Incidentalomas in Gastroenterology and Hepatology: A Narrative Review of Guideline‐Based Management, Ethical Considerations, and a Proposed Framework for Practice

Abstract

ABSTRACT Background and Aim Major advancements in medical imaging have led to higher rates of detection of incidental findings unrelated to the presenting complaint, termed incidentalomas. Despite their rising prevalence in gastroenterology and hepatology, there is a paucity of understanding regarding their clinical management and the ethical problems they entail. We aimed to synthesize the latest guidelines for managing these incidentalomas and review the ethical dilemmas they pose, with a view to formulating a management framework to assist clinicians. Methods We undertook a narrative review by searching MEDLINE (via PubMed) and Embase (January 2010–May 2026) using key search terms. We prioritized recent guidelines and key consensus statements from international societies. We also identified additional ethical literature through targeted searches. Results Management guidelines for incidentalomas in gastroenterology and hepatology share several commonalities. These include characterization using the least invasive tests, size‐based triage, emphasis on growth and morphology, reserve tissue sampling, and referral of indeterminate lesions. However, they differ in intervention thresholds, second‐line tests, and surveillance duration. The principal ethical issues identified include conflicts regarding disclosure and autonomy, care cascades and overdetection, distributive justice and equitable care, and medicolegal accountability. Based on this literature, the authors propose a six‐step framework for managing incidentalomas: anticipate and contextualize, characterize, risk‐stratify, seek multidisciplinary review when required, engage in shared decision‐making, and finally, close the loop. Conclusion Incidentaloma management should follow relevant guidelines and be complemented by a patient‐centered approach, particularly regarding the course of investigation and the duration of follow‐up.