A prospective study of MR enterography versus capsule endoscopy for the surveillance of adult patients with Peutz-Jeghers syndrome. AJR Am J Roentgenol. 2010;195:108-116. [PMID: 20566803 DOI: 10.2214/ajr.09.3174]

The Role of Capsule Endoscopy in the Diagnosis and Management of Small Bowel Tumors: A Narrative Review

Small bowel tumors (SBT) are relatively rare, but have had a steadily increasing incidence in the last few decades. Small bowel capsule endoscopy (SBCE) and device-assisted enteroscopy are the main endoscopic techniques for the study of the small bowel, the latter additionally providing sampling and therapeutic options, and hence acting complementary to SBCE in the diagnostic work-up. Although a single diagnostic modality is often insufficient in the setting of SBTs, SBCE is a fundamental tool to drive further management towards a definitive diagnosis. The aim of this paper is to provide a concise narrative review of the role of SBCE in the diagnosis and management of SBTs.

MUTYH-associated polyposis: Is it time to change upper gastrointestinal surveillance? A single-center case series and a literature overview

BACKGROUND

The presence of Spigelman stage (SS) IV duodenal polyposis is considered the most significant risk factor for duodenal cancer in patients with MUTYH-associated polyposis (MAP). However, advanced SS disease is rarely reported in MAP patients, and no clear recommendations on small bowel (SB) surveillance have been proposed in this patient setting.

AIM

To research more because that case reports of duodenal cancers in MAP suggest that they may develop in the absence of advanced benign SS disease and often involve the distal portion of the duodenum.

METHODS

We describe a series of MAP patients followed up at the Regina Elena National Cancer Institute of Rome (Italy). A literature overview on previously reported SB cancers in MAP is also provided.

RESULTS

We identified two (6%) SB adenocarcinomas with no previous history of duodenal polyposis. Our observations, supported by literature evidence, suggest that the formula for staging duodenal polyposis and predicting risk factors for distal duodenum and jejunal cancer may need to be adjusted to take this into account rather than focusing solely on the presence or absence of SS IV disease.

CONCLUSION

Our study emphasizes the need for further studies to define appropriate upper gastrointestinal surveillance programs in MAP patients.

Small Intestinal Polyp Burden in Pediatric Peutz-Jeghers Syndrome Assessed through Capsule Endoscopy: A Longitudinal Study

The management of pediatric Peutz-Jeghers Syndrome (PJS) focuses on the prevention of intussusception complicating small intestinal (SI) polyposis. This hinges on the accurate appraisal of the polyp burden to tailor therapeutic interventions. Video Capsule Endoscopy (VCE) is an established tool to study SI polyps in children, but an in-depth characterization of polyp burden in this population is lacking. Methods: We performed a retrospective longitudinal cross-sectional analysis of VCE studies in pediatric PJS patients at our institution (CMKC) from 2010 to 2020. Demographic, clinical, and VCE findings reported by three reviewers in tandem were accrued. Polyp burden variables were modeled as functions of patient and study characteristics using linear mixed models adjusted for clustering. Results: The cohort included 15 patients. The total small bowel polyp count and largest polyp size clustered under 30 polyps and <20 mm in size. Luminal occlusion correlated closely with the estimated polyp size. Polyp distribution favored proximal (77%) over distal (66%) small bowel involvement. The adjusted largest polyp size was greater in males. Double Balloon Enteroscopy was associated with a decreased polyp burden. Conclusions: The polyp burden in pediatric PJS patients favors the proximal third of the small intestine, with relatively small numbers and a polyp size amenable to resection through enteroscopy. Male gender and older age were related to an increased polyp burden.

Updates in the diagnosis and management of non-ampullary small-bowel polyposis

Advances in endoscopic instruments and techniques changed the strategy of diagnosis and management for non-ampullary small-bowel polyposis. In patients with Peutz-Jeghers syndrome, gastrointestinal surveillance using capsule endoscopy should commence no later than eight years old. Small bowel polyps >15 mm should be treated to prevent intussusception. Recently, endoscopic ischemic polypectomy and endoscopic reduction of intussusception were described. In patients with familial adenomatous polyposis, the first endoscopic screening using a lateral viewing and a longer endoscope to check the proximal jejunum should be performed around 25 years. Some experts recommend a first duodenal examination with a first colonoscopy (13 years). The surveillance intervals for duodenal polyposis should be adjusted individually. ESGE recommended the resection of every adenoma larger than 1 cm. Cold snare polypectomy has the potential to change the threshold of size for endoscopic resection. In patients with Juvenile polyposis syndrome, small bowel involvement seems infrequent and mostly located in the duodenal part. There is no indication for distal small bowel investigation.

Clinical Guidelines for Diagnosis and Management of Peutz-Jeghers Syndrome in Children and Adults

BACKGROUND

Peutz-Jeghers syndrome (PJS) is a rare disease characterized by the presence of hamartomatous polyposis throughout the gastrointestinal tract, except for the esophagus, along with characteristic mucocutaneous pigmentation. It is caused by germline pathogenic variants of the STK11 gene, which exhibit an autosomal dominant mode of inheritance. Some patients with PJS develop gastrointestinal lesions in childhood and require continuous medical care until adulthood and sometimes have serious complications that significantly reduce their quality of life. Hamartomatous polyps in the small bowel may cause bleeding, intestinal obstruction, and intussusception. Novel diagnostic and therapeutic endoscopic procedures such as small-bowel capsule endoscopy and balloon-assisted enteroscopy have been developed in recent years.

SUMMARY

Under these circumstances, there is growing concern about the management of PJS in Japan, and there are no practice guidelines available. To address this situation, the guideline committee was organized by the Research Group on Rare and Intractable Diseases granted by the Ministry of Health, Labour and Welfare with specialists from multiple academic societies. The present clinical guidelines explain the principles in the diagnosis and management of PJS together with four clinical questions and corresponding recommendations based on a careful review of the evidence and involved incorporating the concept of the Grading of Recommendations Assessment, Development and Evaluation system.

KEY MESSAGES

Herein, we present the English version of the clinical practice guidelines of PJS to promote seamless implementation of accurate diagnosis and appropriate management of pediatric, adolescent, and adult patients with PJS.

Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2022

MR1: ESGE recommends small-bowel capsule endoscopy as the first-line examination, before consideration of other endoscopic and radiological diagnostic tests for suspected small-bowel bleeding, given the excellent safety profile of capsule endoscopy, its patient tolerability, and its potential to visualize the entire small-bowel mucosa.Strong recommendation, moderate quality evidence. MR2: ESGE recommends small-bowel capsule endoscopy in patients with overt suspected small-bowel bleeding as soon as possible after the bleeding episode, ideally within 48 hours, to maximize the diagnostic and subsequent therapeutic yield.Strong recommendation, high quality evidence. MR3: ESGE does not recommend routine second-look endoscopy prior to small-bowel capsule endoscopy in patients with suspected small-bowel bleeding or iron-deficiency anemia.Strong recommendation, low quality evidence. MR4: ESGE recommends conservative management in those patients with suspected small-bowel bleeding and high quality negative small-bowel capsule endoscopy.Strong recommendation, moderate quality evidence. MR5: ESGE recommends device-assisted enteroscopy to confirm and possibly treat lesions identified by small-bowel capsule endoscopy.Strong recommendation, high quality evidence. MR6: ESGE recommends the performance of small-bowel capsule endoscopy as a first-line examination in patients with iron-deficiency anemia when small bowel evaluation is indicated.Strong recommendation, high quality evidence. MR7: ESGE recommends small-bowel capsule endoscopy in patients with suspected Crohn's disease and negative ileocolonoscopy findings as the initial diagnostic modality for investigating the small bowel, in the absence of obstructive symptoms or known bowel stenosis.Strong recommendation, high quality evidence. MR8: ESGE recommends, in patients with unremarkable or nondiagnostic findings from dedicated small-bowel cross-sectional imaging, small-bowel capsule endoscopy as a subsequent investigation if deemed likely to influence patient management.Strong recommendation, low quality evidence. MR9: ESGE recommends, in patients with established Crohn's disease, the use of a patency capsule before small-bowel capsule endoscopy to decrease the capsule retention rate.Strong recommendation, moderate quality evidence. MR10: ESGE recommends device-assisted enteroscopy (DAE) as an alternative to surgery for foreign bodies retained in the small bowel requiring retrieval in patients without acute intestinal obstruction.Strong recommendation, moderate quality evidence. MR11: ESGE recommends DAE-endoscopic retrograde cholangiopancreatography (DAE-ERCP) as a first-line endoscopic approach to treat pancreaticobiliary diseases in patients with surgically altered anatomy (except for Billroth II patients).Strong recommendation, moderate quality evidence.

Inter/Intra-Observer Agreement in Video-Capsule Endoscopy: Are We Getting It All Wrong? A Systematic Review and Meta-Analysis

Video-capsule endoscopy (VCE) reading is a time- and energy-consuming task. Agreement on findings between readers (either different or the same) is a crucial point for increasing performance and providing valid reports. The aim of this systematic review with meta-analysis is to provide an evaluation of inter/intra-observer agreement in VCE reading. A systematic literature search in PubMed, Embase and Web of Science was performed throughout September 2022. The degree of observer agreement, expressed with different test statistics, was extracted. As different statistics are not directly comparable, our analyses were stratified by type of test statistics, dividing them in groups of "None/Poor/Minimal", "Moderate/Weak/Fair", "Good/Excellent/Strong" and "Perfect/Almost perfect" to report the proportions of each. In total, 60 studies were included in the analysis, with a total of 579 comparisons. The quality of included studies, assessed with the MINORS score, was sufficient in 52/60 studies. The most common test statistics were the Kappa statistics for categorical outcomes (424 comparisons) and the intra-class correlation coefficient (ICC) for continuous outcomes (73 comparisons). In the overall comparison of inter-observer agreement, only 23% were evaluated as "good" or "perfect"; for intra-observer agreement, this was the case in 36%. Sources of heterogeneity (high, I2 81.8-98.1%) were investigated with meta-regressions, showing a possible role of country, capsule type and year of publication in Kappa inter-observer agreement. VCE reading suffers from substantial heterogeneity and sub-optimal agreement in both inter- and intra-observer evaluation. Artificial-intelligence-based tools and the adoption of a unified terminology may progressively enhance levels of agreement in VCE reading.

Peutz-Jeghers syndrome revealed by recurrent small bowel intussusceptions in children: A case report

Peutz-Jeghers syndrome is a rare but potentially life-threating syndrome. We report here the case of a young girl who presented recurrent small bowel intussusceptions. Laparotomy exploration showed many jejunal polyps leading to jejunojejunal intussusceptions. These were removed via mini enterotomies and pathological examination concluded to Peutz-Jeghers polyps.

Cronkhite-Canada syndrome: a retrospective analysis of four cases at a single medical center

OBJECTIVE

Cronkhite-Canada syndrome (CCS) is a rare disease that is characterized by multiple gastrointestinal polyps and ectodermal abnormalities. This study aimed to improve the understanding of CCS by presenting our patient data.

METHODS

Clinical features, treatment, and outcomes of four CCS patients at a single medical center were retrospectively analyzed.

RESULTS

The age of the patients ranged from 32 to 61 years (mean: 49.5 years), including three men and one woman. All the patients presented with gastrointestinal symptoms, ectodermal abnormalities, and multiple gastrointestinal polyps. Two patients showed abnormal immune indices. Three patients underwent magnetic resonance enterography, and the typical manifestations of small intestine involvement were diffuse wall thickening, high signal intensity on diffusion-weighted imaging, obvious enhancement, and multiple small nodular enhancements of the small intestine. The main histological manifestations were chronic inflammation and hyperplastic, adenomatoid, and hamartomatoid polyps. Eosinophilic infiltration was observed in two patients. One patient had rectal adenocarcinoma at the time of diagnosis. All the four patients received prednisone at a dose of 0.75-1 mg/kg/day, and had their gastrointestinal symptoms gradually resolved (including two with ectodermal abnormality and endoscopic remission). Two patients are currently receiving low-dose prednisone (2.5-5 mg/day) with no recurrence after a 1.5- and 6-year follow-up periods, respectively.

CONCLUSION

Magnetic resonance enterography has the potential to evaluate small-intestinal lesions in CCSs. Long-term therapy with low doses of prednisone may be beneficial in maintaining remission.

Epidemiology, Risk Factors and Diagnosis of Small Bowel Adenocarcinoma

Simple Summary

Small bowel adenocarcinoma is a rare tumor. Diagnosis is often obtained at an advanced stage and prognosis remains poor. The aim of this review is to report the recent epidemiological and risk factor data related to small bowel adenocarcinoma. New diagnostic tools are also described in this review.

Abstract

Adenocarcinomas of the small intestine are rare tumors but their incidence is increasing. There is a slight male predominance. The median age at diagnosis is the 6th decade. The most frequent primary location is the duodenum. There is no clearly identified environmental risk factor, but adenocarcinomas of the small intestine are associated in almost 20% of cases with predisposing diseases (Crohn’s disease, Lynch syndrome, familial adenomatous polyposis, Peutz–Jeghers syndrome and celiac disease).

Gastrointestinal aspects of Peutz-Jeghers syndrome

There are two main problems in the clinical management of the gastrointestinal (GI) tract in patients with Peutz-Jeghers syndrome (PJS), namely long-term cancer risk and managing polyp related complications (of which the most important clinically is intussusception). Given the rarity of this condition, the evidence base upon which to make recommendations is small. Furthermore, controversies persist regarding the relationship between PJ polyps, cancer development and cancer risk. In this article we will explore some of these controversies, to put into context the recommendations for clinical management of these patients. We will provide an overview, particularly focusing on clinical data, and on the recommendations for clinical management and surveillance of the GI tract in PJS. We highlight knowledge gaps which need to be addressed by further research.

Peutz-Jeghers Syndrome and the Role of Imaging: Pathophysiology, Diagnosis, and Associated Cancers

Simple Summary

The Peutz-Jeghers Syndrome is a rare autosomal dominant syndrome characterized by mucocutaneous pigmentations, multiple gastrointestinal hamartomatous polyps, and an elevated risk of malignancy. Awareness of various Peutz-Jeghers Syndrome imaging patterns, associated malignancies, and their complications is crucial for accurate imaging interpretation and patient management. In this manuscript, we provide an overview of this condition, associated malignancies, and imaging surveillance protocols.

Abstract

The Peutz-Jeghers Syndrome (PJS) is an autosomal dominant neoplastic syndrome defined by hamartomatous polyps through the gastrointestinal tract, development of characteristic mucocutaneous pigmentations, and an elevated lifetime cancer risk. The majority of cases are due to a mutation in the STK11 gene located at 19p13.3. The estimated incidence of PJS ranges from 1:50,000 to 1:200,000. PJS carries an elevated risk of malignancies including gastrointestinal, breast, lung, and genitourinary (GU) neoplasms. Patients with PJS are at a 15- to 18-fold increased malignancy risk relative to the general population. Radiologists have an integral role in the diagnosis of these patients. Various imaging modalities are used to screen for malignancies and complications associated with PJS. Awareness of various PJS imaging patterns, associated malignancies, and their complications is crucial for accurate imaging interpretation and patient management. In this manuscript, we provide a comprehensive overview of PJS, associated malignancies, and surveillance protocols.

Diagnostic Yields and Clinical Impacts of Capsule Endoscopy

Observing the entire small bowel is difficult due to the presence of complex loops and a long length. Capsule endoscopy (CE) provides a noninvasive and patient-friendly method for visualizing the small bowel and colon. Small bowel capsule endoscopy (SBCE) has a critical role in the diagnosis of small bowel disorders through the direct observation of the entire small bowel mucosa and is becoming the primary diagnostic tool for small bowel diseases. Recently, colon capsule endoscopy (CCE) was also considered safe and feasible for obtaining sufficient colonic images in patients with incomplete colonoscopy, in the absence of bowel obstruction. This review article assesses the current status of CE in terms of the diagnostic yield and the clinical impact of SBCE in patients with obscure gastrointestinal bleeding, who have known or suspected Crohn's disease, small bowel tumor and inherited polyposis syndrome, celiac disease, and those who have undergone CCE.

Artificial Intelligence in Small Bowel Endoscopy: Current Perspectives and Future Directions

Artificial intelligence (AI) is a computer system that is able to perform tasks which normally require human intelligence. The role of AI in the field of gastroenterology has been gradually evolving since its inception in the 1950s. Discovery of wireless capsule endoscopy (WCE) and balloon enteroscopy (BE) has revolutionized small gut imaging. While WCE is a relatively patient-friendly and noninvasive mode to examine the nonobstructed small gut, it is limited by a lengthy examination time and the need for expertise in reading images acquired by the capsule. Similarly, BE, despite having the advantage of therapeutic intervention, is costly, invasive, and requires general sedation. Incorporation of concepts like machine learning and deep learning has been used to handle large amounts of data and images in gastroenterology. Interestingly, in small gut imaging, the application of AI has been limited to WCE only. This review was planned to examine and summarize available published data on various AI-based approaches applied to small bowel disease.

We conducted an extensive literature search using Google search engine, Google Scholar, and PubMed database for published literature in English on the application of different AI techniques in small bowel endoscopy, and have summarized the outcome and benefits of these applications of AI in small bowel endoscopy. Incorporation of AI in WCE has resulted in significant advancements in the detection of various lesions starting from dysplastic mucosa, inflammatory and nonmalignant lesions to the detection of bleeding with increasing accuracy and has shortened the lengthy review time in image analysis. As most of the studies to evaluate AI are retrospective, the presence of inherent selection bias cannot be excluded. Besides, the interpretability (black-box nature) of AI models remains a cause for concern. Finally, issues related to medical ethics and AI need to be judiciously addressed to enable its seamless use in future.

PEUTZ-JEGHERS SYNDROME IN RESOURCE-LIMITED SCENARIO

ABSTRACT BACKGROUND: Peutz-Jeghers Syndrome (PJS) is a rare, autosomal dominant disease, caused by deletions in the chromosome 19p33.3/ gene LKB1/STK11. These mutations inactivate a serine/threonine kinase and predispose to carcinogenesis. In PJS, tumors of the gastrointestinal, testicles, pulmonary, breast, pancreas, uterus and ovaries can be found. OBJECTIVE: To evaluate demographics, clinical presentation and complication/outcomes of pediatric patients presenting with Peutz-Jeghers syndrome (PJS), as well as to present and discuss management in the context of limited resources. METHODS: We conducted a retrospective chart review of a cohort of six patients, who were diagnosed and/or followed at the Clinics Hospital, University of Campinas - Sao Paulo/Brazil, between 2000 and 2018. Data analyzed included gender, age of presentation, age of diagnosis, family history, PJS complications. RESULTS: Median age of diagnosis of 6.7 years, with a mean time of follow-up of 8.1 years. Mucocutaneous pigmentation was universally present. Half of the patients had a known family history at the time of diagnosis. On follow up, intestinal intussusception was documented in four out of six patients, in most (three), in different locations and in multiple occasions. The active investigation of siblings and parents of the index case led to the diagnosis of three first-degree relatives in the present case series. CONCLUSION: In this first pediatric PJS Brazilian case series, we report a wide spectrum of PJS manifestations and complications. In a resource limited scenario, despite limitations for the surveillance of complications, the relative frequency of complications was not higher than historically reported.

Roles of Capsule Endoscopy and Device-Assisted Enteroscopy in the Diagnosis and Treatment of Small-Bowel Tumors

With the development of capsule endoscopy (CE) and device-assisted enteroscopy (DAE), the incidence of small-bowel tumors has increased and the characteristics of these tumors have changed. In addition, the diagnostic and therapeutic approaches for small-bowel tumors have diversified. CE is a simple, noninvasive method that aid in the visualization the entire small bowel. CE is considered the initial approach for small-bowel tumors. DAE can be used to perform endoscopic procedures such as bleeding control, polypectomy, stent insertion, and tattooing, as well as for diagnosis through visualization or tissue sampling. Therapeutic intervention with DAE is particularly useful in polyposis syndromes such as familial adenomatous polyposis and Peutz-Jeghers syndrome. This review will discuss the roles of CE and DAE in the diagnosis and treatment of small-bowel tumors.

Safety and efficacy of an enteroscopy-based approach in reducing the polyp burden in patients with Peutz-Jeghers syndrome: experience from a tertiary referral center

Background:

Patients with Peutz–Jeghers syndrome develop hamartomatous polyps in the small bowel, possibly causing anemia, intussusception, and obstruction. We aimed to evaluate the impact of an enteroscopy-based approach, including both device-assisted and intraoperative enteroscopy, on the reduction of the polyp burden in a cohort of adult Peutz–Jeghers syndrome patients.

Materials and methods:

A retrospective study was conducted at Azienda Ospedaliero-Universitaria Città della Salute e della Scienza in Turin, Italy. Consecutive Peutz–Jeghers syndrome patients eligible for device-assisted or intraoperative enteroscopy, between January 2003 and November 2019, were included. Enteroscopy technical issues and complications were recorded. At the time of index enteroscopy, the patients’ clinical records were retrospectively reviewed, and clinical data were recorded until November 2019.

Results:

Overall, 24 patients were included. Before inclusion, 16/24 patients (66.7%) underwent small bowel surgery for polyp-related complications, 13 of which (81.2%) in an emergent setting. Two patients had a history of small bowel neoplasms. During the timeframe, 47 device-assisted enteroscopies and 9 intraoperative enteroscopies were performed, and 247 small bowel polyps were endoscopically removed. The overall complication rate was 12.8% (8.5% for device-assisted enteroscopy, 22.2% for intraoperative enteroscopy). The median observation time was 108 months: in this timeframe, two patients developed small bowel polyp-related complications requiring emergent surgery. No patients developed small bowel cancer, but nine extra-gastrointestinal neoplasms were recorded.

Conclusion:

An enteroscopy-based approach appears to be well tolerated and effective in decreasing polyp-related complications in Peutz–Jeghers syndrome patients, thus reducing the need for emergent surgery. Although the prevention of small bowel polyp-related complications remains the main goal in these patients, the high incidence of extra-gastrointestinal neoplasms appears to be a rising issue.

Guidelines for the management of hereditary colorectal cancer from the British Society of Gastroenterology (BSG)/Association of Coloproctology of Great Britain and Ireland (ACPGBI)/United Kingdom Cancer Genetics Group (UKCGG)

Heritable factors account for approximately 35% of colorectal cancer (CRC) risk, and almost 30% of the population in the UK have a family history of CRC. The quantification of an individual's lifetime risk of gastrointestinal cancer may incorporate clinical and molecular data, and depends on accurate phenotypic assessment and genetic diagnosis. In turn this may facilitate targeted risk-reducing interventions, including endoscopic surveillance, preventative surgery and chemoprophylaxis, which provide opportunities for cancer prevention. This guideline is an update from the 2010 British Society of Gastroenterology/Association of Coloproctology of Great Britain and Ireland (BSG/ACPGBI) guidelines for colorectal screening and surveillance in moderate and high-risk groups; however, this guideline is concerned specifically with people who have increased lifetime risk of CRC due to hereditary factors, including those with Lynch syndrome, polyposis or a family history of CRC. On this occasion we invited the UK Cancer Genetics Group (UKCGG), a subgroup within the British Society of Genetic Medicine (BSGM), as a partner to BSG and ACPGBI in the multidisciplinary guideline development process. We also invited external review through the Delphi process by members of the public as well as the steering committees of the European Hereditary Tumour Group (EHTG) and the European Society of Gastrointestinal Endoscopy (ESGE). A systematic review of 10 189 publications was undertaken to develop 67 evidence and expert opinion-based recommendations for the management of hereditary CRC risk. Ten research recommendations are also prioritised to inform clinical management of people at hereditary CRC risk.

Magnetic resonance enterography

Crohn's disease is a condition of chronic inflammation that may involve any part of the gastrointestinal tract, although it more frequently affects the terminal ileum. Longstanding inflammation may lead to several bowel complications including obstruction, stricture, fistula and abscesses which often necessitate surgery. Cross-sectional imaging methods such as computed tomography and magnetic resonance imaging are being utilized more frequently to assess mural and extramural inflammatory bowel disease manifestations. Magnetic resonance enterography (MRE) for assessment of small bowel is optimal because of absence of ionizing radiation, better soft tissue contrast, development of motion-free sequences and high resolution images. A typical protocol includes pre and postcontrast sequences utilizing an enteric contrast agent for adequate bowel distention and an antiperistaltic agent. Overall, MRE allows the evaluation of disease activity, extraenteric complication and response to therapy with a great impact on patient management. In this review we discuss the features of MRE from patient's preparation and exam protocol to pathological findings.

A Systematic Review of Technical Parameters for MR of the Small Bowel in non-IBD Conditions over the Last Ten Years

Technical guidelines for magnetic resonance imaging (MRI) of the small bowel (SB) in the setting of inflammatory bowel diseases (IBDs) were detailed in a 2017 consensus issued by European Society of Gastrointestinal and Abdominal Radiology (ESGAR) and European Society of Pediatric Radiology (ESPR); however, MRI for non-IBD conditions was not addressed. Hence, we performed a systematic review collecting researches on SB MRI for non-IBDs. The literatures were then divided into morphologic group and functional group. Information about the MRI techniques, gastrointestinal preparation, and details of cine-MRI protocols was extracted. We found that a 1.5 T MRI system, prone positioning, and MR enterography were frequently utilized in clinical practice. Gadolinium contrast sequences were routinely implemented, while diffusion-weighted imaging (DWI) was much less performed. The gastrointestinal preparation varied throughout the studies. No uniform protocols for cine imaging could be established. SB MRI examinations for non-IBDs are far from standardized, especially for functional studies. Recommendations for standard parameters in cine-MRI sequences are difficult to make due to lack of evidentiary support. MRI investigations in non-IBD conditions are needed and the standardization of non-IBD imaging in clinical practice is required.

Optimising the use of small bowel endoscopy: a practical guide

The wireless nature of capsule endoscopy offers patients the least invasive option for small bowel investigation. It is now the first-line test for suspected small bowel bleeding. Furthermore meta-analyses suggest that capsule endoscopy outperforms small bowel imaging for small bowel tumours and is equivalent to CT enterography and magnetic resonance enterography for small bowel Crohn's disease. A positive capsule endoscopy lends a higher diagnostic yield with device-assisted enteroscopy. Device-assisted enteroscopy allows for the application of therapeutics to bleeding points, obtain histology of lesions seen, tattoo lesions for surgical resection or undertake polypectomy. It is however mainly reserved for therapeutics due to its invasive nature. Device-assisted enteroscopy has largely replaced intraoperative enteroscopy. The use of both modalities is discussed in detail for each indication. Current available guidelines are compared to provide a concise review.

Management of Peutz-Jeghers Syndrome in Children and Adolescents: A Position Paper From the ESPGHAN Polyposis Working Group

Peutz-Jeghers syndrome (PJS) is a well-described inherited syndrome, characterized by the development of gastrointestinal polyps, and characteristic mucocutaneous freckling. Development of small bowel intestinal polyps may lead to intussusception in children may require emergency laparotomy with potential loss of bowel. Gastrointestinal polyps may lead to bleeding and anemia. This European Society for Paediatric Gastroenterology Hepatology and Nutrition position paper provides a guide for diagnosis, assessment, and management of PJS in children and adolescents and guidance on avoiding complications from PJS or from the endoscopic procedures performed on these patients.This is the first position paper regarding PJS published by European Society for Paediatric Gastroenterology Hepatology and Nutrition. Literature from PubMed, Medline, and Embase was reviewed and in the absence of evidence, recommendations reflect the opinion of pediatric and adult experts involved in the care of polyposis syndromes. Because many of the studies that form the basis for the recommendations were descriptive and/or retrospective in nature, some of the recommendations are based on expert opinion. This position paper will be helpful in the appropriate management and timing of procedures in children and adolescents with PJS.

Update on small bowel surveillance in hereditary colorectal cancer syndromes

Despite its rarity in the general population, small bowel adenocarcinoma risk is increased in individuals with hereditary colorectal cancer syndromes (HCCS). In the last decade, the advent of capsule endoscopy and device-assisted balloon enteroscopy procedures in patients with HCCS have allowed to investigate the whole small bowel, increasing the diagnostic yield of small bowel tumor. Nonetheless, there is a significant variability in the international guideline recommendations. The aim of this review is to provide an update on surveillance of small bowel in HCCS and to identify the key points for the clinical management of these patients.

MRI of the bowel - beyond inflammatory bowel disease

MR enterography is traditionally used to evaluate inflammatory bowel disease (IBD) both at initial presentation and at follow-up. MR enterography can also be used to evaluate non-IBD conditions such as polyps or other masses of the gastrointestinal tract. In this article, we emphasize how to recognize bowel conditions beyond IBD on conventional abdominal MRI without a specific enterographic technique. In this overview we discuss common and uncommon pediatric bowel conditions beyond IBD seen on MRI including infectious and inflammatory conditions, congenital diseases and tumor and tumor-like conditions. Radiologists should become familiar with the salient imaging features of these bowel conditions to help guide management.

Magnetic Resonance Enterography for Inflammatory and Noninflammatory Conditions of the Small Bowel

Magnetic resonance enterography (MRE) is an effective noninvasive tool for evaluation of inflammatory and noninflammatory conditions of the small bowel. MRE allows for repeated evaluation of patients with Crohn disease without exposure to ionizing radiation, and can be used to assess disease status and direct management. MRE also allows evaluation of neoplastic and other nonneoplastic conditions of the small bowel. Adequate patient preparation and acquisition techniques are required for optimal image quality.

Small-bowel Surveillance in Patients With Peutz-Jeghers Syndrome: Comparing Magnetic Resonance Enteroclysis and Double Balloon Enteroscopy

BACKGROUND AND STUDY AIMS

Small-bowel surveillance with polypectomy of polyps ≥15 mm prevents complications in patients with Peutz-Jeghers syndrome (PJS). We aimed to compare magnetic resonance enteroclysis (MRE) and double balloon enteroscopy (DBE) for diagnostic yield of these polyps and for patient preference.

MATERIALS AND METHODS

PJS patients prospectively underwent MRE followed by proximal DBE within 20 weeks. Endoscopists were blinded to the MRE results. We compared number of polyps ≥15 mm detected by MRE and DBE. Patients' perceptions of both procedures were assessed using questionnaires.

RESULTS

Fifteen PJS patients (67% males, median age 47 y) underwent both MRE and DBE. Polyps ≥15 mm were identified by MRE and/or DBE in 12/15 (80%) patients. There was no significant difference in the detection of polyps ≥15 mm (38 by MRE vs. 50 by DBE, P=0.37). Sensitivity for these polyps was 62% (38/61) for MRE and 82% (50/61) for DBE. Patients' perceived shame and burden did not differ significantly between MRE and DBE. Patients reported significantly more pain during preparation for MRE than for DBE (moderate vs. no pain, P=0.02), although perceived pain during the procedures was comparable (both mild, P=0.89). For future small-bowel surveillance 10/13 (77%) patients preferred DBE over MRE (P=0.09).

CONCLUSIONS

Our results suggest that MRE and DBE have a comparable diagnostic yield of polyps ≥15 mm. However, DBE allows for direct intervention and was preferred over MRE by most patients in this series. Larger cohorts of PJS patients are needed to fully evaluate the diagnostic yield of DBE compared with other modalities.

[When and how should small-bowel capsule endoscopy be used in children?]

Small-bowel capsule endoscopy (CE) has recently been used in children. During the past few years, an intense research activity has defined the advantages and limitations of CE. Its uses have been established in several small-bowel pathologies such as obvious or obscure digestive bleeding, Crohn disease, and hereditary polyposis. Although the absence of biopsy reduces the specificity of CE findings, small-bowel exploration using CE achieves better accuracy in detecting lesions than most radiological examinations. In children, swallowing problems and the risk of retention due to stenosis are the main concerns when using CE: these problems can be solved using endoscopic delivery of the capsule and luminal diameter calibration, respectively. This review focuses on the evidence making CE indispensable to small-bowel exploration.

Clinical Practice Guidelines for the Use of Video Capsule Endoscopy

BACKGROUND & AIMS

Video capsule endoscopy (CE) provides a noninvasive option to assess the small intestine, but its use with respect to endoscopic procedures and cross-sectional imaging varies widely. The aim of this consensus was to provide guidance on the appropriate use of CE in clinical practice.

METHODS

A systematic literature search identified studies on the use of CE in patients with Crohn's disease, celiac disease, gastrointestinal bleeding, and anemia. The quality of evidence and strength of recommendations were rated using the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) approach.

RESULTS

The consensus includes 21 statements focused on the use of small-bowel CE and colon capsule endoscopy. CE was recommended for patients with suspected, known, or relapsed Crohn's disease when ileocolonoscopy and imaging studies were negative if it was imperative to know whether active Crohn's disease was present in the small bowel. It was not recommended in patients with chronic abdominal pain or diarrhea, in whom there was no evidence of abnormal biomarkers typically associated with Crohn's disease. CE was recommended to assess patients with celiac disease who have unexplained symptoms despite appropriate treatment, but not to make the diagnosis. In patients with overt gastrointestinal bleeding, and negative findings on esophagogastroduodenoscopy and colonoscopy, CE should be performed as soon as possible. CE was recommended only in selected patients with unexplained, mild, chronic iron-deficiency anemia. CE was suggested for surveillance in patients with polyposis syndromes or other small-bowel cancers, who required small-bowel studies. Colon capsule endoscopy should not be substituted routinely for colonoscopy. Patients should be made aware of the potential risks of CE including a failed procedure, capsule retention, or a missed lesion. Finally, standardized criteria for training and reporting in CE should be defined.

CONCLUSIONS

CE generally should be considered a complementary test in patients with gastrointestinal bleeding, Crohn's disease, or celiac disease, who have had negative or inconclusive endoscopic or imaging studies.

Intraoperative Enteroscopy: Is There Still a Role?

Intraoperative enteroscopy (IOE) to explore obscure gastrointestinal bleeding is now rarely indicated. IOE allows complete small bowel exploration in 57% to 100% of cases, finds a bleeding source in 80% of cases, allows the recurrence-free management of gastrointestinal bleeding in 76% of cases, but carries a high morbidity and mortality. IOE only remains indicated to guide the intraoperative treatment of preoperatively identified small bowel lesions when nonoperative treatments are unavailable and/or when intraoperative localization by external examination is impossible.

Capsule endoscopy of the small bowel

Capsule endoscopy (CE) is a first line small bowel investigative modality which provides more sensitive mucosal imaging than comparators. It is a non-invasive, non-irradiating tool well tolerated by patients. The risk of retention of the capsule can be minimised by ensuring luminal patency using the Agile patency device. Research continues into how to minimise missed pathology and variability in the identification of pathology or interpretation of images. The consensus is that bowel preparation using laxatives improves visibility and diagnostic yield. Research includes the development of image recognition software, both to eliminate sequentially identical images to improve viewing speed and to select or enhance images likely to represent pathology. However, careful reading by experienced capsule endoscopists remains the benchmark. This should be performed at a speed comfortable to the viewer, probably at a maximum of 15 frames per second. Some prior experience of endoscopy appears to be helpful for novice capsule endoscopists and formal training on a hands-on training course seems to improve pathology recognition, for novices and for those with CE experience.

Current tecniques and new perpectives research of magnetic resonance enterography in pediatric Crohn's disease

Crohn's disease affects more than 500000 individuals in the United States, and about 25% of cases are diagnosed during the pediatric period. Imaging of the bowel has undergone dramatic changes in the past two decades. The endoscopy with biopsy is generally considered the diagnostic reference standard, this combination can evaluates only the mucosa, not inflammation or fibrosis in the mucosa. Actually, the only modalities that can visualize submucosal tissues throughout the small bowel are the computed tomography (CT) enterography (CTE) with the magnetic resonance enterography (MRE). CT generally is highly utilized, but there is growing concern over ionizing radiation and cancer risk; it is a very important aspect to keep in consideration in pediatric patients. In contrast to CTE, MRE does not subject patients to ionizing radiation and can be used to detect detailed morphologic information and functional data of bowel disease, to monitor the effects of medical therapy more accurately, to detect residual active disease even in patients showing apparent clinical resolution and to guide treatment more accurately.

Endoluminal contrast for abdomen and pelvis magnetic resonance imaging

Magnetic resonance (MR) imaging of the abdomen and pelvis can be limited for assessment of different conditions when imaging inadequately distended hollow organs. Endoluminal contrast agents may provide improved anatomic definition and detection of subtle pathology in such scenarios. The available routes of administration for endoluminal contrast agents include oral, endorectal, endovaginal, intravesicular, and through non-physiologic accesses. Appropriate use of endoluminal contrast agents requires a thorough understanding of the clinical indications, available contrast agents, patient preparation, and interaction of the contrast agent with the desired MR imaging protocol. For example, biphasic oral enteric contrast agents are preferred in MR enterography as their signal properties on T1- and T2-weighted imaging allow for evaluation of both intraluminal and bowel wall pathology. In specific situations such as with MR enterography, MR defecography, and accurate local staging of certain pelvic tumors, the use of an endoluminal contrast agent is imperative in providing adequate diagnostic imaging. In other clinical scenarios, the use of an endoluminal contrast agent may serve as an indispensable problem-solving tool.

Disease pattern in Danish patients with Peutz-Jeghers syndrome

PURPOSE

In this paper, we aimed to collect genetic and medical information on all Danish patients with Peutz-Jeghers syndrome (PJS), in order to contribute to the knowledge of phenotype and genotype. Peutz-Jeghers syndrome is a hereditary syndrome characterized by multiple hamartomatous polyps in the GI tract, mucocutaneous pigmentations, and an increased risk of cancer in the GI tract and at extraintestinal sites. Over 90 % of patients harbour a pathogenic mutation in STK11.

METHODS

Based on the Danish Pathology Data Bank, the Danish National Patient Register, as well as information from relevant departments at Danish hospitals, we identified patients and collected clinical and genetic information.

RESULTS

We identified 43 patients of which 14 were deceased. The prevalence was estimated to be ∼1 in 195,000 individuals. The median age at first symptom was 27.5 with invagination of the small bowel as the most frequent presenting symptom. We noted 18 occurrences of cancer at various anatomical sites, including a case of thyroid cancer and penile cancer. Eight of the deceased patients had died of cancer. Eighteen different mutations in STK11 had been detected in 28 patients.

CONCLUSION

This is the first comprehensive study of patients with Peutz-Jeghers syndrome in the Danish population identified from nationwide registers and databases. We have demonstrated that the expressivity of Peutz-Jeghers syndrome varies greatly among the patients, even within the same families, underlining the great phenotypic spectrum. Patients with PJS should be offered surveillance from childhood in order to prevent morbidity and reduce mortality.

Clinics in diagnostic imaging. 159. Jejunal intussusception due to Peutz-Jeghers syndrome

A 21-year-old woman presented with acute onset of upper abdominal pain. A diagnosis of Peutz-Jeghers syndrome (PJS) was made based on the clinical picture of perioral pigmentation with imaging findings of transient jejunojejunal intussusceptions and small bowel polyps, and confirmed by characteristic histopathological appearances of Peutz-Jeghers polyps. PJS is a rare hereditary condition characterised by unique hamartomatous polyps, perioral mucocutaneous pigmentations, and increased susceptibility to gastrointestinal and extraintestinal neoplasms. Patients usually present with recurrent abdominal pain due to intussusception caused by polyps. Other modes of presentations include rectal bleeding and melaena. We describe the imaging findings of PJS and provide a brief review of bowel polyposis syndromes. The latter are relatively rare disorders characterised by multiple polyps in the large or small intestine, with associated risk of malignancies and other extraintestinal manifestations. Awareness of the manifestations and early diagnosis of these syndromes is crucial to prevent further complications.

The Usefulness of Capsule Endoscopy for Small Bowel Tumors

Video capsule endoscopy (VCE) has expanded the range of endoscopic examination of the small bowel. The clinical application of VCE is mainly for obscure gastrointestinal bleeding (OGIB) and small bowel tumor is one of the clinically significant diagnoses of VCE, often requiring subsequent invasive interventions. Small bowel tumors are detected with a frequency of around 4% with VCE in indications of OGIB, iron deficiency anemia, unexplained abdominal pain, and others. Protruding mass with bleeding, mucosal disruption, irregular surface, discolored area, and white villi are suggested as the VCE findings of small bowel tumor. Device assisted enteroscopy (DAE), computed tomography enteroclysis/enterography and magnetic resonance enteroclysis/enterography also have clinical value in small bowel examination and tumor detection, and they can be used with VCE, sequentially or complementarily. Familial adenomatous polyposis, Peutz-Jeghers syndrome, melanoma, lymphoma, and neuroendocrine tumor with hepatic metastasis are the high risk groups for small bowel tumors, and surveillance programs for small bowel tumors are needed. VCE and radiological imaging have value in screening, and in selected cases, DAE can provide more accurate diagnosis and endoscopic treatment. This review describes the usefulness and clinical impact of VCE on small bowel tumors.

Capsule endoscopy: The road ahead

Since its introduction into clinical practice 15 years ago, capsule endoscopy (CE) has become the first-line investigation procedure in some small bowel pathologies, and more recently, dedicated esophageal and colon CE have expanded the fields of application to include the upper and lower gastrointestinal disorders. During this time, CE has become increasingly popular among gastroenterologists, with more than 2 million capsule examinations performed worldwide, and nearly 3000 PubMed-listed studies on its different aspects published. This huge interest in CE may be explained by its non-invasive nature, patient comfort, safety, and access to anatomical regions unattainable via conventional endoscopy. However, CE has several limitations which impede its wider clinical applications, including the lack of therapeutic capabilities, inability to obtain biopsies and control its locomotion. Several research groups are currently working to overcome these limitations, while novel devices able to control capsule movement, obtain high quality images, insufflate the gut lumen, perform chromoendoscopy, biopsy of suspect lesions, or even deliver targeted drugs directly to specific sites are under development. Overlooking current limitations, especially as some of them have already been successfully surmounted, and based on the tremendous progress in technology, it is expected that, by the end of next 15 years, CE able to perform both diagnostic and therapeutic procedures will remain the major form of digestive endoscopy. This review summarizes the literature that prognosticates about the future developments of CE.

Contrast-Enhanced Cross Sectional Imaging and Capsule Endoscopy: New Perspectives for a Whole Picture of the Small Bowel

Small bowel evaluation is a challenging task and has been revolutionized by high-quality contrasted sectional imaging (CT enterography - CTE) and magnetic resonance enterography (MRE) as well as by small bowel capsule endoscopy (SBCE). The decision of which technique to employ during the investigation of small bowel diseases is not always simple or straightforward. Moreover, contraindications may preclude the use of these techniques in some patients, and although they are noninvasive procedures, may present with various complications. SBCE plays a crucial role in the investigation of both obscure gastrointestinal bleeding and Crohn's disease, but it is also useful for surveillance of patients with Peutz-Jeghers syndrome, while CTE is very accurate in small bowel tumours and in established Crohn's Disease, and its use in patients presenting with gastrointestinal bleeding is increasing. MRE, an expensive and not widely available technique, is essential for the study of patients with Crohn's Disease, and presents an attractive alternative to SBCE in Peutz-Jeghers syndrome surveillance. These diagnostic modalities are often not competitive but synergistic techniques. Knowing their characteristics, strengths and limitations, indications, contraindications and potential complications, as well as the adaptation to local availability and expertise, is essential to better select which procedures to perform in each patient, both safely and effectively, in order to optimize management and improve patient outcomes.

Wireless capsule endoscopy of the small intestine in children

Wireless capsule endoscopy (CE) for the diagnosis of small-bowel disease has been in clinical use for more than a decade, and is no longer an emerging technology, but rather one that has reached fruition. This noninvasive technology has been readily embraced by both physicians and patients. Used in the diagnosis of inflammatory bowel disease, for locating sources of obscure gastrointestinal bleeding, and for assessing small-bowel polyp burden in polyposis syndromes as well as for less common indications, CE has transformed the diagnostic algorithms of small-bowel investigations. Although already in widespread use, the technology incorporated into the various CE platforms continues to improve and expand. Here, we briefly review the indications, limitations, and advances in video capsule technology, with an emphasis on its use in pediatrics.

The Importance of Alternative Diagnostic Modalities in the Diagnosis of Small Bowel Tumors After a Negative Capsule Endoscopy

Capsule endoscopy is widely accepted as the preferred diagnostic test in the evaluation of small bowel diseases, especially in the setting of obscure gastrointestinal bleeding. It has revolutionized small bowel examination and has improved the detection of small bowel tumors. However, small bowel tumors are sometimes missed by capsule endoscopy. Furthermore, there are several recent reports comparing capsule endoscopy with other diagnostic modalities, such as double balloon enteroscopy and CT/RM enterography, that challenge the reportedly high negative predictive value of capsule endoscopy in detecting small bowel tumors. We report the case of a patient with overt obscure gastrointestinal bleeding due to a gastrointestinal stromal tumor diagnosed by CT enterography after two negatives capsule endoscopies. This case shows that capsule endoscopy may overlook significant life threatening lesions and highlights the importance of using other diagnostic modalities after a negative capsule endoscopy, especially in patients with a high index of suspicion for small bowel tumoral pathology or persistent/recurrent bleeding.

Pediatric MR enterography: technique and approach to interpretation-how we do it

Magnetic resonance (MR) enterography is an increasingly important pediatric imaging modality that is most often used to evaluate inflammatory bowel disease ( IBD inflammatory bowel disease ), while sparing children and adolescents from potential risks of ionizing radiation exposure. MR enterography allows for evaluation of the bowel lumen and wall, adjacent mesentery and soft tissues, as well as a variety of extraintestinal abdominopelvic IBD inflammatory bowel disease manifestations. While MR enterography can be used to initially confirm the diagnosis of IBD inflammatory bowel disease , particularly small bowel Crohn disease, it has also proven useful in assessing the degree inflammatory activity over time, serving as a radiologic biomarker for response to medical therapy, and identifying a variety of disease-related complications, including strictures, fistulae, and abscesses. The purpose of this review article is to provide radiologists with a systematic approach for MR enterography review and interpretation in children and adolescents with known or suspected of having IBD inflammatory bowel disease and to illustrate both common and infrequent but important imaging findings. Additionally, the authors will present their well-established and clinically successful pediatric MR enterography protocol, up-to-date clinical indications for MR enterography, and briefly mention the role of MR enterography in assessing non- IBD inflammatory bowel disease abnormalities affecting the bowel. Online supplemental material is available for this article .

Indications and selection of MR enterography vs. MR enteroclysis with emphasis on patients who need small bowel MRI and general anaesthesia: results of a survey

Aims

To survey the perceived indications for magnetic resonance imaging of the small bowel (MRE) by experts, when MR enteroclysis (MREc) or MR enterography (MREg) may be chosen, and to determine how the approach to MRE is modified when general anaesthesia (GA) is required.

Materials and methods

Selected opinion leaders in MRE completed a questionnaire that included clinical indications (MREg or MREc), specifics regarding administration of enteral contrast, and how the technique is altered to accommodate GA.

Results

Fourteen responded. Only the diagnosis and follow-up of Crohn’s disease were considered by over 80 % as a valid MRE indication. The remaining indications ranged between 35.7 % for diagnosis of caeliac disease and unknown sources of gastrointestinal bleeding to 78.6 % for motility disorders. The majority chose MREg over MREc for all indications (from 100 % for follow-up of caeliac disease to 57.7 % for tumour diagnosis). Fifty per cent of responders had needed to consider MRE under GA. The most commonly recommended procedural change was MRI without enteral distention. Three had experience with intubation under GA (MREc modification).

Conclusion

Views were variable. Requests for MRE under GA are not uncommon. Presently most opinion leaders suggest standard abdominal MRI when GA is required.

Main messages

• Experts are using MRE for various indications.

• Requests for MRE under general anaesthesia are not uncommon.

• Some radiologists employ MREc under general anaesthesia; others do not distend the small bowel.

Capsule endoscopy versus magnetic resonance enterography for the detection of small bowel polyps in Peutz-Jeghers syndrome

Our study aimed to assess the diagnostic utility of magnetic resonance enterography (MRE) compared to capsule endoscopy (CE) for the detection of small bowel polyps in patients with Peutz-Jeghers syndrome (PJS); with findings verified by balloon enteroscopy (BE). Adult patients were prospectively recruited across two tertiary centres and underwent MRE followed by CE, with a subsequent BE performed in patients with significant (≥10 mm) polyps. The primary endpoint was the total number of significant (≥10 mm) small bowel polyps detected. The number of patients with at least one significant polyp, correlation with BE findings, and patients' preferences were secondary endpoints. A total of 20 patients (7 male; mean age 34.9 years) underwent both investigations. The number of polyps ≥10 mm detected by CE was greater than by MRE (47 vs 14 polyps, P = 0.02). The number of patients with at least one significant polyp identified by CE was 11 (55 %) compared with 7 (35 %) identified by MRE (P = 0.25). Subsequent BE in 12 patients identified a total of 26 significant polyps in 8 patients. The positive predictive value of finding a polyp at BE was higher for MRE (100 %) compared to CE (60 %). Overall patient preferences identified CE as the preferred modality. This prospective study demonstrated that CE identifies significantly more small bowel polyps compared with MRE in patients with PJS. Correlation between the two techniques and subsequent BE however was relatively poor.

ACG clinical guideline: Genetic testing and management of hereditary gastrointestinal cancer syndromes

This guideline presents recommendations for the management of patients with hereditary gastrointestinal cancer syndromes. The initial assessment is the collection of a family history of cancers and premalignant gastrointestinal conditions and should provide enough information to develop a preliminary determination of the risk of a familial predisposition to cancer. Age at diagnosis and lineage (maternal and/or paternal) should be documented for all diagnoses, especially in first- and second-degree relatives. When indicated, genetic testing for a germline mutation should be done on the most informative candidate(s) identified through the family history evaluation and/or tumor analysis to confirm a diagnosis and allow for predictive testing of at-risk relatives. Genetic testing should be conducted in the context of pre- and post-test genetic counseling to ensure the patient's informed decision making. Patients who meet clinical criteria for a syndrome as well as those with identified pathogenic germline mutations should receive appropriate surveillance measures in order to minimize their overall risk of developing syndrome-specific cancers. This guideline specifically discusses genetic testing and management of Lynch syndrome, familial adenomatous polyposis (FAP), attenuated familial adenomatous polyposis (AFAP), MUTYH-associated polyposis (MAP), Peutz-Jeghers syndrome, juvenile polyposis syndrome, Cowden syndrome, serrated (hyperplastic) polyposis syndrome, hereditary pancreatic cancer, and hereditary gastric cancer.