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“Don’t Take Shortcuts,” Endoscopy Researcher Advises
But the work he’s most proud of took place when he was a graduate student at Harvard, working on a master’s degree in epidemiology and biostatistics.
Jovani compared two different types of needles for tissue acquisition with endoscopic ultrasound. His finding that fine needle biopsy is better than fine needle aspiration for lesions isn’t groundbreaking, yet “the reason why I feel proud of that one is because it’s the first paper I did completely by myself,” said Jovani, medical director for advanced therapeutic endoscopy with Gastro Health Florida, in Miami, Florida.
Dr. Jovani has since contributed to countless peer-reviewed articles and book chapters and has presented research findings at meetings across the globe. He will be program director of the upcoming gastroenterology fellowship program at Florida International University School of Medicine, Miami, and participates in several endoscopy panels in the U.S. and in Europe to set guidelines and improve the quality of endoscopic procedures.
Therapeutic endoscopy is a clinical interest of his, specifically in the areas of third space, biliopancreatic and bariatric endoscopy. In an interview, he discussed how he used third space endoscopy to save a patient and improve her quality of life
Indeed, helping patients feel better is the most satisfying part of his career.
“A lot of people may have acute pain or an early cancer or many other problems that they need solving. As a physician, you can be the one who solves it,” said Jovani.
But training in medicine involves hard work, he advised. In the interview, he explained why young doctors should never rely on shortcuts to solve problems.
Therapeutic endoscopy is a specific interest of yours. How has this field advanced since you’ve been practicing gastroenterology?
Dr. Jovani: In the last 10 to 15 years, significant improvements have come along. As an example, lumen-apposing metal stents have revolutionized the way we do therapeutic endoscopy. A lot of procedures were not possible beforehand and we would have to send patients to surgery. Now, these can be done with endoscopy.
Examples include drainage of pancreatic collections, gallbladder drainage, or gastrojejunostomy (a connection between the stomach and the intestine) or reversal of Roux-en-Y gastric bypass to reach and drain the bile duct. Many of these procedures can be done with these metal stents that were not possible beforehand. Bariatric endoscopy is a relatively new field, and that has significantly changed the management of obesity.
There’s also third space endoscopy for the treatment of gastroparesis, achalasia, and early cancer.
What is third space endoscopy and how are you applying it in your practice?
Dr. Jovani: Third space endoscopy refers to a new space that’s created between the mucosa and the muscularis propria into the submucosa. We go in the submucosa, we inject some fluid there, and we cut the submucosa and we separate the mucosa from the muscle.
This allows us to do a lot of procedures. For patients with achalasia, we can tunnel through the submucosa, get into the muscle and perform myotomy, meaning that we can cut the muscle. By doing so, we can treat achalasia with a minimally invasive method. Patients can either go home the next day or even on the same day. The same thing applies for gastroparesis. With early cancer, we can go through in the submucosa, and if the cancer is in the mucosa only, or if it is in the very superficial submucosa, we can treat it without a need for surgery. Sometimes the procedure is simple, but other times it can be very challenging.
Can you discuss a challenging case where you applied third space endoscopy?
Dr. Jovani: It was a gastric cancer case. I did an endoscopic ultrasound for staging purposes. When I saw the lesion, it looked very superficial, like an early cancer of the stomach. I called the surgeon and said I could take it out with endoscopy. And it was in a very difficult location, so it was a very challenging procedure. It took about 12 hours to do it, but I was able to completely take it out. More than a year later, the patient was cancer free and more importantly, we preserved the stomach. Before I did this, she was prepared to undergo total gastrectomy, which meant I would have taken out her entire stomach.
Instead, with this minimally invasive procedure, I was able to take the cancer away and keep the stomach, which preserved her quality of life as well.
When you don’t have the stomach, obviously you adapt, but the quality of life is never the same. The type of food you eat, the frequency of eating, the quality of food you eat is not the same. The fact that we could avoid that in this patient feels very good.
What advice would you give to aspiring medical students?
Dr. Jovani: Do the hard work that’s required to be a doctor. Being a physician is a hard job, but it’s very rewarding. It’s like going to the gym—there really are no shortcuts. You have to do the work, you have to get tired, you have to study hard. You may study things you might not think will be useful to you necessarily in the future field that you choose. If it is GI, you still need to study all the other fields because sometimes patients may have GI diseases that are connecting with other diseases and you won’t know that if you haven’t studied the other diseases.
Patients are not only one disease, but they are also complex patients. Sometimes if you try to correct one disease, you create a complication with the other disease and you might not be aware of that.
Don’t create shortcuts like ChatGPT, things that are becoming fashionable with younger people today. Do the hard work the old way in which you have to memorize things. Knowledge is the only thing that really can help the patient.
Go to GI meetings. Offer to meet people, collaborate, network. Don’t be shy about it. Even if it is not natural to you, just do it. It’ll become more natural as you do it. GI, like any other field, any other endeavor in human society, is something that also depends on interactions. Therefore, it’s good to learn how to interact, how to network, how to do research projects. Even with people from far away, communication is very easy. You don’t really need to do research projects only with people in your local environment. You can do research projects with people who are on the other side of the state or even on the other side of the world.
You place an emphasis on individualized patient care. Can you discuss what that means to you?
Dr. Jovani: It basically means that there isn’t one size fits all in the management of diseases. Obviously there are some general principles that are applicable to everybody, but sometimes for the single specific patient, what works for one patient might not necessarily work for the next patient.
With Endoscopic Retrograde Cholangiopancreatography (ERCP) for example, there are so many things that go into that. Most papilla are in a certain position and it’s relatively easy to cannulate. But there are others that are in very different positions or in different angulations and they might require specific techniques that are not applicable in the majority of cases. You have to adapt to the single patient.How you speak to the patient is also important. Some may prefer a certain type of communication and other patients may prefer another type of communication involving patients or family. You have to adapt to the single patient. You have to understand the different types of personalities and adapt how you explain things or how you communicate disease, or management of disease or even complications to the specific patient. Different approaches are more appropriate for different patients with different needs. At the end of the day, patients are single individuals after all.
Where do you see the field of GI medicine advancing internationally over the next 5 years?
Dr. Jovani: Artificial intelligence or AI is a big player. It will help with diagnostics primarily, at least over the short term. Potentially it can help with therapeutics as well. There’s a lot of investment and excitement and interest in artificial intelligence.
Therapeutic endoscopy robotics, especially in interventional endoscopy, third space endoscopy, is also gaining attention.
With regards to bariatric endoscopy, we should have a CPT code for it in January 2027. This will increase volume because it’ll be covered more by insurance. These are things that will help advance GI in the next five or 10 years.
Lightning Round
What’s one hobby you’d like to pick up?
Kite surfing
What’s your favorite season of the year?
Summer
What’s your favorite way to spend a weekend?
Traveling or going to the beach
If you could have dinner with any historical figure, who would it be?
Jesus Christ
What’s your favorite holiday tradition?
New Year’s Eve
Are you a planner or more spontaneous?
Planner
What’s the best piece of advice you’ve ever received?
You can do it!
What’s your comfort food?
Lasagna
But the work he’s most proud of took place when he was a graduate student at Harvard, working on a master’s degree in epidemiology and biostatistics.
Jovani compared two different types of needles for tissue acquisition with endoscopic ultrasound. His finding that fine needle biopsy is better than fine needle aspiration for lesions isn’t groundbreaking, yet “the reason why I feel proud of that one is because it’s the first paper I did completely by myself,” said Jovani, medical director for advanced therapeutic endoscopy with Gastro Health Florida, in Miami, Florida.
Dr. Jovani has since contributed to countless peer-reviewed articles and book chapters and has presented research findings at meetings across the globe. He will be program director of the upcoming gastroenterology fellowship program at Florida International University School of Medicine, Miami, and participates in several endoscopy panels in the U.S. and in Europe to set guidelines and improve the quality of endoscopic procedures.
Therapeutic endoscopy is a clinical interest of his, specifically in the areas of third space, biliopancreatic and bariatric endoscopy. In an interview, he discussed how he used third space endoscopy to save a patient and improve her quality of life
Indeed, helping patients feel better is the most satisfying part of his career.
“A lot of people may have acute pain or an early cancer or many other problems that they need solving. As a physician, you can be the one who solves it,” said Jovani.
But training in medicine involves hard work, he advised. In the interview, he explained why young doctors should never rely on shortcuts to solve problems.
Therapeutic endoscopy is a specific interest of yours. How has this field advanced since you’ve been practicing gastroenterology?
Dr. Jovani: In the last 10 to 15 years, significant improvements have come along. As an example, lumen-apposing metal stents have revolutionized the way we do therapeutic endoscopy. A lot of procedures were not possible beforehand and we would have to send patients to surgery. Now, these can be done with endoscopy.
Examples include drainage of pancreatic collections, gallbladder drainage, or gastrojejunostomy (a connection between the stomach and the intestine) or reversal of Roux-en-Y gastric bypass to reach and drain the bile duct. Many of these procedures can be done with these metal stents that were not possible beforehand. Bariatric endoscopy is a relatively new field, and that has significantly changed the management of obesity.
There’s also third space endoscopy for the treatment of gastroparesis, achalasia, and early cancer.
What is third space endoscopy and how are you applying it in your practice?
Dr. Jovani: Third space endoscopy refers to a new space that’s created between the mucosa and the muscularis propria into the submucosa. We go in the submucosa, we inject some fluid there, and we cut the submucosa and we separate the mucosa from the muscle.
This allows us to do a lot of procedures. For patients with achalasia, we can tunnel through the submucosa, get into the muscle and perform myotomy, meaning that we can cut the muscle. By doing so, we can treat achalasia with a minimally invasive method. Patients can either go home the next day or even on the same day. The same thing applies for gastroparesis. With early cancer, we can go through in the submucosa, and if the cancer is in the mucosa only, or if it is in the very superficial submucosa, we can treat it without a need for surgery. Sometimes the procedure is simple, but other times it can be very challenging.
Can you discuss a challenging case where you applied third space endoscopy?
Dr. Jovani: It was a gastric cancer case. I did an endoscopic ultrasound for staging purposes. When I saw the lesion, it looked very superficial, like an early cancer of the stomach. I called the surgeon and said I could take it out with endoscopy. And it was in a very difficult location, so it was a very challenging procedure. It took about 12 hours to do it, but I was able to completely take it out. More than a year later, the patient was cancer free and more importantly, we preserved the stomach. Before I did this, she was prepared to undergo total gastrectomy, which meant I would have taken out her entire stomach.
Instead, with this minimally invasive procedure, I was able to take the cancer away and keep the stomach, which preserved her quality of life as well.
When you don’t have the stomach, obviously you adapt, but the quality of life is never the same. The type of food you eat, the frequency of eating, the quality of food you eat is not the same. The fact that we could avoid that in this patient feels very good.
What advice would you give to aspiring medical students?
Dr. Jovani: Do the hard work that’s required to be a doctor. Being a physician is a hard job, but it’s very rewarding. It’s like going to the gym—there really are no shortcuts. You have to do the work, you have to get tired, you have to study hard. You may study things you might not think will be useful to you necessarily in the future field that you choose. If it is GI, you still need to study all the other fields because sometimes patients may have GI diseases that are connecting with other diseases and you won’t know that if you haven’t studied the other diseases.
Patients are not only one disease, but they are also complex patients. Sometimes if you try to correct one disease, you create a complication with the other disease and you might not be aware of that.
Don’t create shortcuts like ChatGPT, things that are becoming fashionable with younger people today. Do the hard work the old way in which you have to memorize things. Knowledge is the only thing that really can help the patient.
Go to GI meetings. Offer to meet people, collaborate, network. Don’t be shy about it. Even if it is not natural to you, just do it. It’ll become more natural as you do it. GI, like any other field, any other endeavor in human society, is something that also depends on interactions. Therefore, it’s good to learn how to interact, how to network, how to do research projects. Even with people from far away, communication is very easy. You don’t really need to do research projects only with people in your local environment. You can do research projects with people who are on the other side of the state or even on the other side of the world.
You place an emphasis on individualized patient care. Can you discuss what that means to you?
Dr. Jovani: It basically means that there isn’t one size fits all in the management of diseases. Obviously there are some general principles that are applicable to everybody, but sometimes for the single specific patient, what works for one patient might not necessarily work for the next patient.
With Endoscopic Retrograde Cholangiopancreatography (ERCP) for example, there are so many things that go into that. Most papilla are in a certain position and it’s relatively easy to cannulate. But there are others that are in very different positions or in different angulations and they might require specific techniques that are not applicable in the majority of cases. You have to adapt to the single patient.How you speak to the patient is also important. Some may prefer a certain type of communication and other patients may prefer another type of communication involving patients or family. You have to adapt to the single patient. You have to understand the different types of personalities and adapt how you explain things or how you communicate disease, or management of disease or even complications to the specific patient. Different approaches are more appropriate for different patients with different needs. At the end of the day, patients are single individuals after all.
Where do you see the field of GI medicine advancing internationally over the next 5 years?
Dr. Jovani: Artificial intelligence or AI is a big player. It will help with diagnostics primarily, at least over the short term. Potentially it can help with therapeutics as well. There’s a lot of investment and excitement and interest in artificial intelligence.
Therapeutic endoscopy robotics, especially in interventional endoscopy, third space endoscopy, is also gaining attention.
With regards to bariatric endoscopy, we should have a CPT code for it in January 2027. This will increase volume because it’ll be covered more by insurance. These are things that will help advance GI in the next five or 10 years.
Lightning Round
What’s one hobby you’d like to pick up?
Kite surfing
What’s your favorite season of the year?
Summer
What’s your favorite way to spend a weekend?
Traveling or going to the beach
If you could have dinner with any historical figure, who would it be?
Jesus Christ
What’s your favorite holiday tradition?
New Year’s Eve
Are you a planner or more spontaneous?
Planner
What’s the best piece of advice you’ve ever received?
You can do it!
What’s your comfort food?
Lasagna
But the work he’s most proud of took place when he was a graduate student at Harvard, working on a master’s degree in epidemiology and biostatistics.
Jovani compared two different types of needles for tissue acquisition with endoscopic ultrasound. His finding that fine needle biopsy is better than fine needle aspiration for lesions isn’t groundbreaking, yet “the reason why I feel proud of that one is because it’s the first paper I did completely by myself,” said Jovani, medical director for advanced therapeutic endoscopy with Gastro Health Florida, in Miami, Florida.
Dr. Jovani has since contributed to countless peer-reviewed articles and book chapters and has presented research findings at meetings across the globe. He will be program director of the upcoming gastroenterology fellowship program at Florida International University School of Medicine, Miami, and participates in several endoscopy panels in the U.S. and in Europe to set guidelines and improve the quality of endoscopic procedures.
Therapeutic endoscopy is a clinical interest of his, specifically in the areas of third space, biliopancreatic and bariatric endoscopy. In an interview, he discussed how he used third space endoscopy to save a patient and improve her quality of life
Indeed, helping patients feel better is the most satisfying part of his career.
“A lot of people may have acute pain or an early cancer or many other problems that they need solving. As a physician, you can be the one who solves it,” said Jovani.
But training in medicine involves hard work, he advised. In the interview, he explained why young doctors should never rely on shortcuts to solve problems.
Therapeutic endoscopy is a specific interest of yours. How has this field advanced since you’ve been practicing gastroenterology?
Dr. Jovani: In the last 10 to 15 years, significant improvements have come along. As an example, lumen-apposing metal stents have revolutionized the way we do therapeutic endoscopy. A lot of procedures were not possible beforehand and we would have to send patients to surgery. Now, these can be done with endoscopy.
Examples include drainage of pancreatic collections, gallbladder drainage, or gastrojejunostomy (a connection between the stomach and the intestine) or reversal of Roux-en-Y gastric bypass to reach and drain the bile duct. Many of these procedures can be done with these metal stents that were not possible beforehand. Bariatric endoscopy is a relatively new field, and that has significantly changed the management of obesity.
There’s also third space endoscopy for the treatment of gastroparesis, achalasia, and early cancer.
What is third space endoscopy and how are you applying it in your practice?
Dr. Jovani: Third space endoscopy refers to a new space that’s created between the mucosa and the muscularis propria into the submucosa. We go in the submucosa, we inject some fluid there, and we cut the submucosa and we separate the mucosa from the muscle.
This allows us to do a lot of procedures. For patients with achalasia, we can tunnel through the submucosa, get into the muscle and perform myotomy, meaning that we can cut the muscle. By doing so, we can treat achalasia with a minimally invasive method. Patients can either go home the next day or even on the same day. The same thing applies for gastroparesis. With early cancer, we can go through in the submucosa, and if the cancer is in the mucosa only, or if it is in the very superficial submucosa, we can treat it without a need for surgery. Sometimes the procedure is simple, but other times it can be very challenging.
Can you discuss a challenging case where you applied third space endoscopy?
Dr. Jovani: It was a gastric cancer case. I did an endoscopic ultrasound for staging purposes. When I saw the lesion, it looked very superficial, like an early cancer of the stomach. I called the surgeon and said I could take it out with endoscopy. And it was in a very difficult location, so it was a very challenging procedure. It took about 12 hours to do it, but I was able to completely take it out. More than a year later, the patient was cancer free and more importantly, we preserved the stomach. Before I did this, she was prepared to undergo total gastrectomy, which meant I would have taken out her entire stomach.
Instead, with this minimally invasive procedure, I was able to take the cancer away and keep the stomach, which preserved her quality of life as well.
When you don’t have the stomach, obviously you adapt, but the quality of life is never the same. The type of food you eat, the frequency of eating, the quality of food you eat is not the same. The fact that we could avoid that in this patient feels very good.
What advice would you give to aspiring medical students?
Dr. Jovani: Do the hard work that’s required to be a doctor. Being a physician is a hard job, but it’s very rewarding. It’s like going to the gym—there really are no shortcuts. You have to do the work, you have to get tired, you have to study hard. You may study things you might not think will be useful to you necessarily in the future field that you choose. If it is GI, you still need to study all the other fields because sometimes patients may have GI diseases that are connecting with other diseases and you won’t know that if you haven’t studied the other diseases.
Patients are not only one disease, but they are also complex patients. Sometimes if you try to correct one disease, you create a complication with the other disease and you might not be aware of that.
Don’t create shortcuts like ChatGPT, things that are becoming fashionable with younger people today. Do the hard work the old way in which you have to memorize things. Knowledge is the only thing that really can help the patient.
Go to GI meetings. Offer to meet people, collaborate, network. Don’t be shy about it. Even if it is not natural to you, just do it. It’ll become more natural as you do it. GI, like any other field, any other endeavor in human society, is something that also depends on interactions. Therefore, it’s good to learn how to interact, how to network, how to do research projects. Even with people from far away, communication is very easy. You don’t really need to do research projects only with people in your local environment. You can do research projects with people who are on the other side of the state or even on the other side of the world.
You place an emphasis on individualized patient care. Can you discuss what that means to you?
Dr. Jovani: It basically means that there isn’t one size fits all in the management of diseases. Obviously there are some general principles that are applicable to everybody, but sometimes for the single specific patient, what works for one patient might not necessarily work for the next patient.
With Endoscopic Retrograde Cholangiopancreatography (ERCP) for example, there are so many things that go into that. Most papilla are in a certain position and it’s relatively easy to cannulate. But there are others that are in very different positions or in different angulations and they might require specific techniques that are not applicable in the majority of cases. You have to adapt to the single patient.How you speak to the patient is also important. Some may prefer a certain type of communication and other patients may prefer another type of communication involving patients or family. You have to adapt to the single patient. You have to understand the different types of personalities and adapt how you explain things or how you communicate disease, or management of disease or even complications to the specific patient. Different approaches are more appropriate for different patients with different needs. At the end of the day, patients are single individuals after all.
Where do you see the field of GI medicine advancing internationally over the next 5 years?
Dr. Jovani: Artificial intelligence or AI is a big player. It will help with diagnostics primarily, at least over the short term. Potentially it can help with therapeutics as well. There’s a lot of investment and excitement and interest in artificial intelligence.
Therapeutic endoscopy robotics, especially in interventional endoscopy, third space endoscopy, is also gaining attention.
With regards to bariatric endoscopy, we should have a CPT code for it in January 2027. This will increase volume because it’ll be covered more by insurance. These are things that will help advance GI in the next five or 10 years.
Lightning Round
What’s one hobby you’d like to pick up?
Kite surfing
What’s your favorite season of the year?
Summer
What’s your favorite way to spend a weekend?
Traveling or going to the beach
If you could have dinner with any historical figure, who would it be?
Jesus Christ
What’s your favorite holiday tradition?
New Year’s Eve
Are you a planner or more spontaneous?
Planner
What’s the best piece of advice you’ve ever received?
You can do it!
What’s your comfort food?
Lasagna
Ergonomic ‘Timeouts’ Make Endoscopy Easier For GIs
Amandeep Shergill, MD, MS, AGAF, always thought she had good hand-eye coordination until she entered her gastroenterology fellowship.
“You’re learning how to scope and the endoscope just feels so awkward in the hands. It can be such a difficult instrument to both learn and to use,” said Dr. Shergill, professor of clinical medicine at University of California, San Francisco.
Her attendings and mentors couldn’t give her the feedback she needed.
“I was told that I wasn’t holding it right. But every time I tried to do something that someone was trying to tell me, it seemed like my hands were too small. I couldn’t hold it the way that they were teaching me to hold it.” She began to wonder: Was this about her or the tool itself?
A deep dive into hand tool interactions and medical device designs led her to human factors and ergonomics. Her fellowship mentor, Ken McQuaid, MD, AGAF, had gone to medical school with David Rempel, MD, MPH who was one of the top-funded ergonomists in the country. “He emailed David and wrote: I have a fellow who’s interested in learning more about ergonomics and applying it to endoscopy,” said Dr. Shergill.
Through her work with Dr. Rempel, she was able to uncover the mechanisms that lead to musculoskeletal disorders in endoscopists.
Over time, she has become a trailblazer in this field, helming the UC Berkeley Center for Ergonomic Endoscopy with Carisa Harris-Adamson PhD, CPE, her ergonomics collaborator. In an interview, she described the unique “timeout” algorithm she created to ease the process of endoscopy for GI physicians.
What is your favorite aspect of being a GI physician?
I really love the diversity of patients and cases. You’re always learning something new. It’s an internal medicine subspecialty and a cognitive field, so we must think about differential diagnoses, risks and benefits of procedures for patients. But as a procedural field, we get to diagnose and immediately treat certain disorders. What’s exciting about GI right now is there’s still so much to learn. I think that we’re still discovering more about how the brain-gut interaction works every day. There’s been additional research about the microbiome and the immense influence it has on both health and disease. The field is continuing to evolve rapidly. There’s always something new to learn, and I think it keeps us fresh.
Tell me about your work in ergonomics and endoscopy.
Ken McQuaid connected me with David Rempel. I worked with David to approach this problem of endoscopy ergonomics from a very rigorous ergonomics perspective. Early in my fellowship, endoscopy ergonomics wasn’t well known. There were few survey-based studies, including one from the American Society for Gastrointestinal Endoscopy (ASGE) that documented a high prevalence of endoscopist injury. But not a lot was known about what was causing injury in endoscopists.
What were the risk factors for endoscopist injury? Instead of just doing another survey, I wanted to show that there was this potential for causation given the design of the endoscopes. I worked with David to do a pilot study where we collected some pinch forces and forearm muscle loads. I was able to collect some pilot data that I used to apply for the ASGE Endoscopic Research Award. And luckily, ASGE supported that work.
Another award I received, the ASGE Career Development Award, was instrumental in allowing me to become more proficient in the science of ergonomics. I was able to leverage that career development award to go back to school. I went to UC Berkeley and got a master’s in environmental health sciences with a focus on ergonomics. It really helped me to lay the foundation and understanding for ergonomics and then apply that to endoscopy to generate a more rigorous scientific background for endoscopy ergonomics and start that conversation within the field of GI.
What leads to musculoskeletal disorders in endoscopists and how can it be prevented?
Musculoskeletal disorders are associated with the repetitive procedures that we’re performing, often utilizing high forces and in non-neutral postures. This is because of how we’re interacting with our tools and how we’re interacting with our environments. The studies I have done with Carisa Harris-Adamson have been able to demonstrate and document the high forces that are required to interact with the endoscope. To turn the control section dials and to torque and manipulate the insertion tube, there are really high distal upper extremity muscle loads that are being applied.
We were able to compare the loads and the forces we were seeing to established risk thresholds from the ergonomics literature and demonstrate that performing endoscopy was associated with moderate to high risk of development of distal upper extremity disorders.
What research are you doing now?
We’re trying to focus more on interventions. We’ve done some studies on engineering controls we can utilize to decrease the loads of holding the scope. First, it was an anti-gravity support arm. More recently we’re hoping to publish data on whether a scope stand can alleviate some of those left distal upper extremity loads because the stand is holding the scope instead of the hand holding the scope. Can we decrease injury risk by decreasing static loading?
Neck and back injuries, which have a high prevalence in endoscopists, are usually associated with how the room is set up. One of the things that I’ve tried to help promote is a pre-procedure ergonomic “timeout.” Before an endoscopist does a procedure, we’re supposed to perform a timeout focused on the patient’s safety. We should also try to advocate for physician safety and an ergonomic timeout. I developed a mnemonic device utilizing the word “MYSELF” to help endoscopists remember the ergonomic timeout checklist: M = monitor, Y = upside-down Y stance, S = scope, E = elbow/ bed position, L = lower extremities, F = free movement of endoscope/ processor placement.
First, thinking about the monitor, “M”, and fixing the monitor height so that the neck is in neutral position. Then, thinking of an upside down “Y” standing straight with the feet either hip width or shoulder width apart, so that the physician has a stable, neutral standing posture. Then “S” is for checking the scope to ensure you have a scope with optimal angulation that’s working properly.
“E” is for elbows — adjusting the bed to an optimal position so that elbows and shoulders are in neutral position. “L” is for lower extremities — are the foot pedals within an easy reach? Do you have comfortable shoes on, an anti-fatigue floor mat if you need it? And then the “F” in “MYSELF” is for the processor placement, to ensure “free movement” of the scope. By placing the processor directly behind you and lining up the processor with the orifice to be scoped, you can ensure free movement of the scope so that you can leverage large movements of the control section to result in tip deflection.
We studied the MYSELF mnemonic device for a pre-procedure ergonomic timeout in a simulated setting and presented our results at Digestive Disease Week (DDW) 2024, where we showed a reduction in ergonomic risk scores based on the Rapid Entire Body Assessment tool.
We presented the results of the scope stand study at DDW 2025 in San Diego this May.
What has been the feedback from physicians who use these supportive tools?
While physicians are very grateful for bringing attention to this issue, and many have found utility in some of the tools that I proposed, I think we still have so much work to do. We’re just all hoping to continue to move this field forward for better tools that are designed more with the breadth of endoscopists in mind.
How do you handle stress and maintain work-life balance?
A few years ago, during DDW I gave a talk entitled “Achieving Work-Life Harmony.” I disclosed at the beginning of the talk that I had not achieved work-life harmony. It’s definitely a difficult thing to do, especially in our field as GI proceduralists, where we’re frequently on call and there are potentially on-call emergencies.
One of the key things that I’ve tried to do is create boundaries to prioritize both things in my personal life and my professional life and really try to stay true to the things that are important to me. For instance, things like family time and mealtimes, I think that’s so critical. Trying to be home on evenings for dinnertime is so important.
One of my GI colleagues, Raj Keswani, MD, MS gave a talk about burnout and described imagining life as juggling balls; trying to figure out which balls are glass balls and need to be handled with care, and which balls are rubber balls.
More often, work is the rubber ball. If you drop it, it’ll bounce back and the work that you have will still be there the next day. Family, friends, our health, those are the glass balls that if they fall, they can get scuffed or shatter sometimes. That image helps me think in the moment. If I need to decide between two competing priorities, which one will still be here tomorrow? Which is the one that’s going to be more resilient, and which is the one that I need to focus on? That’s been a helpful image for me.
I also want to give a shout out to my amazing colleagues. We all pitch in with the ‘juggling’ and help to keep everyone’s ‘balls’ in the air, and cover for each other. Whether it’s a sick patient or whatever’s going on in our personal lives, we always take care of each other.
What advice would you give to aspiring GI fellows or graduating fellows?
GI is such an amazing field and many people end up focusing on the procedural aspect of it. What I think defines an exceptional gastroenterologist and physician in general is adopting both a “growth mindset” and a “mastery mindset.” And really, it starts out with when you’re exploring an area of focus, listening to what consistently draws your attention, what you’re excited about learning more about.
Finding mentors, getting involved in projects, doing deep learning, and really trying to develop an expertise in that area through additional training, coursework, and education. I think that idea of a mastery mindset will really help set you up for becoming deeply knowledgeable about a field.
Lightning Round
Coffee or tea?
Coffee
What’s your favorite book?
Project Hail Mary (audiobook)
Beach vacation or mountain retreat?
Mountain retreat
Early bird or night owl?
Night owl
What’s your go-to comfort food?
Chaat (Indian street food)
Do you prefer dogs or cats?
Dogs
What’s one hobby you’d like to pick up?
Sewing
If you could have dinner with any historical figure, who would it be?
Ruth Bader Ginsburg
What’s your go-to karaoke song?
I Wanna Dance with Somebody
What’s one thing on your bucket list?
To see the Northern Lights
Amandeep Shergill, MD, MS, AGAF, always thought she had good hand-eye coordination until she entered her gastroenterology fellowship.
“You’re learning how to scope and the endoscope just feels so awkward in the hands. It can be such a difficult instrument to both learn and to use,” said Dr. Shergill, professor of clinical medicine at University of California, San Francisco.
Her attendings and mentors couldn’t give her the feedback she needed.
“I was told that I wasn’t holding it right. But every time I tried to do something that someone was trying to tell me, it seemed like my hands were too small. I couldn’t hold it the way that they were teaching me to hold it.” She began to wonder: Was this about her or the tool itself?
A deep dive into hand tool interactions and medical device designs led her to human factors and ergonomics. Her fellowship mentor, Ken McQuaid, MD, AGAF, had gone to medical school with David Rempel, MD, MPH who was one of the top-funded ergonomists in the country. “He emailed David and wrote: I have a fellow who’s interested in learning more about ergonomics and applying it to endoscopy,” said Dr. Shergill.
Through her work with Dr. Rempel, she was able to uncover the mechanisms that lead to musculoskeletal disorders in endoscopists.
Over time, she has become a trailblazer in this field, helming the UC Berkeley Center for Ergonomic Endoscopy with Carisa Harris-Adamson PhD, CPE, her ergonomics collaborator. In an interview, she described the unique “timeout” algorithm she created to ease the process of endoscopy for GI physicians.
What is your favorite aspect of being a GI physician?
I really love the diversity of patients and cases. You’re always learning something new. It’s an internal medicine subspecialty and a cognitive field, so we must think about differential diagnoses, risks and benefits of procedures for patients. But as a procedural field, we get to diagnose and immediately treat certain disorders. What’s exciting about GI right now is there’s still so much to learn. I think that we’re still discovering more about how the brain-gut interaction works every day. There’s been additional research about the microbiome and the immense influence it has on both health and disease. The field is continuing to evolve rapidly. There’s always something new to learn, and I think it keeps us fresh.
Tell me about your work in ergonomics and endoscopy.
Ken McQuaid connected me with David Rempel. I worked with David to approach this problem of endoscopy ergonomics from a very rigorous ergonomics perspective. Early in my fellowship, endoscopy ergonomics wasn’t well known. There were few survey-based studies, including one from the American Society for Gastrointestinal Endoscopy (ASGE) that documented a high prevalence of endoscopist injury. But not a lot was known about what was causing injury in endoscopists.
What were the risk factors for endoscopist injury? Instead of just doing another survey, I wanted to show that there was this potential for causation given the design of the endoscopes. I worked with David to do a pilot study where we collected some pinch forces and forearm muscle loads. I was able to collect some pilot data that I used to apply for the ASGE Endoscopic Research Award. And luckily, ASGE supported that work.
Another award I received, the ASGE Career Development Award, was instrumental in allowing me to become more proficient in the science of ergonomics. I was able to leverage that career development award to go back to school. I went to UC Berkeley and got a master’s in environmental health sciences with a focus on ergonomics. It really helped me to lay the foundation and understanding for ergonomics and then apply that to endoscopy to generate a more rigorous scientific background for endoscopy ergonomics and start that conversation within the field of GI.
What leads to musculoskeletal disorders in endoscopists and how can it be prevented?
Musculoskeletal disorders are associated with the repetitive procedures that we’re performing, often utilizing high forces and in non-neutral postures. This is because of how we’re interacting with our tools and how we’re interacting with our environments. The studies I have done with Carisa Harris-Adamson have been able to demonstrate and document the high forces that are required to interact with the endoscope. To turn the control section dials and to torque and manipulate the insertion tube, there are really high distal upper extremity muscle loads that are being applied.
We were able to compare the loads and the forces we were seeing to established risk thresholds from the ergonomics literature and demonstrate that performing endoscopy was associated with moderate to high risk of development of distal upper extremity disorders.
What research are you doing now?
We’re trying to focus more on interventions. We’ve done some studies on engineering controls we can utilize to decrease the loads of holding the scope. First, it was an anti-gravity support arm. More recently we’re hoping to publish data on whether a scope stand can alleviate some of those left distal upper extremity loads because the stand is holding the scope instead of the hand holding the scope. Can we decrease injury risk by decreasing static loading?
Neck and back injuries, which have a high prevalence in endoscopists, are usually associated with how the room is set up. One of the things that I’ve tried to help promote is a pre-procedure ergonomic “timeout.” Before an endoscopist does a procedure, we’re supposed to perform a timeout focused on the patient’s safety. We should also try to advocate for physician safety and an ergonomic timeout. I developed a mnemonic device utilizing the word “MYSELF” to help endoscopists remember the ergonomic timeout checklist: M = monitor, Y = upside-down Y stance, S = scope, E = elbow/ bed position, L = lower extremities, F = free movement of endoscope/ processor placement.
First, thinking about the monitor, “M”, and fixing the monitor height so that the neck is in neutral position. Then, thinking of an upside down “Y” standing straight with the feet either hip width or shoulder width apart, so that the physician has a stable, neutral standing posture. Then “S” is for checking the scope to ensure you have a scope with optimal angulation that’s working properly.
“E” is for elbows — adjusting the bed to an optimal position so that elbows and shoulders are in neutral position. “L” is for lower extremities — are the foot pedals within an easy reach? Do you have comfortable shoes on, an anti-fatigue floor mat if you need it? And then the “F” in “MYSELF” is for the processor placement, to ensure “free movement” of the scope. By placing the processor directly behind you and lining up the processor with the orifice to be scoped, you can ensure free movement of the scope so that you can leverage large movements of the control section to result in tip deflection.
We studied the MYSELF mnemonic device for a pre-procedure ergonomic timeout in a simulated setting and presented our results at Digestive Disease Week (DDW) 2024, where we showed a reduction in ergonomic risk scores based on the Rapid Entire Body Assessment tool.
We presented the results of the scope stand study at DDW 2025 in San Diego this May.
What has been the feedback from physicians who use these supportive tools?
While physicians are very grateful for bringing attention to this issue, and many have found utility in some of the tools that I proposed, I think we still have so much work to do. We’re just all hoping to continue to move this field forward for better tools that are designed more with the breadth of endoscopists in mind.
How do you handle stress and maintain work-life balance?
A few years ago, during DDW I gave a talk entitled “Achieving Work-Life Harmony.” I disclosed at the beginning of the talk that I had not achieved work-life harmony. It’s definitely a difficult thing to do, especially in our field as GI proceduralists, where we’re frequently on call and there are potentially on-call emergencies.
One of the key things that I’ve tried to do is create boundaries to prioritize both things in my personal life and my professional life and really try to stay true to the things that are important to me. For instance, things like family time and mealtimes, I think that’s so critical. Trying to be home on evenings for dinnertime is so important.
One of my GI colleagues, Raj Keswani, MD, MS gave a talk about burnout and described imagining life as juggling balls; trying to figure out which balls are glass balls and need to be handled with care, and which balls are rubber balls.
More often, work is the rubber ball. If you drop it, it’ll bounce back and the work that you have will still be there the next day. Family, friends, our health, those are the glass balls that if they fall, they can get scuffed or shatter sometimes. That image helps me think in the moment. If I need to decide between two competing priorities, which one will still be here tomorrow? Which is the one that’s going to be more resilient, and which is the one that I need to focus on? That’s been a helpful image for me.
I also want to give a shout out to my amazing colleagues. We all pitch in with the ‘juggling’ and help to keep everyone’s ‘balls’ in the air, and cover for each other. Whether it’s a sick patient or whatever’s going on in our personal lives, we always take care of each other.
What advice would you give to aspiring GI fellows or graduating fellows?
GI is such an amazing field and many people end up focusing on the procedural aspect of it. What I think defines an exceptional gastroenterologist and physician in general is adopting both a “growth mindset” and a “mastery mindset.” And really, it starts out with when you’re exploring an area of focus, listening to what consistently draws your attention, what you’re excited about learning more about.
Finding mentors, getting involved in projects, doing deep learning, and really trying to develop an expertise in that area through additional training, coursework, and education. I think that idea of a mastery mindset will really help set you up for becoming deeply knowledgeable about a field.
Lightning Round
Coffee or tea?
Coffee
What’s your favorite book?
Project Hail Mary (audiobook)
Beach vacation or mountain retreat?
Mountain retreat
Early bird or night owl?
Night owl
What’s your go-to comfort food?
Chaat (Indian street food)
Do you prefer dogs or cats?
Dogs
What’s one hobby you’d like to pick up?
Sewing
If you could have dinner with any historical figure, who would it be?
Ruth Bader Ginsburg
What’s your go-to karaoke song?
I Wanna Dance with Somebody
What’s one thing on your bucket list?
To see the Northern Lights
Amandeep Shergill, MD, MS, AGAF, always thought she had good hand-eye coordination until she entered her gastroenterology fellowship.
“You’re learning how to scope and the endoscope just feels so awkward in the hands. It can be such a difficult instrument to both learn and to use,” said Dr. Shergill, professor of clinical medicine at University of California, San Francisco.
Her attendings and mentors couldn’t give her the feedback she needed.
“I was told that I wasn’t holding it right. But every time I tried to do something that someone was trying to tell me, it seemed like my hands were too small. I couldn’t hold it the way that they were teaching me to hold it.” She began to wonder: Was this about her or the tool itself?
A deep dive into hand tool interactions and medical device designs led her to human factors and ergonomics. Her fellowship mentor, Ken McQuaid, MD, AGAF, had gone to medical school with David Rempel, MD, MPH who was one of the top-funded ergonomists in the country. “He emailed David and wrote: I have a fellow who’s interested in learning more about ergonomics and applying it to endoscopy,” said Dr. Shergill.
Through her work with Dr. Rempel, she was able to uncover the mechanisms that lead to musculoskeletal disorders in endoscopists.
Over time, she has become a trailblazer in this field, helming the UC Berkeley Center for Ergonomic Endoscopy with Carisa Harris-Adamson PhD, CPE, her ergonomics collaborator. In an interview, she described the unique “timeout” algorithm she created to ease the process of endoscopy for GI physicians.
What is your favorite aspect of being a GI physician?
I really love the diversity of patients and cases. You’re always learning something new. It’s an internal medicine subspecialty and a cognitive field, so we must think about differential diagnoses, risks and benefits of procedures for patients. But as a procedural field, we get to diagnose and immediately treat certain disorders. What’s exciting about GI right now is there’s still so much to learn. I think that we’re still discovering more about how the brain-gut interaction works every day. There’s been additional research about the microbiome and the immense influence it has on both health and disease. The field is continuing to evolve rapidly. There’s always something new to learn, and I think it keeps us fresh.
Tell me about your work in ergonomics and endoscopy.
Ken McQuaid connected me with David Rempel. I worked with David to approach this problem of endoscopy ergonomics from a very rigorous ergonomics perspective. Early in my fellowship, endoscopy ergonomics wasn’t well known. There were few survey-based studies, including one from the American Society for Gastrointestinal Endoscopy (ASGE) that documented a high prevalence of endoscopist injury. But not a lot was known about what was causing injury in endoscopists.
What were the risk factors for endoscopist injury? Instead of just doing another survey, I wanted to show that there was this potential for causation given the design of the endoscopes. I worked with David to do a pilot study where we collected some pinch forces and forearm muscle loads. I was able to collect some pilot data that I used to apply for the ASGE Endoscopic Research Award. And luckily, ASGE supported that work.
Another award I received, the ASGE Career Development Award, was instrumental in allowing me to become more proficient in the science of ergonomics. I was able to leverage that career development award to go back to school. I went to UC Berkeley and got a master’s in environmental health sciences with a focus on ergonomics. It really helped me to lay the foundation and understanding for ergonomics and then apply that to endoscopy to generate a more rigorous scientific background for endoscopy ergonomics and start that conversation within the field of GI.
What leads to musculoskeletal disorders in endoscopists and how can it be prevented?
Musculoskeletal disorders are associated with the repetitive procedures that we’re performing, often utilizing high forces and in non-neutral postures. This is because of how we’re interacting with our tools and how we’re interacting with our environments. The studies I have done with Carisa Harris-Adamson have been able to demonstrate and document the high forces that are required to interact with the endoscope. To turn the control section dials and to torque and manipulate the insertion tube, there are really high distal upper extremity muscle loads that are being applied.
We were able to compare the loads and the forces we were seeing to established risk thresholds from the ergonomics literature and demonstrate that performing endoscopy was associated with moderate to high risk of development of distal upper extremity disorders.
What research are you doing now?
We’re trying to focus more on interventions. We’ve done some studies on engineering controls we can utilize to decrease the loads of holding the scope. First, it was an anti-gravity support arm. More recently we’re hoping to publish data on whether a scope stand can alleviate some of those left distal upper extremity loads because the stand is holding the scope instead of the hand holding the scope. Can we decrease injury risk by decreasing static loading?
Neck and back injuries, which have a high prevalence in endoscopists, are usually associated with how the room is set up. One of the things that I’ve tried to help promote is a pre-procedure ergonomic “timeout.” Before an endoscopist does a procedure, we’re supposed to perform a timeout focused on the patient’s safety. We should also try to advocate for physician safety and an ergonomic timeout. I developed a mnemonic device utilizing the word “MYSELF” to help endoscopists remember the ergonomic timeout checklist: M = monitor, Y = upside-down Y stance, S = scope, E = elbow/ bed position, L = lower extremities, F = free movement of endoscope/ processor placement.
First, thinking about the monitor, “M”, and fixing the monitor height so that the neck is in neutral position. Then, thinking of an upside down “Y” standing straight with the feet either hip width or shoulder width apart, so that the physician has a stable, neutral standing posture. Then “S” is for checking the scope to ensure you have a scope with optimal angulation that’s working properly.
“E” is for elbows — adjusting the bed to an optimal position so that elbows and shoulders are in neutral position. “L” is for lower extremities — are the foot pedals within an easy reach? Do you have comfortable shoes on, an anti-fatigue floor mat if you need it? And then the “F” in “MYSELF” is for the processor placement, to ensure “free movement” of the scope. By placing the processor directly behind you and lining up the processor with the orifice to be scoped, you can ensure free movement of the scope so that you can leverage large movements of the control section to result in tip deflection.
We studied the MYSELF mnemonic device for a pre-procedure ergonomic timeout in a simulated setting and presented our results at Digestive Disease Week (DDW) 2024, where we showed a reduction in ergonomic risk scores based on the Rapid Entire Body Assessment tool.
We presented the results of the scope stand study at DDW 2025 in San Diego this May.
What has been the feedback from physicians who use these supportive tools?
While physicians are very grateful for bringing attention to this issue, and many have found utility in some of the tools that I proposed, I think we still have so much work to do. We’re just all hoping to continue to move this field forward for better tools that are designed more with the breadth of endoscopists in mind.
How do you handle stress and maintain work-life balance?
A few years ago, during DDW I gave a talk entitled “Achieving Work-Life Harmony.” I disclosed at the beginning of the talk that I had not achieved work-life harmony. It’s definitely a difficult thing to do, especially in our field as GI proceduralists, where we’re frequently on call and there are potentially on-call emergencies.
One of the key things that I’ve tried to do is create boundaries to prioritize both things in my personal life and my professional life and really try to stay true to the things that are important to me. For instance, things like family time and mealtimes, I think that’s so critical. Trying to be home on evenings for dinnertime is so important.
One of my GI colleagues, Raj Keswani, MD, MS gave a talk about burnout and described imagining life as juggling balls; trying to figure out which balls are glass balls and need to be handled with care, and which balls are rubber balls.
More often, work is the rubber ball. If you drop it, it’ll bounce back and the work that you have will still be there the next day. Family, friends, our health, those are the glass balls that if they fall, they can get scuffed or shatter sometimes. That image helps me think in the moment. If I need to decide between two competing priorities, which one will still be here tomorrow? Which is the one that’s going to be more resilient, and which is the one that I need to focus on? That’s been a helpful image for me.
I also want to give a shout out to my amazing colleagues. We all pitch in with the ‘juggling’ and help to keep everyone’s ‘balls’ in the air, and cover for each other. Whether it’s a sick patient or whatever’s going on in our personal lives, we always take care of each other.
What advice would you give to aspiring GI fellows or graduating fellows?
GI is such an amazing field and many people end up focusing on the procedural aspect of it. What I think defines an exceptional gastroenterologist and physician in general is adopting both a “growth mindset” and a “mastery mindset.” And really, it starts out with when you’re exploring an area of focus, listening to what consistently draws your attention, what you’re excited about learning more about.
Finding mentors, getting involved in projects, doing deep learning, and really trying to develop an expertise in that area through additional training, coursework, and education. I think that idea of a mastery mindset will really help set you up for becoming deeply knowledgeable about a field.
Lightning Round
Coffee or tea?
Coffee
What’s your favorite book?
Project Hail Mary (audiobook)
Beach vacation or mountain retreat?
Mountain retreat
Early bird or night owl?
Night owl
What’s your go-to comfort food?
Chaat (Indian street food)
Do you prefer dogs or cats?
Dogs
What’s one hobby you’d like to pick up?
Sewing
If you could have dinner with any historical figure, who would it be?
Ruth Bader Ginsburg
What’s your go-to karaoke song?
I Wanna Dance with Somebody
What’s one thing on your bucket list?
To see the Northern Lights
Endoscopist Brings Cutting-Edge Tech to Asia-Pacific Region
As the COVID-19 crisis unfolded in early 2020, Tossapol Kerdsirichairat, MD, faced another challenge: his mother’s ovarian cancer diagnosis.
“She chose to remain in Thailand, so I decided to relocate to care for her,” said Dr. Kerdsirichairat, an interventional endoscopist who completed fellowships at the University of Michigan, Ann Arbor, and Johns Hopkins University in Baltimore. The move to Bangkok turned out to be one of the best decisions of his life, he said, as he could support his mother while introducing advanced endoscopic techniques and devices to the region.
“Bangkok is a hub for medical innovation in Asia, offering opportunities to work with a diverse patient population and access to cutting-edge technology,” said Dr. Kerdsirichairat, who works at Bumrungrad International Hospital as a clinical associate professor.
The program is the first of its kind in Thailand and one of the few in the Asia-Pacific region.
“I guide patients and families through understanding their risks and implementing preventive strategies, collaborating with multidisciplinary teams to ensure comprehensive care. It’s incredibly rewarding to see the impact of early tumor detection,” said Dr. Kerdsirichairat, an international member of AGA who was a participant in the AGA Young Delegates Program.
He has set several records in Thailand for the smallest tumor detected, including a 0.3-millimeter (mm) esophageal tumor, a 0.8-mm tumor for stomach cancer, a 5-mm pancreatic tumor, and a 1-mm tumor for colon cancer.
“These were detected through high-standard screening programs, as patients often do not develop symptoms from these subtle lesions,” said Dr. Kerdsirichairat, who discussed in an interview the unique challenges of practicing overseas.
Why did you choose GI?
Gastroenterology is a specialty that uniquely integrates procedural skill, clinical decision making, and a deep understanding of complex biological systems. I was drawn especially to the ability to make a direct and meaningful impact in patients’ lives through advanced endoscopic procedures, while also addressing both acute and chronic diseases, and focusing on cancer prevention. It is incredibly rewarding to perform an endoscopic retrograde cholangiopancreatography (ERCP) for cholangitis and see a patient return to normal the very next day, or to perform an endoscopic ultrasound (EUS) for pancreatic cancer screening in high-risk individuals and detect a sub-centimeter pancreatic tumor.
Realizing that early detection can improve survival by threefold after surgery is a powerful reminder of the difference we can make in patients’ lives. This specialty requires a delicate balance of precision and empathy, which perfectly aligns with my strengths and values as a physician.
You have a wide variety of clinical interests, from endoscopic procedures to cancer research to GERD. What’s your key subspecialty and why?
My primary specialty is advanced endoscopy, which includes techniques such as EUS, ERCP, and endoscopic resection of precancerous and early cancerous lesions. I also focus on cutting-edge, evidence-based techniques recently included in clinical guidelines, such as Transoral Incisionless Fundoplication (TIF). These minimally invasive options allow me to diagnose and treat conditions that once required surgery. The precision and innovation involved in advanced endoscopy enable me to effectively manage complex cases—from diagnosing early cancers to managing bile duct obstructions and resecting precancerous lesions.
Can you describe your work in cancer genetics and screening?
I am deeply committed to the early detection of gastrointestinal cancers, particularly through screening for precancerous conditions and hereditary syndromes. During my general GI training at the University of Michigan, I had the privilege of working with Grace Elta, MD, AGAF, and Michelle Anderson, MD, MSc, renowned experts in pancreatic cancer management. I was later trained by Anne Marie Lennon, PhD, AGAF, who pioneered the liquid biopsy technique for cancer screening through the CancerSEEK project, and Marcia (Mimi) Canto, MD, MHS, who initiated the Cancer of the Pancreas Screening project for high-risk individuals of pancreatic cancer.
I also had the distinction of being the first at Bumrungrad International Hospital to perform endoscopic drainage for pancreatic fluid collections in the setting of multi-organ failure. This endoscopic approach has been extensively validated in the medical literature as significantly improving survival rates compared to surgical drainage. My training in this specialized procedure was conducted under the guidance of the premier group for necrotizing pancreatitis, led by Martin Freeman, MD, at the University of Minnesota.
Later, I contributed to overseeing the Inherited Gastrointestinal Malignancy Clinic of MyCode, a large-scale population-based cohort program focused on cancer screening in Pennsylvania. By December 2024, MyCode had collected blood samples from over 258,000 individuals, analyzed DNA sequences from over 184,000, and provided clinical data that benefits over 142,000 patients. It’s not uncommon for healthy 25-year-old patients to come to our clinic for colon cancer screening after learning from the program that they carry a cancer syndrome, and early screening can potentially save their lives.
What are the key differences between training and practicing medicine in the United States and in an Asian country?
The U.S. healthcare system is deeply rooted in evidence-based protocols and multidisciplinary care, driven by an insurance-based model. In contrast, many Asian countries face challenges such as the dependency on government approval for certain treatments and insurance limitations. Practicing in Asia requires navigating unique cultural, economic, and systemic differences, including varying resource availability and disease prevalence.
What specific challenges have you faced as a GI in Thailand?
As an advanced endoscopist, one of the biggest challenges I faced initially was the difficulty in obtaining the same devices I used in the U.S. for use in Thailand. With support from device companies and mentors in the U.S., I was able to perform groundbreaking procedures, such as the TIF in Southeast Asia and the first use of a full-thickness resection device in Thailand. I am also proud to be part of one of the first few centers worldwide performing the combination of injectable semaglutide and endoscopic sleeve gastroplasty, resulting in a remarkable weight reduction of 44%, comparable to surgical gastric bypass.
In addition, Bumrungrad International Hospital, where I practice, sees over 1.1 million visits annually from patients from more than 190 countries. This offers a unique opportunity to engage with a global patient base and learn from diverse cultures. Over time, although the hospital has professional interpreters for all languages, I have become able to communicate basic sentences with international patients in their preferred languages, including Chinese, Japanese, and Arabic, which has enriched my practice.
What’s your favorite thing to do when you’re not practicing GI?
I enjoy traveling, exploring new cuisines, and spending quality time with family and friends. These activities help me recharge and offer fresh perspectives on life.
Lightning Round
Texting or talking?
Talking. It’s more personal and meaningful.
Favorite city in the U.S.?
Ann Arbor, Michigan
Cat or dog person?
Dog person
Favorite junk food?
Pizza
How many cups of coffee do you drink per day?
Two – just enough to stay sharp, but not jittery.
If you weren’t a GI, what would you be?
Architect
Best place you went on vacation?
Kyoto, Japan
Favorite sport?
Skiing
Favorite ice cream?
Matcha green tea
What song do you have to sing along with when you hear it?
“Everybody” by Backstreet Boys
Favorite movie or TV show?
Forrest Gump and Friends
Optimist or pessimist?
Optimist. I believe in focusing on solutions and possibilities.
As the COVID-19 crisis unfolded in early 2020, Tossapol Kerdsirichairat, MD, faced another challenge: his mother’s ovarian cancer diagnosis.
“She chose to remain in Thailand, so I decided to relocate to care for her,” said Dr. Kerdsirichairat, an interventional endoscopist who completed fellowships at the University of Michigan, Ann Arbor, and Johns Hopkins University in Baltimore. The move to Bangkok turned out to be one of the best decisions of his life, he said, as he could support his mother while introducing advanced endoscopic techniques and devices to the region.
“Bangkok is a hub for medical innovation in Asia, offering opportunities to work with a diverse patient population and access to cutting-edge technology,” said Dr. Kerdsirichairat, who works at Bumrungrad International Hospital as a clinical associate professor.
The program is the first of its kind in Thailand and one of the few in the Asia-Pacific region.
“I guide patients and families through understanding their risks and implementing preventive strategies, collaborating with multidisciplinary teams to ensure comprehensive care. It’s incredibly rewarding to see the impact of early tumor detection,” said Dr. Kerdsirichairat, an international member of AGA who was a participant in the AGA Young Delegates Program.
He has set several records in Thailand for the smallest tumor detected, including a 0.3-millimeter (mm) esophageal tumor, a 0.8-mm tumor for stomach cancer, a 5-mm pancreatic tumor, and a 1-mm tumor for colon cancer.
“These were detected through high-standard screening programs, as patients often do not develop symptoms from these subtle lesions,” said Dr. Kerdsirichairat, who discussed in an interview the unique challenges of practicing overseas.
Why did you choose GI?
Gastroenterology is a specialty that uniquely integrates procedural skill, clinical decision making, and a deep understanding of complex biological systems. I was drawn especially to the ability to make a direct and meaningful impact in patients’ lives through advanced endoscopic procedures, while also addressing both acute and chronic diseases, and focusing on cancer prevention. It is incredibly rewarding to perform an endoscopic retrograde cholangiopancreatography (ERCP) for cholangitis and see a patient return to normal the very next day, or to perform an endoscopic ultrasound (EUS) for pancreatic cancer screening in high-risk individuals and detect a sub-centimeter pancreatic tumor.
Realizing that early detection can improve survival by threefold after surgery is a powerful reminder of the difference we can make in patients’ lives. This specialty requires a delicate balance of precision and empathy, which perfectly aligns with my strengths and values as a physician.
You have a wide variety of clinical interests, from endoscopic procedures to cancer research to GERD. What’s your key subspecialty and why?
My primary specialty is advanced endoscopy, which includes techniques such as EUS, ERCP, and endoscopic resection of precancerous and early cancerous lesions. I also focus on cutting-edge, evidence-based techniques recently included in clinical guidelines, such as Transoral Incisionless Fundoplication (TIF). These minimally invasive options allow me to diagnose and treat conditions that once required surgery. The precision and innovation involved in advanced endoscopy enable me to effectively manage complex cases—from diagnosing early cancers to managing bile duct obstructions and resecting precancerous lesions.
Can you describe your work in cancer genetics and screening?
I am deeply committed to the early detection of gastrointestinal cancers, particularly through screening for precancerous conditions and hereditary syndromes. During my general GI training at the University of Michigan, I had the privilege of working with Grace Elta, MD, AGAF, and Michelle Anderson, MD, MSc, renowned experts in pancreatic cancer management. I was later trained by Anne Marie Lennon, PhD, AGAF, who pioneered the liquid biopsy technique for cancer screening through the CancerSEEK project, and Marcia (Mimi) Canto, MD, MHS, who initiated the Cancer of the Pancreas Screening project for high-risk individuals of pancreatic cancer.
I also had the distinction of being the first at Bumrungrad International Hospital to perform endoscopic drainage for pancreatic fluid collections in the setting of multi-organ failure. This endoscopic approach has been extensively validated in the medical literature as significantly improving survival rates compared to surgical drainage. My training in this specialized procedure was conducted under the guidance of the premier group for necrotizing pancreatitis, led by Martin Freeman, MD, at the University of Minnesota.
Later, I contributed to overseeing the Inherited Gastrointestinal Malignancy Clinic of MyCode, a large-scale population-based cohort program focused on cancer screening in Pennsylvania. By December 2024, MyCode had collected blood samples from over 258,000 individuals, analyzed DNA sequences from over 184,000, and provided clinical data that benefits over 142,000 patients. It’s not uncommon for healthy 25-year-old patients to come to our clinic for colon cancer screening after learning from the program that they carry a cancer syndrome, and early screening can potentially save their lives.
What are the key differences between training and practicing medicine in the United States and in an Asian country?
The U.S. healthcare system is deeply rooted in evidence-based protocols and multidisciplinary care, driven by an insurance-based model. In contrast, many Asian countries face challenges such as the dependency on government approval for certain treatments and insurance limitations. Practicing in Asia requires navigating unique cultural, economic, and systemic differences, including varying resource availability and disease prevalence.
What specific challenges have you faced as a GI in Thailand?
As an advanced endoscopist, one of the biggest challenges I faced initially was the difficulty in obtaining the same devices I used in the U.S. for use in Thailand. With support from device companies and mentors in the U.S., I was able to perform groundbreaking procedures, such as the TIF in Southeast Asia and the first use of a full-thickness resection device in Thailand. I am also proud to be part of one of the first few centers worldwide performing the combination of injectable semaglutide and endoscopic sleeve gastroplasty, resulting in a remarkable weight reduction of 44%, comparable to surgical gastric bypass.
In addition, Bumrungrad International Hospital, where I practice, sees over 1.1 million visits annually from patients from more than 190 countries. This offers a unique opportunity to engage with a global patient base and learn from diverse cultures. Over time, although the hospital has professional interpreters for all languages, I have become able to communicate basic sentences with international patients in their preferred languages, including Chinese, Japanese, and Arabic, which has enriched my practice.
What’s your favorite thing to do when you’re not practicing GI?
I enjoy traveling, exploring new cuisines, and spending quality time with family and friends. These activities help me recharge and offer fresh perspectives on life.
Lightning Round
Texting or talking?
Talking. It’s more personal and meaningful.
Favorite city in the U.S.?
Ann Arbor, Michigan
Cat or dog person?
Dog person
Favorite junk food?
Pizza
How many cups of coffee do you drink per day?
Two – just enough to stay sharp, but not jittery.
If you weren’t a GI, what would you be?
Architect
Best place you went on vacation?
Kyoto, Japan
Favorite sport?
Skiing
Favorite ice cream?
Matcha green tea
What song do you have to sing along with when you hear it?
“Everybody” by Backstreet Boys
Favorite movie or TV show?
Forrest Gump and Friends
Optimist or pessimist?
Optimist. I believe in focusing on solutions and possibilities.
As the COVID-19 crisis unfolded in early 2020, Tossapol Kerdsirichairat, MD, faced another challenge: his mother’s ovarian cancer diagnosis.
“She chose to remain in Thailand, so I decided to relocate to care for her,” said Dr. Kerdsirichairat, an interventional endoscopist who completed fellowships at the University of Michigan, Ann Arbor, and Johns Hopkins University in Baltimore. The move to Bangkok turned out to be one of the best decisions of his life, he said, as he could support his mother while introducing advanced endoscopic techniques and devices to the region.
“Bangkok is a hub for medical innovation in Asia, offering opportunities to work with a diverse patient population and access to cutting-edge technology,” said Dr. Kerdsirichairat, who works at Bumrungrad International Hospital as a clinical associate professor.
The program is the first of its kind in Thailand and one of the few in the Asia-Pacific region.
“I guide patients and families through understanding their risks and implementing preventive strategies, collaborating with multidisciplinary teams to ensure comprehensive care. It’s incredibly rewarding to see the impact of early tumor detection,” said Dr. Kerdsirichairat, an international member of AGA who was a participant in the AGA Young Delegates Program.
He has set several records in Thailand for the smallest tumor detected, including a 0.3-millimeter (mm) esophageal tumor, a 0.8-mm tumor for stomach cancer, a 5-mm pancreatic tumor, and a 1-mm tumor for colon cancer.
“These were detected through high-standard screening programs, as patients often do not develop symptoms from these subtle lesions,” said Dr. Kerdsirichairat, who discussed in an interview the unique challenges of practicing overseas.
Why did you choose GI?
Gastroenterology is a specialty that uniquely integrates procedural skill, clinical decision making, and a deep understanding of complex biological systems. I was drawn especially to the ability to make a direct and meaningful impact in patients’ lives through advanced endoscopic procedures, while also addressing both acute and chronic diseases, and focusing on cancer prevention. It is incredibly rewarding to perform an endoscopic retrograde cholangiopancreatography (ERCP) for cholangitis and see a patient return to normal the very next day, or to perform an endoscopic ultrasound (EUS) for pancreatic cancer screening in high-risk individuals and detect a sub-centimeter pancreatic tumor.
Realizing that early detection can improve survival by threefold after surgery is a powerful reminder of the difference we can make in patients’ lives. This specialty requires a delicate balance of precision and empathy, which perfectly aligns with my strengths and values as a physician.
You have a wide variety of clinical interests, from endoscopic procedures to cancer research to GERD. What’s your key subspecialty and why?
My primary specialty is advanced endoscopy, which includes techniques such as EUS, ERCP, and endoscopic resection of precancerous and early cancerous lesions. I also focus on cutting-edge, evidence-based techniques recently included in clinical guidelines, such as Transoral Incisionless Fundoplication (TIF). These minimally invasive options allow me to diagnose and treat conditions that once required surgery. The precision and innovation involved in advanced endoscopy enable me to effectively manage complex cases—from diagnosing early cancers to managing bile duct obstructions and resecting precancerous lesions.
Can you describe your work in cancer genetics and screening?
I am deeply committed to the early detection of gastrointestinal cancers, particularly through screening for precancerous conditions and hereditary syndromes. During my general GI training at the University of Michigan, I had the privilege of working with Grace Elta, MD, AGAF, and Michelle Anderson, MD, MSc, renowned experts in pancreatic cancer management. I was later trained by Anne Marie Lennon, PhD, AGAF, who pioneered the liquid biopsy technique for cancer screening through the CancerSEEK project, and Marcia (Mimi) Canto, MD, MHS, who initiated the Cancer of the Pancreas Screening project for high-risk individuals of pancreatic cancer.
I also had the distinction of being the first at Bumrungrad International Hospital to perform endoscopic drainage for pancreatic fluid collections in the setting of multi-organ failure. This endoscopic approach has been extensively validated in the medical literature as significantly improving survival rates compared to surgical drainage. My training in this specialized procedure was conducted under the guidance of the premier group for necrotizing pancreatitis, led by Martin Freeman, MD, at the University of Minnesota.
Later, I contributed to overseeing the Inherited Gastrointestinal Malignancy Clinic of MyCode, a large-scale population-based cohort program focused on cancer screening in Pennsylvania. By December 2024, MyCode had collected blood samples from over 258,000 individuals, analyzed DNA sequences from over 184,000, and provided clinical data that benefits over 142,000 patients. It’s not uncommon for healthy 25-year-old patients to come to our clinic for colon cancer screening after learning from the program that they carry a cancer syndrome, and early screening can potentially save their lives.
What are the key differences between training and practicing medicine in the United States and in an Asian country?
The U.S. healthcare system is deeply rooted in evidence-based protocols and multidisciplinary care, driven by an insurance-based model. In contrast, many Asian countries face challenges such as the dependency on government approval for certain treatments and insurance limitations. Practicing in Asia requires navigating unique cultural, economic, and systemic differences, including varying resource availability and disease prevalence.
What specific challenges have you faced as a GI in Thailand?
As an advanced endoscopist, one of the biggest challenges I faced initially was the difficulty in obtaining the same devices I used in the U.S. for use in Thailand. With support from device companies and mentors in the U.S., I was able to perform groundbreaking procedures, such as the TIF in Southeast Asia and the first use of a full-thickness resection device in Thailand. I am also proud to be part of one of the first few centers worldwide performing the combination of injectable semaglutide and endoscopic sleeve gastroplasty, resulting in a remarkable weight reduction of 44%, comparable to surgical gastric bypass.
In addition, Bumrungrad International Hospital, where I practice, sees over 1.1 million visits annually from patients from more than 190 countries. This offers a unique opportunity to engage with a global patient base and learn from diverse cultures. Over time, although the hospital has professional interpreters for all languages, I have become able to communicate basic sentences with international patients in their preferred languages, including Chinese, Japanese, and Arabic, which has enriched my practice.
What’s your favorite thing to do when you’re not practicing GI?
I enjoy traveling, exploring new cuisines, and spending quality time with family and friends. These activities help me recharge and offer fresh perspectives on life.
Lightning Round
Texting or talking?
Talking. It’s more personal and meaningful.
Favorite city in the U.S.?
Ann Arbor, Michigan
Cat or dog person?
Dog person
Favorite junk food?
Pizza
How many cups of coffee do you drink per day?
Two – just enough to stay sharp, but not jittery.
If you weren’t a GI, what would you be?
Architect
Best place you went on vacation?
Kyoto, Japan
Favorite sport?
Skiing
Favorite ice cream?
Matcha green tea
What song do you have to sing along with when you hear it?
“Everybody” by Backstreet Boys
Favorite movie or TV show?
Forrest Gump and Friends
Optimist or pessimist?
Optimist. I believe in focusing on solutions and possibilities.
AI in Gastroenterology and Endoscopy
Dear colleagues,
Since our last Perspectives feature on artificial intelligence (AI) in gastroenterology and hepatology, the field has experienced remarkable growth in both innovation and clinical adoption. AI tools that were once conceptual are now entering everyday practice, with many more on the horizon poised to transform how we diagnose, treat, and manage patients.
Dr. Yuvaraj Singh, Dr. Alessandro Colletta, and Dr. Neil Marya discuss how purpose-built AI models can reduce diagnostic uncertainty in advanced endoscopy. From cholangioscopy systems that outperform standard ERCP sampling in distinguishing malignant biliary strictures to EUS-based platforms that differentiate autoimmune pancreatitis from pancreatic cancer, they envision a near-term future in which machine intelligence enhances accuracy, accelerates decision-making, and refines interpretation—without replacing the clinician’s expertise.
Complementing this, Dr. Dennis Shung takes a broader view across the endoscopy unit and outpatient clinic. He highlights the promise of AI for polyp detection, digital biopsy, and automated reporting, while underscoring the importance of human oversight, workflow integration, and safeguards against misinformation. Dr. Shung also emphasizes the pivotal role professional societies can play in establishing clear standards, ethical boundaries, and trusted frameworks for AI deployment in GI practice.
We hope these perspectives spark practical conversations about when—and how—to integrate AI in your own practice. As always, we welcome your feedback and real-world experience. Join the conversation on X at @AGA_GIHN.
Gyanprakash A. Ketwaroo, MD, MSc, is associate professor of medicine, Yale University, New Haven, and chief of endoscopy at West Haven VA Medical Center, both in Connecticut. He is an associate editor for GI & Hepatology News.
AI Models in Advanced Endoscopy
BY YUVARAJ SINGH, MD; ALESSANDRO COLLETTA, MD; NEIL MARYA, MD
As the adage goes, “if tumor is the rumor, then tissue is the issue, because cancer may be the answer.”
Establishing an accurate diagnosis is the essential first step toward curing or palliating malignancy. From detecting an early neoplastic lesion, to distinguishing between malignant and benign pathology, or to determining when and where to obtain tissue, endoscopists are frequently faced with the challenge of transforming diagnostic suspicion into certainty.
Artificial intelligence (AI), designed to replicate human cognition such as pattern recognition and decision-making, has emerged as a technology to assist gastroenterologists in addressing a variety of different tasks during endoscopy. AI research in gastrointestinal endoscopy has initially focused on computer-aided detection (CADe) of colorectal polyps. More recently, however, there has been increased emphasis on developing AI to assist advanced endoscopists.
For instance, in biliary endoscopy, AI is being explored to improve the notoriously challenging diagnosis of cholangiocarcinoma, where conventional tissue sampling often falls short of providing a definitive diagnosis. Similarly, in the pancreas, AI models are showing potential to differentiate autoimmune pancreatitis (AIP) from pancreatic ductal adenocarcinoma (PDAC), a distinction with profound therapeutic implications. Even pancreatic cysts are beginning to benefit from AI models that refine risk stratification and guide management. Together, these advances underscore how AI is not merely an adjunct but a potentially massive catalyst for reimagining the diagnostic role of advanced endoscopists.
Classifying biliary strictures (MBS) accurately remains a challenge. Standard ERCP-based sampling techniques (forceps biopsy and brush cytology) are suboptimal diagnostic tools with false negative rates for detecting MBS of less than 50%. The diagnostic uncertainty related to biliary stricture classification carries significant consequences for patients. For example, patients with biliary cancer without positive cytology have treatments delayed until a malignant diagnosis is established.
Ancillary technologies to enhance ERCP-based tissue acquisition are still weighed down by low sensitivity and accuracy; even with ancillary use of fluorescent in situ hybridization (FISH), diagnostic yield remains limited. EUS-FNA can help with distal biliary strictures, but this technique risks needle-tract seeding in cases of perihilar disease. Cholangioscopy allows for direct visualization and targeted sampling; however, cholangioscopy-guided forceps biopsies are burdened by low sensitivities.1 Additionally, physician interpretation of visual findings during cholangioscopy often suffers from poor interobserver agreement and poor accuracy.2
To improve the classification of biliary strictures, several groups have studied the application of AI for cholangioscopy footage of biliary pathology. In our lab, we trained an AI incorporating over 2.3 million cholangioscopy still images and nearly 20,000 expert-annotated frames to enhance its development. The AI closely mirrored expert labeling of cholangioscopy images of malignant pathology and, when tested on full cholangioscopy videos of indeterminate biliary strictures, the AI achieved a diagnostic accuracy of 91%—outperforming both brush cytology (63%) and forceps biopsy (61%).3
The results from this initial study were later validated across multiple centers. AI-assisted cholangioscopy could thus offer a reproducible, real-world solution to one of the most persistent diagnostic dilemmas advanced endoscopists face—helping clinicians act earlier and with greater confidence when evaluating indeterminate strictures.
Moving from the biliary tree to the pancreas, autoimmune pancreatitis (AIP) is a benign fibro-inflammatory disease that often frustrates advanced endoscopists as it closely mimics the appearance of pancreatic ductal adenocarcinoma (PDAC). The stakes are high: despite modern diagnostic techniques, including advanced imaging, some patients with pancreatic resections for “suspected PDAC” are still found to have AIP on final pathology. Conventional tools to distinguish AIP from PDAC have gaps: serum IgG4 and EUS-guided biopsies are both specific but insensitive.
Using EUS videos and images of various pancreas pathologies at Mayo Clinic, we developed an AI to tackle this dilemma. After intensive training, the EUS AI achieved a greater accuracy for distinguishing AIP from PDAC than a group of expert Mayo clinic endosonographers.5 In practice, an EUS-AI can identify AIP patterns in real-time, guiding clinicians toward steroid trials or biopsies and reducing the need for unnecessary surgeries.
Looking ahead, there are multiple opportunities for integration of AI into advanced endoscopy practices. Ongoing research suggests that AI could soon assist with identification of pancreas cysts most at risk for malignant transformation, classification of high risk Barrett’s esophagus, and even help with rapid on-site assessment of cytologic specimens obtained during EUS. Beyond diagnosis, AI could likely play an important role in guiding therapeutic interventions. For example, an ERCP AI in the future may be able to provide cannulation assistance or an AI assistant could help endosonographers during deployments of lumen apposing metal stents.
By enhancing image interpretation and procedural consistency, AI has the potential to uphold the fundamental principle of primum non nocere, enabling us to intervene with precision while minimizing harm. AI can also bridge grey zones in clinical practice and narrow diagnostic uncertainty in real time. Importantly, these systems can help clinicians achieve expertise in a fraction of the time it traditionally takes to acquire comparable human proficiency, while offering wider availability across practice settings and reducing interobserver variability that has long challenged endoscopic interpretation.
Currently, adoption is limited by high bias risk, lack of external validation, and interpretability Still, the trajectory of AI suggests a future where these computer technologies will not only support but also elevate human expertise, reshaping the standards of care of diseases managed by advanced endoscopists.
Dr. Singh, Dr. Colletta, and Dr. Marya are based at the Division of Gastroenterology and Hepatology, UMass Chan Medical School, Worcester, Massachusetts. Dr. Marya is a consultant for Boston Scientific, and has no other disclosures. Dr. Singh and Dr. Colletta have no disclosures.
References
1. Navaneethan U, et al. Comparative effectiveness of biliary brush cytology and intraductal biopsy for detection of malignant biliary strictures: a systematic review and meta-analysis. Gastrointest Endosc. 2015 Jan. doi: 10.1016/j.gie.2014.09.017.
2. Stassen PMC, et al. Diagnostic accuracy and interobserver agreement of digital single-operator cholangioscopy for indeterminate biliary strictures. Gastrointest Endosc 2021 Dec. doi: 10.1016/j.gie.2021.06.027.
3. Marya NB, et al. Identification of patients with malignant biliary strictures using a cholangioscopy-based deep learning artificial intelligence (with video). Gastrointest Endosc. 2023 Feb. doi: 10.1016/j.gie.2022.08.021.
4. Marya NB, et al. Multicenter validation of a cholangioscopy artificial intelligence system for the evaluation of biliary tract disease. Endoscopy. 2025 Aug. doi: 10.1055/a-2650-0789.
5. Marya NB, et al. Utilisation of artificial intelligence for the development of an EUS-convolutional neural network model trained to enhance the diagnosis of autoimmune pancreatitis. Gut. 2021 Jul. doi: 10.1136/gutjnl-2020-322821.
AI in General GI and Endoscopy
BY DENNIS L. SHUNG, MD, MHS, PHD
The practice of gastroenterology is changing, but much of it will be rooted in the same – careful, focused attention on endoscopic procedures, and compassionate, attentive care in clinic. Artificial intelligence (AI), like the Industrial Revolution before, is going to transform our practice. This comes with upsides and downsides, and highlights the need for strong leadership from our societies to safeguard the technology for practitioners and patients.
What are the upsides?
AI has the potential to serve as a second set of eyes in detecting colon polyps, increasing the adenoma detection rate (ADR).1 AI can be applied to all areas of the gastrointestinal tract, providing digital biopsies, guiding resection, and ensuring quality, which are all now possible with powerful new endoscopy foundation models, such as GastroNet-5M.2
Additionally. the advent of automating the collection of data into reports may herald the end of our days as data entry clerks. Generative AI also has the potential to give us all the best information at our fingertips, suggesting guideline-based care, providing the most up to date evidence, and guiding the differential diagnosis. The potential for patient-facing AI systems could lead to better health literacy, more meaningful engagement, and improved patient satisfaction.3
What are the downsides?
For endoscopy, AI cannot make up for poor technique to ensure adequate mucosal exposure by the endoscopist, and an increase in AI-supported ADR does not yet convincingly translate into concrete gains in colorectal cancer-related mortality. For the foreseeable future, AI cannot make a connection with the patient in front of us, which is critical in diagnosing and treating patients.
Currently, AI appears to worsen loneliness4, and does not necessarily deepen the bonds or provide the positive touch that can heal, and which for many of us, was the reason we became physicians. Finally, as information proliferates, the information risk to patients and providers is growing – in the future, trusted sources to monitor, curate, and guide AI will be ever more important.
Black Swans
As AI begins to mature, there are risks that lurk beneath the surface. When regulatory bodies begin to look at AI-assisted diagnostics or therapeutics as the new standard of care, reimbursement models may adjust, and providers may be left behind. The rapid proliferation and haphazard adoption of AI could lead to overdependence and deskilling or result in weird and as yet unknown errors that are difficult to troubleshoot.
What is the role of the GI societies?
Specialty societies like AGA are taking leadership roles in determining the bounds of where AIs may tread, not just in providing information to their membership but also in digesting evidence and synthesizing recommendations. Societies must balance the real promise of AI in endoscopy with the practice realities for members, and provide living guidelines that reflect the consensus of members regarding scope of practice with the ability to update as new data become available.5
Societies also have a role as advocates for safety, taking ownership of high-quality content to prevent misinformation. AGA recently announced the development of a chat interface that will be focused on providing its members the highest quality information, and serve as a portal to identify and respond to its members’ information needs. By staying united rather than fragmenting, societies can maintain bounds to protect its members and their patients and advance areas where there is clinical need, together.
Dr. Shung is senior associate consultant, Division of Gastroenterology and Hepatology, and director of clinical generative artificial intelligence and informatics, Department of Medicine, at Mayo Clinic Rochester, Minnesota. He has no disclosures in regard to this article.
References
1. Soleymanjahi S, et al. Artificial Intelligence-Assisted Colonoscopy for Polyp Detection : A Systematic Review and Meta-analysis. Ann Intern Med. 2024 Dec. doi:10.7326/annals-24-00981.
2. Jong MR, et al. GastroNet-5M: A Multicenter Dataset for Developing Foundation Models in Gastrointestinal Endoscopy. Gastroenterology. 2025 Jul. doi: 10.1053/j.gastro.2025.07.030.
3. Soroush A, et al. Generative Artificial Intelligence in Clinical Medicine and Impact on Gastroenterology. Gastroenterology. 2025 Aug. doi: 10.1053/j.gastro.2025.03.038.
4. Mengying Fang C, et al. How AI and Human Behaviors Shape Psychosocial Effects of Extended Chatbot Use: A Longitudinal Randomized Controlled Study. arXiv e-prints. 2025 Mar. doi: 10.48550/arXiv.2503.17473.
5. Sultan S, et al. AGA Living Clinical Practice Guideline on Computer-Aided Detection-Assisted Colonoscopy. Gastroenterology. 2025 Apr. doi:10.1053/j.gastro.2025.01.002.
Dear colleagues,
Since our last Perspectives feature on artificial intelligence (AI) in gastroenterology and hepatology, the field has experienced remarkable growth in both innovation and clinical adoption. AI tools that were once conceptual are now entering everyday practice, with many more on the horizon poised to transform how we diagnose, treat, and manage patients.
Dr. Yuvaraj Singh, Dr. Alessandro Colletta, and Dr. Neil Marya discuss how purpose-built AI models can reduce diagnostic uncertainty in advanced endoscopy. From cholangioscopy systems that outperform standard ERCP sampling in distinguishing malignant biliary strictures to EUS-based platforms that differentiate autoimmune pancreatitis from pancreatic cancer, they envision a near-term future in which machine intelligence enhances accuracy, accelerates decision-making, and refines interpretation—without replacing the clinician’s expertise.
Complementing this, Dr. Dennis Shung takes a broader view across the endoscopy unit and outpatient clinic. He highlights the promise of AI for polyp detection, digital biopsy, and automated reporting, while underscoring the importance of human oversight, workflow integration, and safeguards against misinformation. Dr. Shung also emphasizes the pivotal role professional societies can play in establishing clear standards, ethical boundaries, and trusted frameworks for AI deployment in GI practice.
We hope these perspectives spark practical conversations about when—and how—to integrate AI in your own practice. As always, we welcome your feedback and real-world experience. Join the conversation on X at @AGA_GIHN.
Gyanprakash A. Ketwaroo, MD, MSc, is associate professor of medicine, Yale University, New Haven, and chief of endoscopy at West Haven VA Medical Center, both in Connecticut. He is an associate editor for GI & Hepatology News.
AI Models in Advanced Endoscopy
BY YUVARAJ SINGH, MD; ALESSANDRO COLLETTA, MD; NEIL MARYA, MD
As the adage goes, “if tumor is the rumor, then tissue is the issue, because cancer may be the answer.”
Establishing an accurate diagnosis is the essential first step toward curing or palliating malignancy. From detecting an early neoplastic lesion, to distinguishing between malignant and benign pathology, or to determining when and where to obtain tissue, endoscopists are frequently faced with the challenge of transforming diagnostic suspicion into certainty.
Artificial intelligence (AI), designed to replicate human cognition such as pattern recognition and decision-making, has emerged as a technology to assist gastroenterologists in addressing a variety of different tasks during endoscopy. AI research in gastrointestinal endoscopy has initially focused on computer-aided detection (CADe) of colorectal polyps. More recently, however, there has been increased emphasis on developing AI to assist advanced endoscopists.
For instance, in biliary endoscopy, AI is being explored to improve the notoriously challenging diagnosis of cholangiocarcinoma, where conventional tissue sampling often falls short of providing a definitive diagnosis. Similarly, in the pancreas, AI models are showing potential to differentiate autoimmune pancreatitis (AIP) from pancreatic ductal adenocarcinoma (PDAC), a distinction with profound therapeutic implications. Even pancreatic cysts are beginning to benefit from AI models that refine risk stratification and guide management. Together, these advances underscore how AI is not merely an adjunct but a potentially massive catalyst for reimagining the diagnostic role of advanced endoscopists.
Classifying biliary strictures (MBS) accurately remains a challenge. Standard ERCP-based sampling techniques (forceps biopsy and brush cytology) are suboptimal diagnostic tools with false negative rates for detecting MBS of less than 50%. The diagnostic uncertainty related to biliary stricture classification carries significant consequences for patients. For example, patients with biliary cancer without positive cytology have treatments delayed until a malignant diagnosis is established.
Ancillary technologies to enhance ERCP-based tissue acquisition are still weighed down by low sensitivity and accuracy; even with ancillary use of fluorescent in situ hybridization (FISH), diagnostic yield remains limited. EUS-FNA can help with distal biliary strictures, but this technique risks needle-tract seeding in cases of perihilar disease. Cholangioscopy allows for direct visualization and targeted sampling; however, cholangioscopy-guided forceps biopsies are burdened by low sensitivities.1 Additionally, physician interpretation of visual findings during cholangioscopy often suffers from poor interobserver agreement and poor accuracy.2
To improve the classification of biliary strictures, several groups have studied the application of AI for cholangioscopy footage of biliary pathology. In our lab, we trained an AI incorporating over 2.3 million cholangioscopy still images and nearly 20,000 expert-annotated frames to enhance its development. The AI closely mirrored expert labeling of cholangioscopy images of malignant pathology and, when tested on full cholangioscopy videos of indeterminate biliary strictures, the AI achieved a diagnostic accuracy of 91%—outperforming both brush cytology (63%) and forceps biopsy (61%).3
The results from this initial study were later validated across multiple centers. AI-assisted cholangioscopy could thus offer a reproducible, real-world solution to one of the most persistent diagnostic dilemmas advanced endoscopists face—helping clinicians act earlier and with greater confidence when evaluating indeterminate strictures.
Moving from the biliary tree to the pancreas, autoimmune pancreatitis (AIP) is a benign fibro-inflammatory disease that often frustrates advanced endoscopists as it closely mimics the appearance of pancreatic ductal adenocarcinoma (PDAC). The stakes are high: despite modern diagnostic techniques, including advanced imaging, some patients with pancreatic resections for “suspected PDAC” are still found to have AIP on final pathology. Conventional tools to distinguish AIP from PDAC have gaps: serum IgG4 and EUS-guided biopsies are both specific but insensitive.
Using EUS videos and images of various pancreas pathologies at Mayo Clinic, we developed an AI to tackle this dilemma. After intensive training, the EUS AI achieved a greater accuracy for distinguishing AIP from PDAC than a group of expert Mayo clinic endosonographers.5 In practice, an EUS-AI can identify AIP patterns in real-time, guiding clinicians toward steroid trials or biopsies and reducing the need for unnecessary surgeries.
Looking ahead, there are multiple opportunities for integration of AI into advanced endoscopy practices. Ongoing research suggests that AI could soon assist with identification of pancreas cysts most at risk for malignant transformation, classification of high risk Barrett’s esophagus, and even help with rapid on-site assessment of cytologic specimens obtained during EUS. Beyond diagnosis, AI could likely play an important role in guiding therapeutic interventions. For example, an ERCP AI in the future may be able to provide cannulation assistance or an AI assistant could help endosonographers during deployments of lumen apposing metal stents.
By enhancing image interpretation and procedural consistency, AI has the potential to uphold the fundamental principle of primum non nocere, enabling us to intervene with precision while minimizing harm. AI can also bridge grey zones in clinical practice and narrow diagnostic uncertainty in real time. Importantly, these systems can help clinicians achieve expertise in a fraction of the time it traditionally takes to acquire comparable human proficiency, while offering wider availability across practice settings and reducing interobserver variability that has long challenged endoscopic interpretation.
Currently, adoption is limited by high bias risk, lack of external validation, and interpretability Still, the trajectory of AI suggests a future where these computer technologies will not only support but also elevate human expertise, reshaping the standards of care of diseases managed by advanced endoscopists.
Dr. Singh, Dr. Colletta, and Dr. Marya are based at the Division of Gastroenterology and Hepatology, UMass Chan Medical School, Worcester, Massachusetts. Dr. Marya is a consultant for Boston Scientific, and has no other disclosures. Dr. Singh and Dr. Colletta have no disclosures.
References
1. Navaneethan U, et al. Comparative effectiveness of biliary brush cytology and intraductal biopsy for detection of malignant biliary strictures: a systematic review and meta-analysis. Gastrointest Endosc. 2015 Jan. doi: 10.1016/j.gie.2014.09.017.
2. Stassen PMC, et al. Diagnostic accuracy and interobserver agreement of digital single-operator cholangioscopy for indeterminate biliary strictures. Gastrointest Endosc 2021 Dec. doi: 10.1016/j.gie.2021.06.027.
3. Marya NB, et al. Identification of patients with malignant biliary strictures using a cholangioscopy-based deep learning artificial intelligence (with video). Gastrointest Endosc. 2023 Feb. doi: 10.1016/j.gie.2022.08.021.
4. Marya NB, et al. Multicenter validation of a cholangioscopy artificial intelligence system for the evaluation of biliary tract disease. Endoscopy. 2025 Aug. doi: 10.1055/a-2650-0789.
5. Marya NB, et al. Utilisation of artificial intelligence for the development of an EUS-convolutional neural network model trained to enhance the diagnosis of autoimmune pancreatitis. Gut. 2021 Jul. doi: 10.1136/gutjnl-2020-322821.
AI in General GI and Endoscopy
BY DENNIS L. SHUNG, MD, MHS, PHD
The practice of gastroenterology is changing, but much of it will be rooted in the same – careful, focused attention on endoscopic procedures, and compassionate, attentive care in clinic. Artificial intelligence (AI), like the Industrial Revolution before, is going to transform our practice. This comes with upsides and downsides, and highlights the need for strong leadership from our societies to safeguard the technology for practitioners and patients.
What are the upsides?
AI has the potential to serve as a second set of eyes in detecting colon polyps, increasing the adenoma detection rate (ADR).1 AI can be applied to all areas of the gastrointestinal tract, providing digital biopsies, guiding resection, and ensuring quality, which are all now possible with powerful new endoscopy foundation models, such as GastroNet-5M.2
Additionally. the advent of automating the collection of data into reports may herald the end of our days as data entry clerks. Generative AI also has the potential to give us all the best information at our fingertips, suggesting guideline-based care, providing the most up to date evidence, and guiding the differential diagnosis. The potential for patient-facing AI systems could lead to better health literacy, more meaningful engagement, and improved patient satisfaction.3
What are the downsides?
For endoscopy, AI cannot make up for poor technique to ensure adequate mucosal exposure by the endoscopist, and an increase in AI-supported ADR does not yet convincingly translate into concrete gains in colorectal cancer-related mortality. For the foreseeable future, AI cannot make a connection with the patient in front of us, which is critical in diagnosing and treating patients.
Currently, AI appears to worsen loneliness4, and does not necessarily deepen the bonds or provide the positive touch that can heal, and which for many of us, was the reason we became physicians. Finally, as information proliferates, the information risk to patients and providers is growing – in the future, trusted sources to monitor, curate, and guide AI will be ever more important.
Black Swans
As AI begins to mature, there are risks that lurk beneath the surface. When regulatory bodies begin to look at AI-assisted diagnostics or therapeutics as the new standard of care, reimbursement models may adjust, and providers may be left behind. The rapid proliferation and haphazard adoption of AI could lead to overdependence and deskilling or result in weird and as yet unknown errors that are difficult to troubleshoot.
What is the role of the GI societies?
Specialty societies like AGA are taking leadership roles in determining the bounds of where AIs may tread, not just in providing information to their membership but also in digesting evidence and synthesizing recommendations. Societies must balance the real promise of AI in endoscopy with the practice realities for members, and provide living guidelines that reflect the consensus of members regarding scope of practice with the ability to update as new data become available.5
Societies also have a role as advocates for safety, taking ownership of high-quality content to prevent misinformation. AGA recently announced the development of a chat interface that will be focused on providing its members the highest quality information, and serve as a portal to identify and respond to its members’ information needs. By staying united rather than fragmenting, societies can maintain bounds to protect its members and their patients and advance areas where there is clinical need, together.
Dr. Shung is senior associate consultant, Division of Gastroenterology and Hepatology, and director of clinical generative artificial intelligence and informatics, Department of Medicine, at Mayo Clinic Rochester, Minnesota. He has no disclosures in regard to this article.
References
1. Soleymanjahi S, et al. Artificial Intelligence-Assisted Colonoscopy for Polyp Detection : A Systematic Review and Meta-analysis. Ann Intern Med. 2024 Dec. doi:10.7326/annals-24-00981.
2. Jong MR, et al. GastroNet-5M: A Multicenter Dataset for Developing Foundation Models in Gastrointestinal Endoscopy. Gastroenterology. 2025 Jul. doi: 10.1053/j.gastro.2025.07.030.
3. Soroush A, et al. Generative Artificial Intelligence in Clinical Medicine and Impact on Gastroenterology. Gastroenterology. 2025 Aug. doi: 10.1053/j.gastro.2025.03.038.
4. Mengying Fang C, et al. How AI and Human Behaviors Shape Psychosocial Effects of Extended Chatbot Use: A Longitudinal Randomized Controlled Study. arXiv e-prints. 2025 Mar. doi: 10.48550/arXiv.2503.17473.
5. Sultan S, et al. AGA Living Clinical Practice Guideline on Computer-Aided Detection-Assisted Colonoscopy. Gastroenterology. 2025 Apr. doi:10.1053/j.gastro.2025.01.002.
Dear colleagues,
Since our last Perspectives feature on artificial intelligence (AI) in gastroenterology and hepatology, the field has experienced remarkable growth in both innovation and clinical adoption. AI tools that were once conceptual are now entering everyday practice, with many more on the horizon poised to transform how we diagnose, treat, and manage patients.
Dr. Yuvaraj Singh, Dr. Alessandro Colletta, and Dr. Neil Marya discuss how purpose-built AI models can reduce diagnostic uncertainty in advanced endoscopy. From cholangioscopy systems that outperform standard ERCP sampling in distinguishing malignant biliary strictures to EUS-based platforms that differentiate autoimmune pancreatitis from pancreatic cancer, they envision a near-term future in which machine intelligence enhances accuracy, accelerates decision-making, and refines interpretation—without replacing the clinician’s expertise.
Complementing this, Dr. Dennis Shung takes a broader view across the endoscopy unit and outpatient clinic. He highlights the promise of AI for polyp detection, digital biopsy, and automated reporting, while underscoring the importance of human oversight, workflow integration, and safeguards against misinformation. Dr. Shung also emphasizes the pivotal role professional societies can play in establishing clear standards, ethical boundaries, and trusted frameworks for AI deployment in GI practice.
We hope these perspectives spark practical conversations about when—and how—to integrate AI in your own practice. As always, we welcome your feedback and real-world experience. Join the conversation on X at @AGA_GIHN.
Gyanprakash A. Ketwaroo, MD, MSc, is associate professor of medicine, Yale University, New Haven, and chief of endoscopy at West Haven VA Medical Center, both in Connecticut. He is an associate editor for GI & Hepatology News.
AI Models in Advanced Endoscopy
BY YUVARAJ SINGH, MD; ALESSANDRO COLLETTA, MD; NEIL MARYA, MD
As the adage goes, “if tumor is the rumor, then tissue is the issue, because cancer may be the answer.”
Establishing an accurate diagnosis is the essential first step toward curing or palliating malignancy. From detecting an early neoplastic lesion, to distinguishing between malignant and benign pathology, or to determining when and where to obtain tissue, endoscopists are frequently faced with the challenge of transforming diagnostic suspicion into certainty.
Artificial intelligence (AI), designed to replicate human cognition such as pattern recognition and decision-making, has emerged as a technology to assist gastroenterologists in addressing a variety of different tasks during endoscopy. AI research in gastrointestinal endoscopy has initially focused on computer-aided detection (CADe) of colorectal polyps. More recently, however, there has been increased emphasis on developing AI to assist advanced endoscopists.
For instance, in biliary endoscopy, AI is being explored to improve the notoriously challenging diagnosis of cholangiocarcinoma, where conventional tissue sampling often falls short of providing a definitive diagnosis. Similarly, in the pancreas, AI models are showing potential to differentiate autoimmune pancreatitis (AIP) from pancreatic ductal adenocarcinoma (PDAC), a distinction with profound therapeutic implications. Even pancreatic cysts are beginning to benefit from AI models that refine risk stratification and guide management. Together, these advances underscore how AI is not merely an adjunct but a potentially massive catalyst for reimagining the diagnostic role of advanced endoscopists.
Classifying biliary strictures (MBS) accurately remains a challenge. Standard ERCP-based sampling techniques (forceps biopsy and brush cytology) are suboptimal diagnostic tools with false negative rates for detecting MBS of less than 50%. The diagnostic uncertainty related to biliary stricture classification carries significant consequences for patients. For example, patients with biliary cancer without positive cytology have treatments delayed until a malignant diagnosis is established.
Ancillary technologies to enhance ERCP-based tissue acquisition are still weighed down by low sensitivity and accuracy; even with ancillary use of fluorescent in situ hybridization (FISH), diagnostic yield remains limited. EUS-FNA can help with distal biliary strictures, but this technique risks needle-tract seeding in cases of perihilar disease. Cholangioscopy allows for direct visualization and targeted sampling; however, cholangioscopy-guided forceps biopsies are burdened by low sensitivities.1 Additionally, physician interpretation of visual findings during cholangioscopy often suffers from poor interobserver agreement and poor accuracy.2
To improve the classification of biliary strictures, several groups have studied the application of AI for cholangioscopy footage of biliary pathology. In our lab, we trained an AI incorporating over 2.3 million cholangioscopy still images and nearly 20,000 expert-annotated frames to enhance its development. The AI closely mirrored expert labeling of cholangioscopy images of malignant pathology and, when tested on full cholangioscopy videos of indeterminate biliary strictures, the AI achieved a diagnostic accuracy of 91%—outperforming both brush cytology (63%) and forceps biopsy (61%).3
The results from this initial study were later validated across multiple centers. AI-assisted cholangioscopy could thus offer a reproducible, real-world solution to one of the most persistent diagnostic dilemmas advanced endoscopists face—helping clinicians act earlier and with greater confidence when evaluating indeterminate strictures.
Moving from the biliary tree to the pancreas, autoimmune pancreatitis (AIP) is a benign fibro-inflammatory disease that often frustrates advanced endoscopists as it closely mimics the appearance of pancreatic ductal adenocarcinoma (PDAC). The stakes are high: despite modern diagnostic techniques, including advanced imaging, some patients with pancreatic resections for “suspected PDAC” are still found to have AIP on final pathology. Conventional tools to distinguish AIP from PDAC have gaps: serum IgG4 and EUS-guided biopsies are both specific but insensitive.
Using EUS videos and images of various pancreas pathologies at Mayo Clinic, we developed an AI to tackle this dilemma. After intensive training, the EUS AI achieved a greater accuracy for distinguishing AIP from PDAC than a group of expert Mayo clinic endosonographers.5 In practice, an EUS-AI can identify AIP patterns in real-time, guiding clinicians toward steroid trials or biopsies and reducing the need for unnecessary surgeries.
Looking ahead, there are multiple opportunities for integration of AI into advanced endoscopy practices. Ongoing research suggests that AI could soon assist with identification of pancreas cysts most at risk for malignant transformation, classification of high risk Barrett’s esophagus, and even help with rapid on-site assessment of cytologic specimens obtained during EUS. Beyond diagnosis, AI could likely play an important role in guiding therapeutic interventions. For example, an ERCP AI in the future may be able to provide cannulation assistance or an AI assistant could help endosonographers during deployments of lumen apposing metal stents.
By enhancing image interpretation and procedural consistency, AI has the potential to uphold the fundamental principle of primum non nocere, enabling us to intervene with precision while minimizing harm. AI can also bridge grey zones in clinical practice and narrow diagnostic uncertainty in real time. Importantly, these systems can help clinicians achieve expertise in a fraction of the time it traditionally takes to acquire comparable human proficiency, while offering wider availability across practice settings and reducing interobserver variability that has long challenged endoscopic interpretation.
Currently, adoption is limited by high bias risk, lack of external validation, and interpretability Still, the trajectory of AI suggests a future where these computer technologies will not only support but also elevate human expertise, reshaping the standards of care of diseases managed by advanced endoscopists.
Dr. Singh, Dr. Colletta, and Dr. Marya are based at the Division of Gastroenterology and Hepatology, UMass Chan Medical School, Worcester, Massachusetts. Dr. Marya is a consultant for Boston Scientific, and has no other disclosures. Dr. Singh and Dr. Colletta have no disclosures.
References
1. Navaneethan U, et al. Comparative effectiveness of biliary brush cytology and intraductal biopsy for detection of malignant biliary strictures: a systematic review and meta-analysis. Gastrointest Endosc. 2015 Jan. doi: 10.1016/j.gie.2014.09.017.
2. Stassen PMC, et al. Diagnostic accuracy and interobserver agreement of digital single-operator cholangioscopy for indeterminate biliary strictures. Gastrointest Endosc 2021 Dec. doi: 10.1016/j.gie.2021.06.027.
3. Marya NB, et al. Identification of patients with malignant biliary strictures using a cholangioscopy-based deep learning artificial intelligence (with video). Gastrointest Endosc. 2023 Feb. doi: 10.1016/j.gie.2022.08.021.
4. Marya NB, et al. Multicenter validation of a cholangioscopy artificial intelligence system for the evaluation of biliary tract disease. Endoscopy. 2025 Aug. doi: 10.1055/a-2650-0789.
5. Marya NB, et al. Utilisation of artificial intelligence for the development of an EUS-convolutional neural network model trained to enhance the diagnosis of autoimmune pancreatitis. Gut. 2021 Jul. doi: 10.1136/gutjnl-2020-322821.
AI in General GI and Endoscopy
BY DENNIS L. SHUNG, MD, MHS, PHD
The practice of gastroenterology is changing, but much of it will be rooted in the same – careful, focused attention on endoscopic procedures, and compassionate, attentive care in clinic. Artificial intelligence (AI), like the Industrial Revolution before, is going to transform our practice. This comes with upsides and downsides, and highlights the need for strong leadership from our societies to safeguard the technology for practitioners and patients.
What are the upsides?
AI has the potential to serve as a second set of eyes in detecting colon polyps, increasing the adenoma detection rate (ADR).1 AI can be applied to all areas of the gastrointestinal tract, providing digital biopsies, guiding resection, and ensuring quality, which are all now possible with powerful new endoscopy foundation models, such as GastroNet-5M.2
Additionally. the advent of automating the collection of data into reports may herald the end of our days as data entry clerks. Generative AI also has the potential to give us all the best information at our fingertips, suggesting guideline-based care, providing the most up to date evidence, and guiding the differential diagnosis. The potential for patient-facing AI systems could lead to better health literacy, more meaningful engagement, and improved patient satisfaction.3
What are the downsides?
For endoscopy, AI cannot make up for poor technique to ensure adequate mucosal exposure by the endoscopist, and an increase in AI-supported ADR does not yet convincingly translate into concrete gains in colorectal cancer-related mortality. For the foreseeable future, AI cannot make a connection with the patient in front of us, which is critical in diagnosing and treating patients.
Currently, AI appears to worsen loneliness4, and does not necessarily deepen the bonds or provide the positive touch that can heal, and which for many of us, was the reason we became physicians. Finally, as information proliferates, the information risk to patients and providers is growing – in the future, trusted sources to monitor, curate, and guide AI will be ever more important.
Black Swans
As AI begins to mature, there are risks that lurk beneath the surface. When regulatory bodies begin to look at AI-assisted diagnostics or therapeutics as the new standard of care, reimbursement models may adjust, and providers may be left behind. The rapid proliferation and haphazard adoption of AI could lead to overdependence and deskilling or result in weird and as yet unknown errors that are difficult to troubleshoot.
What is the role of the GI societies?
Specialty societies like AGA are taking leadership roles in determining the bounds of where AIs may tread, not just in providing information to their membership but also in digesting evidence and synthesizing recommendations. Societies must balance the real promise of AI in endoscopy with the practice realities for members, and provide living guidelines that reflect the consensus of members regarding scope of practice with the ability to update as new data become available.5
Societies also have a role as advocates for safety, taking ownership of high-quality content to prevent misinformation. AGA recently announced the development of a chat interface that will be focused on providing its members the highest quality information, and serve as a portal to identify and respond to its members’ information needs. By staying united rather than fragmenting, societies can maintain bounds to protect its members and their patients and advance areas where there is clinical need, together.
Dr. Shung is senior associate consultant, Division of Gastroenterology and Hepatology, and director of clinical generative artificial intelligence and informatics, Department of Medicine, at Mayo Clinic Rochester, Minnesota. He has no disclosures in regard to this article.
References
1. Soleymanjahi S, et al. Artificial Intelligence-Assisted Colonoscopy for Polyp Detection : A Systematic Review and Meta-analysis. Ann Intern Med. 2024 Dec. doi:10.7326/annals-24-00981.
2. Jong MR, et al. GastroNet-5M: A Multicenter Dataset for Developing Foundation Models in Gastrointestinal Endoscopy. Gastroenterology. 2025 Jul. doi: 10.1053/j.gastro.2025.07.030.
3. Soroush A, et al. Generative Artificial Intelligence in Clinical Medicine and Impact on Gastroenterology. Gastroenterology. 2025 Aug. doi: 10.1053/j.gastro.2025.03.038.
4. Mengying Fang C, et al. How AI and Human Behaviors Shape Psychosocial Effects of Extended Chatbot Use: A Longitudinal Randomized Controlled Study. arXiv e-prints. 2025 Mar. doi: 10.48550/arXiv.2503.17473.
5. Sultan S, et al. AGA Living Clinical Practice Guideline on Computer-Aided Detection-Assisted Colonoscopy. Gastroenterology. 2025 Apr. doi:10.1053/j.gastro.2025.01.002.
Combining Upper-Lower GI Screening Feasible, Effective
BERLIN — , including malignancies and lesions requiring ongoing surveillance, according to an interim analysis from the TOGAS study.
“There was an abundance of benign but clinically relevant findings,” said lead investigator Jan Bornschein, MD, gastroenterologist at Oxford University Hospitals NHS Foundation Trust, Oxford, England, who presented the interim resuts of the study at United European Gastroenterology (UEG) Week 2025.
While the study found upper GI neoplasia in only 1.4% of participants, 17.8% of individuals were marked for upper GI endoscopic surveillance.
The results may inform how Europe develops gastric cancer prevention programs alongside those for colorectal cancer, said Bornschein. “If we can combine the upper GI endoscopy with other modalities [colonoscopy], the more likelihood there is that you can have a one-stop test package,” he said. “A combination, particularly for bowel and stomach, is more feasible and also more cost-effective. So far, the findings show that it’s definitely a strategy that, in my opinion, is worth implementing.”
Bornschein and the TOGAS study group hope that the combined approach will prove workable across diverse European settings and will help identify a spectrum of upper GI pathology, from cancers and dysplasia to atrophy and intestinal metaplasia, that can meaningfully affect follow-up surveillance.
Mixed Rates of GI Cancers Across Europe and the US
These findings come amid data showing rising rates of early-onset (younger than 50 years) GI cancers in the US, including colorectal, gastric, pancreatic, and esophageal tumors. These trends, previously reported by this news organization, point to environmental and lifestyle drivers, strengthening the case for earlier detection and risk-tailored strategies for upper GI neoplasia and preneoplastic conditions detected during existing colorectal cancer screening pathways.
However, Bornschein noted that prevalence varies considerably across Europe. “There are areas, particularly in the Eastern regions, and in some parts of the West, for example, Portugal, that have a very high incidence of GI cancers. In the UK or in Germany, we have noticed a decline over the years, so the numbers are actually much better than they used to be.”
The study is the second in a series of three TOGAS pilot studies and was conducted across eight centers (France, Germany, Ireland, Latvia, Lithuania, the Netherlands, Portugal, and Spain) in adults aged 50-74 years attending screening or polyp-surveillance colonoscopy.
A European Society of Gastrointestinal Endoscopy-aligned protocol defining image documentation, biopsy sampling, and quality parameters was followed to ensure a standardized approach. “Marked preneoplastic change” was defined as gastric glandular atrophy or intestinal metaplasia at the Operative Link on Gastritis Assessment/Operative Link on Gastric Intestinal Metaplasia Assessment stage III-IV and/or Endoscopic Grading of Gastric Intestinal Metaplasia > 5, triggering a need for endoscopic surveillance.
Data were gathered on colonoscopy findings (including polyp surveillance and family history), EGD findings plus biopsies, serum pepsinogen, and Helicobacter pylori serology. Outcome measures included the prevalence of gastric cancer and preneoplastic conditions, the diagnostic accuracy of pepsinogen testing, comparisons between national settings, the relevance of upper endoscopy in fecal immunochemical test-positive cases, and overall H pylori prevalence.
Neoplasia and Preneoplasia Found
A total of 846 participants were analyzed. At baseline, the mean age was 62 years, 52.2% were men, and 84.2% were White, despite efforts to recruit a more diverse population. Around 390 participants drank alcohol, and 190 smoked tobacco.
A total of 37.8% of participants had undergone prior EGD, of which 94.7% were performed more than 3 years before the study start. The history of GI surgery was 13.7%, and the history of cancer was 14.5%. Around 11% took aspirin, and 14% took proton pump inhibitors (PPIs). “We were surprised at the low prevalence of PPI use,” remarked Bornschein. “It was also good news that around half were never smokers.”
Key results for upper GI neoplasia included six patients (0.7%) with gastric cancers, three (0.4%) with esophageal cancers, and five (0.6%) with duodenal tumors. H pylori positivity was found in 303 patients (35.8%), with an additional 81 (9.6%) reporting a history of eradication.
Colorectal findings included 15 patients (1.8%) with cancers and colon polyps in 503 (59.5%) participants.
Regarding preneoplastic conditions, endoscopy identified intestinal metaplasia in 174 patients (20.6%), of which 65 (7.7%) were multifocal. Atrophy was observed in 220 patients (26.0%), with 59 (7.0%) showing multifocal atrophic changes. Both intestinal metaplasia and atrophy were found together in 105 (12.4%) patients. Barrett’s esophagus was detected in 31 (3.7%) patients.
“I’d really like to highlight these further benign gastric findings,” said Bornschein. These included gastric ulcers in 28 (3.3%) patients, erosive gastritis in 245 (29.0%) patients, esophageal ulcers in three (0.4%) patients, Los Angeles Community College District classification esophagitis in 13 (1.5%) patients, and duodenal ulcers in 10 (1.2%) patients. “These were asymptomatic, but we were able to identify them,” he noted.
“We’ve had a very low rate of complications (0.01%),” he added.” I don’t want to jinx that now. These were basically related to sedation.”
PROSPERO: Early Detection of Upper GI Conditions in a UK Population
Massimiliano di Pietro, MD, consultant gastroenterologist at Addenbrooke’s Hospital, Cambridge, England, and the principal investigator of the PROSPERO study, which aimed to determine the prevalence of premalignant upper GI conditions in routine endoscopy in the UK, commented on the findings. The TOGAS study focuses on asymptomatic individuals referred for colonoscopy and examines the value of performing an upper GI endoscopy at the same time, he explained. “This approach might identify upper GI conditions that require monitoring, in particular early cancer.”
“On the other hand, the PROSPERO study focuses on patients referred for upper GI symptoms and diagnosis,” he said. Preliminary data from that study, presented during the same session as the TOGAS trial, showed a 13.6% prevalence of premalignant upper GI conditions in a symptomatic UK patient population referred for endoscopy.
“In some respects, the findings were similar, particularly the rate of upper GI cancer at 1.4%, although there were differences in the prevalence of premalignant conditions,” he noted. “This may be explained by the fact that TOGAS is a European study, while PROSPERO is UK-based, where the distribution of upper GI cancers differs, with more esophageal adenocarcinoma vs gastric adenocarcinoma.”
Reflecting on both of the studies, Di Pietro said they are “really important in fulfilling an unmet need in the quality of upper GI endoscopy. Currently, there are no diagnostic quality indicators in upper GI endoscopy, so it’s difficult to rate the performance of endoscopists in the same way as we can in lower GI. It’s really important to understand the population prevalence, both in symptomatic and asymptomatic individuals, of premalignant and malignant upper GI conditions.”
TOGAS 2 is recruiting until February 2026, with 1200 of a potential 1600 participants recruited to date. The data will be used for implementation modeling and to inform quality indicators for future screening programs. Final results and plans for a follow-up study are expected in 2026.
Bornschein declared receiving advisory and speaker fees from Flynn Pharma and Juvisé Pharmaceuticals. Di Pietro reported having no disclosures relevant to the studies discussed.
A version of this article first appeared on Medscape.com.
BERLIN — , including malignancies and lesions requiring ongoing surveillance, according to an interim analysis from the TOGAS study.
“There was an abundance of benign but clinically relevant findings,” said lead investigator Jan Bornschein, MD, gastroenterologist at Oxford University Hospitals NHS Foundation Trust, Oxford, England, who presented the interim resuts of the study at United European Gastroenterology (UEG) Week 2025.
While the study found upper GI neoplasia in only 1.4% of participants, 17.8% of individuals were marked for upper GI endoscopic surveillance.
The results may inform how Europe develops gastric cancer prevention programs alongside those for colorectal cancer, said Bornschein. “If we can combine the upper GI endoscopy with other modalities [colonoscopy], the more likelihood there is that you can have a one-stop test package,” he said. “A combination, particularly for bowel and stomach, is more feasible and also more cost-effective. So far, the findings show that it’s definitely a strategy that, in my opinion, is worth implementing.”
Bornschein and the TOGAS study group hope that the combined approach will prove workable across diverse European settings and will help identify a spectrum of upper GI pathology, from cancers and dysplasia to atrophy and intestinal metaplasia, that can meaningfully affect follow-up surveillance.
Mixed Rates of GI Cancers Across Europe and the US
These findings come amid data showing rising rates of early-onset (younger than 50 years) GI cancers in the US, including colorectal, gastric, pancreatic, and esophageal tumors. These trends, previously reported by this news organization, point to environmental and lifestyle drivers, strengthening the case for earlier detection and risk-tailored strategies for upper GI neoplasia and preneoplastic conditions detected during existing colorectal cancer screening pathways.
However, Bornschein noted that prevalence varies considerably across Europe. “There are areas, particularly in the Eastern regions, and in some parts of the West, for example, Portugal, that have a very high incidence of GI cancers. In the UK or in Germany, we have noticed a decline over the years, so the numbers are actually much better than they used to be.”
The study is the second in a series of three TOGAS pilot studies and was conducted across eight centers (France, Germany, Ireland, Latvia, Lithuania, the Netherlands, Portugal, and Spain) in adults aged 50-74 years attending screening or polyp-surveillance colonoscopy.
A European Society of Gastrointestinal Endoscopy-aligned protocol defining image documentation, biopsy sampling, and quality parameters was followed to ensure a standardized approach. “Marked preneoplastic change” was defined as gastric glandular atrophy or intestinal metaplasia at the Operative Link on Gastritis Assessment/Operative Link on Gastric Intestinal Metaplasia Assessment stage III-IV and/or Endoscopic Grading of Gastric Intestinal Metaplasia > 5, triggering a need for endoscopic surveillance.
Data were gathered on colonoscopy findings (including polyp surveillance and family history), EGD findings plus biopsies, serum pepsinogen, and Helicobacter pylori serology. Outcome measures included the prevalence of gastric cancer and preneoplastic conditions, the diagnostic accuracy of pepsinogen testing, comparisons between national settings, the relevance of upper endoscopy in fecal immunochemical test-positive cases, and overall H pylori prevalence.
Neoplasia and Preneoplasia Found
A total of 846 participants were analyzed. At baseline, the mean age was 62 years, 52.2% were men, and 84.2% were White, despite efforts to recruit a more diverse population. Around 390 participants drank alcohol, and 190 smoked tobacco.
A total of 37.8% of participants had undergone prior EGD, of which 94.7% were performed more than 3 years before the study start. The history of GI surgery was 13.7%, and the history of cancer was 14.5%. Around 11% took aspirin, and 14% took proton pump inhibitors (PPIs). “We were surprised at the low prevalence of PPI use,” remarked Bornschein. “It was also good news that around half were never smokers.”
Key results for upper GI neoplasia included six patients (0.7%) with gastric cancers, three (0.4%) with esophageal cancers, and five (0.6%) with duodenal tumors. H pylori positivity was found in 303 patients (35.8%), with an additional 81 (9.6%) reporting a history of eradication.
Colorectal findings included 15 patients (1.8%) with cancers and colon polyps in 503 (59.5%) participants.
Regarding preneoplastic conditions, endoscopy identified intestinal metaplasia in 174 patients (20.6%), of which 65 (7.7%) were multifocal. Atrophy was observed in 220 patients (26.0%), with 59 (7.0%) showing multifocal atrophic changes. Both intestinal metaplasia and atrophy were found together in 105 (12.4%) patients. Barrett’s esophagus was detected in 31 (3.7%) patients.
“I’d really like to highlight these further benign gastric findings,” said Bornschein. These included gastric ulcers in 28 (3.3%) patients, erosive gastritis in 245 (29.0%) patients, esophageal ulcers in three (0.4%) patients, Los Angeles Community College District classification esophagitis in 13 (1.5%) patients, and duodenal ulcers in 10 (1.2%) patients. “These were asymptomatic, but we were able to identify them,” he noted.
“We’ve had a very low rate of complications (0.01%),” he added.” I don’t want to jinx that now. These were basically related to sedation.”
PROSPERO: Early Detection of Upper GI Conditions in a UK Population
Massimiliano di Pietro, MD, consultant gastroenterologist at Addenbrooke’s Hospital, Cambridge, England, and the principal investigator of the PROSPERO study, which aimed to determine the prevalence of premalignant upper GI conditions in routine endoscopy in the UK, commented on the findings. The TOGAS study focuses on asymptomatic individuals referred for colonoscopy and examines the value of performing an upper GI endoscopy at the same time, he explained. “This approach might identify upper GI conditions that require monitoring, in particular early cancer.”
“On the other hand, the PROSPERO study focuses on patients referred for upper GI symptoms and diagnosis,” he said. Preliminary data from that study, presented during the same session as the TOGAS trial, showed a 13.6% prevalence of premalignant upper GI conditions in a symptomatic UK patient population referred for endoscopy.
“In some respects, the findings were similar, particularly the rate of upper GI cancer at 1.4%, although there were differences in the prevalence of premalignant conditions,” he noted. “This may be explained by the fact that TOGAS is a European study, while PROSPERO is UK-based, where the distribution of upper GI cancers differs, with more esophageal adenocarcinoma vs gastric adenocarcinoma.”
Reflecting on both of the studies, Di Pietro said they are “really important in fulfilling an unmet need in the quality of upper GI endoscopy. Currently, there are no diagnostic quality indicators in upper GI endoscopy, so it’s difficult to rate the performance of endoscopists in the same way as we can in lower GI. It’s really important to understand the population prevalence, both in symptomatic and asymptomatic individuals, of premalignant and malignant upper GI conditions.”
TOGAS 2 is recruiting until February 2026, with 1200 of a potential 1600 participants recruited to date. The data will be used for implementation modeling and to inform quality indicators for future screening programs. Final results and plans for a follow-up study are expected in 2026.
Bornschein declared receiving advisory and speaker fees from Flynn Pharma and Juvisé Pharmaceuticals. Di Pietro reported having no disclosures relevant to the studies discussed.
A version of this article first appeared on Medscape.com.
BERLIN — , including malignancies and lesions requiring ongoing surveillance, according to an interim analysis from the TOGAS study.
“There was an abundance of benign but clinically relevant findings,” said lead investigator Jan Bornschein, MD, gastroenterologist at Oxford University Hospitals NHS Foundation Trust, Oxford, England, who presented the interim resuts of the study at United European Gastroenterology (UEG) Week 2025.
While the study found upper GI neoplasia in only 1.4% of participants, 17.8% of individuals were marked for upper GI endoscopic surveillance.
The results may inform how Europe develops gastric cancer prevention programs alongside those for colorectal cancer, said Bornschein. “If we can combine the upper GI endoscopy with other modalities [colonoscopy], the more likelihood there is that you can have a one-stop test package,” he said. “A combination, particularly for bowel and stomach, is more feasible and also more cost-effective. So far, the findings show that it’s definitely a strategy that, in my opinion, is worth implementing.”
Bornschein and the TOGAS study group hope that the combined approach will prove workable across diverse European settings and will help identify a spectrum of upper GI pathology, from cancers and dysplasia to atrophy and intestinal metaplasia, that can meaningfully affect follow-up surveillance.
Mixed Rates of GI Cancers Across Europe and the US
These findings come amid data showing rising rates of early-onset (younger than 50 years) GI cancers in the US, including colorectal, gastric, pancreatic, and esophageal tumors. These trends, previously reported by this news organization, point to environmental and lifestyle drivers, strengthening the case for earlier detection and risk-tailored strategies for upper GI neoplasia and preneoplastic conditions detected during existing colorectal cancer screening pathways.
However, Bornschein noted that prevalence varies considerably across Europe. “There are areas, particularly in the Eastern regions, and in some parts of the West, for example, Portugal, that have a very high incidence of GI cancers. In the UK or in Germany, we have noticed a decline over the years, so the numbers are actually much better than they used to be.”
The study is the second in a series of three TOGAS pilot studies and was conducted across eight centers (France, Germany, Ireland, Latvia, Lithuania, the Netherlands, Portugal, and Spain) in adults aged 50-74 years attending screening or polyp-surveillance colonoscopy.
A European Society of Gastrointestinal Endoscopy-aligned protocol defining image documentation, biopsy sampling, and quality parameters was followed to ensure a standardized approach. “Marked preneoplastic change” was defined as gastric glandular atrophy or intestinal metaplasia at the Operative Link on Gastritis Assessment/Operative Link on Gastric Intestinal Metaplasia Assessment stage III-IV and/or Endoscopic Grading of Gastric Intestinal Metaplasia > 5, triggering a need for endoscopic surveillance.
Data were gathered on colonoscopy findings (including polyp surveillance and family history), EGD findings plus biopsies, serum pepsinogen, and Helicobacter pylori serology. Outcome measures included the prevalence of gastric cancer and preneoplastic conditions, the diagnostic accuracy of pepsinogen testing, comparisons between national settings, the relevance of upper endoscopy in fecal immunochemical test-positive cases, and overall H pylori prevalence.
Neoplasia and Preneoplasia Found
A total of 846 participants were analyzed. At baseline, the mean age was 62 years, 52.2% were men, and 84.2% were White, despite efforts to recruit a more diverse population. Around 390 participants drank alcohol, and 190 smoked tobacco.
A total of 37.8% of participants had undergone prior EGD, of which 94.7% were performed more than 3 years before the study start. The history of GI surgery was 13.7%, and the history of cancer was 14.5%. Around 11% took aspirin, and 14% took proton pump inhibitors (PPIs). “We were surprised at the low prevalence of PPI use,” remarked Bornschein. “It was also good news that around half were never smokers.”
Key results for upper GI neoplasia included six patients (0.7%) with gastric cancers, three (0.4%) with esophageal cancers, and five (0.6%) with duodenal tumors. H pylori positivity was found in 303 patients (35.8%), with an additional 81 (9.6%) reporting a history of eradication.
Colorectal findings included 15 patients (1.8%) with cancers and colon polyps in 503 (59.5%) participants.
Regarding preneoplastic conditions, endoscopy identified intestinal metaplasia in 174 patients (20.6%), of which 65 (7.7%) were multifocal. Atrophy was observed in 220 patients (26.0%), with 59 (7.0%) showing multifocal atrophic changes. Both intestinal metaplasia and atrophy were found together in 105 (12.4%) patients. Barrett’s esophagus was detected in 31 (3.7%) patients.
“I’d really like to highlight these further benign gastric findings,” said Bornschein. These included gastric ulcers in 28 (3.3%) patients, erosive gastritis in 245 (29.0%) patients, esophageal ulcers in three (0.4%) patients, Los Angeles Community College District classification esophagitis in 13 (1.5%) patients, and duodenal ulcers in 10 (1.2%) patients. “These were asymptomatic, but we were able to identify them,” he noted.
“We’ve had a very low rate of complications (0.01%),” he added.” I don’t want to jinx that now. These were basically related to sedation.”
PROSPERO: Early Detection of Upper GI Conditions in a UK Population
Massimiliano di Pietro, MD, consultant gastroenterologist at Addenbrooke’s Hospital, Cambridge, England, and the principal investigator of the PROSPERO study, which aimed to determine the prevalence of premalignant upper GI conditions in routine endoscopy in the UK, commented on the findings. The TOGAS study focuses on asymptomatic individuals referred for colonoscopy and examines the value of performing an upper GI endoscopy at the same time, he explained. “This approach might identify upper GI conditions that require monitoring, in particular early cancer.”
“On the other hand, the PROSPERO study focuses on patients referred for upper GI symptoms and diagnosis,” he said. Preliminary data from that study, presented during the same session as the TOGAS trial, showed a 13.6% prevalence of premalignant upper GI conditions in a symptomatic UK patient population referred for endoscopy.
“In some respects, the findings were similar, particularly the rate of upper GI cancer at 1.4%, although there were differences in the prevalence of premalignant conditions,” he noted. “This may be explained by the fact that TOGAS is a European study, while PROSPERO is UK-based, where the distribution of upper GI cancers differs, with more esophageal adenocarcinoma vs gastric adenocarcinoma.”
Reflecting on both of the studies, Di Pietro said they are “really important in fulfilling an unmet need in the quality of upper GI endoscopy. Currently, there are no diagnostic quality indicators in upper GI endoscopy, so it’s difficult to rate the performance of endoscopists in the same way as we can in lower GI. It’s really important to understand the population prevalence, both in symptomatic and asymptomatic individuals, of premalignant and malignant upper GI conditions.”
TOGAS 2 is recruiting until February 2026, with 1200 of a potential 1600 participants recruited to date. The data will be used for implementation modeling and to inform quality indicators for future screening programs. Final results and plans for a follow-up study are expected in 2026.
Bornschein declared receiving advisory and speaker fees from Flynn Pharma and Juvisé Pharmaceuticals. Di Pietro reported having no disclosures relevant to the studies discussed.
A version of this article first appeared on Medscape.com.
Forceps Assistance Improves Outcomes in Difficult ERCP Cannulations
The results emerged from the small, single-center SOCCER trial of 152 patients recruited from March 2022 to October 2024 and are published in The American Journal of Gastroenterology.
Both groups had a slightly higher number of female participants, and the mean ages of the participants were 61.9 years in the forceps group and 68.3 years in the no forceps group.
First author Steven M. Hadley Jr, an MD candidate at Northwestern Feinberg School of Medicine in Chicago, and colleagues reported that forceps assistance in difficult cannulations yielded significantly higher success rates than no forceps assistance (100% vs 83.9%; P < .001).
The investigators noted that difficult cannulations during ERCP have a frequency of 42%. Cannulation failure is associated with increased morbidity — including longer hospitalization, increased ICU admissions, readmissions, and increased financial cost — as well as mortality rates of up to 10%.
SOCCER defined difficult cannulation as a papilla in or on the rim of a diverticulum, five or more attempts, attempts lasting 5 or more minutes, or two or more unintended pancreatic duct wire passages. Other features were redundant tissue overlaying the papilla or a type 2, 3, or 4 papilla.
The study found forceps assistance also had a nonstatistically significant lower rate of difficult cannulations than no forceps (57.1% vs 69.1%; P = .132). The rate of post-ERCP pancreatitis (PEP) was similarly low in both groups: 5.7% with forceps vs 3.7% without forceps (P = .705). The no forceps group had significantly more cannulation attempts after randomization than the forceps group (14 vs 8.3; P = .026).
Patients who crossed over to forceps assistance all had successful cannulations.
The technique has long been used to overcome cannulation difficulties, said Timothy B. Gardner, MD, MS, a gastroenterologist at the Dartmouth Hitchcock Medical Center in Lebanon, New Hampshire, and a coauthor of the study. “It was particularly effective for cannulations with redundant tissue limiting access to the papilla,” Gardner told GI & Hepatology News. “We decided to design a randomized trial to determine the extent to which this technique worked. We believed our study would answer an important question that would hopefully lead to an improvement in endoscopy practice.”
While a few case reports and video demos had described the technique, no trials had assessed its effectiveness, Hadley added. “We found the technique to be effective based on our experience, but it was exciting to see that a rigorously designed randomized trial proved that it is indeed a very effective technique to facilitate cannulation.”
Hadley noted the technique does not increase PEP incidence, unlike the commonly used precut sphincterotomy and the double-wire method for difficult cannulations. “As a result, the forceps-assisted technique may be an effective first-line option and may reduce the need for additional, more invasive procedures including surgery and repeat ERCP to obtain the therapeutic intent of the original ERCP.”
The paper outlines the technique’s methodology, he added, “so we believe endoscopists who read the manuscript will be able to start implementing the technique into their practice.”
Commenting on the paper but not involved in it, Christopher J. DiMaio, MD, regional director of Endoscopy for Northwell Health Physician Partners Gastroenterology and a gastroenterologist in Greenlawn, New York, called it potentially helpful but aimed at a niche group of expert practitioners. “The technique appears safe and very effective, which is the number one concern, and I would definitely keep it in my back pocket,” he said. “I expect it will be used more commonly now because of this study.”
He added that although expert endoscopists are familiar with the approach, they use more time-tested and sometimes more aggressive maneuvers to cope with difficult cannulations. “But this is a simple technique using a device that should be available to most high-volume endoscopists.”
DiMaio also noted that he would have liked to see an actual decrease in PEP incidence in the intervention group.
Looking ahead, Hadley said it would be interesting to compare the effectiveness of the double-wire technique against forceps-assisted cannulation in a randomized context. “A study we’re already looking into is seeing whether physician experience with the technique impacts outcomes.”
This study was supported by the American College of Gastroenterology. The authors and DiMaio reported having no relevant competing interests.
A version of this article first appeared on Medscape.com.
The results emerged from the small, single-center SOCCER trial of 152 patients recruited from March 2022 to October 2024 and are published in The American Journal of Gastroenterology.
Both groups had a slightly higher number of female participants, and the mean ages of the participants were 61.9 years in the forceps group and 68.3 years in the no forceps group.
First author Steven M. Hadley Jr, an MD candidate at Northwestern Feinberg School of Medicine in Chicago, and colleagues reported that forceps assistance in difficult cannulations yielded significantly higher success rates than no forceps assistance (100% vs 83.9%; P < .001).
The investigators noted that difficult cannulations during ERCP have a frequency of 42%. Cannulation failure is associated with increased morbidity — including longer hospitalization, increased ICU admissions, readmissions, and increased financial cost — as well as mortality rates of up to 10%.
SOCCER defined difficult cannulation as a papilla in or on the rim of a diverticulum, five or more attempts, attempts lasting 5 or more minutes, or two or more unintended pancreatic duct wire passages. Other features were redundant tissue overlaying the papilla or a type 2, 3, or 4 papilla.
The study found forceps assistance also had a nonstatistically significant lower rate of difficult cannulations than no forceps (57.1% vs 69.1%; P = .132). The rate of post-ERCP pancreatitis (PEP) was similarly low in both groups: 5.7% with forceps vs 3.7% without forceps (P = .705). The no forceps group had significantly more cannulation attempts after randomization than the forceps group (14 vs 8.3; P = .026).
Patients who crossed over to forceps assistance all had successful cannulations.
The technique has long been used to overcome cannulation difficulties, said Timothy B. Gardner, MD, MS, a gastroenterologist at the Dartmouth Hitchcock Medical Center in Lebanon, New Hampshire, and a coauthor of the study. “It was particularly effective for cannulations with redundant tissue limiting access to the papilla,” Gardner told GI & Hepatology News. “We decided to design a randomized trial to determine the extent to which this technique worked. We believed our study would answer an important question that would hopefully lead to an improvement in endoscopy practice.”
While a few case reports and video demos had described the technique, no trials had assessed its effectiveness, Hadley added. “We found the technique to be effective based on our experience, but it was exciting to see that a rigorously designed randomized trial proved that it is indeed a very effective technique to facilitate cannulation.”
Hadley noted the technique does not increase PEP incidence, unlike the commonly used precut sphincterotomy and the double-wire method for difficult cannulations. “As a result, the forceps-assisted technique may be an effective first-line option and may reduce the need for additional, more invasive procedures including surgery and repeat ERCP to obtain the therapeutic intent of the original ERCP.”
The paper outlines the technique’s methodology, he added, “so we believe endoscopists who read the manuscript will be able to start implementing the technique into their practice.”
Commenting on the paper but not involved in it, Christopher J. DiMaio, MD, regional director of Endoscopy for Northwell Health Physician Partners Gastroenterology and a gastroenterologist in Greenlawn, New York, called it potentially helpful but aimed at a niche group of expert practitioners. “The technique appears safe and very effective, which is the number one concern, and I would definitely keep it in my back pocket,” he said. “I expect it will be used more commonly now because of this study.”
He added that although expert endoscopists are familiar with the approach, they use more time-tested and sometimes more aggressive maneuvers to cope with difficult cannulations. “But this is a simple technique using a device that should be available to most high-volume endoscopists.”
DiMaio also noted that he would have liked to see an actual decrease in PEP incidence in the intervention group.
Looking ahead, Hadley said it would be interesting to compare the effectiveness of the double-wire technique against forceps-assisted cannulation in a randomized context. “A study we’re already looking into is seeing whether physician experience with the technique impacts outcomes.”
This study was supported by the American College of Gastroenterology. The authors and DiMaio reported having no relevant competing interests.
A version of this article first appeared on Medscape.com.
The results emerged from the small, single-center SOCCER trial of 152 patients recruited from March 2022 to October 2024 and are published in The American Journal of Gastroenterology.
Both groups had a slightly higher number of female participants, and the mean ages of the participants were 61.9 years in the forceps group and 68.3 years in the no forceps group.
First author Steven M. Hadley Jr, an MD candidate at Northwestern Feinberg School of Medicine in Chicago, and colleagues reported that forceps assistance in difficult cannulations yielded significantly higher success rates than no forceps assistance (100% vs 83.9%; P < .001).
The investigators noted that difficult cannulations during ERCP have a frequency of 42%. Cannulation failure is associated with increased morbidity — including longer hospitalization, increased ICU admissions, readmissions, and increased financial cost — as well as mortality rates of up to 10%.
SOCCER defined difficult cannulation as a papilla in or on the rim of a diverticulum, five or more attempts, attempts lasting 5 or more minutes, or two or more unintended pancreatic duct wire passages. Other features were redundant tissue overlaying the papilla or a type 2, 3, or 4 papilla.
The study found forceps assistance also had a nonstatistically significant lower rate of difficult cannulations than no forceps (57.1% vs 69.1%; P = .132). The rate of post-ERCP pancreatitis (PEP) was similarly low in both groups: 5.7% with forceps vs 3.7% without forceps (P = .705). The no forceps group had significantly more cannulation attempts after randomization than the forceps group (14 vs 8.3; P = .026).
Patients who crossed over to forceps assistance all had successful cannulations.
The technique has long been used to overcome cannulation difficulties, said Timothy B. Gardner, MD, MS, a gastroenterologist at the Dartmouth Hitchcock Medical Center in Lebanon, New Hampshire, and a coauthor of the study. “It was particularly effective for cannulations with redundant tissue limiting access to the papilla,” Gardner told GI & Hepatology News. “We decided to design a randomized trial to determine the extent to which this technique worked. We believed our study would answer an important question that would hopefully lead to an improvement in endoscopy practice.”
While a few case reports and video demos had described the technique, no trials had assessed its effectiveness, Hadley added. “We found the technique to be effective based on our experience, but it was exciting to see that a rigorously designed randomized trial proved that it is indeed a very effective technique to facilitate cannulation.”
Hadley noted the technique does not increase PEP incidence, unlike the commonly used precut sphincterotomy and the double-wire method for difficult cannulations. “As a result, the forceps-assisted technique may be an effective first-line option and may reduce the need for additional, more invasive procedures including surgery and repeat ERCP to obtain the therapeutic intent of the original ERCP.”
The paper outlines the technique’s methodology, he added, “so we believe endoscopists who read the manuscript will be able to start implementing the technique into their practice.”
Commenting on the paper but not involved in it, Christopher J. DiMaio, MD, regional director of Endoscopy for Northwell Health Physician Partners Gastroenterology and a gastroenterologist in Greenlawn, New York, called it potentially helpful but aimed at a niche group of expert practitioners. “The technique appears safe and very effective, which is the number one concern, and I would definitely keep it in my back pocket,” he said. “I expect it will be used more commonly now because of this study.”
He added that although expert endoscopists are familiar with the approach, they use more time-tested and sometimes more aggressive maneuvers to cope with difficult cannulations. “But this is a simple technique using a device that should be available to most high-volume endoscopists.”
DiMaio also noted that he would have liked to see an actual decrease in PEP incidence in the intervention group.
Looking ahead, Hadley said it would be interesting to compare the effectiveness of the double-wire technique against forceps-assisted cannulation in a randomized context. “A study we’re already looking into is seeing whether physician experience with the technique impacts outcomes.”
This study was supported by the American College of Gastroenterology. The authors and DiMaio reported having no relevant competing interests.
A version of this article first appeared on Medscape.com.
GLP-1 Receptor Agonist Use in Gastrointestinal Endoscopy: A Review of Current Evidence and Guidelines
The use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) has increased over the past several years and has become a cornerstone in both diabetes and weight loss management, particularly because of its unique combination of glucose control, weight reduction potential, and cardiac and metabolic benefits. However, increased use of these agents presents a dilemma in gastrointestinal endoscopy as it pertains to their safety and management during the periprocedural period.
highlighting gaps and future directions.
Pharmacology and Mechanisms of Action
GLP-1 RAs have several mechanisms of action that make them relevant in gastrointestinal endoscopy. These medications modulate glucose control via enhancement of glucose-dependent insulin secretion and reduction of postprandial glucagon, which promotes satiety and delays gastric emptying. This delay in gastric emptying mediated by vagal pathways has been postulated to increase gastric residuals, posing a risk for aspiration during anesthesia.1
It is important to also consider the pharmacokinetics of GLP-1 RAs, as some have shorter half-lives on the order of several hours, like exenatide, while others, like semaglutide, are dosed weekly. Additionally, common side effects of GLP-1 RAs include nausea, vomiting, bloating, and early satiety, which pose challenges for patients undergoing endoscopic procedures.
Current Guidelines
Various societies have published guidelines on the periprocedural use of GLP-1 RAs. The American Society of Anesthesiologist (ASA) in 2023 presented early recommendations to hold GLP-1 RAs either day of procedure or week prior depending on pharmacokinetics, because of the risk of delayed gastric emptying and increased potential for aspiration.2 Soon thereafter, a multi-gastroenterology society guideline was released stating more data is needed to decide if GLP-1 RAs need to be held prior to endoscopic procedures.3
In early 2024, the American Gastroenterological Association (AGA) published a rapid clinical update that advocated for a more individualized approach, particularly in light of limited overall data for GLP-1 RAs and endoscopic procedures.4 In asymptomatic patients who follow typical fasting protocols for procedures, it is generally safe to proceed with endoscopy without holding GLP-1 RAs. In symptomatic patients (nausea, abdominal distension, etc), the AGA advises additional precautions, including performing transabdominal ultrasound if feasible to assess retained gastric contents. The AGA also suggests placing a patient on a clear liquid diet the day prior to the procedure — rather than holding GLP-1 RAs — as another reasonable strategy.
The guidelines continue to evolve with newer multi-society guidelines establishing best practices. While initially in 2023 the ASA did recommend holding these medications prior to endoscopy, the initial guidance was based on expert opinion with limited evidence. Newer multi-society guidance published jointly by the ASA along with various gastroenterology societies, including the AGA in December 2024, takes a more nuanced approach.5
The newer guidelines include two main recommendations:
1. Periprocedural management of GLP-1 RAs should be a joint decision among the procedural, anesthesia, and prescribing team balancing metabolic needs vs patient risks.
- In a low-risk patient, one that is asymptomatic and on standard dosing, among other factors, the guidance states that GLP-1 RAs can be continued.
- In higher-risk patients, the original guidance of holding a day or a week prior to endoscopic procedures should be followed.
2. Periprocedural management of GLP-1 RAs should attempt to minimize the aspiration risks loosely associated with delayed gastric emptying.
- Consider a 24-hour clear liquid diet a day prior to the procedure and transabdominal ultrasound to check gastric contents.
- It is acknowledged that this guidance is based on limited evidence and will be evolving as new medications and data are released.
Recent Clinical Studies
Although there is very little data to guide clinicians, several recent studies have been published that can direct clinical decision-making as guidelines continue to be refined and updated.
A multicenter trial of approximately 800 patients undergoing upper endoscopy found a significant difference in rates of retained gastric contents between those that underwent endoscopy who did and did not follow the ASA guidance on periprocedural management of GLP-1 RAs (12.7% vs 4.4%; P < .0001). However, there were no significant differences in rates of aborted procedures or unplanned intubations.
Furthermore, a multivariable analysis was performed controlling for GLP-1 RA type and other factors, which found the likelihood of gastric retention increased by 36% for every 1% increase in hemoglobin A1c. This study suggests that a more individualized approach to holding GLP-1 RA would be applicable rather than a universal periprocedural hold.6
More recently, a single-center study of nearly 600 patients undergoing upper endoscopy showed that while there were slightly increased rates of retained gastric contents (OR 3.80; P = .003) and aborted procedures (1.3% vs 0%; P = .02), the rates of adverse anesthesia events (hypoxia, etc) were similar between the groups and no cases of pulmonary aspiration were noted.7
One single-center study of 57 patients evaluated the safety of GLP-1 RAs in those undergoing endoscopic sleeve gastrectomy. GLP-1 RAs were continued on all patients, but all adhered to a liquid only diet for at least 24 hours prior to the procedure. There were no instances of retained gastric solids, aspiration, or hypoxia. This study suggests that with a 24-hour clear liquid diet and routine NPO recommendations prior to endoscopy, it would be safe to continue GLP-1 RAs. This study provides rationale for the AGA recommendation for a clear liquid diet 24 hours prior to endoscopic procedures for those on GLP-1 RAs.8
A study looking at those who underwent emergency surgery and endoscopy with claims data of use of GLP-1 RAs found an overall incidence of postoperative respiratory complications of 3.5% for those with GLP-1 RAs fill history vs 4.0% for those without (P = .12). Approximately 800 of the 24,000 patients identified had undergone endoscopic procedures for GI bleeding or food impaction. The study overall showed that preoperative use of GLP-1 RAs in patients undergoing surgery or endoscopy, evaluated as a combined group, was not associated with an increased risk of pulmonary complications.9
Lastly, a systematic review and meta-analysis that included 15 studies that quantified gastric emptying using various methods, including gastric emptying scintigraphy and acetaminophen absorption test, found that there was a quantifiable delay in gastric emptying of about 36 minutes, compared to placebo (P < .01), in patients using GLP-1 RAs. However, compared to standard periprocedural fasting, this delay is clinically insignificant and standard fasting protocols would still be appropriate for patients on GLP-1 RAs.10
These studies taken together suggest that while GLP-1 RAs can mildly increase the likelihood of retained gastric contents, there is no statistically significant increase in the risk of aspiration or other anesthesia complications. Furthermore, while decreased gastric emptying is a known effect of GLP-1 RAs, this effect may not be clinically significant in the context of standard periprocedural fasting protocols particularly when combined with a 24-hour clear liquid diet. These findings support at a minimum a more patient-specific strategy for periprocedural management of GLP-1 RAs.
Clinical Implications
These most recent studies, as well as prior studies and guidelines by various societies lead to a dilemma among endoscopists on proper patient counseling on GLP-1 RAs use before endoscopic procedures. Clinicians must balance the metabolic benefits of GLP-1 RAs with potential endoscopic complications and risks.
Holding therapy theoretically decreases aspiration risk and pulmonary complications, though evidence remains low to support this. Holding medication, however, affects glycemic control leading to potential rebound hyperglycemia which may impact and delay plans for endoscopy. With growing indications for the use of GLP-1 RAs, a more tailored patient-centered treatment plan may be required, especially with consideration of procedure indication and comorbidities.
Currently, practice patterns at different institutions vary widely, making standardization much more difficult. Some centers have opted to follow ASA guidelines of holding these medications up to 1 week prior to procedures, while others have continued therapy with no pre-procedural adjustments. This leaves endoscopists to deal with the downstream effects of inconvenience to patients, care delays, and financial considerations if procedures are postponed related to GLP-1 RAs use.
Future Directions
Future studies are needed to make further evidence-based recommendations. Studies should focus on stratifying risks and recommendations based on procedure type (EGD, colonoscopy, etc). More widespread implementation of gastric ultrasound can assist in real-time decision-making, albeit this would require expertise and dedicated time within the pre-procedural workflow. Randomized controlled trials comparing outcomes of patients who continue GLP-1 RAs vs those who discontinue stratified by baseline risk will be instrumental for making concrete guidelines that provide clarity on periprocedural management of GLP-1 RAs.
Conclusion
The periprocedural management of GLP-1 RAs remains a controversial topic that presents unique challenges in endoscopy. Several guidelines have been released by various stakeholders including anesthesiologists, gastroenterologists, and other prescribing providers. Clinical data remains limited with no robust evidence available to suggest that gastric emptying delays caused by GLP-1 RAs prior to endoscopic procedures significantly increases risk of aspiration, pulmonary complications, or other comorbidities. Evolving multi-society guidelines will be important to establish more consistent practices with reassessment of the data as new studies emerge. A multidisciplinary, individualized patient approach may be the best strategy for managing GLP-1 RAs for patients undergoing endoscopic procedures.
Dr. Sekar and Dr. Asamoah are based in the department of gastroenterology at MedStar Georgetown University Hospital, Washington, D.C. Dr. Sekar reports no conflicts of interest in regard to this article. Dr. Asamoah serves on the Johnson & Johnson advisory board for inflammatory bowel disease–related therapies.
References
1. Halim MA et al. Glucagon-Like Peptide-1 Inhibits Prandial Gastrointestinal Motility Through Myenteric Neuronal Mechanisms in Humans. J Clin Endocrinol Metab. 2018 Feb. doi: 10.1210/jc.2017-02006.
2. American Society of Anesthesiologists. American Society of Anesthesiologists releases consensus-based guidance on preoperative use of GLP-1 receptor agonists. 2023 Jun 20. www.asahq.org/about-asa/newsroom/news-releases/2023/06/american-society-of-anesthesiologists-consensus-based-guidance-on-preoperative
3. American Gastroenterological Association. GI multi-society statement regarding GLP-1 agonists and endoscopy. 2023 Jul 25. gastro.org/news/gi-multi-society-statement-regarding-glp-1-agonists-and-endoscopy/.
4. Hashash JG et al. AGA Rapid Clinical Practice Update on the Management of Patients Taking GLP-1 Receptor Agonists Prior to Endoscopy: Communication. Clin Gastroenterol Hepatol. 2024 Apr. doi: 10.1016/j.cgh.2023.11.002.
5. Kindel TL et al; American Gastroenterological Association; American Society for Metabolic and Bariatric Surgery; American Society of Anesthesiologists; International Society of Perioperative Care of Patients with Obesity; Society of American Gastrointestinal and Endoscopic Surgeons. Multi-society Clinical Practice Guidance for the Safe Use of Glucagon-like Peptide-1 Receptor Agonists in the Perioperative Period. Clin Gastroenterol Hepatol. 2024 Oct. doi: 10.1016/j.cgh.2024.10.003.
6. Phan J et al. Glucagon-Like Peptide Receptor Agonists Use Before Endoscopy Is Associated With Low Retained Gastric Contents: A Multicenter Cross-Sectional Analysis. Am J Gastroenterol. 2025 Mar. doi: 10.14309/ajg.0000000000002969.
7. Panchal S et al. Endoscopy and Anesthesia Outcomes Associated With Glucagon-like Peptide-1 Receptor Agonist use in Patients Undergoing Outpatient Upper Endoscopy. Gastrointest Endosc. 2025 Aug. doi:10.1016/j.gie.2025.01.004.
8. Maselli DB et al. Safe Continuation of glucagon-like Peptide 1 Receptor Agonists at Endoscopy: A Case Series of 57 Adults Undergoing Endoscopic Sleeve Gastroplasty. Obes Surg. 2024 Jul. doi: 10.1007/s11695-024-07278-2.
9. Dixit AA et al. Preoperative GLP-1 Receptor Agonist Use and Risk of Postoperative Respiratory Complications. JAMA. 2024 Apr. doi: 10.1001/jama.2024.5003.
10. Hiramoto B et al. Quantified Metrics of Gastric Emptying Delay by Glucagon-Like Peptide-1 Agonists: A systematic review and meta-analysis with insights for periprocedural management. Am J Gastroenterol. 2024 Jun. doi: 10.14309/ajg.0000000000002820.
The use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) has increased over the past several years and has become a cornerstone in both diabetes and weight loss management, particularly because of its unique combination of glucose control, weight reduction potential, and cardiac and metabolic benefits. However, increased use of these agents presents a dilemma in gastrointestinal endoscopy as it pertains to their safety and management during the periprocedural period.
highlighting gaps and future directions.
Pharmacology and Mechanisms of Action
GLP-1 RAs have several mechanisms of action that make them relevant in gastrointestinal endoscopy. These medications modulate glucose control via enhancement of glucose-dependent insulin secretion and reduction of postprandial glucagon, which promotes satiety and delays gastric emptying. This delay in gastric emptying mediated by vagal pathways has been postulated to increase gastric residuals, posing a risk for aspiration during anesthesia.1
It is important to also consider the pharmacokinetics of GLP-1 RAs, as some have shorter half-lives on the order of several hours, like exenatide, while others, like semaglutide, are dosed weekly. Additionally, common side effects of GLP-1 RAs include nausea, vomiting, bloating, and early satiety, which pose challenges for patients undergoing endoscopic procedures.
Current Guidelines
Various societies have published guidelines on the periprocedural use of GLP-1 RAs. The American Society of Anesthesiologist (ASA) in 2023 presented early recommendations to hold GLP-1 RAs either day of procedure or week prior depending on pharmacokinetics, because of the risk of delayed gastric emptying and increased potential for aspiration.2 Soon thereafter, a multi-gastroenterology society guideline was released stating more data is needed to decide if GLP-1 RAs need to be held prior to endoscopic procedures.3
In early 2024, the American Gastroenterological Association (AGA) published a rapid clinical update that advocated for a more individualized approach, particularly in light of limited overall data for GLP-1 RAs and endoscopic procedures.4 In asymptomatic patients who follow typical fasting protocols for procedures, it is generally safe to proceed with endoscopy without holding GLP-1 RAs. In symptomatic patients (nausea, abdominal distension, etc), the AGA advises additional precautions, including performing transabdominal ultrasound if feasible to assess retained gastric contents. The AGA also suggests placing a patient on a clear liquid diet the day prior to the procedure — rather than holding GLP-1 RAs — as another reasonable strategy.
The guidelines continue to evolve with newer multi-society guidelines establishing best practices. While initially in 2023 the ASA did recommend holding these medications prior to endoscopy, the initial guidance was based on expert opinion with limited evidence. Newer multi-society guidance published jointly by the ASA along with various gastroenterology societies, including the AGA in December 2024, takes a more nuanced approach.5
The newer guidelines include two main recommendations:
1. Periprocedural management of GLP-1 RAs should be a joint decision among the procedural, anesthesia, and prescribing team balancing metabolic needs vs patient risks.
- In a low-risk patient, one that is asymptomatic and on standard dosing, among other factors, the guidance states that GLP-1 RAs can be continued.
- In higher-risk patients, the original guidance of holding a day or a week prior to endoscopic procedures should be followed.
2. Periprocedural management of GLP-1 RAs should attempt to minimize the aspiration risks loosely associated with delayed gastric emptying.
- Consider a 24-hour clear liquid diet a day prior to the procedure and transabdominal ultrasound to check gastric contents.
- It is acknowledged that this guidance is based on limited evidence and will be evolving as new medications and data are released.
Recent Clinical Studies
Although there is very little data to guide clinicians, several recent studies have been published that can direct clinical decision-making as guidelines continue to be refined and updated.
A multicenter trial of approximately 800 patients undergoing upper endoscopy found a significant difference in rates of retained gastric contents between those that underwent endoscopy who did and did not follow the ASA guidance on periprocedural management of GLP-1 RAs (12.7% vs 4.4%; P < .0001). However, there were no significant differences in rates of aborted procedures or unplanned intubations.
Furthermore, a multivariable analysis was performed controlling for GLP-1 RA type and other factors, which found the likelihood of gastric retention increased by 36% for every 1% increase in hemoglobin A1c. This study suggests that a more individualized approach to holding GLP-1 RA would be applicable rather than a universal periprocedural hold.6
More recently, a single-center study of nearly 600 patients undergoing upper endoscopy showed that while there were slightly increased rates of retained gastric contents (OR 3.80; P = .003) and aborted procedures (1.3% vs 0%; P = .02), the rates of adverse anesthesia events (hypoxia, etc) were similar between the groups and no cases of pulmonary aspiration were noted.7
One single-center study of 57 patients evaluated the safety of GLP-1 RAs in those undergoing endoscopic sleeve gastrectomy. GLP-1 RAs were continued on all patients, but all adhered to a liquid only diet for at least 24 hours prior to the procedure. There were no instances of retained gastric solids, aspiration, or hypoxia. This study suggests that with a 24-hour clear liquid diet and routine NPO recommendations prior to endoscopy, it would be safe to continue GLP-1 RAs. This study provides rationale for the AGA recommendation for a clear liquid diet 24 hours prior to endoscopic procedures for those on GLP-1 RAs.8
A study looking at those who underwent emergency surgery and endoscopy with claims data of use of GLP-1 RAs found an overall incidence of postoperative respiratory complications of 3.5% for those with GLP-1 RAs fill history vs 4.0% for those without (P = .12). Approximately 800 of the 24,000 patients identified had undergone endoscopic procedures for GI bleeding or food impaction. The study overall showed that preoperative use of GLP-1 RAs in patients undergoing surgery or endoscopy, evaluated as a combined group, was not associated with an increased risk of pulmonary complications.9
Lastly, a systematic review and meta-analysis that included 15 studies that quantified gastric emptying using various methods, including gastric emptying scintigraphy and acetaminophen absorption test, found that there was a quantifiable delay in gastric emptying of about 36 minutes, compared to placebo (P < .01), in patients using GLP-1 RAs. However, compared to standard periprocedural fasting, this delay is clinically insignificant and standard fasting protocols would still be appropriate for patients on GLP-1 RAs.10
These studies taken together suggest that while GLP-1 RAs can mildly increase the likelihood of retained gastric contents, there is no statistically significant increase in the risk of aspiration or other anesthesia complications. Furthermore, while decreased gastric emptying is a known effect of GLP-1 RAs, this effect may not be clinically significant in the context of standard periprocedural fasting protocols particularly when combined with a 24-hour clear liquid diet. These findings support at a minimum a more patient-specific strategy for periprocedural management of GLP-1 RAs.
Clinical Implications
These most recent studies, as well as prior studies and guidelines by various societies lead to a dilemma among endoscopists on proper patient counseling on GLP-1 RAs use before endoscopic procedures. Clinicians must balance the metabolic benefits of GLP-1 RAs with potential endoscopic complications and risks.
Holding therapy theoretically decreases aspiration risk and pulmonary complications, though evidence remains low to support this. Holding medication, however, affects glycemic control leading to potential rebound hyperglycemia which may impact and delay plans for endoscopy. With growing indications for the use of GLP-1 RAs, a more tailored patient-centered treatment plan may be required, especially with consideration of procedure indication and comorbidities.
Currently, practice patterns at different institutions vary widely, making standardization much more difficult. Some centers have opted to follow ASA guidelines of holding these medications up to 1 week prior to procedures, while others have continued therapy with no pre-procedural adjustments. This leaves endoscopists to deal with the downstream effects of inconvenience to patients, care delays, and financial considerations if procedures are postponed related to GLP-1 RAs use.
Future Directions
Future studies are needed to make further evidence-based recommendations. Studies should focus on stratifying risks and recommendations based on procedure type (EGD, colonoscopy, etc). More widespread implementation of gastric ultrasound can assist in real-time decision-making, albeit this would require expertise and dedicated time within the pre-procedural workflow. Randomized controlled trials comparing outcomes of patients who continue GLP-1 RAs vs those who discontinue stratified by baseline risk will be instrumental for making concrete guidelines that provide clarity on periprocedural management of GLP-1 RAs.
Conclusion
The periprocedural management of GLP-1 RAs remains a controversial topic that presents unique challenges in endoscopy. Several guidelines have been released by various stakeholders including anesthesiologists, gastroenterologists, and other prescribing providers. Clinical data remains limited with no robust evidence available to suggest that gastric emptying delays caused by GLP-1 RAs prior to endoscopic procedures significantly increases risk of aspiration, pulmonary complications, or other comorbidities. Evolving multi-society guidelines will be important to establish more consistent practices with reassessment of the data as new studies emerge. A multidisciplinary, individualized patient approach may be the best strategy for managing GLP-1 RAs for patients undergoing endoscopic procedures.
Dr. Sekar and Dr. Asamoah are based in the department of gastroenterology at MedStar Georgetown University Hospital, Washington, D.C. Dr. Sekar reports no conflicts of interest in regard to this article. Dr. Asamoah serves on the Johnson & Johnson advisory board for inflammatory bowel disease–related therapies.
References
1. Halim MA et al. Glucagon-Like Peptide-1 Inhibits Prandial Gastrointestinal Motility Through Myenteric Neuronal Mechanisms in Humans. J Clin Endocrinol Metab. 2018 Feb. doi: 10.1210/jc.2017-02006.
2. American Society of Anesthesiologists. American Society of Anesthesiologists releases consensus-based guidance on preoperative use of GLP-1 receptor agonists. 2023 Jun 20. www.asahq.org/about-asa/newsroom/news-releases/2023/06/american-society-of-anesthesiologists-consensus-based-guidance-on-preoperative
3. American Gastroenterological Association. GI multi-society statement regarding GLP-1 agonists and endoscopy. 2023 Jul 25. gastro.org/news/gi-multi-society-statement-regarding-glp-1-agonists-and-endoscopy/.
4. Hashash JG et al. AGA Rapid Clinical Practice Update on the Management of Patients Taking GLP-1 Receptor Agonists Prior to Endoscopy: Communication. Clin Gastroenterol Hepatol. 2024 Apr. doi: 10.1016/j.cgh.2023.11.002.
5. Kindel TL et al; American Gastroenterological Association; American Society for Metabolic and Bariatric Surgery; American Society of Anesthesiologists; International Society of Perioperative Care of Patients with Obesity; Society of American Gastrointestinal and Endoscopic Surgeons. Multi-society Clinical Practice Guidance for the Safe Use of Glucagon-like Peptide-1 Receptor Agonists in the Perioperative Period. Clin Gastroenterol Hepatol. 2024 Oct. doi: 10.1016/j.cgh.2024.10.003.
6. Phan J et al. Glucagon-Like Peptide Receptor Agonists Use Before Endoscopy Is Associated With Low Retained Gastric Contents: A Multicenter Cross-Sectional Analysis. Am J Gastroenterol. 2025 Mar. doi: 10.14309/ajg.0000000000002969.
7. Panchal S et al. Endoscopy and Anesthesia Outcomes Associated With Glucagon-like Peptide-1 Receptor Agonist use in Patients Undergoing Outpatient Upper Endoscopy. Gastrointest Endosc. 2025 Aug. doi:10.1016/j.gie.2025.01.004.
8. Maselli DB et al. Safe Continuation of glucagon-like Peptide 1 Receptor Agonists at Endoscopy: A Case Series of 57 Adults Undergoing Endoscopic Sleeve Gastroplasty. Obes Surg. 2024 Jul. doi: 10.1007/s11695-024-07278-2.
9. Dixit AA et al. Preoperative GLP-1 Receptor Agonist Use and Risk of Postoperative Respiratory Complications. JAMA. 2024 Apr. doi: 10.1001/jama.2024.5003.
10. Hiramoto B et al. Quantified Metrics of Gastric Emptying Delay by Glucagon-Like Peptide-1 Agonists: A systematic review and meta-analysis with insights for periprocedural management. Am J Gastroenterol. 2024 Jun. doi: 10.14309/ajg.0000000000002820.
The use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) has increased over the past several years and has become a cornerstone in both diabetes and weight loss management, particularly because of its unique combination of glucose control, weight reduction potential, and cardiac and metabolic benefits. However, increased use of these agents presents a dilemma in gastrointestinal endoscopy as it pertains to their safety and management during the periprocedural period.
highlighting gaps and future directions.
Pharmacology and Mechanisms of Action
GLP-1 RAs have several mechanisms of action that make them relevant in gastrointestinal endoscopy. These medications modulate glucose control via enhancement of glucose-dependent insulin secretion and reduction of postprandial glucagon, which promotes satiety and delays gastric emptying. This delay in gastric emptying mediated by vagal pathways has been postulated to increase gastric residuals, posing a risk for aspiration during anesthesia.1
It is important to also consider the pharmacokinetics of GLP-1 RAs, as some have shorter half-lives on the order of several hours, like exenatide, while others, like semaglutide, are dosed weekly. Additionally, common side effects of GLP-1 RAs include nausea, vomiting, bloating, and early satiety, which pose challenges for patients undergoing endoscopic procedures.
Current Guidelines
Various societies have published guidelines on the periprocedural use of GLP-1 RAs. The American Society of Anesthesiologist (ASA) in 2023 presented early recommendations to hold GLP-1 RAs either day of procedure or week prior depending on pharmacokinetics, because of the risk of delayed gastric emptying and increased potential for aspiration.2 Soon thereafter, a multi-gastroenterology society guideline was released stating more data is needed to decide if GLP-1 RAs need to be held prior to endoscopic procedures.3
In early 2024, the American Gastroenterological Association (AGA) published a rapid clinical update that advocated for a more individualized approach, particularly in light of limited overall data for GLP-1 RAs and endoscopic procedures.4 In asymptomatic patients who follow typical fasting protocols for procedures, it is generally safe to proceed with endoscopy without holding GLP-1 RAs. In symptomatic patients (nausea, abdominal distension, etc), the AGA advises additional precautions, including performing transabdominal ultrasound if feasible to assess retained gastric contents. The AGA also suggests placing a patient on a clear liquid diet the day prior to the procedure — rather than holding GLP-1 RAs — as another reasonable strategy.
The guidelines continue to evolve with newer multi-society guidelines establishing best practices. While initially in 2023 the ASA did recommend holding these medications prior to endoscopy, the initial guidance was based on expert opinion with limited evidence. Newer multi-society guidance published jointly by the ASA along with various gastroenterology societies, including the AGA in December 2024, takes a more nuanced approach.5
The newer guidelines include two main recommendations:
1. Periprocedural management of GLP-1 RAs should be a joint decision among the procedural, anesthesia, and prescribing team balancing metabolic needs vs patient risks.
- In a low-risk patient, one that is asymptomatic and on standard dosing, among other factors, the guidance states that GLP-1 RAs can be continued.
- In higher-risk patients, the original guidance of holding a day or a week prior to endoscopic procedures should be followed.
2. Periprocedural management of GLP-1 RAs should attempt to minimize the aspiration risks loosely associated with delayed gastric emptying.
- Consider a 24-hour clear liquid diet a day prior to the procedure and transabdominal ultrasound to check gastric contents.
- It is acknowledged that this guidance is based on limited evidence and will be evolving as new medications and data are released.
Recent Clinical Studies
Although there is very little data to guide clinicians, several recent studies have been published that can direct clinical decision-making as guidelines continue to be refined and updated.
A multicenter trial of approximately 800 patients undergoing upper endoscopy found a significant difference in rates of retained gastric contents between those that underwent endoscopy who did and did not follow the ASA guidance on periprocedural management of GLP-1 RAs (12.7% vs 4.4%; P < .0001). However, there were no significant differences in rates of aborted procedures or unplanned intubations.
Furthermore, a multivariable analysis was performed controlling for GLP-1 RA type and other factors, which found the likelihood of gastric retention increased by 36% for every 1% increase in hemoglobin A1c. This study suggests that a more individualized approach to holding GLP-1 RA would be applicable rather than a universal periprocedural hold.6
More recently, a single-center study of nearly 600 patients undergoing upper endoscopy showed that while there were slightly increased rates of retained gastric contents (OR 3.80; P = .003) and aborted procedures (1.3% vs 0%; P = .02), the rates of adverse anesthesia events (hypoxia, etc) were similar between the groups and no cases of pulmonary aspiration were noted.7
One single-center study of 57 patients evaluated the safety of GLP-1 RAs in those undergoing endoscopic sleeve gastrectomy. GLP-1 RAs were continued on all patients, but all adhered to a liquid only diet for at least 24 hours prior to the procedure. There were no instances of retained gastric solids, aspiration, or hypoxia. This study suggests that with a 24-hour clear liquid diet and routine NPO recommendations prior to endoscopy, it would be safe to continue GLP-1 RAs. This study provides rationale for the AGA recommendation for a clear liquid diet 24 hours prior to endoscopic procedures for those on GLP-1 RAs.8
A study looking at those who underwent emergency surgery and endoscopy with claims data of use of GLP-1 RAs found an overall incidence of postoperative respiratory complications of 3.5% for those with GLP-1 RAs fill history vs 4.0% for those without (P = .12). Approximately 800 of the 24,000 patients identified had undergone endoscopic procedures for GI bleeding or food impaction. The study overall showed that preoperative use of GLP-1 RAs in patients undergoing surgery or endoscopy, evaluated as a combined group, was not associated with an increased risk of pulmonary complications.9
Lastly, a systematic review and meta-analysis that included 15 studies that quantified gastric emptying using various methods, including gastric emptying scintigraphy and acetaminophen absorption test, found that there was a quantifiable delay in gastric emptying of about 36 minutes, compared to placebo (P < .01), in patients using GLP-1 RAs. However, compared to standard periprocedural fasting, this delay is clinically insignificant and standard fasting protocols would still be appropriate for patients on GLP-1 RAs.10
These studies taken together suggest that while GLP-1 RAs can mildly increase the likelihood of retained gastric contents, there is no statistically significant increase in the risk of aspiration or other anesthesia complications. Furthermore, while decreased gastric emptying is a known effect of GLP-1 RAs, this effect may not be clinically significant in the context of standard periprocedural fasting protocols particularly when combined with a 24-hour clear liquid diet. These findings support at a minimum a more patient-specific strategy for periprocedural management of GLP-1 RAs.
Clinical Implications
These most recent studies, as well as prior studies and guidelines by various societies lead to a dilemma among endoscopists on proper patient counseling on GLP-1 RAs use before endoscopic procedures. Clinicians must balance the metabolic benefits of GLP-1 RAs with potential endoscopic complications and risks.
Holding therapy theoretically decreases aspiration risk and pulmonary complications, though evidence remains low to support this. Holding medication, however, affects glycemic control leading to potential rebound hyperglycemia which may impact and delay plans for endoscopy. With growing indications for the use of GLP-1 RAs, a more tailored patient-centered treatment plan may be required, especially with consideration of procedure indication and comorbidities.
Currently, practice patterns at different institutions vary widely, making standardization much more difficult. Some centers have opted to follow ASA guidelines of holding these medications up to 1 week prior to procedures, while others have continued therapy with no pre-procedural adjustments. This leaves endoscopists to deal with the downstream effects of inconvenience to patients, care delays, and financial considerations if procedures are postponed related to GLP-1 RAs use.
Future Directions
Future studies are needed to make further evidence-based recommendations. Studies should focus on stratifying risks and recommendations based on procedure type (EGD, colonoscopy, etc). More widespread implementation of gastric ultrasound can assist in real-time decision-making, albeit this would require expertise and dedicated time within the pre-procedural workflow. Randomized controlled trials comparing outcomes of patients who continue GLP-1 RAs vs those who discontinue stratified by baseline risk will be instrumental for making concrete guidelines that provide clarity on periprocedural management of GLP-1 RAs.
Conclusion
The periprocedural management of GLP-1 RAs remains a controversial topic that presents unique challenges in endoscopy. Several guidelines have been released by various stakeholders including anesthesiologists, gastroenterologists, and other prescribing providers. Clinical data remains limited with no robust evidence available to suggest that gastric emptying delays caused by GLP-1 RAs prior to endoscopic procedures significantly increases risk of aspiration, pulmonary complications, or other comorbidities. Evolving multi-society guidelines will be important to establish more consistent practices with reassessment of the data as new studies emerge. A multidisciplinary, individualized patient approach may be the best strategy for managing GLP-1 RAs for patients undergoing endoscopic procedures.
Dr. Sekar and Dr. Asamoah are based in the department of gastroenterology at MedStar Georgetown University Hospital, Washington, D.C. Dr. Sekar reports no conflicts of interest in regard to this article. Dr. Asamoah serves on the Johnson & Johnson advisory board for inflammatory bowel disease–related therapies.
References
1. Halim MA et al. Glucagon-Like Peptide-1 Inhibits Prandial Gastrointestinal Motility Through Myenteric Neuronal Mechanisms in Humans. J Clin Endocrinol Metab. 2018 Feb. doi: 10.1210/jc.2017-02006.
2. American Society of Anesthesiologists. American Society of Anesthesiologists releases consensus-based guidance on preoperative use of GLP-1 receptor agonists. 2023 Jun 20. www.asahq.org/about-asa/newsroom/news-releases/2023/06/american-society-of-anesthesiologists-consensus-based-guidance-on-preoperative
3. American Gastroenterological Association. GI multi-society statement regarding GLP-1 agonists and endoscopy. 2023 Jul 25. gastro.org/news/gi-multi-society-statement-regarding-glp-1-agonists-and-endoscopy/.
4. Hashash JG et al. AGA Rapid Clinical Practice Update on the Management of Patients Taking GLP-1 Receptor Agonists Prior to Endoscopy: Communication. Clin Gastroenterol Hepatol. 2024 Apr. doi: 10.1016/j.cgh.2023.11.002.
5. Kindel TL et al; American Gastroenterological Association; American Society for Metabolic and Bariatric Surgery; American Society of Anesthesiologists; International Society of Perioperative Care of Patients with Obesity; Society of American Gastrointestinal and Endoscopic Surgeons. Multi-society Clinical Practice Guidance for the Safe Use of Glucagon-like Peptide-1 Receptor Agonists in the Perioperative Period. Clin Gastroenterol Hepatol. 2024 Oct. doi: 10.1016/j.cgh.2024.10.003.
6. Phan J et al. Glucagon-Like Peptide Receptor Agonists Use Before Endoscopy Is Associated With Low Retained Gastric Contents: A Multicenter Cross-Sectional Analysis. Am J Gastroenterol. 2025 Mar. doi: 10.14309/ajg.0000000000002969.
7. Panchal S et al. Endoscopy and Anesthesia Outcomes Associated With Glucagon-like Peptide-1 Receptor Agonist use in Patients Undergoing Outpatient Upper Endoscopy. Gastrointest Endosc. 2025 Aug. doi:10.1016/j.gie.2025.01.004.
8. Maselli DB et al. Safe Continuation of glucagon-like Peptide 1 Receptor Agonists at Endoscopy: A Case Series of 57 Adults Undergoing Endoscopic Sleeve Gastroplasty. Obes Surg. 2024 Jul. doi: 10.1007/s11695-024-07278-2.
9. Dixit AA et al. Preoperative GLP-1 Receptor Agonist Use and Risk of Postoperative Respiratory Complications. JAMA. 2024 Apr. doi: 10.1001/jama.2024.5003.
10. Hiramoto B et al. Quantified Metrics of Gastric Emptying Delay by Glucagon-Like Peptide-1 Agonists: A systematic review and meta-analysis with insights for periprocedural management. Am J Gastroenterol. 2024 Jun. doi: 10.14309/ajg.0000000000002820.
Sterile Water Bottles Deemed Unnecessary for Endoscopy
Like diners saving on drinks,
“No direct evidence supports the recommendation and widespread use of sterile water during gastrointestinal endosco-py procedures,” lead author Deepak Agrawal, MD, chief of gastroenterology & hepatology at the Dell Medical School, University Texas at Austin, and colleagues, wrote in Gastro Hep Advances. “Guidelines recommending sterile water during endoscopy are based on limited evidence and mostly expert opinions.”
After reviewing the literature back to 1975, Dr. Agrawal and colleagues considered the use of sterile water in endoscopy via three frameworks: medical evidence and guidelines, environmental and broader health effects, and financial costs.
Only 2 studies – both from the 1990s – directly compared sterile and tap water use in endoscopy. Neither showed an increased risk of infection from tap water. In fact, some cultures from allegedly sterile water bottles grew pathogenic bacteria, while no patient complications were reported in either study.
“The recommendations for sterile water contradict observations in other medical care scenarios, for example, for the irrigation of open wounds,” Dr. Agrawal and colleagues noted. “Similarly, there is no benefit in using sterile water for enteral feeds in immunosuppressed patients, and tap water enemas are routinely acceptable for colon cleansing before sigmoidoscopies in all patients, irrespective of immune status.”
Current guidelines, including the 2021 US multisociety guideline on reprocessing flexible GI endoscopes and accessories, recommend sterile water for procedures involving mucosal penetration but acknowledge low-quality supporting evidence. These recommendations are based on outdated studies, some unrelated to GI endoscopy, Dr. Agrawal and colleagues pointed out, and rely heavily on cross-referenced opinion statements rather than clinical data.
They went on to suggest a concerning possibility: all those plastic bottles may actually cause more health problems than prevent them. The review estimates that the production and transportation of sterile water bottles contributes over 6,000 metric tons of emissions per year from US endoscopy units alone. What’s more, as discarded bottles break down, they release greenhouse gases and microplastics, the latter of which have been linked to cardiovascular disease, inflammatory bowel disease, and endocrine disruption.
Dr. Agrawal and colleagues also underscored the financial toxicity of sterile water bottles. Considering a 1-liter bottle of sterile water costs $3-10, an endoscopy unit performing 30 procedures per day spends approximately $1,000-3,000 per month on bottled water alone. Scaled nationally, the routine use of sterile water costs tens of millions of dollars each year, not counting indirect expenses associated with stocking and waste disposal.
Considering the dubious clinical upside against the apparent environmental and financial downsides, Dr. Agrawal and colleagues urged endoscopy units to rethink routine sterile water use.
They proposed a pragmatic model: start the day with a new sterile or reusable bottle, refill with tap water for subsequent cases, and recycle the bottle at day’s end. Institutions should ensure their tap water meets safety standards, they added, such as those outlined in the Joint Commission’s 2022 R3 Report on standards for water management.
Dr. Agrawal and colleagues also called on GI societies to revise existing guidance to reflect today’s clinical and environmental realities. Until strong evidence supports the need for sterile water, they wrote, the smarter, safer, and more sustainable option may be simply turning on the tap.
The investigators disclosed relationships with Guardant, Exact Sciences, Freenome, and others.
In an editorial accompanying the study and comments to GI & Hepatology News, Dr. Seth A. Gross of NYU Langone Health urged gastroenterologists to reconsider the use of sterile water in endoscopy.
While the rationale for bottled water has centered on infection prevention, Gross argued that the evidence does not hold up, noting that this practice contradicts modern values around sustainability and evidence-based care.
The two relevant clinical studies comparing sterile versus tap water in endoscopy are almost 30 years old, he said, and neither detected an increased risk of infection with tap water, leading both to conclude that tap water is “safe and practical” for routine endoscopy.
Gross also pointed out the inconsistency of sterile water use in medical practice, noting that tap water is acceptable in procedures with higher infection risk than endoscopy.
“Lastly,” he added, “most people drink tap water and not sterile water on a daily basis without outbreaks of gastroenteritis from bacterial infections.”
Gross’s comments went beyond the data to emphasize the obvious but overlooked environmental impacts of sterile water bottles. He suggested several challenging suggestions to make medicine more ecofriendly, like reducing travel to conferences, increasing the availability of telehealth, and choosing reusable devices over disposables.
But “what’s hiding in plain sight,” he said, “is our use of sterile water.”
While acknowledging that some patients, like those who are immunocompromised, might still warrant sterile water, Gross supported the review’s recommendation to use tap water instead. He called on GI societies and regulatory bodies to re-examine current policy and pursue updated guidance.
“Sometimes going back to the basics,” he concluded, “could be the most innovative strategy with tremendous impact.”
Seth A. Gross, MD, AGAF, is clinical chief in the Division of Gastroenterology & Hepatology at NYU Langone Health, and professor at the NYU Grossman School of Medicine, both in New York City. He reported no conflicts of interest.
In an editorial accompanying the study and comments to GI & Hepatology News, Dr. Seth A. Gross of NYU Langone Health urged gastroenterologists to reconsider the use of sterile water in endoscopy.
While the rationale for bottled water has centered on infection prevention, Gross argued that the evidence does not hold up, noting that this practice contradicts modern values around sustainability and evidence-based care.
The two relevant clinical studies comparing sterile versus tap water in endoscopy are almost 30 years old, he said, and neither detected an increased risk of infection with tap water, leading both to conclude that tap water is “safe and practical” for routine endoscopy.
Gross also pointed out the inconsistency of sterile water use in medical practice, noting that tap water is acceptable in procedures with higher infection risk than endoscopy.
“Lastly,” he added, “most people drink tap water and not sterile water on a daily basis without outbreaks of gastroenteritis from bacterial infections.”
Gross’s comments went beyond the data to emphasize the obvious but overlooked environmental impacts of sterile water bottles. He suggested several challenging suggestions to make medicine more ecofriendly, like reducing travel to conferences, increasing the availability of telehealth, and choosing reusable devices over disposables.
But “what’s hiding in plain sight,” he said, “is our use of sterile water.”
While acknowledging that some patients, like those who are immunocompromised, might still warrant sterile water, Gross supported the review’s recommendation to use tap water instead. He called on GI societies and regulatory bodies to re-examine current policy and pursue updated guidance.
“Sometimes going back to the basics,” he concluded, “could be the most innovative strategy with tremendous impact.”
Seth A. Gross, MD, AGAF, is clinical chief in the Division of Gastroenterology & Hepatology at NYU Langone Health, and professor at the NYU Grossman School of Medicine, both in New York City. He reported no conflicts of interest.
In an editorial accompanying the study and comments to GI & Hepatology News, Dr. Seth A. Gross of NYU Langone Health urged gastroenterologists to reconsider the use of sterile water in endoscopy.
While the rationale for bottled water has centered on infection prevention, Gross argued that the evidence does not hold up, noting that this practice contradicts modern values around sustainability and evidence-based care.
The two relevant clinical studies comparing sterile versus tap water in endoscopy are almost 30 years old, he said, and neither detected an increased risk of infection with tap water, leading both to conclude that tap water is “safe and practical” for routine endoscopy.
Gross also pointed out the inconsistency of sterile water use in medical practice, noting that tap water is acceptable in procedures with higher infection risk than endoscopy.
“Lastly,” he added, “most people drink tap water and not sterile water on a daily basis without outbreaks of gastroenteritis from bacterial infections.”
Gross’s comments went beyond the data to emphasize the obvious but overlooked environmental impacts of sterile water bottles. He suggested several challenging suggestions to make medicine more ecofriendly, like reducing travel to conferences, increasing the availability of telehealth, and choosing reusable devices over disposables.
But “what’s hiding in plain sight,” he said, “is our use of sterile water.”
While acknowledging that some patients, like those who are immunocompromised, might still warrant sterile water, Gross supported the review’s recommendation to use tap water instead. He called on GI societies and regulatory bodies to re-examine current policy and pursue updated guidance.
“Sometimes going back to the basics,” he concluded, “could be the most innovative strategy with tremendous impact.”
Seth A. Gross, MD, AGAF, is clinical chief in the Division of Gastroenterology & Hepatology at NYU Langone Health, and professor at the NYU Grossman School of Medicine, both in New York City. He reported no conflicts of interest.
Like diners saving on drinks,
“No direct evidence supports the recommendation and widespread use of sterile water during gastrointestinal endosco-py procedures,” lead author Deepak Agrawal, MD, chief of gastroenterology & hepatology at the Dell Medical School, University Texas at Austin, and colleagues, wrote in Gastro Hep Advances. “Guidelines recommending sterile water during endoscopy are based on limited evidence and mostly expert opinions.”
After reviewing the literature back to 1975, Dr. Agrawal and colleagues considered the use of sterile water in endoscopy via three frameworks: medical evidence and guidelines, environmental and broader health effects, and financial costs.
Only 2 studies – both from the 1990s – directly compared sterile and tap water use in endoscopy. Neither showed an increased risk of infection from tap water. In fact, some cultures from allegedly sterile water bottles grew pathogenic bacteria, while no patient complications were reported in either study.
“The recommendations for sterile water contradict observations in other medical care scenarios, for example, for the irrigation of open wounds,” Dr. Agrawal and colleagues noted. “Similarly, there is no benefit in using sterile water for enteral feeds in immunosuppressed patients, and tap water enemas are routinely acceptable for colon cleansing before sigmoidoscopies in all patients, irrespective of immune status.”
Current guidelines, including the 2021 US multisociety guideline on reprocessing flexible GI endoscopes and accessories, recommend sterile water for procedures involving mucosal penetration but acknowledge low-quality supporting evidence. These recommendations are based on outdated studies, some unrelated to GI endoscopy, Dr. Agrawal and colleagues pointed out, and rely heavily on cross-referenced opinion statements rather than clinical data.
They went on to suggest a concerning possibility: all those plastic bottles may actually cause more health problems than prevent them. The review estimates that the production and transportation of sterile water bottles contributes over 6,000 metric tons of emissions per year from US endoscopy units alone. What’s more, as discarded bottles break down, they release greenhouse gases and microplastics, the latter of which have been linked to cardiovascular disease, inflammatory bowel disease, and endocrine disruption.
Dr. Agrawal and colleagues also underscored the financial toxicity of sterile water bottles. Considering a 1-liter bottle of sterile water costs $3-10, an endoscopy unit performing 30 procedures per day spends approximately $1,000-3,000 per month on bottled water alone. Scaled nationally, the routine use of sterile water costs tens of millions of dollars each year, not counting indirect expenses associated with stocking and waste disposal.
Considering the dubious clinical upside against the apparent environmental and financial downsides, Dr. Agrawal and colleagues urged endoscopy units to rethink routine sterile water use.
They proposed a pragmatic model: start the day with a new sterile or reusable bottle, refill with tap water for subsequent cases, and recycle the bottle at day’s end. Institutions should ensure their tap water meets safety standards, they added, such as those outlined in the Joint Commission’s 2022 R3 Report on standards for water management.
Dr. Agrawal and colleagues also called on GI societies to revise existing guidance to reflect today’s clinical and environmental realities. Until strong evidence supports the need for sterile water, they wrote, the smarter, safer, and more sustainable option may be simply turning on the tap.
The investigators disclosed relationships with Guardant, Exact Sciences, Freenome, and others.
Like diners saving on drinks,
“No direct evidence supports the recommendation and widespread use of sterile water during gastrointestinal endosco-py procedures,” lead author Deepak Agrawal, MD, chief of gastroenterology & hepatology at the Dell Medical School, University Texas at Austin, and colleagues, wrote in Gastro Hep Advances. “Guidelines recommending sterile water during endoscopy are based on limited evidence and mostly expert opinions.”
After reviewing the literature back to 1975, Dr. Agrawal and colleagues considered the use of sterile water in endoscopy via three frameworks: medical evidence and guidelines, environmental and broader health effects, and financial costs.
Only 2 studies – both from the 1990s – directly compared sterile and tap water use in endoscopy. Neither showed an increased risk of infection from tap water. In fact, some cultures from allegedly sterile water bottles grew pathogenic bacteria, while no patient complications were reported in either study.
“The recommendations for sterile water contradict observations in other medical care scenarios, for example, for the irrigation of open wounds,” Dr. Agrawal and colleagues noted. “Similarly, there is no benefit in using sterile water for enteral feeds in immunosuppressed patients, and tap water enemas are routinely acceptable for colon cleansing before sigmoidoscopies in all patients, irrespective of immune status.”
Current guidelines, including the 2021 US multisociety guideline on reprocessing flexible GI endoscopes and accessories, recommend sterile water for procedures involving mucosal penetration but acknowledge low-quality supporting evidence. These recommendations are based on outdated studies, some unrelated to GI endoscopy, Dr. Agrawal and colleagues pointed out, and rely heavily on cross-referenced opinion statements rather than clinical data.
They went on to suggest a concerning possibility: all those plastic bottles may actually cause more health problems than prevent them. The review estimates that the production and transportation of sterile water bottles contributes over 6,000 metric tons of emissions per year from US endoscopy units alone. What’s more, as discarded bottles break down, they release greenhouse gases and microplastics, the latter of which have been linked to cardiovascular disease, inflammatory bowel disease, and endocrine disruption.
Dr. Agrawal and colleagues also underscored the financial toxicity of sterile water bottles. Considering a 1-liter bottle of sterile water costs $3-10, an endoscopy unit performing 30 procedures per day spends approximately $1,000-3,000 per month on bottled water alone. Scaled nationally, the routine use of sterile water costs tens of millions of dollars each year, not counting indirect expenses associated with stocking and waste disposal.
Considering the dubious clinical upside against the apparent environmental and financial downsides, Dr. Agrawal and colleagues urged endoscopy units to rethink routine sterile water use.
They proposed a pragmatic model: start the day with a new sterile or reusable bottle, refill with tap water for subsequent cases, and recycle the bottle at day’s end. Institutions should ensure their tap water meets safety standards, they added, such as those outlined in the Joint Commission’s 2022 R3 Report on standards for water management.
Dr. Agrawal and colleagues also called on GI societies to revise existing guidance to reflect today’s clinical and environmental realities. Until strong evidence supports the need for sterile water, they wrote, the smarter, safer, and more sustainable option may be simply turning on the tap.
The investigators disclosed relationships with Guardant, Exact Sciences, Freenome, and others.
FROM GASTRO HEP ADVANCES
More Evidence Supports ‘Individualized Approach’ to Pre-Endoscopy GLP-1 RAs
in The American Journal of Gastroenterology. Moreover, most instances occurred in patients using the drugs for type 2 diabetes (T2D) rather than for weight loss alone.
The findings suggest adopting an individualized approach rather than universal preoperative withholding of GLP-1 RAs before endoscopy, concluded Jennifer Phan, MD, medical director of the Hoag Advanced Endoscopy Center in Newport Beach, California, and colleagues. These agents are associated with slowed gastric emptying, possibly raising the risk for pulmonary aspiration. The study identified comorbid uncontrolled T2D as a risk factor for retained gastric contents.
Recommendations from gastroenterological societies and the American Society of Anesthesiologists (ASA) differ regarding pre-endoscopic holding of these ubiquitous agents used for obesity and T2D. “Many patients undergo routine endoscopic procedures, and there was concern from the anesthesia safety perspective for retained gastric contents,” Phan told GI & Hepatology News. “At first these events were seen in a handful of cases; however, out of precaution this resulted in a statement from the ASA recommending that patients hold their GLP-1 medications for at least 1 week prior to a routine endoscopic procedure.”
That guidance resulted in protocol changes within endoscopy units, cancelled procedures, and potential delays in patient care. “We wanted to study whether this concern was clinically valid and to help identify which subgroup of patients are at highest risk in order to best inform anesthesia and endoscopy practices,” Phan added.
The ASA updated its guidance in 2023.
The current study aligns with other research showing that rates of clinically relevant retained gastric contents are < 10%, Phan said. For instance, the American Gastroenterological Association (AGA) published a rapid clinical practice update in November 2023 that found insufficient evidence to support patients stopping the medications before endoscopic procedures. AGA guidance suggests an individual approach for each patient on a GLP-1 RA rather than a blanket statement on how to manage all patients taking the medications.
“Our initial hypothesis was that the rates of clinically relevant retained gastric contents in patients on GLP-1 RA medications would be low,” Phan noted. “This was born out of anecdotal experience of the limited number of aborted procedures we experienced before the ASA statement.”
Her group also hypothesized that the indication for which the GLP-1 RA was prescribed would be important, with patients taking GLP-1 RA medications for diabetes potentially having a higher likelihood of retained contents given the concomitant propensity for delayed gastric motility related to uncontrolled hyperglycemia.
The Study
The investigators identified 815 patients on confirmed GLP-1 RA medications of various types receiving endoscopy from 2021 to 2023 at four centers. Demographics, prescribing practices, and procedure outcomes were captured. GLP-1 RA management of preoperative holding was retroactively classified per ASA guidance.
Of the 815 patients (mean age, 67.7 years; 57.7% women; 53.9% White individuals), 70 (8.7%) exhibited retained gastric contents on endoscopy. Of these 65 (93%) had T2D with a median A1c of 6.5%. Among those with retained contents, most had a minimal (10, 14.3%) or moderate (31, 44.3%) amount of food retained, although 29 (41.4%) had a large quantity. Only one patient required unplanned intubation because of a large quantity of residual content, and none had aspiration events.
In multivariate analysis, the odds ratio of retention in those with diabetes was 4.1. “Given the predominance of diabetes in those with retained gastric contents, we highlight the potential to risk-stratify patients who require further preprocedural consideration,” the authors wrote.
Those with GLP-1 RA held per ASA guidance (406, 49.8%) were less likely to have retained contents (4.4% vs 12.7%; P < .001), but no significant differences for intubation (0% vs 2%; P = .53) or aborting procedure rates (28% vs 18%; P = .40) due to gastric retention were observed.
On multivariable analysis, the likelihood of food retention increased by 36% (95% CI, 1.15-1.60) for every 1% increase in glycosylated hemoglobin after adjusting for GLP-1 RA type and preoperative medication hold.
“Our study can help to differentiate which patients can be at largest risk for retained gastric contents,” Phan said, noting the impact of increasing percentages of A1C. “There’s a 36% increased likelihood of food retention in patients on GLP-1 medications, so a blanket policy to hold GLP-1s in patients who are nondiabetic and taking the medication for obesity may not be the best approach. But if patients have uncontrolled hyperglycemia, then an approach of caution is clinically valid.” In that context, holding the GLP-1 RA injection or lengthening the preoperative clear-liquid diet policy should be considered.
She noted that the study results are generalizable because the study was conducted across multiple types of hospital systems, both university and county, and included all types of GLP-1 RA.
Offering an anesthesiologist’s perspective on the study, Paul Potnuru, MD, an assistant professor in the Department of Anesthesiology, Critical Care, and Pain Medicine at UTHealth Houston and not involved in the study, called the findings “somewhat reassuring” but said the risk for aspiration was still a consideration.
A recent review, however, reported that the risk for GLP-1 RA-associated pulmonary aspiration was low.
Potnuru acknowledged that the original ASA guidance on preoperative GLP-1 RA cessation led to some confusion. “There were not a lot of data on the issue, but some studies found that even with stopping GLP-1s 2 weeks preoperatively some patients still retained gastric content,” he told GI & Hepatology News.
A study at his center recently reported that 56% of GLP-1 RA users had increased pre-anesthesia residual gastric content compared with 19% of nonusers.
From the anesthesiologist’s clinical vantage point, the margin of safety is an issue even if aspiration risk is low. “If there’s a 1 in 1000 chance or even a 1 in 3000 chance, that can be considered too high,” Potnuru said.
He further noted that the current study included only 815 patients, not nearly enough for definitive data. In addition, a retrospective study based on medical records can’t really capture all the real-world procedural changes made in the operating room. “It’s common for anesthesiologists not to document all cases of intubation, for example,” he said.
While the ideal is a completely empty stomach, he agreed that a practical alternative to stopping GLP-1 RA therapy, especially that prescribed for diabetes, would be a 24-hour liquid diet, which would clear the stomach quickly. “If you stop these drugs in patients taking them for diabetes, you get a worsening of their glycemic control,” he said.
He noted that patients have different risk tolerances, with some willing to go ahead even if ultrasound shows gastric retention, while some opt to cancel.
Prospective studies are needed, Potnuru added, “because you find more if you know what you’re looking for.” His center is starting a clinical trial in 150 patients to assess the impact of a 24-hour, liquids-only diet on gastric retention.
According to Phan, other research is following GLP-1 RA users undergoing colonoscopy. “Future studies can look at the added value of point-of-care abdominal ultrasound to see if it increases precision preoperative management in these patients on GLP-1 medications.”
Other groups are examining the safety of these agents in the general context of sedation. “It’s worth noting that the studies are being done on currently available medications and may not apply to future medications such as triple agonists or anti-amylins that may come on the market in the near future,” Phan said.
This study received no financial support. Neither the study authors nor Potnuru had any conflicts of interest.
A version of this article appeared on Medscape.com.
in The American Journal of Gastroenterology. Moreover, most instances occurred in patients using the drugs for type 2 diabetes (T2D) rather than for weight loss alone.
The findings suggest adopting an individualized approach rather than universal preoperative withholding of GLP-1 RAs before endoscopy, concluded Jennifer Phan, MD, medical director of the Hoag Advanced Endoscopy Center in Newport Beach, California, and colleagues. These agents are associated with slowed gastric emptying, possibly raising the risk for pulmonary aspiration. The study identified comorbid uncontrolled T2D as a risk factor for retained gastric contents.
Recommendations from gastroenterological societies and the American Society of Anesthesiologists (ASA) differ regarding pre-endoscopic holding of these ubiquitous agents used for obesity and T2D. “Many patients undergo routine endoscopic procedures, and there was concern from the anesthesia safety perspective for retained gastric contents,” Phan told GI & Hepatology News. “At first these events were seen in a handful of cases; however, out of precaution this resulted in a statement from the ASA recommending that patients hold their GLP-1 medications for at least 1 week prior to a routine endoscopic procedure.”
That guidance resulted in protocol changes within endoscopy units, cancelled procedures, and potential delays in patient care. “We wanted to study whether this concern was clinically valid and to help identify which subgroup of patients are at highest risk in order to best inform anesthesia and endoscopy practices,” Phan added.
The ASA updated its guidance in 2023.
The current study aligns with other research showing that rates of clinically relevant retained gastric contents are < 10%, Phan said. For instance, the American Gastroenterological Association (AGA) published a rapid clinical practice update in November 2023 that found insufficient evidence to support patients stopping the medications before endoscopic procedures. AGA guidance suggests an individual approach for each patient on a GLP-1 RA rather than a blanket statement on how to manage all patients taking the medications.
“Our initial hypothesis was that the rates of clinically relevant retained gastric contents in patients on GLP-1 RA medications would be low,” Phan noted. “This was born out of anecdotal experience of the limited number of aborted procedures we experienced before the ASA statement.”
Her group also hypothesized that the indication for which the GLP-1 RA was prescribed would be important, with patients taking GLP-1 RA medications for diabetes potentially having a higher likelihood of retained contents given the concomitant propensity for delayed gastric motility related to uncontrolled hyperglycemia.
The Study
The investigators identified 815 patients on confirmed GLP-1 RA medications of various types receiving endoscopy from 2021 to 2023 at four centers. Demographics, prescribing practices, and procedure outcomes were captured. GLP-1 RA management of preoperative holding was retroactively classified per ASA guidance.
Of the 815 patients (mean age, 67.7 years; 57.7% women; 53.9% White individuals), 70 (8.7%) exhibited retained gastric contents on endoscopy. Of these 65 (93%) had T2D with a median A1c of 6.5%. Among those with retained contents, most had a minimal (10, 14.3%) or moderate (31, 44.3%) amount of food retained, although 29 (41.4%) had a large quantity. Only one patient required unplanned intubation because of a large quantity of residual content, and none had aspiration events.
In multivariate analysis, the odds ratio of retention in those with diabetes was 4.1. “Given the predominance of diabetes in those with retained gastric contents, we highlight the potential to risk-stratify patients who require further preprocedural consideration,” the authors wrote.
Those with GLP-1 RA held per ASA guidance (406, 49.8%) were less likely to have retained contents (4.4% vs 12.7%; P < .001), but no significant differences for intubation (0% vs 2%; P = .53) or aborting procedure rates (28% vs 18%; P = .40) due to gastric retention were observed.
On multivariable analysis, the likelihood of food retention increased by 36% (95% CI, 1.15-1.60) for every 1% increase in glycosylated hemoglobin after adjusting for GLP-1 RA type and preoperative medication hold.
“Our study can help to differentiate which patients can be at largest risk for retained gastric contents,” Phan said, noting the impact of increasing percentages of A1C. “There’s a 36% increased likelihood of food retention in patients on GLP-1 medications, so a blanket policy to hold GLP-1s in patients who are nondiabetic and taking the medication for obesity may not be the best approach. But if patients have uncontrolled hyperglycemia, then an approach of caution is clinically valid.” In that context, holding the GLP-1 RA injection or lengthening the preoperative clear-liquid diet policy should be considered.
She noted that the study results are generalizable because the study was conducted across multiple types of hospital systems, both university and county, and included all types of GLP-1 RA.
Offering an anesthesiologist’s perspective on the study, Paul Potnuru, MD, an assistant professor in the Department of Anesthesiology, Critical Care, and Pain Medicine at UTHealth Houston and not involved in the study, called the findings “somewhat reassuring” but said the risk for aspiration was still a consideration.
A recent review, however, reported that the risk for GLP-1 RA-associated pulmonary aspiration was low.
Potnuru acknowledged that the original ASA guidance on preoperative GLP-1 RA cessation led to some confusion. “There were not a lot of data on the issue, but some studies found that even with stopping GLP-1s 2 weeks preoperatively some patients still retained gastric content,” he told GI & Hepatology News.
A study at his center recently reported that 56% of GLP-1 RA users had increased pre-anesthesia residual gastric content compared with 19% of nonusers.
From the anesthesiologist’s clinical vantage point, the margin of safety is an issue even if aspiration risk is low. “If there’s a 1 in 1000 chance or even a 1 in 3000 chance, that can be considered too high,” Potnuru said.
He further noted that the current study included only 815 patients, not nearly enough for definitive data. In addition, a retrospective study based on medical records can’t really capture all the real-world procedural changes made in the operating room. “It’s common for anesthesiologists not to document all cases of intubation, for example,” he said.
While the ideal is a completely empty stomach, he agreed that a practical alternative to stopping GLP-1 RA therapy, especially that prescribed for diabetes, would be a 24-hour liquid diet, which would clear the stomach quickly. “If you stop these drugs in patients taking them for diabetes, you get a worsening of their glycemic control,” he said.
He noted that patients have different risk tolerances, with some willing to go ahead even if ultrasound shows gastric retention, while some opt to cancel.
Prospective studies are needed, Potnuru added, “because you find more if you know what you’re looking for.” His center is starting a clinical trial in 150 patients to assess the impact of a 24-hour, liquids-only diet on gastric retention.
According to Phan, other research is following GLP-1 RA users undergoing colonoscopy. “Future studies can look at the added value of point-of-care abdominal ultrasound to see if it increases precision preoperative management in these patients on GLP-1 medications.”
Other groups are examining the safety of these agents in the general context of sedation. “It’s worth noting that the studies are being done on currently available medications and may not apply to future medications such as triple agonists or anti-amylins that may come on the market in the near future,” Phan said.
This study received no financial support. Neither the study authors nor Potnuru had any conflicts of interest.
A version of this article appeared on Medscape.com.
in The American Journal of Gastroenterology. Moreover, most instances occurred in patients using the drugs for type 2 diabetes (T2D) rather than for weight loss alone.
The findings suggest adopting an individualized approach rather than universal preoperative withholding of GLP-1 RAs before endoscopy, concluded Jennifer Phan, MD, medical director of the Hoag Advanced Endoscopy Center in Newport Beach, California, and colleagues. These agents are associated with slowed gastric emptying, possibly raising the risk for pulmonary aspiration. The study identified comorbid uncontrolled T2D as a risk factor for retained gastric contents.
Recommendations from gastroenterological societies and the American Society of Anesthesiologists (ASA) differ regarding pre-endoscopic holding of these ubiquitous agents used for obesity and T2D. “Many patients undergo routine endoscopic procedures, and there was concern from the anesthesia safety perspective for retained gastric contents,” Phan told GI & Hepatology News. “At first these events were seen in a handful of cases; however, out of precaution this resulted in a statement from the ASA recommending that patients hold their GLP-1 medications for at least 1 week prior to a routine endoscopic procedure.”
That guidance resulted in protocol changes within endoscopy units, cancelled procedures, and potential delays in patient care. “We wanted to study whether this concern was clinically valid and to help identify which subgroup of patients are at highest risk in order to best inform anesthesia and endoscopy practices,” Phan added.
The ASA updated its guidance in 2023.
The current study aligns with other research showing that rates of clinically relevant retained gastric contents are < 10%, Phan said. For instance, the American Gastroenterological Association (AGA) published a rapid clinical practice update in November 2023 that found insufficient evidence to support patients stopping the medications before endoscopic procedures. AGA guidance suggests an individual approach for each patient on a GLP-1 RA rather than a blanket statement on how to manage all patients taking the medications.
“Our initial hypothesis was that the rates of clinically relevant retained gastric contents in patients on GLP-1 RA medications would be low,” Phan noted. “This was born out of anecdotal experience of the limited number of aborted procedures we experienced before the ASA statement.”
Her group also hypothesized that the indication for which the GLP-1 RA was prescribed would be important, with patients taking GLP-1 RA medications for diabetes potentially having a higher likelihood of retained contents given the concomitant propensity for delayed gastric motility related to uncontrolled hyperglycemia.
The Study
The investigators identified 815 patients on confirmed GLP-1 RA medications of various types receiving endoscopy from 2021 to 2023 at four centers. Demographics, prescribing practices, and procedure outcomes were captured. GLP-1 RA management of preoperative holding was retroactively classified per ASA guidance.
Of the 815 patients (mean age, 67.7 years; 57.7% women; 53.9% White individuals), 70 (8.7%) exhibited retained gastric contents on endoscopy. Of these 65 (93%) had T2D with a median A1c of 6.5%. Among those with retained contents, most had a minimal (10, 14.3%) or moderate (31, 44.3%) amount of food retained, although 29 (41.4%) had a large quantity. Only one patient required unplanned intubation because of a large quantity of residual content, and none had aspiration events.
In multivariate analysis, the odds ratio of retention in those with diabetes was 4.1. “Given the predominance of diabetes in those with retained gastric contents, we highlight the potential to risk-stratify patients who require further preprocedural consideration,” the authors wrote.
Those with GLP-1 RA held per ASA guidance (406, 49.8%) were less likely to have retained contents (4.4% vs 12.7%; P < .001), but no significant differences for intubation (0% vs 2%; P = .53) or aborting procedure rates (28% vs 18%; P = .40) due to gastric retention were observed.
On multivariable analysis, the likelihood of food retention increased by 36% (95% CI, 1.15-1.60) for every 1% increase in glycosylated hemoglobin after adjusting for GLP-1 RA type and preoperative medication hold.
“Our study can help to differentiate which patients can be at largest risk for retained gastric contents,” Phan said, noting the impact of increasing percentages of A1C. “There’s a 36% increased likelihood of food retention in patients on GLP-1 medications, so a blanket policy to hold GLP-1s in patients who are nondiabetic and taking the medication for obesity may not be the best approach. But if patients have uncontrolled hyperglycemia, then an approach of caution is clinically valid.” In that context, holding the GLP-1 RA injection or lengthening the preoperative clear-liquid diet policy should be considered.
She noted that the study results are generalizable because the study was conducted across multiple types of hospital systems, both university and county, and included all types of GLP-1 RA.
Offering an anesthesiologist’s perspective on the study, Paul Potnuru, MD, an assistant professor in the Department of Anesthesiology, Critical Care, and Pain Medicine at UTHealth Houston and not involved in the study, called the findings “somewhat reassuring” but said the risk for aspiration was still a consideration.
A recent review, however, reported that the risk for GLP-1 RA-associated pulmonary aspiration was low.
Potnuru acknowledged that the original ASA guidance on preoperative GLP-1 RA cessation led to some confusion. “There were not a lot of data on the issue, but some studies found that even with stopping GLP-1s 2 weeks preoperatively some patients still retained gastric content,” he told GI & Hepatology News.
A study at his center recently reported that 56% of GLP-1 RA users had increased pre-anesthesia residual gastric content compared with 19% of nonusers.
From the anesthesiologist’s clinical vantage point, the margin of safety is an issue even if aspiration risk is low. “If there’s a 1 in 1000 chance or even a 1 in 3000 chance, that can be considered too high,” Potnuru said.
He further noted that the current study included only 815 patients, not nearly enough for definitive data. In addition, a retrospective study based on medical records can’t really capture all the real-world procedural changes made in the operating room. “It’s common for anesthesiologists not to document all cases of intubation, for example,” he said.
While the ideal is a completely empty stomach, he agreed that a practical alternative to stopping GLP-1 RA therapy, especially that prescribed for diabetes, would be a 24-hour liquid diet, which would clear the stomach quickly. “If you stop these drugs in patients taking them for diabetes, you get a worsening of their glycemic control,” he said.
He noted that patients have different risk tolerances, with some willing to go ahead even if ultrasound shows gastric retention, while some opt to cancel.
Prospective studies are needed, Potnuru added, “because you find more if you know what you’re looking for.” His center is starting a clinical trial in 150 patients to assess the impact of a 24-hour, liquids-only diet on gastric retention.
According to Phan, other research is following GLP-1 RA users undergoing colonoscopy. “Future studies can look at the added value of point-of-care abdominal ultrasound to see if it increases precision preoperative management in these patients on GLP-1 medications.”
Other groups are examining the safety of these agents in the general context of sedation. “It’s worth noting that the studies are being done on currently available medications and may not apply to future medications such as triple agonists or anti-amylins that may come on the market in the near future,” Phan said.
This study received no financial support. Neither the study authors nor Potnuru had any conflicts of interest.
A version of this article appeared on Medscape.com.
Endoscopic Lifting Agents: AGA Issues New Clinical Practice Update
Published in Clinical Gastroenterology and Hepatology, the commentary reviews available agents and provides clinically relevant commentary on their indications and use — with the caveat that it is not a formal systematic review but rather empirical advice for endoscopists. No formal rating of the quality of evidence or strength of recommendations was performed.
Led by Tobias Zuchelli, MD, a clinical associate professor at Michigan State University and a gastroenterologist at the Henry Ford Health System in Detroit, the expert panel noted that endoscopists are increasingly resecting precancerous lesions and early cancers of the gastrointestinal tract.
“Although new endoscopic procedures have been developed, there had not been much in terms of high-quality guidance on lifting agents,” panelist Amit V. Patel, MD, a professor of medicine at Duke University and director of Endoscopy at Durham Veterans Affairs Medical Center in Durham, North Carolina, told GI & Hepatology News. “With our better understanding and use of techniques, this commentary was timely. It summarizes the available data on the topic and includes our clinical experiences.”
Filling that knowledge gap, the document reviews in detail the timing and methods of agent injection according to procedure type, including the dynamic needle approach, the empirical merits of different agents such as saline (with or without blue contrast) and viscous agents, as well as lift-enhancing assistive devices — for example, the ERBEJET 2 high-pressure water jet, an adjustable hydrosurgical device to facilitate lifting. A chart provides an at-a-glance summary of agents and their pros and cons.
“The feedback from gastroenterologists so far has been quite positive on social media and on GI channels,” Patel said.
Endoscopic resection has evolved from snare polypectomy to endoscopic mucosal resection (EMR) and now, endoscopic submucosal dissection (ESD). The primary benefit of submucosal lifting is the creation of a separating submucosal cushion between the lesion and muscularis propria (MP), which reduces the risk for immediate or delayed perforation of the muscle. Adding a contrast agent also demarcates lesion margins and stains the submucosa, which is fundamental to ESD and allows for assessment of MP injury during EMR.
For decades, homemade solutions were used to lift lesions before removal, with the sentinel agent being normal saline, later mixed with a blue contrast agent, usually indigo carmine or methylene blue. The authors noted that some endoscopists performing ESD start the submucosal injection and incision using a prepackaged viscous solution. “The endoscopist may continue with the viscous fluid or transition to saline or another less expensive solution,” they wrote.
Saline tends to dissipate more quickly than viscous solutions, however. In 2015, the polymer compound SIC-8000 became the first FDA-approved submucosal injection agent. Since then, several other fluids have come on the market, although homemade agents remain available.
Among the update’s recommendations, the fluid selected for EMR should be determined by lesion size, predicted histology, and endoscopist preference. Based on the US Multi-Society Task Force (USMSTF) on Colorectal Cancer, submucosal injection is optional for nonpedunculated colorectal lesions (NPCRLs) of intermediate size (10-19 mm).
Cold snare polypectomy without submucosal injection was later found to be non-inferior to other resection methods utilizing submucosal injection for NPCRLs ≤ 15 mm.
The update noted that the USMSTF considers EMR first-line therapy for most NPCRLs ≥ 20 mm and advocates viscous solutions as preferred, while the use of lifting agents for pedunculated polyps is generally at the discretion of the endoscopist.
For Patel, the main “clinical pearls” in the update are adding a contrast agent to normal saline, using a viscous agent for cold EMR, and manipulating the injection needle first tangentially and then dynamically toward the lumen to maximize separation of the lesion.
In terms of the ideal, an optimal lifting solution would be readily available, inexpensive, and premixed, providing a sustained submucosal cushion. “However, this ideal solution currently does not exist. Injection fluids should, therefore, be selected based on planned resection method, predicted histology, local expertise and preferences, and cost,” the panelists wrote.
Added Patel, “A lot of the agents out there check most of these boxes, but we’re hoping for further development toward the ideal.”
Offering a nonparticipant’s perspective on the overview, Wasseem Skef, MD, a gastroenterologist at UTHealth Houston, found the update very useful. “It always helps to have the literature summarized,” he told GI & Hepatology News. “It’s a pretty balanced review that pulls together the various options but allows people to stick to their preferred practice.”
In his practice, the lifting agent selected depends on the type of resection. “Viscous agents are generally more popular for EMR-type resections,” Skef said. One unanswered question, he noted, is whether adding a hemostatic agent would be superior to a viscous agent alone. “But overall, this is a nice summary of available agents. Gastroenterologists should consider these different options if doing procedures like EMR.”
This review was sponsored by the AGA Institute.
Zuchelli is a consultant for Boston Scientific. Patel consults for Medpace, Renexxion, and Sanofi. Skef reported having no relevant disclosures.
A version of this article appeared on Medscape.com .
Published in Clinical Gastroenterology and Hepatology, the commentary reviews available agents and provides clinically relevant commentary on their indications and use — with the caveat that it is not a formal systematic review but rather empirical advice for endoscopists. No formal rating of the quality of evidence or strength of recommendations was performed.
Led by Tobias Zuchelli, MD, a clinical associate professor at Michigan State University and a gastroenterologist at the Henry Ford Health System in Detroit, the expert panel noted that endoscopists are increasingly resecting precancerous lesions and early cancers of the gastrointestinal tract.
“Although new endoscopic procedures have been developed, there had not been much in terms of high-quality guidance on lifting agents,” panelist Amit V. Patel, MD, a professor of medicine at Duke University and director of Endoscopy at Durham Veterans Affairs Medical Center in Durham, North Carolina, told GI & Hepatology News. “With our better understanding and use of techniques, this commentary was timely. It summarizes the available data on the topic and includes our clinical experiences.”
Filling that knowledge gap, the document reviews in detail the timing and methods of agent injection according to procedure type, including the dynamic needle approach, the empirical merits of different agents such as saline (with or without blue contrast) and viscous agents, as well as lift-enhancing assistive devices — for example, the ERBEJET 2 high-pressure water jet, an adjustable hydrosurgical device to facilitate lifting. A chart provides an at-a-glance summary of agents and their pros and cons.
“The feedback from gastroenterologists so far has been quite positive on social media and on GI channels,” Patel said.
Endoscopic resection has evolved from snare polypectomy to endoscopic mucosal resection (EMR) and now, endoscopic submucosal dissection (ESD). The primary benefit of submucosal lifting is the creation of a separating submucosal cushion between the lesion and muscularis propria (MP), which reduces the risk for immediate or delayed perforation of the muscle. Adding a contrast agent also demarcates lesion margins and stains the submucosa, which is fundamental to ESD and allows for assessment of MP injury during EMR.
For decades, homemade solutions were used to lift lesions before removal, with the sentinel agent being normal saline, later mixed with a blue contrast agent, usually indigo carmine or methylene blue. The authors noted that some endoscopists performing ESD start the submucosal injection and incision using a prepackaged viscous solution. “The endoscopist may continue with the viscous fluid or transition to saline or another less expensive solution,” they wrote.
Saline tends to dissipate more quickly than viscous solutions, however. In 2015, the polymer compound SIC-8000 became the first FDA-approved submucosal injection agent. Since then, several other fluids have come on the market, although homemade agents remain available.
Among the update’s recommendations, the fluid selected for EMR should be determined by lesion size, predicted histology, and endoscopist preference. Based on the US Multi-Society Task Force (USMSTF) on Colorectal Cancer, submucosal injection is optional for nonpedunculated colorectal lesions (NPCRLs) of intermediate size (10-19 mm).
Cold snare polypectomy without submucosal injection was later found to be non-inferior to other resection methods utilizing submucosal injection for NPCRLs ≤ 15 mm.
The update noted that the USMSTF considers EMR first-line therapy for most NPCRLs ≥ 20 mm and advocates viscous solutions as preferred, while the use of lifting agents for pedunculated polyps is generally at the discretion of the endoscopist.
For Patel, the main “clinical pearls” in the update are adding a contrast agent to normal saline, using a viscous agent for cold EMR, and manipulating the injection needle first tangentially and then dynamically toward the lumen to maximize separation of the lesion.
In terms of the ideal, an optimal lifting solution would be readily available, inexpensive, and premixed, providing a sustained submucosal cushion. “However, this ideal solution currently does not exist. Injection fluids should, therefore, be selected based on planned resection method, predicted histology, local expertise and preferences, and cost,” the panelists wrote.
Added Patel, “A lot of the agents out there check most of these boxes, but we’re hoping for further development toward the ideal.”
Offering a nonparticipant’s perspective on the overview, Wasseem Skef, MD, a gastroenterologist at UTHealth Houston, found the update very useful. “It always helps to have the literature summarized,” he told GI & Hepatology News. “It’s a pretty balanced review that pulls together the various options but allows people to stick to their preferred practice.”
In his practice, the lifting agent selected depends on the type of resection. “Viscous agents are generally more popular for EMR-type resections,” Skef said. One unanswered question, he noted, is whether adding a hemostatic agent would be superior to a viscous agent alone. “But overall, this is a nice summary of available agents. Gastroenterologists should consider these different options if doing procedures like EMR.”
This review was sponsored by the AGA Institute.
Zuchelli is a consultant for Boston Scientific. Patel consults for Medpace, Renexxion, and Sanofi. Skef reported having no relevant disclosures.
A version of this article appeared on Medscape.com .
Published in Clinical Gastroenterology and Hepatology, the commentary reviews available agents and provides clinically relevant commentary on their indications and use — with the caveat that it is not a formal systematic review but rather empirical advice for endoscopists. No formal rating of the quality of evidence or strength of recommendations was performed.
Led by Tobias Zuchelli, MD, a clinical associate professor at Michigan State University and a gastroenterologist at the Henry Ford Health System in Detroit, the expert panel noted that endoscopists are increasingly resecting precancerous lesions and early cancers of the gastrointestinal tract.
“Although new endoscopic procedures have been developed, there had not been much in terms of high-quality guidance on lifting agents,” panelist Amit V. Patel, MD, a professor of medicine at Duke University and director of Endoscopy at Durham Veterans Affairs Medical Center in Durham, North Carolina, told GI & Hepatology News. “With our better understanding and use of techniques, this commentary was timely. It summarizes the available data on the topic and includes our clinical experiences.”
Filling that knowledge gap, the document reviews in detail the timing and methods of agent injection according to procedure type, including the dynamic needle approach, the empirical merits of different agents such as saline (with or without blue contrast) and viscous agents, as well as lift-enhancing assistive devices — for example, the ERBEJET 2 high-pressure water jet, an adjustable hydrosurgical device to facilitate lifting. A chart provides an at-a-glance summary of agents and their pros and cons.
“The feedback from gastroenterologists so far has been quite positive on social media and on GI channels,” Patel said.
Endoscopic resection has evolved from snare polypectomy to endoscopic mucosal resection (EMR) and now, endoscopic submucosal dissection (ESD). The primary benefit of submucosal lifting is the creation of a separating submucosal cushion between the lesion and muscularis propria (MP), which reduces the risk for immediate or delayed perforation of the muscle. Adding a contrast agent also demarcates lesion margins and stains the submucosa, which is fundamental to ESD and allows for assessment of MP injury during EMR.
For decades, homemade solutions were used to lift lesions before removal, with the sentinel agent being normal saline, later mixed with a blue contrast agent, usually indigo carmine or methylene blue. The authors noted that some endoscopists performing ESD start the submucosal injection and incision using a prepackaged viscous solution. “The endoscopist may continue with the viscous fluid or transition to saline or another less expensive solution,” they wrote.
Saline tends to dissipate more quickly than viscous solutions, however. In 2015, the polymer compound SIC-8000 became the first FDA-approved submucosal injection agent. Since then, several other fluids have come on the market, although homemade agents remain available.
Among the update’s recommendations, the fluid selected for EMR should be determined by lesion size, predicted histology, and endoscopist preference. Based on the US Multi-Society Task Force (USMSTF) on Colorectal Cancer, submucosal injection is optional for nonpedunculated colorectal lesions (NPCRLs) of intermediate size (10-19 mm).
Cold snare polypectomy without submucosal injection was later found to be non-inferior to other resection methods utilizing submucosal injection for NPCRLs ≤ 15 mm.
The update noted that the USMSTF considers EMR first-line therapy for most NPCRLs ≥ 20 mm and advocates viscous solutions as preferred, while the use of lifting agents for pedunculated polyps is generally at the discretion of the endoscopist.
For Patel, the main “clinical pearls” in the update are adding a contrast agent to normal saline, using a viscous agent for cold EMR, and manipulating the injection needle first tangentially and then dynamically toward the lumen to maximize separation of the lesion.
In terms of the ideal, an optimal lifting solution would be readily available, inexpensive, and premixed, providing a sustained submucosal cushion. “However, this ideal solution currently does not exist. Injection fluids should, therefore, be selected based on planned resection method, predicted histology, local expertise and preferences, and cost,” the panelists wrote.
Added Patel, “A lot of the agents out there check most of these boxes, but we’re hoping for further development toward the ideal.”
Offering a nonparticipant’s perspective on the overview, Wasseem Skef, MD, a gastroenterologist at UTHealth Houston, found the update very useful. “It always helps to have the literature summarized,” he told GI & Hepatology News. “It’s a pretty balanced review that pulls together the various options but allows people to stick to their preferred practice.”
In his practice, the lifting agent selected depends on the type of resection. “Viscous agents are generally more popular for EMR-type resections,” Skef said. One unanswered question, he noted, is whether adding a hemostatic agent would be superior to a viscous agent alone. “But overall, this is a nice summary of available agents. Gastroenterologists should consider these different options if doing procedures like EMR.”
This review was sponsored by the AGA Institute.
Zuchelli is a consultant for Boston Scientific. Patel consults for Medpace, Renexxion, and Sanofi. Skef reported having no relevant disclosures.
A version of this article appeared on Medscape.com .
FROM CLINICAL GASTROENTEROLOGY AND HEPATOLOGY