INTRODUCTION:Cirrhosis is a global health challenge associated with significant morbidity and mortality. Sarcopenia is a clinically relevant prognostic marker in cirrhosis but is frequently overlooked in traditional prognostic scores. Gold standard diagnosis relies on imaging modalities that are expensive, not widely available, and involve radiation exposure, creating a need for a simple, reliable surrogate marker that can be incorporated into prognostic systems. Calf circumference (CC) meets these requirements as a practical screening tool with potential future utility within prognostic assessment, pending further validation. AREAS COVERED:A literature search of PubMed, Scopus, Embase, CINAHL, the Cochrane Library, Informed, and the JBI Database of Systematic Reviews (January 2000-November 2025) identified publications on sarcopenia in cirrhosis and the use of CC as a screening tool. International guidelines, systematic reviews, meta-analyses, large observational cohort studies, and narrative reviews were included. This review summarizes the pathophysiology and prognostic relevance of sarcopenia in cirrhosis and evaluates the utility of CC as a cost-effective screening measure with prognostic potential. EXPERT OPINION:CC is a feasible, low-cost surrogate marker of sarcopenia in cirrhosis with potential for integration into prognostic scores. Future studies should focus on validating standardized cutoffs and incorporating CC into prognostic models.
INTRODUCTION:Hepatitis C virus (HCV) affects approximately 47 million people worldwide and remains a major cause of chronic liver disease and liver-related mortality. Although direct-acting antiviral (DAA) therapy has transformed HCV into a highly curable infection, persistent gaps in diagnosis, linkage to care, harm reduction coverage, and health-system capacity impede progress toward World Health Organization (WHO) 2030 elimination targets. AREAS COVERED:This review summarizes advances in HCV therapeutics, including pangenotypic DAA regimens, shortened treatment strategies, and emerging antiviral agents, and examines treatment in special populations, including decompensated cirrhosis, acute HCV, transplant recipients, children, people who inject drugs, and pregnant women. It also explores diagnostic innovations and implementation strategies to accelerate elimination, including point-of-care HCV RNA testing, reflex testing, decentralized care, and microelimination frameworks. PubMed, Embase, and Google Scholar were searched from inception to March 2026. EXPERT OPINION:Modern DAA regimens cure over 95% across most populations, but eliminating HCV as a public health threat will require prioritizing underserved populations, simplified diagnostic pathways, equitable access to treatment and retreatment, and investment in harm reduction. Antenatal DAA therapy, ultra-short regimens, and long-acting antivirals represent the next frontier, though elimination will depend on implementation science as much as pharmacological innovation.
INTRODUCTION:Common variable immunodeficiency disorder (CVID) is the most common symptomatic primary immunodeficiency disorder and, given its predilection to affect the gastrointestinal (GI) tract, will be encountered in the practice of a general gastroenterologist, as well as those with more focused interests. AREAS COVERED:Gastrointestinal and hepatic manifestations of CVID - their clinical presentation, endoscopic, imaging and pathological features. Also reviewed, in detail, diagnostic and therapeutic issues that the clinician may be confronted with in dealing with these disorders. EXPERT OPINION:Among the protean GI manifestations of CVID a predisposition to enteric infections, chronic gastritis, enteropathy and a form of inflammatory bowel disease feature prominently. Each poses diagnostic and therapeutic challenges; differentiation from celiac disease, Crohn's disease and ulcerative colitis may be challenging, emphasizing the need for awareness of the possibility of CVID when clinical features are atypical. The liver may also be involved, and the gastroenterologist needs to be especially aware of the higher prevalence of gastrointestinal cancer in this patient population.
INTRODUCTION:Survivorship after critical illness is frequently complicated by muscle wasting and gastrointestinal (GI) dysfunction, driving prolonged functional impairment. Nutrition is a modifiable determinant across the intensive care unit (ICU)-to-home continuum, yet delivery is commonly limited by feeding intolerance and fragmented transitions of care. AREAS COVERED:This expert opinion review synthesizes evidence identified via a narrative search of MEDLINE/PubMed and key guideline/reference screening, focusing on GI dysfunction as a barrier to enteral nutrition (EN) in the ICU, phase-adapted energy and protein provision, and strategies to restore intake during ward recovery and after discharge, including high-energy, protein-dense oral nutritional supplements (ONS). EXPERT OPINION:Nutrition should be delivered as a structured pathway rather than a single ICU intervention. Early EN with proactive, symptom-targeted management of GI dysfunction, coupled with stepwise protein escalation aligned to metabolic phase and organ function, may help reduce avoidable deficits. The early post-ICU period is an anabolic 'window of opportunity' that warrants intake monitoring, deliberate tapering of tube feeds only once oral intake is reliable, and routine post-discharge ONS for patients at nutritional risk. Research should prioritize pragmatic trials of phase-specific targets and transition-of-care models.
INTRODUCTION:Acid-related gastrointestinal diseases, particularly gastroesophageal reflux disease (GERD) and peptic ulcer disease (PUD), remain major global health burdens despite decades of proton pump inhibitor (PPI)-based therapy. Persistent symptoms, nocturnal acid breakthrough, refractory disease, antibiotic resistance in Helicobacter pylori infection, and interindividual pharmacogenomic variability continue to limit current management strategies. AREAS COVERED:This review summarizes therapeutic advances in acid-related diseases, focusing on articles published between 2020 and 2025 and on potassium-competitive acid blockers (P-CABs), mucosal protective agents, adjunctive pharmacotherapies, endoscopic anti-reflux interventions, and precision medicine studies. Literature from randomized controlled trials, meta-analyses, international guidelines, and observational studies was reviewed to evaluate the efficacy, safety, and clinical positioning of emerging therapies in GERD, PUD, and H. pylori eradication. The search was conducted in PubMed. EXPERT OPINION:P-CABs, particularly vonoprazan, represent the most important advance in acid suppression in recent decades, offering faster, more potent, and more predictable acid inhibition than PPIs. Precision approaches integrating GERD phenotyping, pharmacogenomics, and antibiotic susceptibility testing are shifting management toward individualized care. However, long-term safety data, cost-effectiveness analyses, and robust comparative trials remain limited. Future progress will likely depend on combining phenotype-directed pharmacologic, endoscopic, and microbiome-informed strategies supported by artificial intelligence-driven diagnostics and treatment selection.
INTRODUCTION:Fibrostenotic Crohn's disease remains a major unmet clinical need, as currently licensed therapies primarily target inflammation and have not been shown to prevent fibrosis progression or reverse established strictures. Renewed interest in intestinal fibrosis, coupled with an expanding therapeutic pipeline, has prompted renewed debate over whether anti-fibrotic therapy in Crohn's disease represents hype or a realistic therapeutic opportunity. AREAS COVERED:This special report summarizes emerging anti-fibrotic strategies in Crohn's disease, including clinical data for ontunisertib and preclinical evidence for anti-TL1A therapies and obefazimod. It also examines lessons from successful anti-fibrotic drug development in pulmonary and hepatic fibrosis, focusing on pathway selection, patient stratification, endpoint development, and trial design. EXPERT OPINION:Early clinical and translational findings suggest that targeting fibrosis in Crohn's disease may be feasible. In the authors' view, the greater challenge lies in developing the tools and trial frameworks needed to demonstrate that therapies can alter the course of fibrostenotic disease.
INTRODUCTION:Gastric varices represent a challenging clinical scenario due to the severity of consequences when bleeding occurs, the cohort of patients in which it occurs, and a paucity of high-quality prospective data to guide treatment decisions. While a range of endoscopic and radiologic management strategies are now available, ambiguity exists about when to utilize each of these therapies. AREAS COVERED:This study comprehensively reviewed current management considerations and the positioning of available treatment modalities for gastric varices. A literature search was performed using PubMed to identify peer-reviewed articles published until December 2025. EXPERT OPINION:While a lack of large, randomized trials limits the ability to provide definitive guidance for the management of gastric varices, individualized patient care and a multidisciplinary approach with close collaboration between hepatologists, interventional endoscopists, and radiologists is vital. Prompt endoscopic assessment remains important and allows initial management with either direct endoscopic injection (cyanoacrylate glue or thrombin) or if available, EUS-guided therapy. Further follow‑up endoscopic or EUS-guided therapies appear to be safe and effective, but definitive management with radiologic procedures such as transjugular intrahepatic portosystemic shunt to address global portal hypertension or retrograde transvenous obliteration procedures is highly successful and should also be considered.
Accurate assessment of inflammatory activity in inflammatory bowel diseases (IBD) such as Crohn's disease (CD) and ulcerative colitis (UC) remains a major clinical challenge. Positron emission tomography (PET) with fibroblast activation protein inhibitors (FAPI) has recently attracted considerable interest for its ability to visualize fibroblast-associated tissue remodeling and stromal activation in inflammatory conditions. In the study under evaluation, Debus et al. report a retrospective pilot study of [68Ga]Ga-FAPI-46 PET/CT for noninvasive characterization and activity assessment of CD and UC. Forty-three histologically confirmed IBD patients (20 CD and 23 UC) and 43 matched controls underwent dynamic abdominal (60 min) and whole-body [68Ga]Ga-FAPI-46 PET/CT to quantify FAPI uptake, kinetics, and lesion burden, with imaging findings compared with colonoscopy. They found significantly higher FAPI uptake in both FAPI-positive lesions and in many 'healthy-appearing' gut segments of IBD patients versus controls; uptake was greater in active versus inactive disease, and lesions displayed two characteristic kinetic patterns that can further stratify inflammatory disease. The study is an important, hypothesis-generating contribution that supports the feasibility and biological plausibility of FAPI PET for IBD, but its retrospective design, modest sample size, limited histologic lesion-level correlation and control selection temper conclusions about diagnostic performance and clinical utility.
INTRODUCTION:The Lyon 2.0 consensus was established to further refine the original Lyon Consensus and address gaps in reflux testing and endoscopic diagnosis of GERD. It represents a significant advancement in the diagnostic framework of GERD through modern definition of GERD, endoscopy findings, conclusive evidence of GERD and reflux testing metrics and thresholds. AREAS COVERED:This is an overall review of the different aspects of GERD diagnosis that were updated in the Lyon 2 consensus compared with the original Lyon Consensus. The review also provides an expert opinion of Lyon 2.0 limitations, emphasizing practical implementation challenges, evidentiary gaps, and the need for a more globally adaptable and data-driven approach. EXPERT OPINION:Lyon 2.0 consensus has markedly advanced GERD diagnosis by establishing a modern definition of GERD, identifying conclusive endoscopic findings for GERD, and introducing updated, standardized metrics and thresholds for reflux testing, along with guidance on appropriate testing both off and on therapy. However, there are several limitations to Lyon Consensus that should be recognized and they include, global access to esophageal testing, disparities, dependence on specialized expertise, regional variability in normative thresholds, reliance on PPI-centric definitions, inadequate integration of nonacid pepsin-mediated injury, and inherent consensus methodology biases.
INTRODUCTION:Proton pump inhibitors (PPIs) are among the most frequently prescribed medications in pediatric practice. While highly effective in acid-mediated disorders, concerns regarding overuse, inappropriate indications, and potential adverse effects have emerged, particularly in infants and children with nonspecific symptoms. AREAS COVERED:This review summarizes the current evidence on the indications, efficacy, and safety of PPIs in the pediatric population. A literature search was performed in PubMed/MEDLINE and Embase, supplemented by landmark earlier studies and current clinical practice guidelines. We discuss guideline recommendations and examine the role of PPIs across different clinical scenarios including gastroesophageal reflux disease, esophagitis, eosinophilic esophagitis and special populations. Particular attention is given to emerging data on adverse outcomes, including infections, microbiome alterations, and long-term safety concerns. Strategies for appropriate prescribing, deprescribing, and individualized patient management are also addressed. EXPERT OPINION:PPIs remain overprescribed in pediatrics, often for indications lacking clear benefit. Future efforts should prioritize diagnostic precision, short-term therapeutic trials and systematic deprescribing strategies. A shift toward stewardship-based prescribing, combined with improved clinician education and use of objective diagnostic tools, is essential to optimize outcomes and minimize unnecessary exposure.
INTRODUCTION:Metabolic dysfunction-associated steatotic liver disease (MASLD) is recognized as the most prevalent liver disease worldwide. Globally, it has impacted millions of individuals. With the recent change in terminology, MASLD is no longer a diagnosis of exclusion but rather a criterion-based diagnosis anchored around metabolic dysfunction. In addition to progressive liver fibrosis leading to cirrhosis, MASLD has been linked to extrahepatic complications, which include cardiovascular disease, non-liver-associated malignancies, and other adverse metabolic outcomes. Importantly, disease severity and prognosis are heterogeneous and are influenced by genetic susceptibility, environmental exposures, metabolic comorbidities, and behavioral risk factors. AREAS COVERED:This review provides a contemporary overview of the global incidence and prevalence of MASLD. In addition, it also summarizes recent temporal trends to predict future disease burden. Ultimately, this review seeks to clarify the evolving epidemiologic landscape of MASLD and highlight key gaps that must be addressed to inform effective prevention, surveillance, and health system planning. EXPERT OPINION:The rising prevalence of MASLD demands a shift from generic management to precision medicine. Since disease progression varies wildly based on genetics and metabolic profiles, future care must prioritize identifying high-risk phenotypes early. Without targeted interventions, the recognition of MASLD-related complications will be delayed.
INTRODUCTION:Endoscopic ultrasound-guided choledochoduodenostomy using lumen-apposing metal stents (EUS-CDS-L) has evolved as a main therapeutic option for distal malignant biliary obstruction after failed endoscopic retrograde cholangiopancreatography (ERCP). This review aimed to provide a comprehensive overview of the technical aspects for performing EUS-CDS-L. AREAS COVERED:This review summarized the current evidence on all apsects of the EUS-CDS-L procedure, focusing on pre-procedural, procedural, and post-procedural management. We conducted a structured, detailed search of multiple databases (PubMed, Web of Science, Embase, and the Cochrane Library) from January 2010 to March 2026. EXPERT OPINION:EUS-CDS-L should be considered the preferred rescue strategy after failed ERCP in patients with distal malignant biliary obstruction (DMBO), given its consistently high technical and clinical success rates and acceptable safety profile. Beyond salvage therapy, accumulating high-quality evidence suggests EUS-CDS-L's potential role as a primary drainage modality in selected patients, particularly in specializing centers. However, variability in technique, stent selection, and peri-procedural management continues to limit standardization. Future efforts should focus on protocol and peri-procedural harmonization.
INTRODUCTION:Clinically significant portal hypertension (CSPH) is related to poor prognosis and its early detection is crucial for timely clinical interventions, such as initiation of nonselective-beta-blockers. The hepatic vein pressure gradient remains the gold standard to diagnose CSPH; however, noninvasive tests (NITs) have been developed as valuable alternatives. In this review, we summarize the diagnostic performance and clinical utility of such techniques in patients with compensated advanced chronic liver disease (cACLD). AREAS COVERED:A comprehensive literature search was performed, focusing on imaging methods, including elastographic techniques, ultrasound (US)-, magnetic resonance (MR)- and computed tomography (CT)-based methods, as well as serum biomarkers for the assessment of CSPH. The diagnostic accuracy of these techniques for the detection of esophageal varices is also discussed. Evidence on the combined use of NITs, emerging predictive models and developments following the Baveno VII consensus is summarized. EXPERT OPINION:NITs, particularly liver and spleen stiffness measurement, have been validated for the diagnosis of CSPH. Baveno VII has incorporated these tools into its recommendations for the management of cACLD. Future research should focus on the establishment of etiology-specific cutoff values and the further validation of alternative methods, such as MR elastography, spleen stiffness measurement and contrast enhanced US.
INTRODUCTION:Gastrointestinal (GI) bleeding is a frequent and potentially life-threatening emergency that imposes a substantial healthcare burden worldwide. Over the past three decades, advances in endoscopic technology and technique have transformed management, shifting the emphasis from predominantly diagnostic procedures to targeted, minimally invasive therapeutic interventions across the upper, lower, and small bowel. AREAS COVERED:This review synthesizes current evidence and guideline-based strategies for endoscopic management of GI bleeding, with a structured focus on non-variceal and variceal upper GI bleeding, lower GI bleeding, and small bowel bleeding. Key therapeutic modalities include combination therapies for peptic ulcer bleeding, band ligation for esophageal and selected gastric varices, argon plasma coagulation (APC) for vascular malformations and tumor bleeding, and emerging approaches such as over-the-scope clips (OTSC), hemostatic powders, radiofrequency ablation (RFA), and self-expandable metal stents (SEMS). Capsule endoscopy and device-assisted enteroscopy have markedly improved the evaluation and treatment of small bowel bleeding. We also review risk stratification scores, transfusion strategies, and timing of endoscopy, all of which are crucial to optimizing outcomes. EXPERT OPINION:Successful management of GI bleeding demands a personalized approach integrating patient-specific factors, bleeding etiology, and local expertise. Emerging technologies, particularly artificial intelligence (AI)-assisted imaging and novel hemostatic devices, are poised to refine diagnosis, risk prediction, and therapy selection. Nonetheless, clinical judgment, multidisciplinary collaboration, rigorous training, and thoughtful resource allocation remain paramount to ensure safe, effective, and sustainable care in this rapidly evolving field.
INTRODUCTION:Biliary tract tumors comprise a group of poor prognosis malignancies, most of them being diagnosed at an advanced stage. Standard treatments include surgery with curative intent and adjuvant chemotherapy. Even so, the benefit obtained is marginal, and relapses are frequent. AREAS COVERED:Here, we made a review of the literature trying to summarize all trials related to adjuvant therapy, as well as those yet to come. We also focused on detecting the unmet needs in this field, which may represent a change in the current strategy. EXPERT OPINION:A clear definition of resectability, risk stratification, intensification of treatment with immunotherapy, and targeted therapies, as well as moving treatment from an adjuvant to a perioperative scenario are, in our view, factors that could increase the rate of cure in this scenario.
INTRODUCTION:In Western countries gallstone prevalence is around 10%. 80% are cholesterol stones. The elucidation of their pathophysiology, particularly from the 1970s to the 1990s, led to the development of various non-surgical treatments. The disadvantages of these therapies, together with the development of minimally invasive gallbladder removal, have largely rendered non-surgical approaches obsolete. However, a relatively high proportion of patients who undergo cholecystectomy do not become completely symptom-free. To this end, we address the role of non-surgical therapy for uncomplicated gallbladder stones, which has received little attention in recent decades. AREAS COVERED:Based on extensive research in PubMed we present the pathophysiology of stones, oral litholysis, direct litholysis and shock wave lithotripsy. The role of these treatments to surgery in selective therapy as well as primary and secondary prevention is discussed. Moreover, we allude to the association of cholesterol gallstones with cardiovascular disorders. EXPERT OPINION:Too little is known about when and how gallstones develop and how gallstones respond to preventive measures regarding cardiovascular diseases. Further research is needed for a more individualized therapy - especially with respect to non-surgical approaches - of the rather benign gallstone disease that nevertheless has a high impact on health economics.
INTRODUCTION:Variceal bleeding (VB) is a defining event of decompensation in cirrhosis and remains cause of morbidity and mortality. The presence of other decompensating events determines management and prognosis. AREAS COVERED:This review discusses risk-stratified management and prevention of VB, including acute therapy, indications for transjugular intrahepatic portosystemic shunt (TIPS), and stage-specific primary and secondary prophylaxis. A PubMed/MEDLINE search prioritized trials, meta-analyses, and guidelines. EXPERT OPINION:In patients presenting with VB, standard management consists of vasoconstrictive drugs, antibiotics, and endoscopic variceal ligation (EVL). If bleeding cannot be controlled, TIPS placement should be considered. Recent studies show preemptive TIPS confers survival benefit in patients at high risk of failing standard therapy, defined as Child-Pugh scores 10-13 or 8-9 with active bleeding at endoscopy. In patients whose bleeding is controlled who do not undergo TIPS during the acute episode, secondary prophylaxis consists of nonselective beta-blockers (NSBBs) plus EVL. In patients with ascites, NSBB or EVL is recommended for high-risk varices to prevent first bleeding. In compensated cirrhosis, the goal is to prevent decompensation, including VB, ascites, and hepatic encephalopathy. Therapy targets patients at high risk of decompensation defined by clinically significant portal hypertension using elastography and platelet count. NSBBs, preferably carvedilol, are recommended.
