Mistakes in imaging hepatic lesions and how to avoid them

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Mistakes in imaging hepatic lesions and how to avoid them

Katja De Paepe

Summary

AI Generated

This article addresses eight common mistakes in the interpretation and acquisition of radiological images of incidental liver lesions, which are increasingly detected with cross-sectional imaging.

Incidental liver lesions encompass a large group of benign and malignant lesions, and combined use of different imaging modalities is often required for accurate diagnosis.
Clinicians and radiologists must be familiar with each imaging modality's strengths and limitations and aware of common pitfalls that can confound correct interpretation.
MRI plays an essential role in the characterisation of liver lesions, and a standard MRI protocol with sequence explanations is provided.
Recommendations for avoiding mistakes are based on clinical experience and literature where possible.
This material is most relevant for clinicians and radiologists involved in liver imaging interpretation.

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References

Mistakes

References

Mistake 1 Mistake 2 Mistake 3 Mistake 4 Mistake 5 Mistake 6 Mistake 7 Mistake 8

Lim, J. & Singal, A. G. Surveillance and Diagnosis of Hepatocellular Carcinoma. Clin. Liver Dis. 13, 2–5 (2019). [Link]

Singal, A. G., Pillai, A. & Tiro, J. Early detection, curative treatment, and survival rates for hepatocellular carcinoma surveillance in patients with cirrhosis: a meta-analysis. PLoS Med. 11, e1001624 (2014) [Link]

Tzartzeva, K. et al. Surveillance Imaging and Alpha Fetoprotein for Early Detection of Hepatocellular Carcinoma in Patients With Cirrhosis: A Meta-analysis. Gastroenterology 154, 1706-1718.e1 (2018). [Link]

Simmons, O. et al. Predictors of adequate ultrasound quality for hepatocellular carcinoma surveillance in patients with cirrhosis. Aliment. Pharmacol. Ther. 45, 169–177 (2017) [Link]

LI-RADS ® v2017 US Core. [Link]

Vietti Violi, N., Fowler, K. J., Sirlin, C. B. & Taouli, B. Abbreviated Magnetic Resonance Imaging for HCC Surveillance. Clin. Liver Dis. 17, 133–138 (2021). [Link]

Bedogni, G., Nobili, V. & Tiribelli, C. Epidemiology of fatty liver: an update. World J. Gastroenterol. 20, 9050–4 (2014). [Link]

Vilgrain, V. et al. Hepatic steatosis: A major trap in liver imaging. Diagn. Interv. Imaging 94, 713–727 (2013) [Link]

Jang, J. K., Jang, H. J., Kim, J. S. & Kim, T. K. Focal fat deposition in the liver: diagnostic challenges on imaging. Abdom. Radiol. 42, 1667–1678 (2017).

10.

CT/MRI Diagnostic Table [Link]

11.

Zane, K. E., Cloyd, J. M., Mumtaz, K. S., Wadhwa, V. & Makary, M. S. Metastatic disease to the liver: Locoregional therapy strategies and outcomes. World J. Clin. Oncol. 12, 725–745 (2021) [Link]

12.

Galle, P. R. et al. EASL Clinical Practice Guidelines: Management of hepatocellular carcinoma q. Journal of Hepatology 69, (2018) [Link]

13.

Alnammi, M., Wortman, J., Therrien, J. & Afnan, J. MRI features of treated hepatocellular carcinoma following locoregional therapy: a pictorial review. Abdom. Radiol. (New York) 47, 2299–2313 (2022) [Link]

14.

Brink, J. A. & Wagner, B. J. Pathways for the Spread of Disease in the Abdomen and Pelvis. in 57–65 (Springer, Cham, 2018). doi:10.1007/978-3-319-75019-4_6 [Link]

15.

Panagiotopoulou, P. B., Courcoutsakis, N., Tentes, A. & Prassopoulos, P. CT imaging of peritoneal carcinomatosis with surgical correlation: a pictorial review. Insights Imaging 12, 168 (2021). [Link]

16.

Sherif, A. M., Musa, E. R., Kedar, R. & Fu, L. Subcapsular hepatic endometriosis: case report and review of the literature. Radiol. case reports 11, 303–308 (2016). [Link]

17.

Ahlawat, S. et al. Magnetic resonance neurography of peripheral nerve tumors and tumorlike conditions. Neuroimaging Clin N Am. 24, 589–601 (2014). [Link]

18.

Schieda, N. et al. Renal and adrenal masses containing fat at MRI: Proposed nomenclature by the society of abdominal radiology disease-focused panel on renal cell carcinoma. J. Magn. Reson. Imaging 49, 917–926 (2019). [Link]

19.

Caseiro-Alves, F. et al. Liver haemangioma: common and uncommon findings and how to improve the differential diagnosis. Eur. Radiol. 17, 1544–1554 (2007). [Link]

20.

Vilgrain, V. et al. Imaging of Atypical Hemangiomas of the Liver with Pathologic Correlation. RadioGraphics 20, 379–397 (2000). [Link]

21.

Chen, L. et al. Meta-analysis of gadoxetic acid disodium (Gd-EOB-DTPA)-enhanced magnetic resonance imaging for the detection of liver metastases. PLoS One 7, e48681 (2012). [Link]

22.

Doo, K. W. et al. ‘Pseudo washout’ sign in high-flow hepatic hemangioma on gadoxetic acid contrast-enhanced MRI mimicking hypervascular tumor. AJR. Am. J. Roentgenol. 193, W490-6 (2009). [Link]

23.

Paulatto, L. et al. Colorectal liver metastases: radiopathological correlation. Insights Imaging 11, 99 (2020). [Link]

24.

Elsayes, K. M. et al. Spectrum of pitfalls, pseudolesions, and potential misdiagnoses in cirrhosis. Am. J. Roentgenol. 211, 87–96 (2018). [Link]

Abstract

Incidental liver lesions are increasingly found due to the incremental use of cross-sectional imaging. They encompass a large group of benign and malignant lesions, and the combined use of different imaging modalities is often required to make an accurate diagnosis. It is of utmost importance for clinicians and radiologists to be familiar with each imaging modality's strengths and limitations and be aware of common pitfalls that can confound the correct interpretation of findings. The article will discuss eight common mistakes in the interpretation and acquisition of radiological images. Recommendations on avoiding these mistakes will be based on clinical experience and literature where possible. As MRI plays an essential role in the characterisation of liver lesions, a standard MRI protocol with a brief explanation of the sequences has been added for reference

Topics

Hepatobiliary Radiology & Imaging

Citation

DePaepe K. Mistakes in imaging hepatic lesions and how to avoid them. UEG Education 2022; 22: 37-42.

Published

2022

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Mistakes in endoscopic treatment of Barrett oesophagus neoplasia and how to avoid them

Jacques J. Bergman, Roos E. Pouw, Eva Verheij

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References

Mistakes

References

Mistake 1 Mistake 2 Mistake 3 Mistake 4 Mistake 5 Mistake 6 Mistake 7 Mistake 8

Lim, J. & Singal, A. G. Surveillance and Diagnosis of Hepatocellular Carcinoma. Clin. Liver Dis. 13, 2–5 (2019). [Link]

Simmons, O. et al. Predictors of adequate ultrasound quality for hepatocellular carcinoma surveillance in patients with cirrhosis. Aliment. Pharmacol. Ther. 45, 169–177 (2017) [Link]

LI-RADS ® v2017 US Core. [Link]

Vietti Violi, N., Fowler, K. J., Sirlin, C. B. & Taouli, B. Abbreviated Magnetic Resonance Imaging for HCC Surveillance. Clin. Liver Dis. 17, 133–138 (2021). [Link]

Bedogni, G., Nobili, V. & Tiribelli, C. Epidemiology of fatty liver: an update. World J. Gastroenterol. 20, 9050–4 (2014). [Link]

Vilgrain, V. et al. Hepatic steatosis: A major trap in liver imaging. Diagn. Interv. Imaging 94, 713–727 (2013) [Link]

Jang, J. K., Jang, H. J., Kim, J. S. & Kim, T. K. Focal fat deposition in the liver: diagnostic challenges on imaging. Abdom. Radiol. 42, 1667–1678 (2017).

10.

CT/MRI Diagnostic Table [Link]

11.

Zane, K. E., Cloyd, J. M., Mumtaz, K. S., Wadhwa, V. & Makary, M. S. Metastatic disease to the liver: Locoregional therapy strategies and outcomes. World J. Clin. Oncol. 12, 725–745 (2021) [Link]

12.

Galle, P. R. et al. EASL Clinical Practice Guidelines: Management of hepatocellular carcinoma q. Journal of Hepatology 69, (2018) [Link]

13.

14.

Brink, J. A. & Wagner, B. J. Pathways for the Spread of Disease in the Abdomen and Pelvis. in 57–65 (Springer, Cham, 2018). doi:10.1007/978-3-319-75019-4_6 [Link]

15.

Panagiotopoulou, P. B., Courcoutsakis, N., Tentes, A. & Prassopoulos, P. CT imaging of peritoneal carcinomatosis with surgical correlation: a pictorial review. Insights Imaging 12, 168 (2021). [Link]

16.

Sherif, A. M., Musa, E. R., Kedar, R. & Fu, L. Subcapsular hepatic endometriosis: case report and review of the literature. Radiol. case reports 11, 303–308 (2016). [Link]

17.

Ahlawat, S. et al. Magnetic resonance neurography of peripheral nerve tumors and tumorlike conditions. Neuroimaging Clin N Am. 24, 589–601 (2014). [Link]

18.

19.

Caseiro-Alves, F. et al. Liver haemangioma: common and uncommon findings and how to improve the differential diagnosis. Eur. Radiol. 17, 1544–1554 (2007). [Link]

20.

Vilgrain, V. et al. Imaging of Atypical Hemangiomas of the Liver with Pathologic Correlation. RadioGraphics 20, 379–397 (2000). [Link]

21.

Chen, L. et al. Meta-analysis of gadoxetic acid disodium (Gd-EOB-DTPA)-enhanced magnetic resonance imaging for the detection of liver metastases. PLoS One 7, e48681 (2012). [Link]

22.

Doo, K. W. et al. ‘Pseudo washout’ sign in high-flow hepatic hemangioma on gadoxetic acid contrast-enhanced MRI mimicking hypervascular tumor. AJR. Am. J. Roentgenol. 193, W490-6 (2009). [Link]

23.

Paulatto, L. et al. Colorectal liver metastases: radiopathological correlation. Insights Imaging 11, 99 (2020). [Link]

24.

Elsayes, K. M. et al. Spectrum of pitfalls, pseudolesions, and potential misdiagnoses in cirrhosis. Am. J. Roentgenol. 211, 87–96 (2018). [Link]

Abstract

Barrett’s oesophagus is a premalignant condition of the distal oesophagus predisposing to oesophageal adenocarcinoma. Given the potential for malignant progression and the poor prognosis of eosophageal adenocarcinoma when diagnosed at a symptomatic stage, patients with known Barrett oesophagus undergo regular endoscopic surveillance to detect neoplastic progression at an early and preferably endoscopically, treatable stage. Endoscopic management of early Barrett oesophagus neoplasia consists of a combination of endoscopic imaging, endoscopic resection and endoscopic ablation. Below we discuss a number of mistakes that are frequently made when managing Barrett oesophagus neoplasia and how to avoid them. Much of this discussion draws on existing guidelines (for background reading, check the ESGE Barrett oesophagus guideline), but in many instances the underlying evidence (even in the guideline) is missing and therefore many of our practically driven recommendations are based on common sense and our experience in this field.

Topics

Oesophagus

Citation

Verheij EPD, Pouw RE and Bergman JJ. Mistakes in endoscopic treatment of Barrett oesophagus neoplasia and how to avoid them. UEG Education 2021; 21: 35–39.

Published

2021

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Mistakes in inflammatory bowel disease and reproduction and how to avoid them

C. Janneke van der Woude, Shannon Kanis

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Summary is not available for this content yet.

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References

Mistakes

References

Mistake 1 Mistake 2 Mistake 3 Mistake 4 Mistake 5 Mistake 6 Mistake 7 Mistake 8

Lim, J. & Singal, A. G. Surveillance and Diagnosis of Hepatocellular Carcinoma. Clin. Liver Dis. 13, 2–5 (2019). [Link]

Simmons, O. et al. Predictors of adequate ultrasound quality for hepatocellular carcinoma surveillance in patients with cirrhosis. Aliment. Pharmacol. Ther. 45, 169–177 (2017) [Link]

LI-RADS ® v2017 US Core. [Link]

Vietti Violi, N., Fowler, K. J., Sirlin, C. B. & Taouli, B. Abbreviated Magnetic Resonance Imaging for HCC Surveillance. Clin. Liver Dis. 17, 133–138 (2021). [Link]

Bedogni, G., Nobili, V. & Tiribelli, C. Epidemiology of fatty liver: an update. World J. Gastroenterol. 20, 9050–4 (2014). [Link]

Vilgrain, V. et al. Hepatic steatosis: A major trap in liver imaging. Diagn. Interv. Imaging 94, 713–727 (2013) [Link]

Jang, J. K., Jang, H. J., Kim, J. S. & Kim, T. K. Focal fat deposition in the liver: diagnostic challenges on imaging. Abdom. Radiol. 42, 1667–1678 (2017).

10.

CT/MRI Diagnostic Table [Link]

11.

Zane, K. E., Cloyd, J. M., Mumtaz, K. S., Wadhwa, V. & Makary, M. S. Metastatic disease to the liver: Locoregional therapy strategies and outcomes. World J. Clin. Oncol. 12, 725–745 (2021) [Link]

12.

Galle, P. R. et al. EASL Clinical Practice Guidelines: Management of hepatocellular carcinoma q. Journal of Hepatology 69, (2018) [Link]

13.

14.

Brink, J. A. & Wagner, B. J. Pathways for the Spread of Disease in the Abdomen and Pelvis. in 57–65 (Springer, Cham, 2018). doi:10.1007/978-3-319-75019-4_6 [Link]

15.

Panagiotopoulou, P. B., Courcoutsakis, N., Tentes, A. & Prassopoulos, P. CT imaging of peritoneal carcinomatosis with surgical correlation: a pictorial review. Insights Imaging 12, 168 (2021). [Link]

16.

Sherif, A. M., Musa, E. R., Kedar, R. & Fu, L. Subcapsular hepatic endometriosis: case report and review of the literature. Radiol. case reports 11, 303–308 (2016). [Link]

17.

Ahlawat, S. et al. Magnetic resonance neurography of peripheral nerve tumors and tumorlike conditions. Neuroimaging Clin N Am. 24, 589–601 (2014). [Link]

18.

19.

Caseiro-Alves, F. et al. Liver haemangioma: common and uncommon findings and how to improve the differential diagnosis. Eur. Radiol. 17, 1544–1554 (2007). [Link]

20.

Vilgrain, V. et al. Imaging of Atypical Hemangiomas of the Liver with Pathologic Correlation. RadioGraphics 20, 379–397 (2000). [Link]

21.

Chen, L. et al. Meta-analysis of gadoxetic acid disodium (Gd-EOB-DTPA)-enhanced magnetic resonance imaging for the detection of liver metastases. PLoS One 7, e48681 (2012). [Link]

22.

Doo, K. W. et al. ‘Pseudo washout’ sign in high-flow hepatic hemangioma on gadoxetic acid contrast-enhanced MRI mimicking hypervascular tumor. AJR. Am. J. Roentgenol. 193, W490-6 (2009). [Link]

23.

Paulatto, L. et al. Colorectal liver metastases: radiopathological correlation. Insights Imaging 11, 99 (2020). [Link]

24.

Elsayes, K. M. et al. Spectrum of pitfalls, pseudolesions, and potential misdiagnoses in cirrhosis. Am. J. Roentgenol. 211, 87–96 (2018). [Link]

Abstract

Inflammatory bowel disease (IBD) is a chronic relapsing gastrointestinal disease, often affecting young people during their fertile years. The chronic character of IBD means that lifelong medical treatment is often required. As such, it is not surprising that questions often arise about fertility and pregnancy in patients with IBD. The most important risk factor for adverse pregnancy outcomes in IBD patients is the presence of disease activity during pregnancy. Indeed, negative pregnancy outcomes (e.g. spontaneous abortion, preterm delivery and low birth weight) are associated with disease activity at the time of conception and during pregnancy.

Topics

IBD Primary Care

Citation

Cite this article as: Kanis SL and van der Woude CJ. Mistakes in inflammatory bowel disease and reproduction and how to avoid them. UEG Education 2016: 16: 20–23.

Published

2024

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Mistakes in eosinophilic oesophagitis and how to avoid them

Alfredo J. Lucendo, Javier Molina-Infante

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References

Mistakes

References

Mistake 1 Mistake 2 Mistake 3 Mistake 4 Mistake 5 Mistake 6 Mistake 7 Mistake 8

Lim, J. & Singal, A. G. Surveillance and Diagnosis of Hepatocellular Carcinoma. Clin. Liver Dis. 13, 2–5 (2019). [Link]

Simmons, O. et al. Predictors of adequate ultrasound quality for hepatocellular carcinoma surveillance in patients with cirrhosis. Aliment. Pharmacol. Ther. 45, 169–177 (2017) [Link]

LI-RADS ® v2017 US Core. [Link]

Vietti Violi, N., Fowler, K. J., Sirlin, C. B. & Taouli, B. Abbreviated Magnetic Resonance Imaging for HCC Surveillance. Clin. Liver Dis. 17, 133–138 (2021). [Link]

Bedogni, G., Nobili, V. & Tiribelli, C. Epidemiology of fatty liver: an update. World J. Gastroenterol. 20, 9050–4 (2014). [Link]

Vilgrain, V. et al. Hepatic steatosis: A major trap in liver imaging. Diagn. Interv. Imaging 94, 713–727 (2013) [Link]

Jang, J. K., Jang, H. J., Kim, J. S. & Kim, T. K. Focal fat deposition in the liver: diagnostic challenges on imaging. Abdom. Radiol. 42, 1667–1678 (2017).

10.

CT/MRI Diagnostic Table [Link]

11.

Zane, K. E., Cloyd, J. M., Mumtaz, K. S., Wadhwa, V. & Makary, M. S. Metastatic disease to the liver: Locoregional therapy strategies and outcomes. World J. Clin. Oncol. 12, 725–745 (2021) [Link]

12.

Galle, P. R. et al. EASL Clinical Practice Guidelines: Management of hepatocellular carcinoma q. Journal of Hepatology 69, (2018) [Link]

13.

14.

Brink, J. A. & Wagner, B. J. Pathways for the Spread of Disease in the Abdomen and Pelvis. in 57–65 (Springer, Cham, 2018). doi:10.1007/978-3-319-75019-4_6 [Link]

15.

Panagiotopoulou, P. B., Courcoutsakis, N., Tentes, A. & Prassopoulos, P. CT imaging of peritoneal carcinomatosis with surgical correlation: a pictorial review. Insights Imaging 12, 168 (2021). [Link]

16.

Sherif, A. M., Musa, E. R., Kedar, R. & Fu, L. Subcapsular hepatic endometriosis: case report and review of the literature. Radiol. case reports 11, 303–308 (2016). [Link]

17.

Ahlawat, S. et al. Magnetic resonance neurography of peripheral nerve tumors and tumorlike conditions. Neuroimaging Clin N Am. 24, 589–601 (2014). [Link]

18.

19.

Caseiro-Alves, F. et al. Liver haemangioma: common and uncommon findings and how to improve the differential diagnosis. Eur. Radiol. 17, 1544–1554 (2007). [Link]

20.

Vilgrain, V. et al. Imaging of Atypical Hemangiomas of the Liver with Pathologic Correlation. RadioGraphics 20, 379–397 (2000). [Link]

21.

Chen, L. et al. Meta-analysis of gadoxetic acid disodium (Gd-EOB-DTPA)-enhanced magnetic resonance imaging for the detection of liver metastases. PLoS One 7, e48681 (2012). [Link]

22.

Doo, K. W. et al. ‘Pseudo washout’ sign in high-flow hepatic hemangioma on gadoxetic acid contrast-enhanced MRI mimicking hypervascular tumor. AJR. Am. J. Roentgenol. 193, W490-6 (2009). [Link]

23.

Paulatto, L. et al. Colorectal liver metastases: radiopathological correlation. Insights Imaging 11, 99 (2020). [Link]

24.

Elsayes, K. M. et al. Spectrum of pitfalls, pseudolesions, and potential misdiagnoses in cirrhosis. Am. J. Roentgenol. 211, 87–96 (2018). [Link]

Abstract

Eosinophilic oesophagitis (EoE) is a chronic immune-mediated inflammatory condition that is confined to the oesophagus. Clinically, EoE is characterized by symptoms of oesophageal dysfunction; histologically, by eosinophil-predominant inflammation.1,2 At present, EoE is the second-most frequent cause of chronic oesophagitis (gastro-oesophageal reflux disease [GORD] is the primary cause) and the foremost cause of dysphagia and food impaction in young adults and children.

Topics

Oesophagus

Citation

Molina-Infante J and Lucendo AJ. Mistakes in eosinophilic oesophagitis and how to avoid them. UEG Education 2017: 17; 6–9.

Published

2024

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Risk factors, epidemiology and prognosis of cholangiocarcinoma

Iago Rodríguez-Lago 1, Nina Barner-Rasmussen 2

Affiliations

1 Hospital Universitario de Galdakao, Bilbao, Spain

2 Helsinki University Hospital, Finland

Summary

AI Generated

Summary is not available for this content yet.

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Abstract

Topics

Hepatobiliary

Published

2022

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Mistakes in endoscopic treatment of Barrett oesophagus neoplasia and how to avoid them

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UEG Standards and Guidelines

Clinical Practice Guideline

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Endoscopic tissue sampling – Part 2: Lower gastrointestinal tract. European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Roos E. Pouw

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AI Generated

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Guideline

Main recommendations

1 ESGE suggests performing segmental biopsies (at least two from each segment), which should be placed in different specimen containers (ileum, cecum, ascending, transverse, descending, and sigmoid colon, and rectum) in patients with clinical and endoscopic signs of colitis.
Weak recommendation, low quality of evidence

2 ESGE recommends taking two biopsies from the right hemicolon (ascending and transverse colon) and, in a separate container, two biopsies from the left hemicolon (descending and sigmoid colon) when microscopic colitis is suspected.
Strong recommendation, low quality of evidence.

3 ESGE recommends pancolonic dye-based chromoendoscopy or virtual chromoendoscopy with targeted biopsies of any visible lesions during surveillance endoscopy in patients with inflammatory bowel disease.
Strong recommendation, moderate quality of evidence.

4 ESGE suggests that, in high risk patients with a history of colonic neoplasia, tubular-appearing colon, strictures, ongoing therapy-refractory inflammation, or primary sclerosing cholangitis, chromoendoscopy with targeted biopsies can be combined with four-quadrant non-targeted biopsies every 10cm along the colon.
Weak recommendation, low quality of evidence.

5 ESGE recommends that, if pouch surveillance for dysplasia is performed, visible abnormalities should be biopsied, with at least two biopsies systematically taken from each of the afferent ileal loop, the efferent blind loop, the pouch, and the anorectal cuff.
Strong recommendation, low quality of evidence.

6 ESGE recommends that, in patients with known ulcerative colitis and endoscopic signs of inflammation, at least two biopsies be obtained from the worst affected areas for the assessment of activity or the presence of cytomegalovirus; for those with no evident endoscopic signs of inflammation, advanced imaging technologies may be useful in identifying areas for targeted biopsies to assess histologic remission if this would have therapeutic consequences.
Strong recommendation, low quality of evidence

7 ESGE suggests not biopsying endoscopically visible inflammation or normal-appearing mucosa to assess disease activity in known Crohn’s disease.
Weak recommendation, low quality of evidence.

8 ESGE recommends that adequately assessed colorectal polyps that are judged to be premalignant should be fully excised rather than biopsied.
Strong recommendation, low quality of evidence.

9 ESGE recommends that, where endoscopically feasible, potentially malignant colorectal polyps should be excised en bloc rather than being biopsied. If the endoscopist cannot confidently perform en bloc excision at that time, careful representative images (rather than biopsies) should be taken of the potential focus of cancer, and the patient should be rescheduled or referred to an expert center.
Strong recommendation, low quality of evidence.

10 ESGE recommends that, in malignant lesions not amenable to endoscopic excision owing to deep invasion, six carefully targeted biopsies should be taken from the potential focus of cancer.
Strong recommendation, low quality of evidence

Publisher

European Society of Gastrointestinal Endoscopy

Guideline

Clinical Practice Guideline

Topics

Endoscopy

Citation

Endoscopy 2021; 53, 1261–1273

Published

2021

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Oesophageal cancer with Massimiliano di Pietro (Part 1)

Massimiliano di Pietro, Pradeep Mundre

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Abstract

Topics

Digestive Oncology Endoscopy Oesophagus

Published

2025

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Oesophageal cancer with Massimiliano di Pietro (Part 1)

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