Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most prevalent chronic liver disorder in children and is increasingly recognized as a multisystem condition. Among its extrahepatic manifestations, gastrointestinal (GI) comorbidities significantly influence disease progression and long-term outcomes. A deeper understanding of the liver - gut pathophysiological interplay is essential for developing integrated, multidisciplinary management strategies. This narrative review summarizes current evidence on hepatic and GI comorbidities in pediatric MASLD. A comprehensive literature search was conducted across PubMed, EMBASE, and Google Scholar to identify relevant studies published to date. Beyond disease progression, the review highlights the wide spectrum of GI comorbidities, potential malignancy risks, and emerging pathophysiological insights that may inform the development of targeted therapeutic strategies. MASLD is a significant early-life risk factor for various GI comorbidities, highlighting the need for thorough GI assessment in pediatric MASLD management. Early detection, prevention, and comprehensive management are essential to reduce long-term complications and slow disease progression. Developing pediatric-specific guidelines and validated noninvasive biomarkers is crucial to enable standardized screening, risk stratification, and monitoring. Continued research - especially incorporating omics technologies - is vital for improving risk prediction, enabling earlier diagnosis, and advancing personalized therapies, ultimately enhancing outcomes and reducing disease burden.

ABSTRACT Introduction The diagnostic management of biliary strictures remains a complex clinical challenge requiring evidence-based guidance. Multiple societies, including the European Society of Gastrointestinal Endoscopy (ESGE), American College of Gastroenterology (ACG), and American Society for Gastrointestinal Endoscopy (ASGE), have recently published guidelines with both consensus and divergence (Table 1). Areas Covered A comparative analysis of the ESGE, ACG, and ASGE guidelines reveals shared principles, such as the role of MRI/MRCP in initial evaluation (moderate quality evidence), limited utility of tumor markers alone (low to very low quality evidence), and preference for metal stents in palliation (moderate quality evidence). Key differences arise in tissue acquisition for perihilar strictures, with ACG/ASGE discouraging EUS-guided sampling in surgical candidates (low-quality evidence), while ESGE conditionally supports its use in non-resectable cases candidates (low-quality evidence). The ASGE provides conditional recommendations on bilateral stenting for malignant hilar obstruction, not emphasized in other guidelines. Expert Opinion Although founded on similar evidence, guideline variations reflect differing risk tolerance and resource considerations. Clinicians must recognize these nuances to tailor management. Future research should clarify EUS seeding risk, evaluate cost-effectiveness, and inform harmonized guideline updates.

ABSTRACT Introduction Abdominal pain disorders (APDs), including irritable bowel syndrome (IBS) and functional abdominal pain – not otherwise specified (FAP), are highly prevalent in children and significantly impact quality of life. This review highlights advances addressing the need for standardized, evidence-based management in this population. Areas covered This review summarizes the first evidence-based treatment guidelines for pediatric IBS and FAP, developed jointly by the European and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. The recommendations were based on a systematic review of randomized controlled trials identified through searches in PubMed, Embase, and Cochrane CENTRAL databases [1984 - June 2023]. Strong recommendations were issued for hypnotherapy and cognitive behavioral therapy, with conditional suggestions for probiotics, symbiotics, peppermint oil, soluble fiber, and selected pharmacologic agents. To complement this work, we performed an updated literature search covering studies published after June 2023. Expert opinion These guidelines represent a critical advancement in standardizing the management of pediatric APDs by showing how each recommendation is supported by the available evidence. They offer practical guidance for clinicians navigating a complex and often fragmented treatment landscape. Future efforts should prioritize addressing current knowledge gaps and evaluating the impact of these recommendations on clinical outcomes.

ABSTRACT Introduction Crohn’s disease (CD) is a chronic inflammatory condition with a highly variable course and unpredictable treatment response. As the therapeutic landscape expands, there is a growing need for biomarkers that can support earlier diagnosis, risk-stratification, treatment selection, and that can inform monitoring or discontinuation strategies. Areas Covered This review explores the current state of biomarker development and application in CD across multiple disease stages – from prediction and prognosis to therapeutic response and monitoring. It critically appraises the evidence for serologic, genetic, transcriptomic, proteomic, and epigenetic markers, and highlights their potential roles, limitations, and barriers to clinical implementation. Expert Opinion Despite major scientific advances, precision medicine in CD remains largely unrealized, hindered by a lack of validated and deployable biomarkers. The field must urgently pivot from discovery to implementation, embedding biomarkers into clinical trial design, validating multi-omic signatures across diverse subtypes, and overcoming real-world barriers of cost, standardization, and regulation. We can no longer accept navigating CD management blindfolded. Precision medicine should no longer be a distant aspiration. It should be the standard we hold ourselves to. The ceiling will only break when we stop accepting it.

ABSTRACT Introduction Bariatric surgical interventions such as laparoscopic sleeve gastrectomy (LSG), Roux-en-Y gastric bypass (RYGB), One-Anastomosis Gastric Bypass (OAGB) and Laparoscopic Adjustable Gastric Banding (LAGB) have proven to be effective in long-term management of obesity. These procedures result in changes in anatomy and in motor and secretory function of the gastrointestinal (GI) tract. Areas covered This review covers the changes in gastrointestinal motility and their consequences observed after the various types of bariatric surgery. A systematic literature search on motility disorders of esophagus, stomach, small and large bowel until August 2025 was performed (PubMed). Esophageal motility a higher prevalence of dysphagia and post-obesity surgery esophageal dysfunction (POSED) is seen after bariatric surgery due to gastric restriction (intragastric high-pressure zone, esophageal outflow obstruction). Gastroesophageal reflux disease (GERD) is already common in people with obesity and may significantly increase after bariatric surgery dependent of the type of procedure (LSG, not RYGB). Gastrointestinal motility: bariatric surgery results in significant acceleration of gastric emptying and of small intestinal transit (LSG > RYGB) with delay in colonic transit. Clinical considerations relevant for preoperative work-up, selection of bariatric procedure-type and postoperative follow-up of GI-motility disorders induced by bariatric surgery have been provided.

ABSTRACT Introduction Colorectal cancer (CRC) represents a global public health challenge, ranking as the third most prevalent cancer globally. Population-based screening programs for average-risk populations have proven effective in reducing incidence and mortality of CRC through early detection of cancer. The fecal immunochemical test (FIT), the standard diagnostic method in many nations, still falls short in diagnostic effectiveness, resulting in undetected adenomas and, more significantly, unnecessary colonoscopies. Areas covered One of the primary research focuses in the field of CRC is the discovery of new, noninvasive biomarkers. Recent studies, including metagenomic meta-analyses, have discovered common microbial signatures able to reproducibly discriminate between patients with CRC and healthy controls. Based on this evidence, international guidelines have recently recommended the use of microbiome-based biomarkers for CRC screening in clinical settings, although such studies have yet to be conducted. Expert Opinion This field of research needs considerable multidisciplinary efforts, including large and geographically different meta-cohorts, and the application of state-of-the-art computational approaches, to identify reproducible signatures able to predict early lesions. Such diagnostic tool would revolutionize CRC screening. More widely, it would provide a mind-set shift in the clinical and scientific community promoting the exploitation of diagnostic and therapeutic microbiome tools in clinical practice.

ABSTRACT Introduction Hepatocellular carcinoma (HCC) is a leading cause of morbidity and mortality in patients with cirrhosis and carries a substantial public health burden. Primary liver cancer is the sixth most common cancer worldwide. Despite guideline recommendations for HCC surveillance, pooled surveillance rates are around 18%. Further, racial, ethnic, and socioeconomic disparities exist. Along the HCC care continuum, care gaps exist from access to care, to surveillance, and ultimately in linkage to treatment. Areas covered A literature search was performed utilizing PubMed to review peer-reviewed articles published from 2000 to present. Key landmark studies are reviewed highlighting the care gaps in cirrhosis management, HCC surveillance, and treatment. These studies underscore the complex interplay of systems, provider, and patient level factors that influence care gaps experienced by patients with HCC. Expert opinion Despite low adherence to HCC surveillance and care gaps, there are several opportunities to ensure equitable access to care while achieving personalized, precision medicine. Future efforts will need to focus on multi-disciplinary care while ensuring that providers are knowledgeable and able to provider culturally competent care.

ABSTRACT Introduction Non-variceal upper gastrointestinal bleeding (NVUGIB) is a common gastroenterological emergency associated with significant morbidity and mortality. According to current gastroenterological guidelines, esophagogastroduodenoscopy (EGD) represents the first-line modality for both diagnosis and treatment of NVUGIB. As opposed to lower gastrointestinal bleeding, multidetector-row computed tomography angiography (MDCTA) has a limited and no well-established role in the diagnostic process of NVUGIB. However, gastroenterological guidelines mainly focus on peptic-related NVUGIB only. Moreover, the adoption of MDCTA in NVUGIB has recently been encountered in radiological guidelines for special situations. Areas covered The aim of our study was to comprehensively review and discuss the current and potential indications of MDCTA and its technical aspects in the diagnostic process of NVUGIB. A comprehensive literature search of PubMed, EMBASE, and Google Scholar databases was conducted through May 2025 to identify pertinent studies. Expert opinion Although EGD undoubtedly represents the cornerstone in both diagnosis and treatment of most NVUGIB cases, MDCTA has emerged as a promising adjunct diagnostic tool, especially among clinically severe cases and those due to rare, non-peptic sources. However, evidence is still scarce, and further studies are needed to clarify its role in this scenario.

ABSTRACT Introduction Subcutaneous infliximab (SC-IFX) is an efficacious medication for inflammatory bowel disease (IBD). However, there is limited information about treatment optimization following loss of response (LOR), the role of therapeutic drug monitoring (TDM), and combination therapy with an immunomodulator (IMM) and efficacy of SC-IFX in perianal fistulizing Crohn’s disease (CD). Areas covered This narrative review will provide an overview of the efficacy of SC-IFX in IBD including perianal fistulising CD, the effectiveness of dose escalation after LOR, and the role of TDM and IMM use. A literature search was performed using PubMed and reviewed references from applicable manuscripts and abstracts from major gastrointestinal medical congresses between January 2021 and 20 May 2025. Expert opinion Current data suggest that SC-IFX is effective in the treatment of IBD. Moreover, cumulative data suggest that dose escalation is effective in recapturing response in patients with LOR, and that higher drug concentrations are associated with better outcomes. However, there are still major gaps in understanding the role of drug clearance, immunogenicity, and the role of TDM for optimizing SC-IFX. Moreover, the impact of body mass index and concomitant IMM therapy on clinical outcomes as well as the efficiency of SC-IFX in more complicated IBD phenotypes remains to be elucidated.

Asymptomatic bile duct stones are increasingly diagnosed by imaging studies. Guidelines recommend endoscopic retrograde cholangiopancreatography (ERCP) for the treatment of bile duct stones, but evidence regarding short- and long-term outcomes of asymptomatic bile duct stones remains inadequate. This review summarized evidence about clinical outcomes and technical tips of ERCP for asymptomatic bile duct stones through a literature search of PubMed until March 2025. Long-term outcomes including cholangitis, cholecystitis, biliary pancreatitis, and spontaneous passage of bile duct stones among patients who selected the wait-and-see strategy were also summarized. According to the recent evidence of short- and long-term outcomes, we discussed the pros and cons of each treatment option and proposed a treatment strategy for asymptomatic bile duct stones. Despite guideline recommendations for endoscopic removal, ERCP for asymptomatic bile duct stones is associated with a high incidence of post-ERCP pancreatitis (PEP) and clinicians need to mitigate the risk of PEP by including administration of non-steroidal anti-inflammatory drugs, prophylactic pancreatic stent, or peri-procedural aggressive hydration. Considering the probability of spontaneous stone passage, the wait-and-see strategy might be a treatment option.