Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most prevalent chronic liver condition in older adults, yet its management in the geriatric context remains poorly characterized. This review examines the unique pathophysiology, diagnostic challenges, and tailored therapeutic strategies for MASLD in the aging population. The convergence of inflammaging, mitochondrial senescence, and the deteriorating liver-muscle axis drives distinct geriatric MASLD phenotypes, including “Lean MASLD” and post-menopausal sex-reversal. These processes promote progression to metabolic dysfunction-associated steatohepatitis (MASH), the inflammatory stage of the disease. Chronodisruption—potentially mediated by melatonin deficiency and nuclear factor-kappa B activation—has been proposed as a novel driver. Advanced liver fibrosis has been associated with systemic biological aging. Diagnostically, standard Fibrosis-4 index thresholds are unreliable in patients over 65, and “silent cirrhosis” with normal aminotransferases is common. Carbon-ion radiotherapy has emerged as a potentially sarcopenia-friendly treatment option for MASLD-related hepatocellular carcinoma. Managing geriatric MASLD requires a paradigm shift from liver-centric histological targets toward functional longevity. Avoiding the “Sarcopenia Trap,” recalibrating non-invasive fibrosis tests with age-adjusted thresholds, promoting alcohol abstinence, and addressing chronodisruption are essential components of a holistic, individualized care framework.
Irritable bowel syndrome is a common disorder of gut-brain interaction characterized by chronic abdominal pain and altered bowel habits in the absence of structural pathology. Its pathophysiology reflects a complex interplay between the central nervous system, enteric nervous system, microbiota, immune signaling, epithelial barrier dysfunction etc. Despite advances in the understanding of the mechanisms causing IBS, the diagnosis of IBS remains primarily symptom-based, necessitating the use of objective tools to improve diagnostic precision and personalized management. This review synthesizes highlights existing literature on IBS biomarkers, including inflammatory markers (cytokines, C-reactive protein), microbial signatures (gut microbiota composition, anti-CdtB and anti-vinculin antibodies), metabolic indicators (bile acids, short-chain fatty acids), and markers of intestinal permeability (zonulin) to assess their applications in the diagnosis and management of IBS. We also examined emerging multi-omics technologies that identify the complex patterns linking the gut, the brain and the microbiota. Early research focusing on single biomarkers demonstrated limited diagnostic utility due to the heterogeneous and multifactorial nature of IBS. Recent advances support the development of composite, mechanism-based biomarker panels that integrate multiple biological domains, offering improved representation of underlying pathophysiological processes. These developments mark a shift from a single-marker approach toward multidimensional biomarker strategies. This narrative review synthesizes current evidence and proposes a framework for integrating biomarkers into clinical practice. Biomarkers are best utilized following a positive symptom-based diagnosis and exclusion of alarm features, to stratify patients into biologically relevant subtypes and guide targeted therapy. This supports a transition from exclusion-based diagnosis of IBS towards a positive and more precise one.
High-resolution manometry (HRM), the gold standard for diagnosing esophageal motility disorders, remains constrained by inter-rater variability, limited access to expert esophagologists, and inadequate training infrastructure. Many gastroenterology fellowship programs provide insufficient motility training, and dedicated expert centers remain geographically concentrated. Emerging Artificial intelligence (AI) tools have the potential to automate diagnosis, and augment clinician interpretive capacity and democratizing expert-level motility assessment. Twenty-two studies encompassing over 5,000 patients were synthesized across three overlapping developmental phases: early machine learning for feature extraction and classification; deep learning deployed toward automated pattern recognition and motility classification and emerging multimodal and large language model–based frameworks augmenting clinical interpretation and decision-making, with diagnostic accuracies ranging from 71 to 97
Malnutrition and sarcopenia are increasingly recognized as clinically meaningful but underappreciated components of gastrointestinal (GI) motility disorders. This review examines the prevalence, pathophysiology, assessment, and clinical care of malnutrition in the context of patients with GI motility disease. Emerging data demonstrate a high burden of malnutrition in GI motility conditions, including gastroparesis and chronic intestinal pseudo-obstruction. Mechanisms include reduced oral intake, restrictive eating patterns, malabsorption, inflammation, and physical deconditioning. Novel approaches to assessment, incorporating muscle mass and function, highlight limitations of weight-based metrics alone. Multidisciplinary care remains vital to caring for this patient population. Sarcopenia and malnutrition are modifiable and underrecognized contributors to morbidity in GI motility disorders. Implementing screening and multidisciplinary, nutrition-focused interventions may improve patient-centered outcomes and should be integrated into clinical care and future research.
This review evaluates the evolving management strategies for common bile duct stones (CBDSs), focusing on standard endoscopic techniques, advanced intraductal interventions for refractory stones, and contemporary minimally invasive surgical options. While endoscopic retrograde cholangiopancreatography with sphincterotomy remains the cornerstone of therapy, recent evidence highlights the efficacy and safety of endoscopic papillary large balloon dilation and single-operator cholangioscopy-guided lithotripsy for difficult and refractory stones. Concurrently, laparoscopic common bile duct exploration has proven effective as a single-stage definitive treatment, demonstrating safety and stone clearance outcomes equivalent to the traditional two-stage endoscopic-surgical approach. The management of CBDSs has shifted from a rigid, standardized protocol to a highly tailored clinical algorithm. No single gold-standard strategy is applicable to every scenario. Optimal outcomes are achieved through a flexible, multidisciplinary approach that customizes intervention based on stone characteristics, patient anatomy, and available institutional expertise.
Solitary rectal ulcer syndrome (SRUS) is a gastrointestinal disorder with a varied range of clinical, endoscopic and histological features. It is often misdiagnosed as inflammatory bowel disease or rectal malignancy. This review aims to outline a practical approach to diagnosing and managing SRUS. The aetiology remains unclear, with contributing factors such as mucosal prolapse, ischemia, paradoxical puborectalis contraction, and digital trauma. Diagnosis involves a comprehensive approach, including clinical history, digital rectal examination, endoscopy, histopathology, and physiological studies. Treatment includes lifestyle modifications, biofeedback therapy, topical agents, sclerotherapy, and surgical intervention for refractory cases. Ongoing surveillance is necessary, especially in patients at high risk for recurrence. Management of SRUS should be individualised and multidisciplinary, particularly in patients with psychiatric comorbidities or during pregnancy, where invasive interventions are minimised. Further research and standardised treatment protocols for SRUS are needed.
The microbiome in the esophagus has been an area of early active investigation. In the past 5 years, advancements in next-generation sequencing and computational analysis have provided a more detailed picture of the esophageal microbiome. This review will examine the most recent advances in the past 5 years on the study of microbiome changes in healthy and diseased esophagus to better understand the link between microbiome and esophageal diseases, potentially leading to new prevention or treatment strategies. The microbiome has a key set of baseline parameters in the usual or non-diseased esophageal lumen. There are measurable changes in the baseline microbiome species of different disease phenotypes including eosinophilic esophagitis, gastroesophageal reflux disease, Barrett’s esophagus and achalasia. Some studies suggest that certain microbiome features may even be associated with worse outcomes. Dysbiosis of esophageal microbiome is implicated in various esophageal disorders, including GERD, Barrett’s esophagus, EoE, and achalasia. However, confounding factors such as antibiotic use, PPI use, dietary habits, and geographic location influence microbiome variability and make the standardized study of this field challenging. The next phase of research will need to include more focus on larger scale studies with reproducible parameters. As some features of the microbiome are associated with disease progression, there are multiple new avenues of intervention potentially available with an improved understanding of the human esophageal microbiome.
Colorectal cancer (CRC) remains a major global and Malaysian public health concern, with increasing recognition of gut dysbiosis as a contributor to colorectal tumorigenesis. This review examines fermented durian tempoyak as a culturally relevant, probiotic-rich traditional food with potential application in CRC prevention through gut microbiome modulation. Dysbiosis may promote CRC through disruption of gut barrier integrity, chronic mucosal inflammation, immune dysregulation, reactive oxygen species (ROS)-mediated DNA damage, and altered microbial metabolism leading to carcinogenic metabolites such as secondary bile acids and hydrogen sulphide. Tempoyak commonly contains lactic acid bacteria, particularly Lactiplantibacillus plantarum, as well as Limosilactobacillus fermentum and Levilactobacillus brevis. Preclinical evidence suggests that related LAB strains can attenuate NF-κB, MAPK, STAT3, IL-17, and COX-2-associated inflammatory pathways, reduce immune-cell infiltration and oxidative stress, restore mucus and tight junction proteins, modulate bile acid metabolism, and reduce tumor burden in CRC or colitis-associated CRC models. Current evidence supports the mechanistic plausibility of tempoyak-associated LABs as microbiome-based agents for CRC chemoprevention. However, direct evidence using tempoyak-derived strains remains limited, and translation is constrained by strain-specific effects, microbial variability, sensory acceptability, safety and standardisation issues, and uncertain LAB viability after cooking. Future studies should prioritise strain characterisation, starter culture standardisation, probiotic stabilisation strategies, CRC-specific preclinical models, and well-designed human trials in high-risk populations.
Barrett’s esophagus (BE) is the only known precursor for esophageal adenocarcinoma. Patients diagnosed in endoscopy-based screening and surveillance programs have improved outcomes, but there are many limitations with current screening and surveillance paradigms. This review examines novel technologies aimed at improving current BE screening and surveillance strategies. BE risk stratification algorithms have decent discriminatory performance but are cumbersome to implement. Non-endoscopic screening tools, including swallowable cell collection devices, have shown good sensitivity and cost-effectiveness. Early studies of serum biomarkers, such as microRNA assays, have yielded promising results but warrant further validation. WATS-3D appears to increase dysplasia yield among patients undergoing surveillance. Tissue-based biomarkers may assist in risk stratification. Novel, non-endoscopic technologies have the potential to enrich the BE screening population and improve outcomes, although most require further validation. Collaboration with primary care providers is critical to maximize the impact of such interventions.
This review synthesizes current literature on the use of Endoscopic ultrasound (EUS) in congenital gastrointestinal (GI) conditions. Special emphasis is placed on pediatric applications, where EUS is increasingly recognized as both feasible and safe. EUS has transformed the evaluation and management of congenital anomalies affecting the GI tract and pancreaticobiliary system, and has been shown to be safe and effective in the pediatric population. By combining high-resolution imaging with the ability to perform real-time interventions, EUS addresses diagnostic uncertainties that historically required cross-sectional imaging or invasive surgery. EUS offers precise diagnostics, minimally invasive evaluation, and therapeutic guidance in pediatric patients, potentially avoiding surgical intervention. Larger pediatric multicenter registries are needed to further validate its use in children. Widespread adoption remains limited by the scarcity of EUS-trained pediatric gastroenterologists and the lack of specialized equipment designed for small children.
Fundoplication is still the cornerstone of surgical intervention for patients with gastroesophageal reflux disease unresponsive to medical management. While generally successful in resolving typical symptoms and improving patients’ quality of life, post-fundoplication symptoms unrelated to anatomical failure occur in a notable proportion of individuals. These complaints include persistent dysphagia, gas-bloat syndrome, delayed gastric emptying, dumping syndrome, chest pain, and diarrhea. Advances in physiological research has contributed to a more comprehensive understanding of the pathogenesis, prevention, and management of these postoperative symptoms. This review synthesizes recent literature regarding gastrointestinal functional complaints following fundoplication, with emphasis on pathophysiology, diagnostic approaches, and evidence-based management strategies. Post-fundoplication complaints may be associated with incomplete preoperative work-up, untailored surgical procedure, defective surgical technique, or pre-existing disorders. Persistent dysphagia, gas-bloat syndrome, delayed gastric emptying, diarrhea, chest pain, and dumping syndrome are reported in up to 50 • Fundoplication remains the foundation of surgical therapy for patients with medically refractory gastroesophageal reflux disease. • Although antireflux procedures are highly effective to decrease typical symptom and enhance quality of life, a significant subset of patients experience postoperative gastrointestinal functional complaints. • Persistent dysphagia, defined as lasting more than three months, is observed in 3–24
Crohn’s disease (CD) often causes intestinal strictures that impair quality of life. Endoscopic balloon dilation (EBD) has long been the standard, but durability is limited. This review summarizes advances in endoscopic management, focusing on updates from 2019–2025. EBD achieves high technical success (90–95
Endoscopic retrograde cholangiopancreatography is an advanced endoscopic procedure used mainly for the purpose of biliary intervention. During an ERCP a duodenoscope is used to assess the ampulla of Vater to inject contrast medium into the common bile duct through biliary cannulation. Biliary cannulation can be challenging, with studies showing unsuccessful biliary cannulation with standard technique greater than 10
Underwater Endoscopic Submucosal Dissection (U-ESD) is a novel technique used to overcome the limitations of conventional ESD, particularly for gravity-side and fibrotic gastrointestinal lesions. This review aims to highlight the recent advancements in U-ESD, emphasizing its practical advantages as well as challenges that should be addressed for future applications. Due to the buoyancy effect created by saline, U-ESD provides natural traction as well as magnification to facilitate en bloc lesion resection without the need for additional traction devices. Recent findings, including “bubble-free” U-ESD techniques have addressed previous concerns by minimizing trapped air bubbles and visual obstruction to further advance the U-ESD method. U-ESD offers an effective and safe method for the removal of complex gastrointestinal lesions through enhanced visualization and natural traction. Although challenges such as bleeding control remain, with ongoing refinements in the technique, U-ESD may become the standard in advanced therapeutic endoscopy.
To provide an overview of current dietary elimination strategies for eosinophilic esophagitis (EoE) and propose a practical, patient-centered approach to guide dietary therapy. Empiric elimination diets, including one- (1FED), two- (2FED), four- (4FED), and six-food (6FED) elimination strategies, have demonstrated varying efficacy, with broader elimination generally associated with higher histologic remission rates. Elemental diets remain the most effective but are often impractical. Allergy testing-directed diets have limited utility due to poor predictive accuracy. Recent data support a step-up approach—beginning with 1FED or 2FED and escalating as needed—as effective and better tolerated. Dietary elimination remains a cornerstone of EoE treatment. A stepwise, empiric approach that minimizes dietary burden while maintaining clinical efficacy is recommended. Personalizing diet therapy based on patient preferences and response can improve adherence and outcomes, and future research should continue refining strategies to balance efficacy, cost, and quality of life.
Despite advances in surgery, chemotherapy, and radiation treatments for pancreatic ductal adenocarcinoma (PDAC), 5-year mortality rates remain high. Although surgery remains the standard of care for pancreatic cancer and precancerous pancreatic lesions, many patients are not considered surgical candidates at the time of diagnosis. Therefore, alternative therapies must be explored for non-surgical patients. This article aims to do a comprehensive literature study and present the most recent information on ablative therapies, particularly endoscopic ultrasound (EUS)-guided RFA (EUS-RFA). Emerging literature demonstrates that endoscopic ultrasound (EUS)-guided RFA (EUS-RFA) may reduce both primary and distant tumor growth by modifying the tumor microenvironment, promoting cytokine production, and stimulating immune activation, thereby allowing tumor reduction. Reducing tumor size can allow for surgical intervention and can even serve as an adjunct to chemotherapy or as a palliative measure. The remarkable ability to reduce tumor progression makes RFA a very promising non-surgical therapy technique that has the potential to reduce morbidity and mortality. There are several thermal ablative therapies, including radio non-surgical candidates. Emerging literature demonstrates that endoscopic ultrasound (EUS)-guided RFA (EUS-RFA) may reduce both primary and distant tumor growth by modifying the tumor microenvironment, promoting cytokine production, and stimulating immune activation, thereby allowing tumor reduction. Reducing tumor size can allow for surgical intervention and can even serve as an adjunct to chemotherapy or as a palliative measure. The remarkable ability to reduce tumor progression makes RFA a very promising non-surgical therapy technique that has the potential to reduce morbidity and mortality.
Dysphagia recurrence after myotomy for achalasia presents a complex clinical challenge. This review highlights causes of recurrent dysphagia, diagnostic strategies, and management options following laparoscopic Heller myotomy (LHM) or per-oral endoscopic myotomy (POEM). Both POEM and LHM demonstrate durable efficacy, but recurrence arises from incomplete myotomy, blown-out myotomy (BOM), fundoplication-related obstruction, anatomic esophageal body abnormalities, esophageal dysmotility, or gastroesophageal reflux disease (GERD). In the diagnostic evaluation, functional lumen imaging probe (FLIP) and high-resolution manometry (HRM) provide complementary assessments of esophageal and esophagogastric junction dynamics, while timed barium esophagram (TBE) and endoscopy detect structural issues. Redo myotomy (POEM or LHM), pneumatic dilation (PD), and emerging techniques, such as per-oral plication of the esophagus (POPE), offer targeted therapy with favorable safety and symptom improvement. Recurrent dysphagia is multifactorial, requiring comprehensive esophageal evaluation. Advanced diagnostics and minimally invasive interventions expand therapeutic options, particularly in end-stage disease.
This manuscript addresses high-yield topics related to sexual and reproductive health (SRH) in adolescents and young women with inflammatory bowel disease (IBD) including puberty, menstruation, contraception, fertility, pregnancy, preventive care, and counseling strategies. Adolescent and young women with IBD are at risk for delayed puberty, menstrual cycle disorders, unintended pregnancy, and cervical cancer. Active disease or a history of intra-abdominal surgery can negatively impact fertility and pregnancy outcomes. With appropriate screening, counseling and education, and shared decision making, providers can optimize both IBD and SRH outcomes. Further research in needed to specifically understand the role of pre-conception counseling in the adolescent setting, optimal management of menstrual cycle disorders in women with IBD, and the safety of newer medications during pregnancy.
Endoscopic resection (ER) has transformed the management of early gastrointestinal (GI) malignancies by offering curative treatment with low morbidity and organ preservation. Traditionally restricted to mucosal disease with negligible risk of lymph node metastasis (LNM), recent advances in technique and risk stratification have prompted a re-evaluation of ER indications for esophageal, gastric, and colorectal cancers. This review summarizes the oncologic rationale, current evidence, and emerging technologies supporting the safe expansion of ER indications across GI malignancies. s: Refined histopathologic criteria, enhanced en-bloc resection through endoscopic submucosal dissection, and the introduction of endoscopic full-thickness resection have expanded curative resection to select early GI malignancies previously considered surgical. Clinical outcomes from large series demonstrate comparable long-term survival to surgery when rigorous selection and surveillance criteria are applied, while minimizing morbidity. Molecular biomarkers, artificial intelligence (AI)-based predictive models, and sentinel node mapping are promising tools to further improve risk assessment for occult LNM. Expansion of ER indications for early GI cancers is feasible and increasingly practiced in expert centers with outcomes approximating those of surgical resection. Ongoing integration of precision diagnostics, molecular profiling, and AI-driven risk models promises to further refine patient selection. However, widespread adoption should proceed within structured, evidence-based frameworks to prevent undertreatment of potentially curable disease and maintain oncologic integrity.
