INTRODUCTION: Large language models are increasingly used in clinical decision-making, but their role in appropriateness-based indications is uncertain. METHODS: We conducted a vignette-based Italian survey comparing esophagogastroduodenoscopy appropriateness by 5 artificial intelligence (AI) (ChatGPT-4.0, ChatGPT-4.5, Gemini, Claude AI, OpenEvidence) at 2 times (April and September 2025) with gastroenterologists, residents, and general practitioners, using American Society for Gastrointestinal Endoscopy and European Society of Gastrointestinal Endoscopy guidelines. RESULTS: A total of 135 physicians participated. AI performance varied over time: accuracies ranged from 50%–90% in April to 63%–80% in September, with ChatGPT-4.5 and ChatGPT-4.0 outperforming physicians in September. DISCUSSION: Temporal and prompt variability highlight the need for multirun, longitudinal evaluation before clinical adoption.

Endoscopic nasobiliary drainage (ENBD) is a well-established technique for biliary decompression in both benign and malignant conditions. Over the past decades, its role has been extensively evaluated in comparison with endoscopic biliary stenting and percutaneous transhepatic biliary drainage. ENBD provides distinct clinical advantages, including real-time monitoring of bile output, the possibility to perform irrigation, and the ability to collect bile samples for cytological analysis. However, it also presents specific challenges such as patient discomfort, tube dislodgement, and the need for careful maintenance. This narrative review synthesizes current evidence from randomized controlled trials, retrospective cohorts, systematic reviews, and meta-analyses, highlighting the main indications, technical innovations, comparative outcomes with alternative drainage techniques, and strategies to prevent complications. Furthermore, it discusses emerging approaches aimed at improving patient tolerance, procedural efficiency, and environmental sustainability, offering an updated framework for optimizing patient management in both benign and malignant biliary obstruction.