Digestive System
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Pancreatic cancer tends to have an ominous character, partly cause disease is a) advanced age, so even in resectable cases many patients are unfit for surgery and b) most cancers are borderline resecable, irresectable or metastatic. (80% of the pancreatic cancers are diagnosed in advanced stages)

Even in patient with surgical resection, the 5-year survival is quoted as 27%

A recent review showed that 5-year survival is 30% in Ia (T1 N0 M0- single 2cm or less panc mass)  dropping to 11.8% in Ib ( T2 N0 M0, this is single mass 2-4cm). When putting all the stages together, the 5 year survival is only 5%.

The best possible outcome would theorically be in an early cancer, 2cm or less (T1), found either incidentally (or if it gives symptoms very early), resectable (non conctacting vessels and not involving other anatomical structures, as well as surgically accesible)  and in a fit patient amenable for surgery.

Check the guidelines

based on the American Association for the study of liver diseases  guidelines

This is a healthy patient wihout history of mental health illness or impaired cognitive issues.  Age and sex may suggest EoE or peptic stricture as possible etiology.

As there is no suspicion of intentional multiple foreing body ingestions, x ray would not be necessary. (Xray can be very useful to guide us when radiopaque objects have been ingested, to see whereabouts in the GI tract they may be lying)  As there is no subcutaneous emphysema or abdominal pain or guarding to suggest any perforation , a CT scan would not be needed.

As per the timing, ASGE  recommends emergent endoscopy for complete esophageal obstruction. ESGE   recommends emergent (preferably within 2 hours, but at the latest within 6 hours) gastroduodenoscopy for foreign bodies inducing complete esophageal obstruction, and for sharp-pointed objects or batteries in the esophagus. The cough and sialorrhaea suggest a complete obstruction.

They recommend urgent (within 24 hours)  for other esophageal foreign bodies without complete obstruction 

AGA-For patients with suspected non bony food bolus impaction without complications (eg,no evidence of perforation or respiratory distress),endoscopy may be performed without obtaining radiographs.

Glucagon 1mg iv can be given to induce esophageal relaxation and try and avoid urgent endoscopy, however it should not delay endoscopy and definetely we do not need 6-10 hours to see if it works.

Methotrexate, same as Azathioprine or Mercaptopurine, is NOT recommended for inducing remission , but to maintain remission. It can take up to 12 weeks to work However, these immunomodulators should be started earlier when patient is responding to first line treatment, in order to maintain remission and prevent flareups,  especially those with extensive disease or other poor prognostic features (early age at diagnosis, penetrating or stricturing disease, neeed for steroid, high CRP, smoker) should be considered for early introduction of biological therapy (dual biologic plus immunomodulator)

Active Crohn’s first line of treatment is an 8-week course of systemic corticosteroids to induce remission. Budesonide can be used  in mild-moderate case of ileal crohns, but should be escalated to systemic treatment if patient does not response.

Exclusive Enteral Nutrition (EEN) may be used to induce remission in mild to moderate Crohn’s disease patients where avoidance of corticosteroid is desired, and in those who are motivated to adhere strictly to EEN for up to 8 weeks. As this is a young male, this could be a possibility that may be worth exploring with paediatricians , dietitian and surgical team involvement. Howwever the fact that CRP is so high makes this case not  the ideal  candidate as he is already presenting systemic inflammation and there should be a good window of time needed  for this diet to work.

See BSG IBD guidelines 

The lower cutoff for FIB 4   >1.3.  Less than 1.3 rules out advanced fibrosis, and >1.3 needs further investigations.

In elderly patients (>65 yo) this threlsholds has low especificity (many false positive patients who do not really have advanced fibrosis) therefore the cutoff proposed in those is 2 (Fib 4 <2 rules out significant fibrosis)

>2.67 is the upper threshold for advanced fibrosis. Patients scoring this have high chance of advance fibrosis and should be referred to liver clinic

Check the guidelines

Although Adenocarcinoma is the most rapidly growing esophageal cancer, still the most common type of esophageal cancer worldwide is esophageal squamous cell carcinoma (SCC). The highest-risk area, called the “esophageal cancer belt,” includes portions of northern Iran, southern Russia, central Asian countries, and northern China, where SCC dominates all cases by 90%. These are very dense populated areas.

However, in Western countries like the United States, esophageal adenocarcinoma has become more common in recent decades, particularly in the lower part of the esophagus and the gastroesophageal junction (GEJ). This increase in adenocarcinoma is often linked to conditions like Barrett esophagus and gastroesophageal reflux disease (GERD).

In summary:

• Worldwide: Esophageal squamous cell carcinoma (SCC) is the most common.
• Western countries (US and Europe): Esophageal adenocarcinoma has surpassed SCC in incidence.

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%

Misty mesentery refers to a non-specific radiological finding characterized by increased attenuation within the mesenteric fat on computed tomography  imaging.  It mimics mistiness as localised fat stranding in the mesentery.  Many processes can lead to the appearance including infiltration by inflammatory cells, oedema, lymphatic accumulation, haemorrhage, tumour infiltration, and fibrosis.  Tipically reflects mesentery panniculitis  ( rare  benign condition characterized by chronic inflammation  of adipose tissue mainly of the small bowel mesentery) But can be the results of any inflammatory or neoplasic process. That is why it is needed to consider also vasculitis, lymphomas, inflammatory process or GI neoplasia.