This week in Gastroenterology

Welcome to This Week in Gastroenterology. This week we're covering 10 notable papers spanning interventional endoscopy and biliary access, liver disease frameworks from hepatocellular carcinoma to steatotic liver disease, and a set of studies reshaping how we screen for and manage luminal disease. Let's dive in.

We'll start with interventional endoscopy, where three papers ask whether newer techniques and devices actually deliver. The most directly practice-relevant comes from the American Journal of Gastroenterology, an international propensity score-matched analysis across 29 centres in the United States, Canada, and Europe comparing advanced cannulation techniques against early endoscopic ultrasound-guided biliary drainage in patients with distal malignant biliary obstruction and a dilated common bile duct who had difficult cannulation at ERCP [3]. Standard cannulation failed in about one in five of more than ten thousand ERCPs. After matching, adverse events occurred in roughly 18 percent of patients pushed through with advanced cannulation versus about 9 percent with early endoscopic ultrasound-guided drainage — essentially half the complication rate — and post-procedural pancreatitis drove most of that excess, occurring in about 12 percent of the advanced cannulation group. Technical success was also higher with the endoscopic ultrasound approach, 96 percent versus 82 percent, while clinical success was comparable. This is retrospective and confounded by the fact that only high-volume centres offer early endoscopic ultrasound-guided drainage, but it argues that in a patient with malignant distal obstruction and a bile duct over 12 millimetres, persisting with precut and advanced cannulation manoeuvres may be the riskier path. Staying with endoscopic ultrasound, a single-centre randomised non-inferiority trial in Gastrointestinal Endoscopy compared endoscopic ultrasound-guided liver biopsy using a 19-gauge Franseen needle against percutaneous ultrasound-guided biopsy with an 18-gauge full-core needle in 90 patients with parenchymal liver disease [2]. The endoscopic approach did not just meet non-inferiority, it was superior: adequate specimens in nearly 98 percent versus 64 percent, with median total specimen length of about 7 centimetres versus 2, and a median of 42 complete portal tracts versus 9. Even a single endoscopic pass beat percutaneous biopsy. The trade-offs are real, though — percutaneous specimens were far less fragmented and wider, and adverse events were more common with the endoscopic route, about 27 percent versus 4 percent, although nearly all were minor. Less encouraging is a prospective cohort, also in Gastrointestinal Endoscopy, of just over a thousand patients undergoing ERCP with either disposable elevator-cap duodenoscopes or conventional reusable ones [5]. Multidrug-resistant pathogen-associated post-ERCP cholangitis occurred in exactly 2.5 percent of both groups, with no difference after propensity matching, and no difference in overall cholangitis, adverse events, or procedure time. Surveillance cultures did find contamination only in the conventional scopes, but that microbiologic advantage did not translate into any clinical benefit, and the investigators stopped enrolment early on that basis. For now, disposable elevator caps look like a solution in search of a demonstrated clinical problem outside possibly high-risk populations.

Turning to the liver, two papers offer frameworks rather than trial data, and both argue that our current categories are too rigid. In Hepatology, a multidisciplinary panel of 20 North American experts used a modified Delphi process to build BEACON-HCC, a treatment allocation framework for hepatocellular carcinoma that explicitly incorporates external beam radiation therapy, transarterial radioembolization, and combined systemic-locoregional therapy, and that stratifies on intrahepatic tumour burden, vascular invasion, and adverse prognostic markers rather than stage alone [1]. In a pilot of 29 real-world cases, external expert decisions agreed with BEACON-HCC recommendations 97 percent of the time versus 72 percent for the 2025 Barcelona Clinic Liver Cancer recommendations. That gap essentially quantifies how far Barcelona staging has drifted from what North American tumour boards actually do. It is worth being clear that this is expert consensus validated against expert opinion — circular by design — and empiric validation through the HCC-Live Consortium is still pending. A parallel argument appears in Nature Reviews Gastroenterology and Hepatology, where a global review of steatotic liver disease makes the case that metabolic dysfunction-associated steatotic liver disease, alcohol-related liver disease, and the combined category are not distinct boxes but a dynamic spectrum [9]. Both alcohol intake and cardiometabolic risk fluctuate over time, so a label assigned once at diagnosis is often wrong later; misclassification is common, largely because patients under-report drinking, and the authors push for objective biomarkers such as phosphatidylethanol alongside systematic cardiometabolic assessment and non-invasive fibrosis staging. They also flag a real gap: most emerging steatohepatitis drug trials exclude patients with meaningful alcohol use, which is precisely the population filling our clinics.

On the luminal side, screening and long-held assumptions both came under scrutiny. The Lancet Gastroenterology and Hepatology published DENEB, a multicentre biomarker study developing a blood test based on 19 cell-free and 20 exosomal microRNAs measured by quantitative PCR, built across discovery cohorts in Spain and Japan and then trained and tested in non-overlapping clinical cohorts [4]. In the testing cohort of 230 participants, the test distinguished colorectal cancer and advanced adenomas from people with a negative colonoscopy with an area under the curve of 95 percent, and sensitivity for colorectal cancer of any stage was 91 percent. The important claim here is advanced adenoma detection, which is where existing blood-based tests have underperformed and which determines whether a blood test can prevent cancer rather than merely detect it. Two cautions: this is a case-control design enriched for cancer, including treatment-naive patients recruited before surgery, so performance in an average-risk screening population will almost certainly be lower, and this needs prospective screening validation before it changes practice. Screening of a different kind was addressed in Alimentary Pharmacology and Therapeutics, where investigators serologically screened over 6,000 adults in a nationally representative Finnish cohort and found 92 people, about 1.5 percent, with undiagnosed coeliac disease [8]. At diagnosis they had lower ferritin, more anaemia, and an altered lipid profile. Critically, at 11-year follow-up, those treated with a gluten-free diet had mental health, quality of life, and cardiometabolic markers comparable to controls, and mortality was no different after adjustment. That addresses the main objection to population screening — that you medicalise asymptomatic people and impose a burdensome diet — and the authors read the benefit-harm balance as favourable, though the follow-up group was only 50 patients.

Two more luminal papers close out the week. In Inflammatory Bowel Diseases, a multicentre real-world analysis of the TriNetX United States network tested the long-standing hypothesis that appendectomy modifies ulcerative colitis [10]. Across propensity-matched comparisons of appendectomy before and after diagnosis, there was no association with the five-year composite of steroid use or colectomy, no difference in colectomy alone, and no difference in advanced therapy initiation. Two isolated signals emerged — less intravenous steroid use after appendectomy preceding diagnosis, and less advanced therapy in patients aged 18 to 40 after appendectomy — but against many comparisons these are hypothesis-generating at best. The pragmatic message is that appendectomy should not be offered as a therapeutic manoeuvre in ulcerative colitis. Complementing that, Annals of Internal Medicine published a clinical review on inflammatory bowel disease focused squarely on health care maintenance — vaccination, cancer screening, bone and cardiometabolic health, nutrition, and psychosocial well-being — and on clarifying which of those tasks belong to the gastroenterologist and which to primary care [6]. Finally, a meta-analysis in Alimentary Pharmacology and Therapeutics pooling 92 studies and over 60,000 patients found that peptic ulcers attributable to neither Helicobacter pylori nor NSAIDs account for about 13 percent of all ulcers, 11 percent of bleeding ulcers, and 22 percent of perforated ulcers, with the bleeding proportion rising over time and in countries with lower Helicobacter prevalence [7]. In practice, a negative Helicobacter test and no NSAID history in a patient with an ulcer should prompt a search for other causes rather than reassurance.

If you only have time for one paper this week, make it the international comparison of advanced cannulation versus early endoscopic ultrasound-guided biliary drainage in the American Journal of Gastroenterology [3]. It addresses a decision most therapeutic endoscopists face several times a month, and it suggests that our default reflex — keep trying at the papilla — carries roughly double the complication rate of switching approaches.

Here are the key takeaways from this week in Gastroenterology. In distal malignant biliary obstruction with a dilated duct and difficult cannulation, consider pivoting early to endoscopic ultrasound-guided drainage rather than escalating cannulation techniques. Endoscopic ultrasound-guided liver biopsy yields substantially more tissue than percutaneous biopsy but with more, mostly minor, adverse events — choose based on what the tissue question demands. Disposable elevator-cap duodenoscopes reduced culture positivity but did not reduce post-ERCP cholangitis, so do not expect a clinical infection benefit. Hepatocellular carcinoma allocation frameworks are shifting toward tumour biology and newer radiation and radioembolization options, and steatotic liver disease is best treated as a dynamic spectrum with objective alcohol biomarkers rather than fixed categories. And two assumptions took hits this week: appendectomy does not improve long-term ulcerative colitis outcomes, and roughly one in eight peptic ulcers is neither Helicobacter- nor NSAID-related.

That's your roundup for This Week in Gastroenterology. The full transcript and references are available on the episode page in your AudioScholar library. This is an AI-curated summary — for clinical decisions, always consult primary sources and current guidelines. See you next week.

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