Digestive System
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Delirium tremens is a form of severe withdrawal syndrome in which, long term alcohol has chronically bound to GABA receptors and modified its expression( GABA is the inhibitory neurotransmitter which normally reduces neuronal excitability) . This leads to  GABA downregulation of α1- and α3-containing GABA-A receptors (Liang and Olsen, 2014). GABAA receptor downregulation may contribute to anxiety and shakes of withdrawal once alcohol is not present in the nervous system. Also, chronic hyperestimulation of the GABA system by alcohol leads to brain mechanism of up-regulation of the postsynaptic N-methyl-D-aspartate (NMDA) type of glutamate receptor, which mediates the postsynaptic excitatory effects of glutamate to counteract this inhibitory effect of GABA, and once alcohol is suppressed this excitatory system takes over causing autonomic hyperactivity, tachicardia, cardiovascular collapse, seizures or even comma and death.

See AASLD  and BSG guidelines

Difficult case. In this patient, option A is false- This is a very early stage ≤2cm (BCLC 0)

HCC requieres always an individualised treatment. Knowing that patient is fit and wihtout portal hypertension, he could be amenable for resection. However ablation has been proved to be as effective as surgery with less adverse events, so it would probably be indicated in such as small lesion as first line. The bigger the lesions, the less efficacious ablation is as can leave tumoral tissue untreated. In this case, transplant  certainly could be considered but would not be an ideal first line option as still is <2cm and Child A does not warrant the inclusion in list.

If this HCC was between 2-5cm, treatment could be trasplant (however Child A has per se no indication for transplant, being in the list with modify MELD can be tricky and has risk of tumour progression) surgical resection or ablation, based on radiological features , patient background and preferences

If multifocal HCC,  transplant is ususally the recommended 1st line therapy, whereas TACE/SIRT would be an option in non transplant candidates, unless the lesions are in the same lobe and accesible, in which case occasionally surgical resection can be offered.

If mass>7cm, this surpasses even the Expanded Milan criteria, and we know the risks of HCC invasion, recurrence and mortality after transplant are too high, therefore TACE/ SIRT/ Stereotactic resection or surgical resection are options based on patients features.

It is not 2 times higher, it is actually > 10 times higher!!

This is the reason ADR is probably  the most important surrogate marker of a good  quality colonoscopy, (others are bowel preparation, caecal intubation and withdrawal time) and we need to maintain ADR  at least >20%

Audit C score has 3 questions and if score is 5 or more, should prompt the full AUDIT of 10 questions.  Most questions ask about the past year alcohol habits. In a full AUDIT , any 15 or above represents high risk of alcohol dependence.

Number 3 is correct but not universal. A standard drink in US contains 14g, 10g in many EU countries and 8g in the UK. EASL advices to standardise to 10g (1 unit) but this is down to the individual countries. https://auditscreen.org/

It is expected that up to 1 in 2 patients who are positive in faecal inmunochemistry test  (FIT) can have pathology (polyps or cancer) This can be seen in  results such as the QUALISCOPIA group or the UK bowel screening  report

Underwater EMR is a technique in which instead of gas, the colon is insuflated with liquid (usually water, less common saline). The water makes the mucosa 'float' by reducing the wall tension and this separates the layers of the mucosa-submucosa naturally without injecting lifting solution.  This makes flat polyps easy to get grasped. Scar appears small after resection, but when water is aspirated and air insuflatted, one can see the scars are usually much bigger than they appear with water.  See this image from Spadaccini et al 

Check the guidelines

Check the ESGE  guidelines

The AGA guidelines recommend random biopsies of the cardia and distal 2 cm of the tubular esophagus.

This is a case of Clostridioides (Clostridium) difficile colitis with typical pseudomembranes on the colonic mucosa.  Elderly and nursing home patients are risk factors. We should take biopsies and ask for faecal sample (GDH and /or culture for toxigenic C.diff) because pseudomembrane rarely can have other causes (Staphylococcus aureus, CMV, radiation, ischemic, chemotherapy)

Patient does not meet the definition of Severe (>15000 leucocytes or deranged Creatinin) or fulminant (hypotension, septic shock, megacolon)

Most guidelines no longer recommend Metronidazole for C.diff as first line unless no other alternative available.  Despite ACG recommends either Vancomycin or Fidaxomicin as first line, (Fidaxomicin is more expensive) the European guidelines recommend Fidaxomicin over Vancomycin (Vancomycin is a perfect acceptable good choice , however despite both curing the infection in about the same rates (76.2% vs 70.5%),  lower recurrence rates with fidaxomicin are described (8.3% vs 32.6%) which could justify its higher cost.