Figure 1. Common endoscopic modalities. (A): Conventional HD endoscopy showing Barrett’s esophagus with lesion (circled). (B): Image in 1A under NBI. Area of abnormal vascular and mucosal patterns (circled) is concerning for malignancy. (C): EUS of the esophagus. Arrows denote 5 alternating hyperechoic/hypoechoic layers: (1) mucosal surface, (2) muscularis mucosa, (3) submucosa, (4) muscularis propia, (5) serosa. (D): ERCP in hilar cholangiocarcinoma. Left image: dilation of intrahepatic bile ducts because of complete blockage of the common hepatic duct (arrow). Right image: improved flow of bile/contrast after deployment of plastic biliary stent across the malignant obstruction.

Figure 1. Common endoscopic modalities. (A): Conventional HD endoscopy showing Barrett’s esophagus with lesion (circled). (B): Image in 1A under NBI. Area of abnormal vascular and mucosal patterns (circled) is concerning for malignancy. (C): EUS of the esophagus. Arrows denote 5 alternating hyperechoic/hypoechoic layers: (1) mucosal surface, (2) muscularis mucosa, (3) submucosa, (4) muscularis propia, (5) serosa. (D): ERCP in hilar cholangiocarcinoma. Left image: dilation of intrahepatic bile ducts because of complete blockage of the common hepatic duct (arrow). Right image: improved flow of bile/contrast after deployment of plastic biliary stent across the malignant obstruction.

Figure 2. Surveillance guidelines for Barrett’s esophagus. a “Treated” assumes complete eradication of intestinal metaplasia (CEIM). b Treatment is recommended in all cases of high-grade dysplasia.

Figure 3. Surveillance guidelines for mucinous pancreatic cysts (Adapted from the 2018 ACG Clinical Guideline: Diagnosis and Management of Pancreatic Cysts). a Size-based surveillance guidelines only apply in the absence of high-risk features (see Table 1).

Figure 4. (A): Endoscopic mucosal resection (EMR) by band and snare technique: (I) Initial 1 cm, slightly raised esophageal lesion with surrounding Barrett’s esophagus. (II) Abnormal mucosal area is being capture completely into the cap with a cuff of normal surrounding mucosa. (III) Snare deployed around the band and resected using blended current. (IV) Resection base after cautery of underlying vessels. (B): Endoscopic Submucosal Dissection (ESD): (I) Initial large, well-demarcated lesion of the stomach. Lesions of the border are usually marked in the beginning and methylene bue or other lifting agents are injected to elevate the lesion (not performed here). (II) The lesion is resected with a needle-knife using electrocautery, starting at the previously demarcated margins. (III) Base of the lesion that has been fully resected. (IV) 3 cm resected lesion.

Figure 4. (A): Endoscopic mucosal resection (EMR) by band and snare technique: (I) Initial 1 cm, slightly raised esophageal lesion with surrounding Barrett’s esophagus. (II) Abnormal mucosal area is being capture completely into the cap with a cuff of normal surrounding mucosa. (III) Snare deployed around the band and resected using blended current. (IV) Resection base after cautery of underlying vessels. (B): Endoscopic Submucosal Dissection (ESD): (I) Initial large, well-demarcated lesion of the stomach. Lesions of the border are usually marked in the beginning and methylene bue or other lifting agents are injected to elevate the lesion (not performed here). (II) The lesion is resected with a needle-knife using electrocautery, starting at the previously demarcated margins. (III) Base of the lesion that has been fully resected. (IV) 3 cm resected lesion.

Table 1. Screening Guidelines for pre-malignant upper GI lesions.

Table 1. Screening Guidelines for pre-malignant upper GI lesions.

Screening/Surveillance GuidelinesHigh Risk FeaturesScreening or Surveillance ModalitiesBarrett’s esophagus (BE)Men w/ chronic GERD (>5 years) occurring > once/week and ≥2 risk factors (ACG 2022)(1) Age > 50
(2) Caucasian race
(3) Tobacco use
(4) Obesity
(5) First-degree relative with BE or EAC.Upper endoscopy (EGD)
-“gold standard” for diagnosis and treatment

Transnasal endoscopy (screening only):
-good sensitivity (91%) and specificity (96%)
-cheaper than EGD
-cannot perform interventions

Cytosponge (screening only):
-cheaper than EGD
-cannot perform interventions
-Newer technique; not widely used in the United States

Gastric intestinal metaplasia (GIM)Routine screening NOT recommended.

Surveillance every 3–5 years in patients with GIM and high-risk features (AGA 2018)

(1) Incomplete intestinal metaplasia
(2) Extensive GIM
(3) Family history of gastric cancer
(4) Immigration from a high incidence region Upper endoscopyPancreatic cystic neoplasms
(IPMN and MCN)Routine screening NOT recommended.

Cysts with high-risk features should undergo EUS-FNA to evaluate histology.

Cysts without high-risk features should undergo surveillance (ACG 2018).

(1) Cyst size ≥ 2 cm
(2) Main pancreatic duct dilation > 5 mm *
(3) Solid cystic component
(4) Enhancing mural nodule > 5 mm *
(5) ≥3 mm growth in 1 year
(6) Obstructive jaundice *
(7) Symptomatic cyst
(8) Family history of pancreatic cancer
(9) New onset diabetesMRCP (preferred)
-Generally preferred first-line

EUS
-Used in high-risk cases and when imaging is non-diagnostic

Duodenal adenomaPatients with familial adenomatous polyposis: based on Spigelman classification (stage 0-IV).

No definitive surveillance guidelines for patients without FAP.

Components of Spigelman class:
(1) Increased polyp number (>20)
(2) Polyp > 10 mm
(3) Villous histology
(4) High grade dysplasiaUpper endoscopy

Table 2. Categories of Pancreatic Cysts.

Table 2. Categories of Pancreatic Cysts.

Cyst CategoryImaging Appearance
(MRI and EUS)Fluid EvaluationRisk for MalignancyPseudocystThick-walled
AnechoicBrown color
Elevated amylase/lipase
Low CEANoSerous cystadenomaMicrocystic with “honeycomb” appearance
Central calcificationThin, clear
Low amylase/lipase
Low CEANo aSolid pseudopapillary neoplasmSolid + cystic componentNecrotic debrisYesMucinous Cystic Neoplasm (MCN)Macrocystic
+/− septations
Peripheral calcifications
+/− solid component bMucinous
Variable amylase (usually low)
High CEAYesIntraductal Papillary Mucinous Neoplasm (IPMN)Dilated pancreatic duct c
+/− septations
+/− solid componentMucinous
High amylase
High CEAYes d

Table 3. Upper GI cancer Staging and Treatment.

Table 3. Upper GI cancer Staging and Treatment.

Staging ModalitiesEndoscopic Treatment OptionsLuminal Upper GI cancer aEUS:
-First line for T-staging (sensitivity is 81% for stage T1/T2, >90% for T3/T4) and N-staging
-EUS-FNA can help for N-staging via lymph node biopsy, although results can be technique-limited

CT:
-Used for M-staging
-Lower sensitivity and specificity for N-staging, when compared to EUS

Endoscopic techniques (EMR, ESD) generally feasible for T1a tumors ≤2 cm

Surgical resection vs systemic therapy for larger and more advanced tumors

Extraluminal upper GI cancer bEUS:
-Sensitivity and specificity for T and N staging highest in pancreatic cancer (compared to gallbladder cancer or cholangiocarcinoma)

Laparoscopy:
-Most accurate diagnostic modality for gallbladder cancer and cholangiocarcinoma

Cross-sectional imaging:
-Modality of choice for diagnosing intrahepatic cholangiocarcinoma and evaluating resectability in pancreatic cancer
-Used for M-staging

Generally, endoscopy has only a palliative role (RFA, stenting)