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Main Recommendations MR1 ESGE recommends small-bowel capsule endoscopy as the first-line examination, before consideration of other endoscopic and radiological diagnostic tests for suspected small-bowel bleeding, given the excellent safety profile of capsule endoscopy, its patient tolerability, and its potential to visualize the entire small-bowel mucosa.Strong recommendation, moderate quality evidence. MR2 ESGE recommends small-bowel capsule endoscopy in patients with overt suspected small-bowel bleeding as soon as possible after the bleeding episode, ideally within 48 hours, to maximize the diagnostic and subsequent therapeutic yield.Strong recommendation, high quality evidence. MR3 ESGE does not recommend routine second-look endoscopy prior to small-bowel capsule endoscopy in patients with suspected small-bowel bleeding or iron-deficiency anemia.Strong recommendation, low quality evidence. MR4 ESGE recommends conservative management in those patients with suspected small-bowel bleeding and high quality negative small-bowel capsule endoscopy.Strong recommendation, moderate quality evidence. MR5 ESGE recommends device-assisted enteroscopy to confirm and possibly treat lesions identified by small-bowel capsule endoscopy.Strong recommendation, high quality evidence. MR6 ESGE recommends the performance of small-bowel capsule endoscopy as a first-line examination in patients with iron-deficiency anemia when small bowel evaluation is indicated.Strong recommendation, high quality evidence. MR7 ESGE recommends small-bowel capsule endoscopy in patients with suspected Crohn’s disease and negative ileocolonoscopy findings as the initial diagnostic modality for investigating the small bowel, in the absence of obstructive symptoms or known bowel stenosis.Strong recommendation, high quality evidence. MR8 ESGE recommends, in patients with unremarkable or nondiagnostic findings from dedicated small-bowel cross-sectional imaging, small-bowel capsule endoscopy as a subsequent investigation if deemed likely to influence patient management.Strong recommendation, low quality evidence. MR9 ESGE recommends, in patients with established Crohn’s disease, the use of a patency capsule before small-bowel capsule endoscopy to decrease the capsule retention rate.Strong recommendation, moderate quality evidence. MR10 ESGE recommends device-assisted enteroscopy (DAE) as an alternative to surgery for foreign bodies retained in the small bowel requiring retrieval in patients without acute intestinal obstruction.Strong recommendation, moderate quality evidence. MR11 ESGE recommends DAE-endoscopic retrograde cholangiopancreatography (DAE-ERCP) as a first-line endoscopic approach to treat pancreaticobiliary diseases in patients with surgically altered anatomy (except for Billroth II patients).Strong recommendation, moderate quality evidence.

The primary aim of this study was to assess the reliability, intra- and inter-observer variation of the SPICE, Mucosal protrusion angle (MPA) and SHYUNG scores in differentiating a subepithelial mass (SEM) from a bulge.This retrospective multicentre study analysed the 3 scores, radiological studies, enteroscopy and/or surgical findings.100 patients with a potential SEM (mean age 57.6years) were recruited with 75 patients having pathology. In patients with a SEM the mean SPICE score was 2.04 (95% CI 1.82-2.26) as compared to 1.16 (95% CI 0.81-1.51) without any pathology (AUC 0.74, p0.001), with a fair intra-observer agreement (Kappa 0.3, p0.001) and slight inter-observer agreement (Kappa 0.14, p0.05). SPICE had a 37.3% sensitivity and 92.0% specificity in distinguishing between a SEM and bulge, whereas MPA90˚ had 58.7% and 76.0% respectively, with poor intra-observer(p = 0.05) and interobserver agreement (p = 0.64). The SHYUNG demonstrated a moderate intra-observer (Kappa 0.44, p0.001) and slight inter-observer reliability (Kappa 0.18, p0.001). The sensitivity of an elevated SHYUNG score (≥4) in identifying a SEM was 18.7% with a specificity of 92.0% (AUC 0.71, p = 0.002).Though these scores are easy to use, they have, at best, slight to moderate intra and inter-observer agreement. Their overall diagnostic performances are limited.

In recent years, panintestinal capsule endoscopy (PCE) with double-headed capsules has been used to perform complete, single-sitting exploration of both small bowel and colon in different clinical conditions. Double-headed capsules for colonic examination (CCE) have been exploited first in this setting, followed by newer generations of capsules (i.e. PillCam Crohn, PCC) specifically engineered for this purpose. The aim of this study was to evaluate the feasibility of PCE in the form of a systematic review. We performed a comprehensive literature search to identify papers in which CE was specifically used for a PCE of the gastrointestinal tract. Data on CE, bowel preparation regimen, rate of cleanliness and completeness, and data on transit times were analyzed. The primary outcome was to assess the feasibility of a whole-gut exploration with CE. Sixteen (n = 16) studies including 915 CE procedures with CCE1 (n = 134), CCE2 (n = 357) and PCC (n = 424) were included. 13/16 studies were performed in the setting of Crohn's disease. Cleanliness and completeness rates were acceptable in all studies, ranging from 63.9% and 68.6% to 100%, respectively. In conclusion, PCE is a feasible technique, although further structured studies are needed to explore its full potential.

Background and study aims When capsule endoscopy (CE) detects a small bowel (SB) target lesion that may be manageable with enteroscopy, the selection of the insertion route is critical. Time- and progression-based CE indices have been proposed for localization of SB lesions. This systematic review analysed the role of CE transit indicators in choosing the insertion route for double-balloon enteroscopy (DBE). Methods A comprehensive literature search identified papers assessing the role of CE on the choice of the route selection for DBE. Data on CE, criteria for route selection, and DBE success parameters were retrieved and analyzed according to the PRISMA statement. Risk of bias was assessed through the STROBE assessment. The primary outcome evaluated was DBE success rate in reaching a SB lesion, measured as the ratio of positive initial DBE to the number of total DBE. Results Seven studies including 262 CEs requiring subsequent DBE were selected. Six studies used time-based indices and one used the PillCam Progress indicator. SB lesions were identified and insertion route was selected according to a specific cut-off, using fixed landmarks for defining SB transit except for one study in which the mouth-cecum transit was considered. DBE success rate was high in all studies, ranging from 78.3 % to 100 %. Six of seven studies were high quality. Conclusions The precise localization of SB lesions remains an open issue, and larger studies are required to determine the most accurate index for selecting the DBE insertion route. In the future, 3 D localization technologies and tracking systems will be essential to accomplish this tricky task.

The introduction of capsule endoscopy two decades ago marked the beginning of the “small bowel revolution”. Since then, the rapid evolution of microtechnology has allowed the development of drug delivery systems (DDS) designed to address some of the needs that are not met by standard drug delivery. To overcome the complex anatomy and physiology of the gastrointestinal (GI) tract, several DDS have been developed, including many prototypes being designed, built and eventually produced with ingenious drug-release mechanisms and anchoring systems allowing targeted therapy. This review highlights the currently available systems for drug delivery in the GI tract and discusses the needs, limitations, and future considerations of these technologies.

After more than 15 years since its introduction into clinical practice, indications for device-assisted enteroscopy have greatly expanded. Alongside the consolidated indications such as the diagnosis and treatment of small bowel bleeding, Crohn's disease, hereditary polyposis, small-bowel tumors and complicated celiac disease, device-assisted enteroscopy is nowadays largely used to perform endoscopic retrograde cholangiopancreatography in patients with altered anatomy, stent placement, retrieval of foreign bodies, direct insertion of jejunal feeding tubes, and in selected cases of incomplete colonoscopy. This has been made possible by the technical improvements of the enteroscopes and accessories and by the widespread use of the method. Device-assisted enteroscopy endotherapy currently offers a safe and effective alternative to major surgery and often represents the preferred option for treatment of small-bowel pathology. Its safety profile is favourable even in the elderly patient, provided that it is performed in high-volume and experienced centers. The evolution of the enteroscopy technique is a challenge for the future and could be facilitated by the new enteroscopes models. These prototypes need a thorough clinical and safety assessment especially for the complex therapeutic procedures. Large prospective, multicenter studies should be performed to assess whether the use of device-assisted enteroscopy leads to improved patients' long-term outcomes.

Background and Aims Little is known about small-bowel (SB) capsule endoscopy (CE) in patients with a history of gastric surgery. This study aims to evaluate the feasibility and diagnostic yield (DY) of orally ingested SB-CE in patients with surgically altered gastric anatomy. Methods Twenty-four European centers retrospectively identified patients who had SB-CE after total or subtotal gastrectomy. The primary outcome was the DY of SB-CE (intermediate P1 to highly P2 relevant findings). Secondary outcomes were gastric and SB transit times, completion, cleanliness, and adverse event rates. Results Studied were 248 procedures from 243 patients (mean age, 62 years) with a history of partial gastrectomy (Billroth I, 13.1%; Billroth II, 34.6%), total gastrectomy (7.4%), Whipple procedure (12.8%), sleeve gastrectomy (7.2%), or gastric bypass surgery (24.7%). Obscure GI bleeding was the most frequent indication (85.1%). SB completion rate was 84.3%. One capsule retention in the SB was noted (adverse event rate, .4%). Median SB transit time was 286 minutes (interquartile range [235; 387]). Cleanliness was rated as adequate in 92.1% of procedures. After exclusion of abnormalities found at the upper anastomotic site, the DY was 43.6%, with inflammatory/ulcerated lesions observed more frequently (23.4%) than vascular lesions (21.0%). Conclusions SB-CE seems to be feasible and safe in selected patients with a history of major gastric surgery and comes with a high DY. The spectrum of abnormal SB findings in these patients may be different from what is known from the literature in nonoperated patients.

Small bowel capsule endoscopy (SBCE) was introduced into clinical practice almost 20 years ago and, nowadays, it is an essential tool for the study of the small bowel. SBCE allows a radiation-free examination of the entire mucosal surface of the small bowel with high-quality images, limited invasivity and a good safety profile. Nevertheless, the main limitation of SBCE is the lack of any possible direct therapeutic intervention. Indications for SBCE have evolved throughout the years, from "old" ones such as suspected small bowel bleeding (still the main indication for SBCE) to newer ones such as refractory celiac disease, hereditary polyposis syndromes and Crohn's disease. Thus, nowadays SBCE has a key role in the diagnostic algorithms in many conditions. Furthermore, the introduction in the SBCE field of cutting-edge technologies, as artificial intelligence systems, is likely to shorten the reading time making SBCE even more effective and easy to perform. Preliminary data are extremely promising and solid evidence is being gathered by current studies.

Pancreatic fluid collections (PFCs) develop as a result of damage to the major or peripheral pancreatic ducts, complication due to acute or chronic pancreatitis, trauma or iatrogenic causes. PFCs include pancreatic pseudocysts (PPs) and walled-off necrosis (WON). PFCs usually resolve spontaneously and are asymptomatic, but if they persist, increase in dimension or became symptomatics, therapeutic intervention is required. Available therapeutic interventions include surgical, percutaneous, and endoscopic drainage. The endoscopic approach is nowadays considered the first line-treatment of PFCs due to various advantages when compared with surgical or percutaneous drainage: decreased morbidity, length of hospital stay, and reduced costs. In the last few years, the endoscopic ultrasound (EUS)-guided transmural drainage, initially with plastic stents, gained popularity. More recently, fully covered self-expanding lumen-apposing metal stents (LAMS) have been demonstrated to be both, safe and effective with high clinical and technical success, reducing the risk of perforation, peritoneal leakage, migration and facilitating the drainage of necrotic contents. In the last few years, several studies evaluating the safety and efficacy of LAMS and their differences with plastic stents have been performed, but literature on the removal timing of this device and associated complications is still limited. The aim of this review is to analyze studies reporting information about the retrieval timing of LAMS and the related adverse events.

Endoscopic injection of glues, clotting factors, or sclerosing agents is a well-known therapy for the treatment of non-variceal upper gastrointestinal bleeding (NVUGIB), but less is known about endoscopic ultrasound (EUS)-guided treatments. In this setting, literature data are scarce, and no randomized controlled trials are available. We performed a review of the existing literature in order to evaluate the role of EUS-guided therapies in the management of NVUGIB. The most common treated lesions were Dieulafoy’s lesions, pancreatic pseudoaneurysms, and gastrointestinal stromal tumors (GISTs). Mostly, the treatments were performed as a salvage option after failure of conventional endoscopic hemostatic attempts, showing good efficacy and a good safety profile, also documented by Doppler monitoring of treated lesions. EUS-guided therapies may be an effective option in the treatment of refractory NVUGIB, thus avoiding radiological or surgical management. Nevertheless, available literature still lacks robust data.

Background and aim of the work: Intraductal papillary mucinous neoplasms (IPMN) of the pancreas are cystic lesions with malignant potential. Given their increasing incidence in the latest years, a precise characterization and management of these lesions have become more and more crucial: even though the majority of IPMN has a benign and indolent course, it is fundamental to early recognize and stratify patients in order to accurately plan a tailored follow-up and to individuate those that would benefit of surgical treatment. The aim of this paper is to highlight the most recent evidence on IPMN available in the current literature. Methods: We performed a review of the recent literature and of the recent guidelines about pancreatic cystic lesions, especially IPMN. Results: The incidence of IPMN is now on the rise: an increasing number of patients, possibly because of the increasing diagnostic yield of imaging techniques, is being diagnosed with pancreatic cystic lesions, a great part of which are IPMN. The possibility of malignant transformation requires a careful approach to these patients, in the need of tailoring the follow-up and the therapy. Conclusion: A detailed diagnosis, the determination of risk factors for malignant transformation and a multisciplinary approach are of foremost importance for an effective management of IPMN. (www.actabiomedica.it)

The treatment of Bouveret syndrome lacks specific guidelines and is strictly interdisciplinary. Especially, if electrohydraulic lithotripsy is not available and endoscopic removal fails, a timely surgical approach is advised.

Background: Patients with Peutz–Jeghers syndrome develop hamartomatous polyps in the small bowel, possibly causing anemia, intussusception, and obstruction. We aimed to evaluate the impact of an enteroscopy-based approach, including both device-assisted and intraoperative enteroscopy, on the reduction of the polyp burden in a cohort of adult Peutz–Jeghers syndrome patients. Materials and methods: A retrospective study was conducted at Azienda Ospedaliero-Universitaria Città della Salute e della Scienza in Turin, Italy. Consecutive Peutz–Jeghers syndrome patients eligible for device-assisted or intraoperative enteroscopy, between January 2003 and November 2019, were included. Enteroscopy technical issues and complications were recorded. At the time of index enteroscopy, the patients’ clinical records were retrospectively reviewed, and clinical data were recorded until November 2019. Results: Overall, 24 patients were included. Before inclusion, 16/24 patients (66.7%) underwent small bowel surgery for polyp-related complications, 13 of which (81.2%) in an emergent setting. Two patients had a history of small bowel neoplasms. During the timeframe, 47 device-assisted enteroscopies and 9 intraoperative enteroscopies were performed, and 247 small bowel polyps were endoscopically removed. The overall complication rate was 12.8% (8.5% for device-assisted enteroscopy, 22.2% for intraoperative enteroscopy). The median observation time was 108 months: in this timeframe, two patients developed small bowel polyp-related complications requiring emergent surgery. No patients developed small bowel cancer, but nine extra-gastrointestinal neoplasms were recorded. Conclusion: An enteroscopy-based approach appears to be well tolerated and effective in decreasing polyp-related complications in Peutz–Jeghers syndrome patients, thus reducing the need for emergent surgery. Although the prevention of small bowel polyp-related complications remains the main goal in these patients, the high incidence of extra-gastrointestinal neoplasms appears to be a rising issue.

Pancreatic schwannomas are very rare tumors, usually diagnosed incidentally after surgery. In literature, only 17 patients underwent endoscopic ultrasound (EUS) with fine-needle aspiration and diagnosis was reached only in 9 subjects. We report the case of a woman in whom a computed tomography revealed a mass in the uncinate process of the pancreas. EUS–fine-needle aspiration demonstrated a 1.3 × 1.1 cm hypoechoic lesion, cytology revealed sheets of spindle cells, and immunocytochemistry led to the diagnosis of schwannoma. Relying on EUS features and on the low proliferation index, a follow-up program was set. Four years later, the patient is asymptomatic and the mass is unchanged.

We report a rare case of gastric fistulization in a patient with main-duct (MD) intraductal papillary mucinous neoplasm (IPMN). Fistulization to adjacent organs is a rare complication of this disease, mainly affecting the duodenum; the fact that the stomach was the only organ involved makes this case even more peculiar. The diagnosis of the fistula was made after examination with endoscopic ultrasound, since a previous computed tomography scan could not detect it.

Zollinger-Ellison syndrome (ZES) is a clinical syndrome characterized by gastric acid hypersecretion due to the ectopic secretion of gastrin by a gastrinoma, a neuroendocrine tumor (NET) which mostly develops in the duodenum and in the pancreas. This syndrome was first described by Zollinger and Ellison in 1964; if left untreated, ZES can lead to multiple complications mainly due to gastric hypersecretion and some patients can suffer from the complications of an advanced metastatic disease. Although its clinical features are considered typical, the diagnosis of ZES is often challenging for the clinician. A previous review was published in 2005 by our group, but in 12 years many things have changed: the diagnostic tools have been improved and many different therapeutical options are now available.