What changed recently

ACG replaced its 2021 diverticular disease guideline with a document focused on colonic diverticulitis, formalising selective rather than routine antibiotics for low-risk acute uncomplicated disease and listing the high-risk features (immunocompromise, frailty, unsafe outpatient care) that still warrant them. It also recommends against probiotics, mesalamine and rifaximin for recurrence prevention, drops nut/seed/popcorn avoidance, and limits post-recovery colonoscopy to complicated disease or patients with alarm features or overdue screening.

The 2025 AASLD/IDSA guideline tackles six GRADE-based questions the 2018 guidance left unresolved, including whether to treat HBsAg-positive people in the immune-tolerant and indeterminate phases, when to withdraw antiviral therapy, and HCC surveillance in HBV coinfection and after HBsAg loss. Recommendations from 2018 that were not revisited remain in force, and an integrated algorithm combines old and new guidance.

The 2025 ACG guideline moves away from the 2018 step-up model, suggesting against requiring failure of conventional therapy before starting advanced therapy and endorsing early treat-to-target management with therapy chosen by phenotype and prior exposure. It also recommends combination infliximab plus a thiopurine over either agent alone in biologic- and immunomodulator-naive patients.

This update revises the 2019 ACG ulcerative colitis guideline with five years of new trial evidence, expanding and repositioning advanced therapies for moderate-to-severe disease. Etrasimod, an S1P receptor modulator, is newly recommended for both induction and maintenance of remission.

EASL's 2025 hepatitis B guideline shifts from indefinite viral suppression toward personalised, finite therapy with functional cure (sustained HBsAg loss) as the goal. Newer biomarkers including quantitative HBsAg, HBcrAg and HBV RNA are built into disease staging, treatment selection and decisions about safely stopping antivirals.

The 2024 ECCO therapeutics update adds strong recommendations for the newer agents risankizumab (maintenance) and upadacitinib (induction and maintenance) in moderate-to-severe Crohn's disease, broadening options beyond anti-TNF and older biologics. It also restructures the guidance into actionable practice points alongside the GRADE recommendations carried over from 2020.

Rising North American clarithromycin and levofloxacin resistance led ACG to drop those regimens as empiric first-line choices unless susceptibility testing supports them. Optimized 14-day bismuth quadruple therapy became the preferred empiric option, alongside newly endorsed rifabutin triple and vonoprazan-based dual or triple regimens.

This update of the 2016 EASL-EASD-EASO NAFLD guideline redefines the disease as MASLD, requiring hepatic steatosis plus at least one cardiometabolic risk factor and absence of harmful alcohol intake. It formalises non-invasive case-finding for fibrosis in people with type 2 diabetes, obesity or abnormal liver enzymes, and for the first time recommends considering resmetirom for non-cirrhotic MASH with stage 2 or greater fibrosis.

The 2024 ACG guideline replaces the 2013 version's aggressive hydration advice with moderately aggressive fluid resuscitation and now specifies lactated Ringer's over normal saline. It also incorporates a decade of newer evidence on preventing post-ERCP pancreatitis, including periprocedural fluid loading.

The 2023 AASLD guidance adopts the new MASLD/MASH nomenclature agreed by multisociety Delphi consensus in place of NAFLD/NASH, and makes noninvasive tests such as FIB-4 and elastography the primary route for identifying moderate-to-advanced fibrosis rather than liver biopsy. It also expands the use of noninvasive markers for risk prediction and follow-up of treatment response.

Maastricht VI keeps most Maastricht V diagnostic indications but adds explicit third- and fourth-line eradication strategies and high-dose PPI plus amoxicillin dual therapy, and pushes molecular testing for H. pylori and its antibiotic susceptibility. It also strengthens the case for eradication as gastric cancer prevention at any adult age.

The 2022 ECCO therapeutics guideline drops methotrexate for maintenance after the MERIT-UC trial showed no benefit over placebo, and incorporates evidence for vedolizumab, ustekinumab and tofacitinib. Rigid treatment hierarchies were moved out of the recommendations into the supporting text so new agents can be slotted in.

The 2022 ACG guideline kept the 8-week empiric PPI trial but added a strong recommendation to dose PPIs 30-60 minutes before a meal and a conditional endorsement of on-demand or intermittent PPI therapy in non-erosive reflux disease. It also substantially rewrote guidance on extraesophageal symptoms, refractory GERD, and antireflux surgical and endoscopic options.

The Task Force lowered the age to begin average-risk colorectal cancer screening from 50 to 45, citing rising incidence in younger adults, and graded screening at 45-49 as a B recommendation while screening at 50-75 stays grade A. The grade B rating still triggers insurance coverage requirements for the newly included age band.

The 2021 ACG guideline withdrew the 2012 suggestion that pre-endoscopic PPI may be considered, making no recommendation either way after meta-analysis showed no effect on rebleeding or mortality. It also widened the very-low-risk group eligible for discharge from the emergency department to a Glasgow-Blatchford score of 0-1 (previously 0) and specified twice-daily PPI for two weeks after endoscopic hemostasis in high-risk ulcers, while keeping the restrictive 7 g/dL transfusion threshold.

The 2021 ESGE update issues a strong recommendation against urgent endoscopy within 12 hours, since trial evidence showed no outcome advantage over early endoscopy performed within 24 hours of haemodynamic resuscitation. It also refreshes guidance on cap-mounted clips and topical haemostatic powders as salvage options when standard haemostasis fails.

This edition supersedes the 2018 EASL recommendations and is declared the last of the series, reflecting how standardised DAA therapy has become. It endorses simplified treatment with pangenotypic sofosbuvir/velpatasvir or glecaprevir/pibrentasvir without genotyping in eligible patients, using non-invasive fibrosis assessment rather than biopsy before therapy.

The 2019 WSES document upgrades the 2014 WSES position paper into full consensus guidelines agreed at the 2018 World Congress of Emergency Surgery, covering diagnosis, antibiotic use, intensive care, operative management and the open abdomen. It reinforces nonoperative management of sterile necrosis and reserves percutaneous, endoscopic or surgical intervention mainly for infected necrosis.

ASGE tightened its risk stratification for suspected choledocholithiasis: the high-probability group is now limited to ascending cholangitis, a stone seen on imaging, or bilirubin above 4 mg/dL together with a dilated bile duct, while acute pancreatitis and bilirubin of 1.8-4 mg/dL were dropped as predictors and the intermediate category was consolidated. The result is markedly higher specificity and fewer patients sent straight to diagnostic ERCP, with more directed first to EUS, MRCP or intraoperative cholangiography.