9 in 2 panels allowed differentiating MBS from BBS with up to 0.929 ROC-AUC and 89.8% accuracy. In this study, a newly developed SRM-based assay proved able to simultaneously quantify multiple biomarkers in bile samples. The combination of bile biomarkers with serum CA19-9 was highly accurate for the diagnosis of MBS. Liquid biopsy of bile based on targeted MS is eligible to support MBS diagnosis in clinical practice., (© 2020 The Authors. Clinical and Translational Science published by Wiley Periodicals LLC on behalf of the American Society for Clinical Pharmacology and Therapeutics.)

Direct oral anticoagulants are being increasingly used in patients with non-valvular atrial fibrillation and venous thromboembolism, due to their improved efficacy/ safety ratio, a predictable anticoagulant effect without need for routine coagulation monitoring, and fewer food and drug interactions compared with vitamin K antagonists. Gastrointestinal bleeding remains a serious complication, whose management is challenging for gastroenterologists due to the lack of a standardized clinical approach. Clinical experience on periendoscopic management of these drugs is still limited and there is a paucity of clinical data supporting guidelines recommendations', and this ultimately turns out in different, unsubstantiated and potentially harmful practices of patient management. Present study will provide a thorough revision on the risk of GI bleeding for DOAC therapy and the identification of patient risk factors to individualize treatment. Moreover, the approach to management of DOACs in case of bleeding complications is discussed, and an algorithm of different strategies in presence or not of plasma level measurement is proposed. Finally the periendoscopic management for elective procedures will be reviewed, at the light of the guideline recommendations and new evidences from observational studies., (Copyright © 2020 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

1:  ESGE recommends that each center implements a written policy regarding the management of iatrogenic perforations, including the definition of procedures that carry a higher risk of this complication. This policy should be shared with the radiologists and surgeons at each center. 2 : ESGE recommends that in the case of an endoscopically identified perforation, the endoscopist reports its size and location, with an image, and statement of the endoscopic treatment that has been applied. 3:  ESGE recommends that symptoms or signs suggestive of iatrogenic perforation after an endoscopic procedure should be rapidly and carefully evaluated and documented with a computed tomography (CT) scan. 4 : ESGE recommends that endoscopic closure should be considered depending on the type of the iatrogenic perforation, its size, and the endoscopist expertise available at the center. Switch to carbon dioxide (CO2) endoscopic insufflation, diversion of digestive luminal content, and decompression of tension pneumoperitoneum or pneumothorax should also be performed. 5 : ESGE recommends that after endoscopic closure of an iatrogenic perforation, further management should be based on the estimated success of the endoscopic closure and on the general clinical condition of the patient. In the case of no or failed endoscopic closure of an iatrogenic perforation, and in patients whose clinical condition is deteriorating, hospitalization and surgical consultation are recommended., Competing Interests: M. Barthet’s department has received a research grant from Boston Scientific. G. Paspatis has received consultancy fees from Boston Scientific (2019). A. Repici has received consultancy fees from Boston Scientific (2019 – 2020); his department has received a research grant from Boston Scientific (2018 – 2020). B. Saunders’ department has received a research grant and loan of equipment from Olympus (2019 to present). J.E. van Hooft has received lecture fees from Medtronics (2014 – 2015, 2019) and Cook Medical (2019), and consultancy fees from Boston Scientific (2014 – 2017); her department has received research grants from Cook Medical (2014 – 2018) and Abbott (2014 – 2017). M. Arvanitakis, A. Dhillon, J.M. Dumonceau, M. Fragaki, J.M. Gonzalez, S.Y. Turino, and R.L.J. van Wanrooij have no competing interests., (© Georg Thieme Verlag KG Stuttgart · New York.)

The following recommendations for post-polypectomy colonoscopic surveillance apply to all patients who had one or more polyps that were completely removed during a high quality baseline colonoscopy. 1: ESGE recommends that patients with complete removal of 1 - 4 < 10 mm adenomas with low grade dysplasia, irrespective of villous components, or any serrated polyp < 10 mm without dysplasia, do not require endoscopic surveillance and should be returned to screening.Strong recommendation, moderate quality evidence.If organized screening is not available, repetition of colonoscopy 10 years after the index procedure is recommended.Strong recommendation, moderate quality evidence. 2: ESGE recommends surveillance colonoscopy after 3 years for patients with complete removal of at least 1 adenoma ≥ 10 mm or with high grade dysplasia, or ≥ 5 adenomas, or any serrated polyp ≥ 10 mm or with dysplasia. Strong recommendation, moderate quality evidence. 3: ESGE recommends a 3 - 6-month early repeat colonoscopy following piecemeal endoscopic resection of polyps ≥ 20 mm.Strong recommendation, moderate quality evidence. A first surveillance colonoscopy 12 months after the repeat colonoscopy is recommended to detect late recurrence.Strong recommendation, high quality evidence. 4: If no polyps requiring surveillance are detected at the first surveillance colonoscopy, ESGE suggests to perform a second surveillance colonoscopy after 5 years. Weak recommendation, low quality evidence.After that, if no polyps requiring surveillance are detected, patients can be returned to screening. 5: ESGE suggests that, if polyps requiring surveillance are detected at first or subsequent surveillance examinations, surveillance colonoscopy may be performed at 3 years. Weak recommendation, low quality evidence.A flowchart showing the recommended surveillance intervals is provided (Fig. 1)., Competing Interests: M. Bretthauer’s department has received support and cooperation from the EndoBRAIN study from Olympus Europa SE (from 2019 ongoing). E. Dekker has received consultancy honoraria from Fujifilm, Olympus, Tillots, GI Supply, and CPP-FAP, and speakers’ fees from Olympus, Roche and GI Supply; she has endoscopic equipment on loan and receives a research grant from Fujifilm. L.M. Helsingen’s department has received support and cooperation from the EndoBRAIN study from Olympus Europa SE (from 2019 ongoing). J.E. van Hooft has received lecture fees from Medtronics (from 2014 to 2015 and 2019) and Cook Medical (2019), and consultancy fees from Boston Scientific (2014 – 2017); her department has received research grants from Cook Medical (2014 – 2019) and Abbott (2014 – 2017). M. Pellisé has received consultancy and speaker’s fees from Norgine Iberia (2015 – 2019), a consultancy fee from GI Supply (2019), speaker’s fees from Casen Recordati (2016 – 2019), Olympus (2018), and Jansen (2018), and research funding from Fujifilm Spain (2019), Fujifilm Europe (2020), and Casen Recordati (2020); her department has received loan material from Fujifilm Spain (from 2017 ongoing), a research grant from Olympus Europe (2005 – 2019), and loan material and a research grant from Fujifilm Europe (2020 – 2021); she is a Board member of ESGE and SEED; and receives a fee from Thieme as an Endoscopy Co-Editor. J. Regula has received sponsorship and lecture fees from Ipsen Pharma and Alfasigma (2017 – 2020). M. Rutter is a member of the British Society of Gastroenterology. G. Antonelli, A. Bleijenberg, S. Chaussade, M. Dinis-Ribeiro, J.-M. Dumonceau, M. Ferlitsch, A. Gimeno-Garcia, C. Hassan, R. Jover, M. Kalager, C. Pox, E. Quintero, and L. Ricciardello, and C. Senore have no competing interests., (© Georg Thieme Verlag KG Stuttgart · New York.)

It is frequently challenging to make the correct diagnosis in patients with biliary strictures. This is particularly important as errors may have disastrous consequences. Benign-appearing strictures treated with stents may later be revealed to be malignant and unnecessary surgery for benign strictures carries a high morbidity rate. In the first part of the review, the essential information that clinicians need to know about diseases responsible for biliary strictures is presented, with a focus on the most recent data. Then, the characteristics and pitfalls of the methods used to make the diagnosis are summarized. These include serum biomarkers, imaging studies, and endoscopic modalities. As tissue diagnosis is the only 100% specific tool, it is described in detail, including techniques for tissue acquisition and their yields, how to prepare samples, and what to expect from the pathologist. Tricks to increase diagnostic yields are described. Clues are then presented for the differential diagnosis between primary and secondary sclerosing cholangitis, IgG4-related sclerosing cholangitis, cholangiocarcinoma, pancreatic cancer, autoimmune pancreatitis, and less frequent diseases. Finally, algorithms that will help to achieve the correct diagnosis are proposed., Competing Interests: Conflict of interest statement: The authors declare that there is no conflict of interest., (© The Author(s), 2020.)

Background & Aims: Efficacy of bowel preparation is an important determinant of outcomes of colonoscopy. It is not clear whether approved low-volume polyethylene glycol (PEG) and non-PEG regimens are as effective as high-volume PEG regimens when taken in a split dose., Methods: In a systematic review of multiple electronic databases through January 31, 2019 with a registered protocol (PROSPERO: CRD42019128067), we identified randomized controlled trials that compared low- vs high-volume bowel cleansing regimens, administered in a split dose, for colonoscopy. The primary efficacy outcome was rate of adequate bowel cleansing, and the secondary efficacy outcome was adenoma detection rate. Primary tolerability outcomes were compliance, tolerability, and willingness to repeat. We calculated relative risk (RR) and 95% CI values and assessed heterogeneity among studies by using the I 2 statistic. The overall quality of evidence was assessed using the GRADE framework., Results: In an analysis of data from 17 randomized controlled trials, comprising 7528 patients, we found no significant differences in adequacy of bowel cleansing between the low- vs high-volume split-dose regimens (86.1% vs 87.4%; RR, 1.00; 95% CI, 0.98-1.02) and there was minimal heterogeneity (I 2 = 17%). There was no significant difference in adenoma detection rate (RR, 0.96; 95% CI, 0.87-1.08) among 4 randomized controlled trials. Compared with high-volume, split-dose regimens, low-volume split-dose regimens had higher odds for compliance or completion (RR, 1.06; 95% CI, 1.02-1.10), tolerability (RR, 1.39; 95% CI, 1.12-1.74), and willingness to repeat bowel preparation (RR, 1.41; 95% CI, 1.20-1.66). The overall quality of evidence was moderate., Conclusions: Based on a systematic review of 17 randomized controlled trials, low-volume, split-dose regimens appear to be as effective as high-volume, split-dose regimens in bowel cleansing and are better tolerated, with superior compliance., (Copyright © 2020 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Prophylaxis: 1:  ESGE recommends routine rectal administration of 100 mg of diclofenac or indomethacin immediately before endoscopic retrograde cholangiopancreatography (ERCP) in all patients without contraindications to nonsteroidal anti-inflammatory drug administration.Strong recommendation, moderate quality evidence. 2:  ESGE recommends prophylactic pancreatic stenting in selected patients at high risk for post-ERCP pancreatitis (inadvertent guidewire insertion/opacification of the pancreatic duct, double-guidewire cannulation).Strong recommendation, moderate quality evidence. 3:  ESGE suggests against routine endoscopic biliary sphincterotomy before the insertion of a single plastic stent or an uncovered/partially covered self-expandable metal stent for relief of biliary obstruction.Weak recommendation, moderate quality evidence. 4:  ESGE recommends against the routine use of antibiotic prophylaxis before ERCP.Strong recommendation, moderate quality evidence. 5:  ESGE suggests antibiotic prophylaxis before ERCP in the case of anticipated incomplete biliary drainage, for severely immunocompromised patients, and when performing cholangioscopy.Weak recommendation, moderate quality evidence. 6:  ESGE suggests tests of coagulation are not routinely required prior to ERCP for patients who are not on anticoagulants and not jaundiced.Weak recommendation, low quality evidence., Treatment: 7:  ESGE suggests against salvage pancreatic stenting in patients with post-ERCP pancreatitis.Weak recommendation, low quality evidence. 8:  ESGE suggests temporary placement of a biliary fully covered self-expandable metal stent for post-sphincterotomy bleeding refractory to standard hemostatic modalities.Weak recommendation, low quality evidence. 9:  ESGE suggests to evaluate patients with post-ERCP cholangitis by abdominal ultrasonography or computed tomography (CT) scan and, in the absence of improvement with conservative therapy, to consider repeat ERCP. A bile sample should be collected for microbiological examination during repeat ERCP.Weak recommendation, low quality evidence., Competing Interests: T. Beyna receives consultancy fees from Olympus, Boston Scientific, and Cook (ongoing), and lecture fees from Olympus, Boston Scientific, and Medtronic (ongoing). M. Dinis-Ribeiro receives a fee as Co-Editor-in-Chief of Endoscopy journal. I. Hritz has provided consultancy and training for Olympus (2017 to present), and consultancy for Pentax Medical (2018). I. Papanikolaou has provided consultancy for Boston Scientific (25 April and 21 March, 2018). A. Tringali provided consultancy for Boston Scientific (3 April 2019); he has received publication fees from UpToDate. J.E. van Hooft has received lecture fees from Medtronics (2014 – 2015) and consultancy fees from Boston Scientific (2014 – 2017); her department has received research grants from Cook Medical (2014 – 2018) and Abbott (2014 – 2017). G. Vanbiervliet has provided consultancy to Boston Scientific (2016 to present) and Cook Medical (2019 to present). L. Aabakken, C. Kapral, J.M. Dumonceau, S. Lakhtakia, A. Mariani, G. Paspatis, F. Radaelli, and A. Veitch have no competing interests., (© Georg Thieme Verlag KG Stuttgart · New York.)

ESGE recommends a low fiber diet on the day preceding colonoscopy.Strong recommendation, moderate quality evidence.ESGE recommends the use of enhanced instructions for bowel preparation.Strong recommendation, moderate quality evidence.ESGE suggests adding oral simethicone to bowel preparation.Weak recommendation, moderate quality evidence.ESGE recommends split-dose bowel preparation for elective colonoscopy.Strong recommendation, high quality evidence.ESGE recommends, for patients undergoing afternoon colonoscopy, a same-day bowel preparation as an acceptable alternative to split dosing.Strong recommendation, high quality evidence.ESGE recommends to start the last dose of bowel preparation within 5 hours of colonoscopy, and to complete it at least 2 hours before the beginning of the procedure.Strong recommendation, moderate quality evidence.ESGE recommends the use of high volume or low volume PEG-based regimens as well as that of non-PEG-based agents that have been clinically validated for routine bowel preparation. In patients at risk for hydroelectrolyte disturbances, the choice of laxative should be individualized.Strong recommendation, moderate quality evidence., Competing Interests: R. Benamouzig has provided consultancy to Alfasigma. R. Bisschops has received speaker’s fees from Norgine (1 January 2017 to present); he is Co-Editor of Endoscopy. E. Dekker is Co-Editor of Endoscopy. M. Dinis-Ribeiro is Co-Editor-in-Chief of Endoscopy. J. East received a speaker fee from Falk (January 2018); his department received support from Boston Scientific (March 2018 to March 2019). I. Gralnek declares consultancy, MAB, and share ownership in Motus GI (2014 to present). C. Hassan provides consultancy to Norgine; his department receives support from Alfasigma. R. Jover has received travel grants from Norgine (2015 to 2019); he has provided advisory services to Norgine (2015 to 2019), Alfasigma (2017 to 2018), GI Supply (2018 to 2019), and CPP Pharmaceuticals (2019); his department has received research grants from MSD (2010 to 2019). M.F. Kaminski has provided speaking and teaching services to Olympus, Alfasigma, and Norgine (2017 to present) and Fujinon (2018 to present), consultancy to Olympus (2017 to present), and advisory services to Alfasigma (2017 to present). M. Pellisé has received consultancy fees from Norgine Iberia (2012 to 2017, 2019 to present), and speaker’s fees from Casen Recordati (2018) and Olympus (2017); her department has been loaned equipment from Fujifilm (2017 to present); she is on the Endoscopy Board. F. Radaelli has received consultancy fees from Norgine (January 2018 to December 2018). C. Spada has received consultancy fees from Norgina and Alfasigma (2016 to 2019). J.E. van Hooft has received lecture fees from Medtronics (2014 to 2015) and Cook Medical (2019), and consultancy fees from Boston Scientific (2014 to 2017); her department has received research grants from Cook Medical (2014 to 2018) and Abbott (2014 to 2017). H. Awadie, M. Bretthauer, J.-M. Dumonceau, M. Ferlitsch, L. Frazzoni, L. Fuccio, C. Mangas-Sanjuan, K. Triantafyllou, and G. Vanella have no competing interests., (© Georg Thieme Verlag KG Stuttgart · New York.)

ESGE recommends offering stone extraction to all patients with common bile duct stones, symptomatic or not, who are fit enough to tolerate the intervention.Strong recommendation, low quality evidence.ESGE recommends liver function tests and abdominal ultrasonography as the initial diagnostic steps for suspected common bile duct stones. Combining these tests defines the probability of having common bile duct stones.Strong recommendation, moderate quality evidence.ESGE recommends endoscopic ultrasonography or magnetic resonance cholangiopancreatography to diagnose common bile duct stones in patients with persistent clinical suspicion but insufficient evidence of stones on abdominal ultrasonography.Strong recommendation, moderate quality evidence.ESGE recommends the following timing for biliary drainage, preferably endoscopic, in patients with acute cholangitis, classified according to the 2018 revision of the Tokyo Guidelines:- severe, as soon as possible and within 12 hours for patients with septic shock- moderate, within 48 - 72 hours- mild, elective.Strong recommendation, low quality evidence.ESGE recommends endoscopic placement of a temporary biliary plastic stent in patients with irretrievable biliary stones that warrant biliary drainage.Strong recommendation, moderate quality of evidence.ESGE recommends limited sphincterotomy combined with endoscopic papillary large-balloon dilation as the first-line approach to remove difficult common bile duct stones. Strong recommendation, high quality evidence.ESGE recommends the use of cholangioscopy-assisted intraluminal lithotripsy (electrohydraulic or laser) as an effective and safe treatment of difficult bile duct stones.Strong recommendation, moderate quality evidence.ESGE recommends performing a laparoscopic cholecystectomy within 2 weeks from ERCP for patients treated for choledocholithiasis to reduce the conversion rate and the risk of recurrent biliary events. Strong recommendation, moderate quality evidence., Competing Interests: A. Anderloni has provided consultancy to Boston Scientific (2016 – 2018) and Olympus (2018). M. Barthet’s department received a research grant (2016 – 2018). D. Domagk’s department has received workshop, consultancy, and speaker’s fees from Hitachi (2016 to present), and speaker’s fees and symposia support from Dr. Falk Foundation and Olympus (both 2015 to present). I. Hritz has provided consultancy and training for Olympus (2017 to present) and consultancy to Pentax Medical (2018 to present). G. Paspatis has received sponsorship for invited speeches from Boston Scientific (2014 – 2018). T. Ponchon has been on the advisory board of Olympus (2018) and his department has received clinical research funding from Fujifilm (2018). J. E. van Hooft received lecture fees from Medtronics (2014 – 2015) and provided consultancy to Boston Scientific (2014 – 2016), her department has received research grants from Cook Medical (2014 – 2018) and Abbott (2014 – 2017). E. J. Williams was chair of the British Society of Gastroenterology writing group for guidelines on common bile duct stones (2014 – 2017). L. Aabakken, P. Ah-Soune, M. Arvanitakis, J.-M. Dumonceau, J.-F. Gigot, G. Karamanolis, A. Laghi, G. Manes, A. Mariani, K. Paraskeva, J. Pohl, F. Swahn, R. ter Steege, A. Tringali, and A. Vezakis have no competing interests., (© Georg Thieme Verlag KG Stuttgart · New York.)

Patients with chronic atrophic gastritis or intestinal metaplasia (IM) are at risk for gastric adenocarcinoma. This underscores the importance of diagnosis and risk stratification for these patients. High definition endoscopy with chromoendoscopy (CE) is better than high definition white-light endoscopy alone for this purpose. Virtual CE can guide biopsies for staging atrophic and metaplastic changes and can target neoplastic lesions. Biopsies should be taken from at least two topographic sites (antrum and corpus) and labelled in two separate vials. For patients with mild to moderate atrophy restricted to the antrum there is no evidence to recommend surveillance. In patients with IM at a single location but with a family history of gastric cancer, incomplete IM, or persistent Helicobacter pylori gastritis, endoscopic surveillance with CE and guided biopsies may be considered in 3 years. Patients with advanced stages of atrophic gastritis should be followed up with a high quality endoscopy every 3 years. In patients with dysplasia, in the absence of an endoscopically defined lesion, immediate high quality endoscopic reassessment with CE is recommended. Patients with an endoscopically visible lesion harboring low or high grade dysplasia or carcinoma should undergo staging and treatment. H. pylori eradication heals nonatrophic chronic gastritis, may lead to regression of atrophic gastritis, and reduces the risk of gastric cancer in patients with these conditions, and it is recommended. H. pylori eradication is also recommended for patients with neoplasia after endoscopic therapy. In intermediate to high risk regions, identification and surveillance of patients with precancerous gastric conditions is cost-effective., Competing Interests: M. Leja has shares in and receives a salary from the Digestive Diseases Centre GASTRO, SIA (from approximately 2000 to present); his department receives research support with a special offer for reagents (including for pepsinogen detection) from Eiken Chemical (2013 to present); he is a Board member of the Latvian Association of Gastroenterology (from approximately 2000 to present), F. Megraud’s department has received a grant from Allergan (2014 to February 2019). J. E. van Hooft has received lecture fees from Medtronic (2014 – 2015) and consultancy fees from Boston Scientific (2014 – 2016); her department has received research grants from Cook Medical (2014 – 2018) and Abbott (2014 – 2017). B. Annibale, M. Areia, R. Barros, F. Carneiro, M. Dinis-Ribeiro, J.-M. Dumonceau, G. Esposito, J.-F. Fléjou, M. Garrido, I. Kikuste, E. J. Kuipers, D. Libânio, R. Marcos-Pinto, T. Matysiak-Budnik, and P. Pimentel-Nunes have no competing interests., (© Georg Thieme Verlag KG Stuttgart · New York.)

ESGE suggests endoscopic therapy and/or extracorporeal shockwave lithotripsy (ESWL) as the first-line therapy for painful uncomplicated chronic pancreatitis (CP) with an obstructed main pancreatic duct (MPD) in the head/body of the pancreas. The clinical response should be evaluated at 6 - 8 weeks; if it appears unsatisfactory, the patient's case should be discussed again in a multidisciplinary team and surgical options should be considered.Weak recommendation, low quality evidence.ESGE suggests, for the selection of patients for initial or continued endoscopic therapy and/or ESWL, taking into consideration predictive factors associated with a good long-term outcome. These include, at initial work-up, absence of MPD stricture, a short disease duration, non-severe pain, absence or cessation of cigarette smoking and of alcohol intake, and, after initial treatment, complete removal of obstructive pancreatic stones and resolution of pancreatic duct stricture with stenting.Weak recommendation, low quality evidence.ESGE recommends ESWL for the clearance of radiopaque obstructive MPD stones larger than 5 mm located in the head/body of the pancreas and endoscopic retrograde cholangiopancreatography (ERCP) for MPD stones that are radiolucent or smaller than 5 mm. Strong recommendation, moderate quality evidence.ESGE suggests restricting the use of endoscopic therapy after ESWL to patients with no spontaneous clearance of pancreatic stones after adequate fragmentation by ESWL.Weak recommendation, moderate quality evidence.ESGE suggests treating painful dominant MPD strictures with a single 10-Fr plastic stent for one uninterrupted year if symptoms improve after initial successful MPD drainage. The stent should be exchanged if necessary, based on symptoms or signs of stent dysfunction at regular pancreas imaging at least every 6 months. ESGE suggests consideration of surgery or multiple side-by-side plastic stents for symptomatic MPD strictures persisting beyond 1 year after the initial single plastic stenting, following multidisciplinary discussion. Weak recommendation, low quality evidence.ESGE recommends endoscopic drainage over percutaneous or surgical treatment for uncomplicated chronic pancreatitis (CP)-related pseudocysts that are within endoscopic reach.Strong recommendation, moderate quality evidence.ESGE recommends retrieval of transmural plastic stents at least 6 weeks after pancreatic pseudocyst regression if MPD disruption has been excluded, and long-term indwelling of transmural double-pigtail plastic stents in patients with disconnected pancreatic duct syndrome.Strong recommendation, low quality evidence.ESGE suggests the temporary insertion of multiple side-by-side plastic stents or of a fully covered self-expandable metal stent (FCSEMS) for treating CP-related benign biliary strictures.Weak recommendation, moderate quality evidence.ESGE recommends maintaining a registry of patients with biliary stents and recalling them for stent removal or exchange.Strong recommendation, low quality evidence., Competing Interests: G. P. Aithal receives consultancy fees from Shire (September 2015 to present), Pfizer (July 2018 to present), and GSK and Agios (February 2018 to present). A. Anderloni has provided consultancy to Boston Scientific (2017 – 2018). M. J. Bruno has received lecturing and consultancy fees from Boston Scientific, Cook Medical, and Pentax Medical (ongoing) and consultancy fees from Mylan (ongoing); his department is involved in investigator- and industry-initiated studies with Boston Scientific, Cook Medical, and Pentax Medical (ongoing); he is a member (no financial benefit) of the Dutch Pancreatitis Study Group J. Devière receives research support from Olympus for institutional review board-approved studies (ongoing); his department receives research support from Boston Scientific for institutional review board-approved studies (ongoing). J. E. Domínguez-Muñoz has received speaker’s honoraria from Boston Scientific (2018); his department has received financial support for educational activities from Pentax and Boston Scientific (2017 – 2018) and Medtronic (2018). J.-W. Poley receives speaker’s fees and travel expenses from Pentax, Boston Scientific, and Cook Endoscopy (ongoing), and consultancy fees from Boston Scientific and Cook Endoscopy (ongoing). A. Sanchez-Yague has provided paid consultancy to Boston Scientific (2015 – 2018). J. E. van Hooft has received lecture fees from Medtronic (2014 – 2015) and consultancy fees from Boston Scientific (2014 – 2016); her department has received research grants from Cook Medical (2014 – 2018) and Abbott (2014 – 2017). M. Arvanitakis, P. Cantú, M. Delhaye, J.-M. Dumonceau, S. Lekkerkerker, M. Ramchandani, N. Reddy, A. Tringali, and T. Vaysse have no competing interests., (© Georg Thieme Verlag KG Stuttgart · New York.)

This Position Statement from the European Society of Gastrointestinal Endoscopy (ESGE) and the European Society of Gastroenterology Nurses and Associates (ESGENA) sets standards for the reprocessing of flexible endoscopes and endoscopic devices used in gastroenterology. An expert working group of gastroenterologists, endoscopy nurses, chemists, microbiologists, and industry representatives provides updated recommendations on all aspects of reprocessing in order to maintain hygiene and infection control., Competing Interests: U. Beilenhoff has provided consultancy to Boston Scientific since July 2017. H. Biering has done customer presentations and trainings, moderated workshops, and provided consultancy to Richard Wolf GmbH, Olympus Europa, Dr. Weigert, and Ecolab. R. Blum is employed by Olympus Europa, who hold patents on endoscopes in general; he is a member of the DIN/CEN/ISO TC/198/WG13 standards group for safe reprocessing of endoscopes. M. Cimbro has been employed by CBC Europe since 2002; she has been a consultant since 2011 to ANOTE-ANIGEA (Italian Association of Gastroenterology and Endoscopy Nurses). M. Jung’s hospital has received sponsorship from Olympus Optical and other companies for an EUS/endoscopy course (22nd September 2017). B. Kampf is employed by Olympus Europa, who hold patents on endoscopes in general. M. Pietsch’s department has received third-party funding from Olympus for a research project, from 2015 to 2017. L. Pineau has provided training on hygiene and medical device evaluation for Pentax, Olympus, and Fujifilm, from 1999 to 2017. T. Ponchon has served on an advisory board for Fujifilm (January 2015 to October 2017). J. Brljak, J.-M. Dumonceau, C. Hassan, C. Neumann, S. Rejchrt, J.-F. Rey, V. Schmidt, J. Tillett, and J. van Hooft have no competing interests., (© Georg Thieme Verlag KG Stuttgart · New York.)

ESGE recommends against routine preoperative biliary drainage in patients with malignant extrahepatic biliary obstruction; preoperative biliary drainage should be reserved for patients with cholangitis, severe symptomatic jaundice (e. g., intense pruritus), or delayed surgery, or for before neoadjuvant chemotherapy in jaundiced patients. Strong recommendation, moderate quality evidence. ESGE recommends the endoscopic placement of a 10-mm diameter self-expandable metal stent (SEMS) for preoperative biliary drainage of malignant extrahepatic biliary obstruction. Strong recommendation, moderate quality evidence.ESGE recommends SEMS insertion for palliative drainage of of extrahepatic malignant biliary obstruction. Strong recommendation, high quality evidence. ESGE recommends against the insertion of uncovered SEMS for the drainage of extrahepatic biliary obstruction of unconfirmed etiology. Strong recommendation, low quality evidence. ESGE suggests against routine preoperative biliary drainage in patients with malignant hilar obstruction. Weak recommendation, low quality evidence.ESGE recommends uncovered SEMSs for palliative drainage of malignant hilar obstruction. Strong recommendation, moderate quality evidence.ESGE recommends temporary insertion of multiple plastic stents or of a fully covered SEMS for treatment of benign biliary strictures. Strong recommendation, moderate quality evidence.ESGE recommends endoscopic placement of plastic stent(s) to treat bile duct leaks that are not due to transection of the common bile duct or common hepatic duct. Strong recommendation, moderate quality evidence., Competing Interests: G. Costamagna has provided research support to Cook Medical and Taewoong; his department has received research support from Boston Scientific. J. Devière’s department has received research support for institutional review board-approved studies, from Olympus (ongoing), Boston Scientific (ongoing), and Cook Medical (from 2015 to 2016). F. Prat has provided consultancy to Olympus (2016 to 2018, continuing) and Boston Scientific (2015 to 2018, continuing). P.D. Siersema has provided research support to Ella-CS (from June 2016 to present). J. van Hooft has received lecture fees from Medtronic (from 2014 to 2015) and consultancy fees from Boston Scientific (from 2014 to 2016); her department has received research grants from Cook Medical (from 2014 to 2017) and Abbott (from 2014 to 2017). G. Vanbiervliet has provided consultancy to Boston Scientific (from 2016 to present). D. Blero, J.-M. Dumonceau, J. García-Cano, T. Gyökeres, C. Hassan, B. Mangiavillano, I.S. Papanikolaou, A. Schmidt, and A. Tringali have no competing interests., (© Georg Thieme Verlag KG Stuttgart · New York.)

1:  ESGE suggests using contrast-enhanced computed tomography (CT) as the first-line imaging modality on admission when indicated and up to the 4th week from onset in the absence of contraindications. Magnetic resonance imaging (MRI) may be used instead of CT in patients with contraindications to contrast-enhanced CT, and after the 4th week from onset when invasive intervention is considered because the contents (liquid vs. solid) of pancreatic collections are better characterized by MRI and evaluation of pancreatic duct integrity is possible. Weak recommendation, low quality evidence. 2:  ESGE recommends against routine percutaneous fine needle aspiration (FNA) of (peri)pancreatic collections. Strong recommendation, moderate quality evidence. FNA should be performed only if there is suspicion of infection and clinical/imaging signs are unclear. Weak recommendation, low quality evidence. 3:  ESGE recommends initial goal-directed intravenous fluid therapy with Ringer's lactate (e. g. 5 - 10 mL/kg/h) at onset. Fluid requirements should be patient-tailored and reassessed at frequent intervals. Strong recommendation, moderate quality evidence. 4:  ESGE recommends against antibiotic or probiotic prophylaxis of infectious complications in acute necrotizing pancreatitis. Strong recommendation, high quality evidence. 5:  ESGE recommends invasive intervention for patients with acute necrotizing pancreatitis and clinically suspected or proven infected necrosis. Strong recommendation, low quality evidence.ESGE suggests that the first intervention for infected necrosis should be delayed for 4 weeks if tolerated by the patient. Weak recommendation, low quality evidence. 6:  ESGE recommends performing endoscopic or percutaneous drainage of (suspected) infected walled-off necrosis as the first interventional method, taking into account the location of the walled-off necrosis and local expertise. Strong recommendation, moderate quality evidence. 7:  ESGE suggests that, in the absence of improvement following endoscopic transmural drainage of walled-off necrosis, endoscopic necrosectomy or minimally invasive surgery (if percutaneous drainage has already been performed) is to be preferred over open surgery as the next therapeutic step, taking into account the location of the walled-off necrosis and local expertise. Weak recommendation, low quality evidence. 8:  ESGE recommends long-term indwelling of transluminal plastic stents in patients with disconnected pancreatic duct syndrome. Strong recommendation, low quality evidence. Lumen-apposing metal stents should be retrieved within 4 weeks to avoid stent-related adverse effects.Strong recommendation, low quality evidence., Competing Interests: J. Albert has received speaker’s honoraria from Fujifilm (2015 – 2016), Falk foundation, and Covidien/Medtronic (2015 – 2017), and both research and speaker’s honoraria from Olympus Europe (2015 – 2017). A. Badaoui received a travel grant from Boston Scientific (2016). M. Barthet is a consultant for and receives research support from Boston Scientific (2016 to present). J. Devière has received research support from Cook Medical (until 2016) and from Boston Scientific (ongoing); his department is receiving research support from Olympus (ongoing). I. Hritz is a consultant (speaker/tutor) for Olympus Europe (ongoing). I. Papanikolaou is co-editor for social media with the Endoscopy journal. J.-W. Poley has received consultancy, travel, and speaker’s fees from Cook Endoscopy and Boston Scientific (ongoing). S. Seewald has received consultancy fees from Boston Scientific (until 2016), and from Olympus and Cook Medical (ongoing). J. van Hooft received lecture fees from Medtronics (2014 – 2015) and a consultancy fee from Boston Scientific (2014 – 2016); her department received research grants from Cook Medical and Abbott (2014 – 2017). K. van Lienden is receiving consultancy and speaker’s fees from Cook Medical (ongoing). M. Arvanitakis, M. A. Bali, M. Besselink, M. Delhaye, J.-M. Dumonceau, A. Ferreira, T. Gyökeres, T. Hucl, M. Milashka, H. van Santvoort, G. Vanbiervliet, and R. Voermans have no competing interests., (© Georg Thieme Verlag KG Stuttgart · New York.)

Non-variceal upper gastrointestinal bleeding (NVUGIB) is bleeding that develops in the oesophagus, stomach or proximal duodenum. Peptic ulcers, caused by Helicobacter pylori infection or use of NSAIDs and low-dose aspirin (LDA), are the most common cause. Although the incidence and mortality associated with NVUGIB have been decreasing owing to considerable advances in the prevention and management of NVUGIB over the past 20 years, it remains a common clinical problem with an annual incidence of ∼67 per 100,000 individuals in the United States in 2012. NVUGIB is a medical emergency, and mortality is in the range ∼1-5%. After resuscitation and initial assessment, early (within 24 hours) diagnostic and therapeutic endoscopy together with intragastric pH control with proton pump inhibitors (PPIs) form the basis of treatment. With a growing ageing population treated with antiplatelet and/or anticoagulant medications, the clinical management of NVUGIB is complex as the risk between gastrointestinal bleeding events and adverse cardiovascular events needs to be balanced. The best clinical approach includes identification of risk factors and prevention of bleeding; available strategies include continuous treatment with PPIs or H. pylori eradication in those at increased risk of developing NVUGIB. Treatment with PPIs and/or use of cyclooxygenase-2-selective NSAIDs should be implemented in those patients at risk of NVUGIB who need NSAIDs and/or LDA.

1 Prerequisites. The clinical service provider should obtain confirmation from the endoscope washer-disinfector (EWD) manufacturer that all endoscopes intended to be used can be reprocessed in the EWD. 2 Installation qualification. This can be performed by different parties but national guidelines should define who has the responsibilities, taking into account legal requirements. 3 Operational qualification. This should include parametric tests to verify that the EWD is working according to its specifications. 4 Performance qualification. Testing of cleaning performance, microbiological testing of routinely used endoscopes, and the quality of the final rinse water should be considered in all local guidelines. The extent of these tests depends on local requirements. According to the results of type testing performed during EWD development, other parameters can be tested if local regulatory authorities accept this. Chemical residues on endoscope surfaces should be searched for, if acceptable test methods are available. 5 Routine inspections. National guidelines should consider both technical and performance criteria. Individual risk analyses performed in the validation and requalification processes are helpful for defining appropriate test frequencies for routine inspections., Competing Interests: Competing interests: U. Beilenhoff has provided consultancy to Boston Scientific since July 2017. H. Biering has done customer presentations and trainings, moderated workshops, and provided consultancy to Richard Wolf GmbH, Olympus Europa, Dr. Weigert, and Ecolab. R. Blum is employed by Olympus Europa, who hold patents on endoscopes in general; he is a member of the DIN/CEN/ISO TC/198 /WG13 standards group for safe reprocessing of endoscopes. M. Cimbro has been employed by CBC Europe since 2002; she has been a consultant since 2011 to ANOTE-ANIGEA (Italian Association of Gastroenterology and Endoscopy Nurses). M. Jung’s hospital has received sponsorship from Olympus Optical and other companies for an EUS/endoscopy course (22nd September 2017). M. Pietsch’s department has received third-party funding from Olympus for a research project, from 2015 to 2017. L. Pineau has provided training on hygiene and medical device evaluation for Pentax, Olympus, and Fujifilm, from 1999 to 2017. T. Ponchon has served on an advisory board for Fujifilm (January 2015 to October 2017). J. Brljak, J.-M. Dumonceau, C. Hassan, C. Neumann, S. Rejchrt, J.-F. Rey, V. Schmidt, J. Tillett, and J. van Hooft have no competing interests., (© Georg Thieme Verlag KG Stuttgart · New York.)

Patients should be informed about the benefits and risks of endoscopic retrograde cholangiopancreatography (ERCP)Only specially trained and competent personnel should carry out endoscope reprocessing.Manufacturers of duodenoscopes should provide detailed instructions on how to use and reprocess their equipment.In the case of modifications to their equipment, manufacturers should provide updated instructions for use.Detailed reprocessing protocols based on the manufacturer's instructions for use should clearly lay out the different reprocessing steps necessary for each endoscope model.Appropriate cleaning equipment should be used for duodenoscopes in compliance with the manufacturer's instructions for use. Only purpose-designed, endoscope type-specific, single-use cleaning brushes should be used, to ensure optimal cleaning. As soon as the endoscope is withdrawn from the patient, bedside cleaning should be performed, followed by leak testing, thorough manual cleaning steps, and automated reprocessing, in order to: · Remove debris from external and internal surfaces;. · Prevent any drying of body fluids, blood, or debris;. · Prevent any formation of biofilms.. In addition to the leak test, visual inspection of the distal end as well as regular maintenance of duodenoscopes should be performed according to the manufacturer's instructions for use, in order to detect any damage at an early stage.The entire reprocessing procedure in endoscope washer-disinfectors (EWDs) should be validated according to the European and International Standard, EN ISO 15883. Routine technical tests of EWDs should be performed according to the validation reports.Microbiological surveillance of a proportion of the department's endoscopes should be performed every 3 months, with the requirement that all endoscopes used in the unit are tested at least once a year.In the case of suspected endoscopy-related infection, the relevant device (e. g., endoscope, EWD) should be taken out of service until adequate corrective actions have been taken. Outbreaks should be managed by a multidisciplinary team, including endoscopy, hygiene, and microbiology experts, manufacturers, and regulatory bodies, according to national standards and/or laws. In the case of suspected multidrug-resistant organism (MDRO) outbreaks, close cooperation between the endoscopy unit and the clinical health provider is essential (including infection control departments and hospital hygienists)., Competing Interests: Competing interests: U. Beilenhoff has provided consultancy to Boston Scientific since July 2017. H. Biering has done customer presentations and trainings, moderated workshops, and provided consultancy to Richard Wolf GmbH, Olympus Europa, Dr. Weigert, and Ecolab. Reinhard Blum is employed by Olympus Europa, who hold patents on endoscopes in general; he is a member of the DIN/CEN/ISO TC/198/WG13 standards group for safe reprocessing of endoscopes. M. Cimbro has been employed by CBC Europe since 2002; she has been a consultant since 2011 to ANOTE-ANIGEA (Italian Association of Gastroenterology and Endoscopy Nurses). M. Jung's hospital has received sponsorship from Olympus Optical and other companies for an EUS/endoscopy course (22nd September 2017). M. Pietsch's department has received third-party funding from Olympus for a research project, from 2015 to 2017. L. Pineau has provided training on hygiene and medical device evaluation for Pentax, Olympus, and Fujifilm, from 1999 to 2017. T. Ponchon has served on an Advisory board for Fujifilm (January 2015 to October 2017). J. Brljak, J.-M. Dumonceau, C. Hassan, C. Neumann, S. Rejchrt, J.-F. Rey, V. Schmidt, J. Tillett, and J. van Hooft have no competing interests., (© Georg Thieme Verlag KG Stuttgart · New York.)

For routine EUS-guided sampling of solid masses and lymph nodes (LNs) ESGE recommends 25G or 22G needles (high quality evidence, strong recommendation); fine needle aspiration (FNA) and fine needle biopsy (FNB) needles are equally recommended (high quality evidence, strong recommendation).When the primary aim of sampling is to obtain a core tissue specimen, ESGE suggests using 19G FNA or FNB needles or 22G FNB needles (low quality evidence, weak recommendation).ESGE recommends using 10-mL syringe suction for EUS-guided sampling of solid masses and LNs with 25G or 22G FNA needles (high quality evidence, strong recommendation) and other types of needles (low quality evidence, weak recommendation). ESGE suggests neutralizing residual negative pressure in the needle before withdrawing the needle from the target lesion (moderate quality evidence, weak recommendation).ESGE does not recommend for or against using the needle stylet for EUS-guided sampling of solid masses and LNs with FNA needles (high quality evidence, strong recommendation) and suggests using the needle stylet for EUS-guided sampling with FNB needles (low quality evidence, weak recommendation).ESGE suggests fanning the needle throughout the lesion when sampling solid masses and LNs (moderate quality evidence, weak recommendation).ESGE equally recommends EUS-guided sampling with or without on-site cytologic evaluation (moderate quality evidence, strong recommendation). When on-site cytologic evaluation is unavailable, ESGE suggests performance of three to four needle passes with an FNA needle or two to three passes with an FNB needle (low quality evidence, weak recommendation).For diagnostic sampling of pancreatic cystic lesions without a solid component, ESGE suggests emptying the cyst with a single pass of a 22G or 19G needle (low quality evidence, weak recommendation). For pancreatic cystic lesions with a solid component, ESGE suggests sampling of the solid component using the same technique as in the case of other solid lesions (low quality evidence, weak recommendation).ESGE does not recommend antibiotic prophylaxis for EUS-guided sampling of solid masses or LNs (low quality evidence, strong recommendation), and suggests antibiotic prophylaxis with fluoroquinolones or beta-lactam antibiotics for EUS-guided sampling of cystic lesions (low quality evidence, weak recommendation). ESGE suggests that evaluation of tissue obtained by EUS-guided sampling should include histologic preparations (e. g., cell blocks and/or formalin-fixed and paraffin-embedded tissue fragments) and should not be limited to smear cytology (low quality evidence, weak recommendation)., Competing Interests: Competing interests: M. Barthet has provided consultancy and research support to Boston Scientific (from September 2015). S. Carrara has provided a paid lecture/course for Boston Scientific and for Olympus (2016). P. Deprez is providing paid consultancy to Boston Scientific and to Cook (January 2016 to December 2017, for both); his department is receiving sponsorship from Boston Scientific, Olympus, and Cook (January 2016 to December 2017, for all). J. Iglesias-Garcia has been a speaker and provided teaching activities for Boston Scientific (from 2016). B. Napoleon has received fees from Boston Scientific for educational workshops (2014 to present), and fees from Olympus for organisation of EUS 2016; his department has received support from Olympus for the organization of a meeting on contrast EUS (2015). J.E. van Hooft’s department is currently receiving research grants from Cook Medical, Boston Scientific, and Olympus; since 2015 she has been a member of EUS platform, a national network of professionals. G.P. Aithal, P.G. Arcidiacono, P. Bastos, J.-M. Dumonceau, P. Eisendrath, G. Fernández-Esparrach, A. Fornelli, A. Gines, C. Hassan, C. Jenssen, P. Kaye, A. Larghi, M. Polkowski, and A. Seicean have no competing interests., (© Georg Thieme Verlag KG Stuttgart · New York.)

I thank R. Cabadas and J. Álvarez-Escudero (1). 1. Apologies accepted. 2. The statistical significance of the difference in proportions seems doubtful. 3. Although these small studies do not allow us to confirm the safety of endoscopist-directed propofol sedation, they deserve a short comment as they represent the best available level of evidence (RCTs) and are also informative. 4. Hypoxemia, hypotension and bradycardia are frequent and have no clinical consequences in most cases. 5. The authors started this chapter by stating "scientific opinions must be carefully based" (3); 6. As quotation marks were used, the correct reference should have been cited in that paragraph. 7. The point is that, under correct conditions as detailed in the ESGE Guidelines (4,5), propofol is as safe as midazolam/fentanyl.

Background & Aims: Algorithms for diagnosis of malignant common bile duct (CBD) stenoses are complex and lack accuracy. Malignant tumors secrete large numbers of extracellular vesicles (EVs) into surrounding fluids; EVs might therefore serve as biomarkers for diagnosis. We investigated whether concentrations of EVs in bile could discriminate malignant from nonmalignant CBD stenoses., Methods: We collected bile and blood samples from 50 patients undergoing therapeutic endoscopic retrograde cholangiopancreatography at university hospitals in Europe for CBD stenosis of malignant (pancreatic cancer, n = 20 or cholangiocarcinoma, n = 5) or nonmalignant (chronic pancreatitis [CP], n = 15) origin. Ten patients with CBD obstruction due to biliary stones were included as controls. EV concentrations in samples were determined by nanoparticle tracking analyses. The discovery cohort comprised the first 10 patients with a diagnosis of pancreatic cancer, based on tissue analysis, and 10 consecutive controls. Using samples from these subjects, we identified a threshold concentration of bile EVs that could best discriminate between patients with pancreatic cancer from controls. We verified the diagnostic performance of bile EV concentration by analyzing samples from the 30 consecutive patients with a diagnosis of malignant (pancreatic cancer or cholangiocarcinoma, n = 15) or nonmalignant (CP, n = 15) CBD stenosis. Samples were compared using the Mann-Whitney test and nonparametric Spearman correlation analysis. Receiver operating characteristic area under the curve was used to determine diagnostic accuracy., Results: In both cohorts, the median concentration of EVs was significantly higher in bile samples from patients with malignant CBD stenoses than controls or nonmalignant CBD stenoses (2.41 × 10 15 vs 1.60 × 10 14 nanoparticles/L in the discovery cohort; P < .0001 and 4.00 × 10 15 vs 1.26 × 10 14 nanoparticles/L in the verification cohort; P < .0001). A threshold of 9.46 × 10 14 nanoparticles/L in bile best distinguished patients with malignant CBD from controls in the discovery cohort. In the verification cohort, this threshold discriminated malignant from nonmalignant CBD stenoses with 100% accuracy. Serum concentration of EVs distinguished patients with malignant vs patients with nonmalignant CBD stenoses with 63.3% diagnostic accuracy., Conclusions: Concentration of EVs in bile samples discriminates between patients with malignant vs nonmalignant CBD stenosis with 100% accuracy. Further studies are needed to confirm these findings. Clinical Trial registration no: ISRCTN66835592., (Copyright © 2017 AGA Institute. Published by Elsevier Inc. All rights reserved.)

For pancreatic solid lesions, ESGE recommends performing endoscopic ultrasound (EUS)-guided sampling as first-line procedure when a pathological diagnosis is required. Alternatively, percutaneous sampling may be considered in metastatic disease.Strong recommendation, moderate quality evidence.In the case of negative or inconclusive results and a high degree of suspicion of malignant disease, ESGE suggests re-evaluating the pathology slides, repeating EUS-guided sampling, or surgery.Weak recommendation, low quality evidence.In patients with chronic pancreatitis associated with a pancreatic mass, EUS-guided sampling results that do not confirm cancer should be interpreted with caution.Strong recommendation, low quality evidence.For pancreatic cystic lesions (PCLs), ESGE recommends EUS-guided sampling for biochemical analyses plus cytopathological examination if a precise diagnosis may change patient management, except for lesions ≤ 10 mm in diameter with no high risk stigmata. If the volume of PCL aspirate is small, it is recommended that carcinoembryonic antigen (CEA) level determination be done as the first analysis.Strong recommendation, low quality evidence.For esophageal cancer, ESGE suggests performing EUS-guided sampling for the assessment of regional lymph nodes (LNs) in T1 (and, depending on local treatment policy, T2) adenocarcinoma and of lesions suspicious for metastasis such as distant LNs, left liver lobe lesions, and suspected peritoneal carcinomatosis.Weak recommendation, low quality evidence.For lymphadenopathy of unknown origin, ESGE recommends performing EUS-guided (or alternatively endobronchial ultrasound [EBUS]-guided) sampling if the pathological result is likely to affect patient management and no superficial lymphadenopathy is easily accessible.Strong recommendation, moderate quality evidence.In the case of solid liver masses suspicious for metastasis, ESGE suggests performing EUS-guided sampling if the pathological result is likely to affect patient management, and (i) the lesion is poorly accessible/not detected at percutaneous imaging, or (ii) a sample obtained via the percutaneous route repeatedly yielded an inconclusive result.Weak recommendation, low quality evidence., Competing Interests: Competing interests: S. Carrara has provided consultancy to Boston Scientific (since 2016) and to Olympus (since 2015). L. Czakó has received honoraria from Olympus (2014 to 2016). P. H. Deprez has provided consultancy to Boston Scientific and Olympus (both 2015 to 2017). P. Fockens has provided consultancy to Fujifilm, Olympus, Medtronic, Cook, and Boston Scientific (from 2016/2017). R. F. Havre has been provided by Samsung Medison with the use of an ultrasound scanner for research, from March to December 2017; he is a member of the Norwegian Society of Gastroenterology (since 2006). C. Jenssen’s department received a research grant of 4000 € from Novartis (2012 to 2015). A. Larghi has provided consultancy to Boston Scientific (2016 to 2017). J. E. van Hooft has received lecture fees from Medtronic (2014 to 2015) and consultancy fees from Boston Scientific (2014 to 2016); her department has received research grants from Cook Medical and Abbott (both 2014 to 2017). P. Vilmann provides consultancy to MediGlobe (from 1991 to 2019). G. P. Aithal, P. G. Arcidiacono, P. Bastos, J.-M. Dumonceau, G. Fernández-Esparrach, A. Ginès, C. Hassan, J. Iglesias-Garcia, M. Polkowski, and G. Vanbiervliet have no competing interests., (© Georg Thieme Verlag KG Stuttgart · New York.)

1  ESGE/EASL recommend that, as the primary diagnostic modality for PSC, magnetic resonance cholangiography (MRC) should be preferred over endoscopic retrograde cholangiopancreatography (ERCP).Moderate quality evidence, strong recommendation. 2  ESGE/EASL suggest that ERCP can be considered if MRC plus liver biopsy is equivocal or contraindicated in patients with persisting clinical suspicion of PSC. The risks of ERCP have to be weighed against the potential benefit with regard to surveillance and treatment recommendations.Low quality evidence, weak recommendation. 6  ESGE/EASL suggest that, in patients with an established diagnosis of PSC, MRC should be considered before therapeutic ERCP.Weak recommendation, low quality evidence. 7  ESGE/EASL suggest performing endoscopic treatment with concomitant ductal sampling (brush cytology, endobiliary biopsies) of suspected significant strictures identified at MRC in PSC patients who present with symptoms likely to improve following endoscopic treatment.Strong recommendation, low quality evidence. 9  ESGE/EASL recommend weighing the anticipated benefits of biliary papillotomy/sphincterotomy against its risks on a case-by-case basis.Strong recommendation, moderate quality evidence.Biliary papillotomy/sphincterotomy should be considered especially after difficult cannulation.Strong recommendation, low quality evidence. 16  ESGE/EASL suggest routine administration of prophylactic antibiotics before ERCP in patients with PSC.Strong recommendation, low quality evidence. 17  EASL/ESGE recommend that cholangiocarcinoma (CCA) should be suspected in any patient with worsening cholestasis, weight loss, raised serum CA19-9, and/or new or progressive dominant stricture, particularly with an associated enhancing mass lesion.Strong recommendation, moderate quality evidence. 19  ESGE/EASL recommend ductal sampling (brush cytology, endobiliary biopsies) as part of the initial investigation for the diagnosis and staging of suspected CCA in patients with PSC.Strong recommendation, high quality evidence., Competing Interests: Competing interests: J. Albert has received (from 2015 to 2016) speaker’s honoraria from Fujifilm, the Falk Foundation, Covidien/Medtronic, and Olympus Europe, an honorarium from Covidien/Medtronic for advisory services, and research support from Olympus Europe. P. Fickert has served on advisory boards for Dr. Falk Pharma and Intercept; his department has received unrestricted research grants from the Falk Foundation (since 2010) and Gilead (since 2012); he is listed as co-inventor in two patents filed by the Medical University of Graz for the use of norUDCA in the treatment of liver diseases and arteriosclerosis (publication numbers WO2006119803 and WO20099013334). A. Laghi has received a speaker fee from GE Healthcare (October 2016). J.-W. Poley receives consultancy, travel, and speaker fees from Cook Endoscopy; his department receives financial support for consultancy, travel, and speaking from Boston Scientific; he receives travel and consultancy fees from Pentax. C. Ponsioen’s department is receiving research support from Olympus and Fujifilm. C. Schramm has served on an advisory board for Intercept Pharmaceuticals (2016), and has given lectures sponsored by Intercept and the Falk Foundation. F. Swahn has served on a scientific advisory board for Rhenman & Partners, and has given lectures sponsored by Cook Medical Sweden and Boston Scientific Nordic. L. Aabakken, M. Arvanitakis, O. Chazouilleres, J.-M. Dumonceau, M. Färrkkilä, C. Hassan, G. Hirschfield, T. Karlsen, M. Marzioni, M. Fernandez, S. Pereira, J. Pohl, and A. Tringali have no competing interests., (© Georg Thieme Verlag KG Stuttgart · New York.)

1  ESGE recommends cold snare polypectomy (CSP) as the preferred technique for removal of diminutive polyps (size ≤ 5 mm). This technique has high rates of complete resection, adequate tissue sampling for histology, and low complication rates. (High quality evidence, strong recommendation.) 2  ESGE suggests CSP for sessile polyps 6 - 9 mm in size because of its superior safety profile, although evidence comparing efficacy with hot snare polypectomy (HSP) is lacking. (Moderate quality evidence, weak recommendation.) 3  ESGE suggests HSP (with or without submucosal injection) for removal of sessile polyps 10 - 19 mm in size. In most cases deep thermal injury is a potential risk and thus submucosal injection prior to HSP should be considered. (Low quality evidence, strong recommendation.) 4  ESGE recommends HSP for pedunculated polyps. To prevent bleeding in pedunculated colorectal polyps with head ≥ 20 mm or a stalk ≥ 10 mm in diameter, ESGE recommends pretreatment of the stalk with injection of dilute adrenaline and/or mechanical hemostasis. (Moderate quality evidence, strong recommendation.) 5  ESGE recommends that the goals of endoscopic mucosal resection (EMR) are to achieve a completely snare-resected lesion in the safest minimum number of pieces, with adequate margins and without need for adjunctive ablative techniques. (Low quality evidence; strong recommendation.) 6  ESGE recommends careful lesion assessment prior to EMR to identify features suggestive of poor outcome. Features associated with incomplete resection or recurrence include lesion size > 40 mm, ileocecal valve location, prior failed attempts at resection, and size, morphology, site, and access (SMSA) level 4. (Moderate quality evidence; strong recommendation.) 7  For intraprocedural bleeding, ESGE recommends endoscopic coagulation (snare-tip soft coagulation or coagulating forceps) or mechanical therapy, with or without the combined use of dilute adrenaline injection. (Low quality evidence, strong recommendation.)An algorithm of polypectomy recommendations according to shape and size of polyps is given (Fig. 1)., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: There have been substantial improvements in the management of chronic pancreatitis, leading to the publication of several national guidelines during recent years. In collaboration with United European Gastroenterology, the working group on 'Harmonizing diagnosis and treatment of chronic pancreatitis across Europe' (HaPanEU) developed these European guidelines using an evidence-based approach., Methods: Twelve multidisciplinary review groups performed systematic literature reviews to answer 101 predefined clinical questions. Recommendations were graded using the Grading of Recommendations Assessment, Development and Evaluation system and the answers were assessed by the entire group in a Delphi process online. The review groups presented their recommendations during the 2015 annual meeting of United European Gastroenterology. At this one-day, interactive conference, relevant remarks were voiced and overall agreement on each recommendation was quantified using plenary voting (Test and Evaluation Directorate). After a final round of adjustments based on these comments, a draft version was sent out to external reviewers., Results: The 101 recommendations covered 12 topics related to the clinical management of chronic pancreatitis: aetiology (working party (WP)1), diagnosis of chronic pancreatitis with imaging (WP2 and WP3), diagnosis of pancreatic exocrine insufficiency (WP4), surgery in chronic pancreatitis (WP5), medical therapy (WP6), endoscopic therapy (WP7), treatment of pancreatic pseudocysts (WP8), pancreatic pain (WP9), nutrition and malnutrition (WP10), diabetes mellitus (WP11) and the natural course of the disease and quality of life (WP12). Using the Grading of Recommendations Assessment, Development and Evaluation system, 70 of the 101 (70%) recommendations were rated as 'strong' and plenary voting revealed 'strong agreement' for 99 (98%) recommendations., Conclusions: The 2016 HaPanEU/United European Gastroenterology guidelines provide evidence-based recommendations concerning key aspects of the medical and surgical management of chronic pancreatitis based on current available evidence. These recommendations should serve as a reference standard for existing management of the disease and as a guide for future clinical research.