We read with interest the multicenter study by Lee et al on non-esophageal eosinophilic gastrointestinal diseases. Although most patients responded well to conventional therapies, high relapse rates highlight the limitations of these treatments. To address this, we suggest that endoscopic ultrasound be considered in clinical practice for selected patients with suspected deeper-layer involvement, obstructive symptoms, unexplained ascites, severe disease, or discordance between symptom severity and mucosal biopsy findings. Furthermore, fecal microbiota transplantation and leukapheresis warrant further investigation as potential novel therapeutic strategies. As current evidence is largely limited to case reports and indirect disease models, these approaches require additional mechanistic and preclinical studies to evaluate their efficacy and safety. Individualized regimens should also be considered to optimize outcomes in this challenging disease.
BACKGROUND Therapeutic endoscopic retrograde cholangiopancreatography for giant common bile duct stones with pancreaticobiliary maljunction (PBM) in children remains challenging. As a congenital anomaly, PBM is characterized by anatomical variants that may predispose affected children to recurrent pancreatitis and adversely affect growth and development. CASE SUMMARY A 6-year-old boy was admitted with nonprojectile vomiting and intermittent abdominal pain that had begun one week before admission. Yellowing of the skin and sclerae developed four days before admission followed by fever with a peak temperature of 38.8 ℃ and lethargy two days before admission. No pruritus, joint swelling or pain, diarrhea, bloody stools, abdominal distension, rash, or petechiae was reported. After admission, abdominal color ultrasound and magnetic resonance cholangiopancreatography were performed. Laboratory testing revealed a white blood cell count of 16.3 × 109/L, a neutrophil percentage of 91.5%, and a C-reactive protein level of 68.68 mg/L. The clinical diagnoses included acute suppurative cholangitis, biliary pancreatitis, common bile duct stones, PBM, and pancreas divisum. Symptoms were relieved after endoscopic retrograde cholangiopancreatography-based stone extraction and biliary decompression. CONCLUSION In this case, an individualized endoscopic stone-extraction strategy combined with endoscopic sphincterotomy was successfully used to remove the biliary stones and relieve the obstruction. The patient’s clinical symptoms resolved rapidly after the procedure, thereby providing favorable conditions for subsequent definitive surgery.
Difficult main pancreatic duct stones in chronic pancreatitis are challenging not only because they are hard to fragment, but because duct clearance does not necessarily translate into durable clinical benefit. Pain relief, freedom from repeated procedures, and avoidance of later surgery should therefore be considered separately from technical clearance. Extracorporeal shock wave lithotripsy (ESWL), usually followed by endoscopic retrograde cholangiopancreatography (ERCP), remains a guideline-supported option for radiopaque stones measuring at least 5 mm in the pancreatic head or body, as well as for large, dense, multiple, or diffuse stone burdens. Digital pancreatoscopy-guided electrohydraulic lithotripsy or laser lithotripsy offers a different advantage: Direct intraductal visualization, targeted fragmentation, and immediate assessment of residual fragments, strictures, and drainage. We reviewed English-language publications available through May 2026. Current data show high technical success in selected patients, and some observational studies suggest fewer treatment sessions than with ESWL. However, randomized comparative data remain limited, and sham controlled and surgery comparison trials show that ductal clearance alone is an incomplete measure of patient benefit. The key question is therefore which patients are most likely to benefit from pancreatoscopy-guided lithotripsy, how it should be sequenced with ESWL and ERCP, how procedural risk and treatment burden should be weighed, and when surgery should be considered earlier. This mini-review presents a practical framework in which pancreatoscopy is used selectively, not as a replacement for ESWL or only as a rescue technique.
Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is a significant complication of endoscopic retrograde cholangiopancreatography. Its pathogenesis is multifactorial, with elevated intraductal hydrostatic pressure as a primary cause. I read with interest and commend Amalou et al recently published a study in World Journal of Gastrointestinal Endoscopy for their study on the prevention of PEP using lactated Ringer’s (LR) solution in combination with indomethacin. The editorial focuses on non-endoscopic strategies for PEP prevention, critically evaluating the currently available evidence. Rectal administration of non-steroidal anti-inflammatory drugs (NSAIDs) is an established cornerstone of pharmacological prophylaxis due to robust evidence of efficacy, safety, and cost-effectiveness. Aggressive periprocedural intravenous hydration with LR solution has also demonstrated benefit in reducing the incidence and severity of PEP, although its incremental value when combined with rectal NSAIDs has achieved mixed results in large trials. Such a combination may offer advantages, particularly for moderate-to-severe PEP, but is not universally superior to NSAID monotherapy. Prophylaxis should be stratified according to patient risk. Future directions should aim to optimize risk prediction and personalize prophylactic protocols to improve clinical implementation and patient outcomes.
Endoscopic retrograde cholangiopancreatography (ERCP) is currently recommended as the gold standard treatment modality for distal malignant biliary obstruction (DMBO), with percutaneous transhepatic biliary drainage being historically regarded as the second-line strategy in case of ERCP failure. Following the recent advent of therapeutic endoscopic ultrasound, various endoscopic ultrasound-guided biliary drainage techniques have been advocated as the preferred second-line options, as they are associated with fewer adverse events and morbidity compared to percutaneous transhepatic biliary drainage. Moreover, they have also been proposed as promising first-line alternatives to ERCP. However, the capability of both the historical and emerging biliary drainage modalities to normalize total bilirubin in patients with DMBO is underreported and evidence is still lacking, especially regarding the emerging ones. Notably, bilirubin normalization is regarded as mandatory before starting chemotherapy, thus representing a crucial outcome of any biliary drainage method for DMBO. Our study summarizes and discusses the current evidence regarding the effectiveness of currently available endoscopic biliary drainage techniques for bilirubin normalization in DMBO.
Duodenal adenomas are clinically significant premalignant lesions; however, their management is frequently challenging due to fibrosis, recurrence, and the procedural risks associated with resection-based techniques such as endoscopic mucosal resection and endoscopic submucosal dissection. Cryoballoon ablation (CBA) has recently emerged as a non-resection alternative that delivers controlled nitrous oxide-based cryotherapy while reducing the likelihood of deep mural injury. A recent two-center retrospective series by Modirian et al published in World Journal of Gastrointestinal Endoscopy involving ten patients demonstrated the high technical success and meaningful clinical efficacy of CBA for non-circumferential flat adenomas including lesions with severe fibrosis that precluded effective snare capture. Most patients achieved substantial lesion regression or complete eradication with an excellent safety profile, requiring only occasional repeat sessions. In contrast, bulky circumferential sessile lesions showed minimal or no response, underscoring an important limitation of this modality. Current evidence indicates that CBA represents a valuable therapeutic option for carefully selected complex duodenal adenomas; however, prospective studies are needed to clarify the long-term durability, recurrence rates, and optimal candidates for this approach.
A recent study by Naidu et al published in the World Journal of Gastrointestinal Endoscopy prospectively evaluated the bilirubin normalization rate and its kinetics following endoscopic retrograde pancreatic cholangiography in both benign and malignant extrahepatic biliary obstructions. This letter highlighted the crucial role of the bilirubin normalization in evaluating the efficacy of any biliary drainage technique, especially in the malignant setting. However, despite its significant impact on clinical and oncological outcomes, the bilirubin normalization rate is often underreported in favor of the clinical success defined by a reduction of total bilirubin of 50%-75% within 2-4 weeks. Nevertheless, this clinical success is not synonymous with bilirubin normalization. The systematic evaluation of this key outcome in a standardized fashion should be strongly encouraged in future trials, especially in those comparing standard-of-care techniques with emerging ones.
Difficult biliary cannulation during endoscopic retrograde cholangiopancreatography (ERCP) increases the risk of post-ERCP pancreatitis and procedural failure. This narrative minireview summarizes cannulation strategies and evidence-based escalation techniques, including needle-knife papillotomy, needle-knife fistulotomy, and transpancreatic sphincterotomy. Early recognition of difficult cannulation, the use of predefined stop criteria to limit papillary trauma, and selection of rescue techniques based on pancreatic duct access and clinical context can maximize outcomes from ERCP.
BACKGROUND National Comprehensive Cancer Network guidelines recommend patients with >= 10 lifetime adenomas undergo genetic evaluation for polyposis syndromes. Lynch syndrome (LS) has not historically been considered a polyposis syndrome. We utilized our hereditary gastrointestinal tumor registry to determine the number of lifetime adenomas in LS patients, and to assess differences in demographic and clinical factors between those with < 10 adenomas and those with >= 10. AIM To describe a cohort of patients with LS who have developed polyposis that may be used to improve endoscopic surveillance guidelines in this population. METHODS Medical records from LS patients enrolled in our registry since 2005 (n = 260) were reviewed for colonoscopy outcomes, colorectal cancer diagnosis, and other clinical factors. Groups of interest were compared using Fisher's exact test and Wilcoxon-Mann-Whitney test. RESULTS Three patients were excluded, leaving 257 individuals for data analysis. Most patients were female and white. Mean follow-up time was 6.8 years. Eleven (4.3%) patients had >= 10 adenomas. Number of colonoscopies and follow-up time were significantly higher in patients with >= 10 adenomas compared with those diagnosed with < 10. For assessment of differences between the two groups, we limited our analysis to include those with >= 6 lifetime colonoscopies (n = 92). No significant differences in the evaluated characteristics were observed between those with >= 10 adenomas and those with < 10. MSH6 and MSH2 were the most commonly affected genes in the >= 10 adenomas group, accounting for 45.5% each, together representing 90.9% (10/11) of the polyposis cohort, compared to 24.7% and 35.8%, respectively, in the < 10 adenomas group. CONCLUSION Polyposis occurs in LS; possibly, more frequently among those with MSH6 or MSH2 pathogenic variants. LS should be included as a differential for attenuated polyposis.
This invited commentary discusses the recent study by Alali et al , published in the World Journal of Gastrointestinal Endoscopy , which investigated the feasibility and safety of endoscopic ultrasound-guided liver biopsy (EUS-LB) for diagnosing parenchymal liver disease. The study demonstrated a high diagnostic yield and a low rate of serious complications, supporting the efficacy of EUS-LB as an alternative to percutaneous liver biopsy. The study also highlighted technical factors that improve tissue acquisition. While commending the multi-center findings and technical insights, we discuss limitations of the retrospective design and modest sample, compare EUS-LB with traditional biopsy modalities, and emphasize the need for larger prospective studies to validate and generalize these results.
For decades, Helicobacter pylori (H. pylori )-associated gastric diseases have been interpreted through a largely compartmentalized immunological lens, in which local mucosal inflammation is viewed as the primary driver of pathology and systemic immune responses are relegated to secondary or epiphenomenal roles. This framework, while useful, struggles to explain the remarkable heterogeneity of gastric outcomes arising from anatomically localized infection. Emerging human data increasingly suggest that gastric pathology may be embedded within broader systemic immune configurations, raising the possibility that circulating immune responses actively interact with local gastric processes rather than merely reflecting them. Within this context, recent work examining systemic cytokine dynamics before and after H. pylori eradication offers timely and provocative insights. The study by de Melo et al in the World Journal of Gastrointestinal Endoscopy demonstrates that gastritis and duodenal ulcer are associated with distinct systemic cytokine signatures and that bacterial eradication induces phenotype-specific immune recalibration rather than uniform immunological resolution. These findings challenge reductionist interpretations of gastric disease and support an integrated mucosal-systemic immune axis as a conceptual framework for understanding divergent gastric phenotypes. By reframing H. pylori -associated disease in this way, the study invites critical reassessment of long-standing assumptions regarding immune hierarchy and causality in gastric pathology. Recognizing systemic immunity as an active participant rather than a passive bystander may influence how immunological data are interpreted and how future studies are designed.
BACKGROUND The optimal bowel preparation for small bowel capsule endoscopy (SBCE) has not been standardized. AIM To compare the rate of complete examinations, quality of bowel preparation, diagnostic yield and tolerability, using three protocols for SBCE. METHODS A prospective, multicentre, randomized study including patients submitted to SBCE was conducted. Patients ingested a booster once the capsule reached the small bowel, randomized into one of three protocols: (1) 1 L of polyethylene glycol (PEG); (2) 1 L of PEG and ascorbic acid; and (3) 1 L of water. The patients' bowel preparation was evaluated with Small Bowel CLEansing Assessment and Report. RESULTS A total of 261 patients were included, 96 (36.8%) in protocol 1, 93 (35.6%) in protocol 2 and 72 (27.6%) in protocol 3. The rate of complete examinations, adequate bowel preparation and diagnostic yield were comparable among the groups (P = 0.655, P = 0.193 and P = 0.589, respectively). The overall Small Bowel CLEansing Assessment and Report score was similar among the protocols (P = 0.236). Although the preparation of the third tertile had a lower score using protocol 3 (protocol 1: 2.5 +/- 0.1 vs 2: 2.6 +/- 0.1 vs 3: 2.3 +/- 0.1, P = 0.021), it did not compromise the mucosal visualization, maintaining a mean score above 2 and similar diagnostic yield among the protocols (P = 0.850). The patients' reported tolerability was higher in protocol 3 (protocol 1: 2.8 +/- 0.1 vs 2: 3.0 +/- 0.2 vs 3: 0.6 +/- 0.1, P < 0.001). CONCLUSION Using 1 L of water as a booster in SBCE was better tolerated and associated with comparable rates of complete examinations, adequate bowel preparation and diagnostic yield vs PEG with or without ascorbic acid.
Endoscopic ultrasound (EUS) remains operator-dependent with notable diagnostic variability. This review synthesizes recent artificial intelligence (AI) advances within an integrated “Prediction-Navigation-Diagnosis” framework to transform EUS practice. Preoperatively, AI aids risk stratification and procedure planning. Intraoperatively, real-time navigation systems reduce anatomical blind-spot miss rates by approximately 10% and guide puncture paths. Postoperatively, AI enhances diagnostic accuracy for various gastrointestinal lesions, and cytology models alleviate reliance on scarce pathological resources. However, clinical adoption faces challenges including data heterogeneity, high costs, ethical ambiguities, and insufficient regulatory frameworks. Future translation depends on standardizing multimodal data, developing accessible algorithms, establishing human-AI collaboration guidelines, and advancing adaptive regulations. Overcoming these barriers may enable AI-enhanced EUS to achieve a more consistent, safe, and accessible intelligent workflow.
In this editorial, we comment on the article by Pietrzak et al published in the recent issue of the World Journal of Gastrointestinal Endoscopy . Malignant hilar biliary obstruction remains a formidable challenge for endoscopists. While endoscopic retrograde cholangiopancreatography continues to represent the cornerstone of biliary drainage, malignant hilar biliary obstruction often requires a multimodal approach that incorporates percutaneous-guided techniques, either as complementary or salvage strategies. Emerging evidence also supports the integration of endoscopic ultrasound-guided biliary drainage as a planned adjunct in selected cases to optimize biliary drainage, reduce the need for re-intervention, and improve clinical outcomes. In this editorial, we review current guideline recommendations and key technical considerations, emphasizing the role of endoscopic ultrasound-guided biliary drainage in expert hands for patients with complex hilar anatomy or incomplete drainage after endoscopic retrograde cholangiopancreatography.
BACKGROUND Acute appendicitis is an infrequent etiology of lower gastrointestinal bleeding (LGIB), with approximately 20 reported cases globally. To the best of our knowledge, xanthogranulomatous appendicitis (XGA) presenting with LGIB has not been described in the literature. CASE SUMMARY The patient was a 41-year-old man admitted for blood in stool for 1 day. He had previously been healthy. One month ago, the patient underwent a routine health check-up, which revealed a hemoglobin (HGB) level of 145 g/L. Following hematochezia, repeat laboratory testing showed a quick decrease in HGB level to 94 g/L. Emergency colonoscopy revealed dark red blood throughout the intestinal lumen, with visible fresh red bleeding emanating from the appendiceal lumen. Bleeding was intermittent. After copious irrigation with normal saline, observation for approximately 3 minutes found persistent fresh red bleeding from the appendiceal lumen, while no blood staining was observed in the terminal ileum. The patient underwent laparoscopic appendectomy, and postoperative pathology suggested XGA with mucosal ulceration and hemorrhage. CONCLUSION XGA represents an unusual etiology of LGIB.
Standardized reporting of endoscopy-related adverse events (AE) remains challenging. Definitions, severity thresholds, and attribution windows vary across units, and documentation practices substantially influence observed event rates. A recent registry-based comparison of two AE classification systems illustrates that strong concordance in severity grading does not, in itself, resolve implementation challenges at the boundary between incidents and non-events, nor does it address under-ascertainment. In this letter, we trace the evolution of endoscopy AE nomenclature, from earlier documentation-intensive approaches to contemporary frameworks that prioritize clinical consequence and treatment-based grading. Drawing on external real-world validation data and published commentaries, we argue that endoscopy units should prioritize a dual-stream safety framework: Severity-graded adverse-event reporting for clinically consequential harms, alongside structured capture of incidents and near-misses for prevention-oriented learning. We further highlight the need for procedure-stratified interpretation, explicit documentation of local post-procedural pathways, robust ascertainment workflows, and separate monitoring of diagnostic delay and procedural appropriateness.
Portal hypertension is a major complication of chronic liver disease and cirrhosis, causing significant morbidity and mortality through gastroesophageal varices, portal hypertensive gastropathy (PHG), and variceal hemorrhage. Although endoscopy has long been central to diagnosing and treating these complications, advances in endoscopic ultrasound (EUS) have expanded its role and given rise to the novel field of endo-hepatology, an evolving paradigm in which advanced EUS techniques transform endoscopy from a primarily therapeutic tool for variceal hemorrhage into an integrated platform for hemodynamic assessment, tissue characterization, and targeted intervention within a single session. A comprehensive narrative review of the literature was conducted to summarize both established and novel endoscopic approaches to portal hypertension management, including their indications, advantages, limitations, and integration with risk stratification tools, pharmacologic therapies, and multidisciplinary care pathways. Conventional modalities, including endoscopic variceal ligation, sclerotherapy, cyanoacrylate injection, and argon plasma coagulation, remain essential for managing esophageal and gastric varices and PHG. Newer EUS-based techniques, including EUS-guided coil and glue therapy, portal pressure gradient measurement, and liver biopsy, provide complementary approaches that enable more precise hemodynamic assessment and targeted intervention. These advances illustrate the transition from conventional bleeding-focused endoscopic management to an integrated endo-hepatology platform that supports personalized management of portal hypertension. Further studies are needed to define optimal patient selection, comparative effectiveness, and long-term outcomes.
