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 Low amplitude propagated contractions (LAPC) Haustral contractions, triggered by chyme, facilitate the slow movement and mixing of food to enhance water absorption. Those are slow, segmenting movements that further mix chyme, most comoon in proximal colon.  (5 to 40 mm Hg) and last about 3  seconds.They happen  about every 30 minutes. 

Check the ESGE  guidelines

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

With his age, cholesterol:HDL ratio and the BMI the QRISK score is >10% therefore statins are indicated in his case.

Abdominal US is indicated in all cases of abnormal liver blood test.  If proved to have MASLD (Fatty liver on the US) then should be screened for Hb1Ac for type 2 diabetes.

Lifestyle modification is the most important treatment in his case.

Even though doing a FibroScan is never bad practice (it is non invasive and very helpful to estimate the level of liver fibrosis) the fact is that FibroScan would be strictly indicated IF the FIb4-score was > 2 (remember the cutoff in >65 yo is 2 instead of 1.3).

Paquet (Or Modified Paquet that contains 3 categories insted of 4) is the classification used for esophageal varices. Zargar is used for caustic injury

EREFS (EoE reference endoscopic score) is used to grade Eosinophilic esophagitis.

Kodsi is used for staging Candidiasis:

Grade I, a few raised white plaques up to 2 mm in size without edema or ulceration.

Grade II, multiple raised white plaques greater than 2 mm in size without ulceration.

Grade III, confluent, linear, and nodular elevated plaques.

Grade IV, finding of grade III with increased friability of the mucous membranes and occasional narrowing of the lumen

In general, EMR recurrence  (presence of residual polypoid tissue at the level of the scar in control colonoscopy) is described as high as 20-30%.    Currently it is recommended to treat the margins of the scar immediately after polyp resection to reduce this rate.  Treating with APC or soft snare coagulation (this latter is preferred in the ESGE guidelines) help significantly reduce the recurrence

See Bourkes group RCT

See metanalisis

1. True.  Around 80%  of AIH will be either ANA or ASMA+, 8% AMA+, 2% LKM+. 30% SLA+
2.  True. Less than 50% in reduction of transaminases in 4 weeks after treatment is considered Non-response. (Occurs in 17% of treated patients and assoiciates a 7-fold risk of liver related death )
3.  False. Previous guidedlines suggested this parameter, but now we consider response when complete normalisation of transmanisases and IgG.   Liver biopsy is very useful to asses histological response if Modified Ishak hepatitis activity index (mHAI) <4 /18, however histology response lags behind biochemical response by several months: in one  RCT, only 28% and 50% of patients receiving prednisolone±azathioprine achieved histological remission after 6 and 12 months, respectively. Thus, repeat biopsy to confirm remission is not recommended over the first 2 years

4.  True. Since the response criteria are more strict, there will be 20-30% who wont achieve complete biochemical remission.  These scenarios are tricky, we need to compare the overall response, patient adeherence to treatment, considering Azathioprine adeherence and metabolism:  Measuring Thioguanin nucleotides- TGN-  to see that they are in therapeutic range(>220 pmol/8×10) and  Metilmercaptoruine ( MeMP) > 5700 can confirm that the patient is taking the right dose,  Also there are specific situations in which transaminases can remain slightly abnormal due to other causes like MASLD or drug related, and IgG is commonly raised in conditions like cirrhosis.

Check BSG guidelines AIH

Difficult case with patient older than 65 and comorbidities with moderately to severely active ulcerative colitis.

Vedolizumab should be indicated in his case as it performs better than anti TNFs in ulcerative colitis, confirming the results of the Varsity study.   ( Over a 5 year period, drug persistence is higher in patients treated with vedolizumab as compared to anti-TNF therapies and loss of response is less frequent again in the vedolizumab group). Age or previous TIA /AV block are not contraindications for anti-TNF (only Moderate-severe heart failure, which is not the case) So even though Adalimumab would be a valid option, it should be ideally used if Vedolizumab fails.

JAK inhibitor (Tofacitinib) should not be prescribed in people with a history of cardiovascular disease (eg. heart attack or stroke) at increased risk of cardiovascular problems (eg. current or past long-time smokers) at increased risk of cancer or aged 65 years and over unless no suitable alternative

Ozanibod could be an oral alternative , however second-degree Mobitz type II atrioventricular (AV) bloc and TIA within the previous 6 months contraindicates its use.

Off the quizz options, another good one would be Ustekinumab (interleukin 12&23 antagonist drug ) as not contraindicated here and equally valid to Vedolizumab.

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

Despite they all are good options that could be considered. We need to see:

• Size (abut 12-13mm in size)
• Mucosal pattern (looks like sessile serrated lession or SSP-  with clouded surface and indistictive borders - see  WASP classification - : The lesion has NO suspicious areas of submucosal invasion
• Shape- 0-IIa of Paris classification (despite the name sessile serrated lesion, this is the nomenclature for that type of serrated lesions, although the majority of them are in fact flat, not sessile)
• Position- Right vs left colon (risk of perforation,  lesion is easy accesible or not in case of delayed bleed)

With all in mind, the most difficult option would be cold snare as >10mm and having broad base, it would be difficult to fully grasp the tissue, close and cut through with cold snare. ESGE guidelines recommend cold snare in small (<10mm ) and in >10mm they suggest hot polypectomy or piecemeal cold snare resection.

So the options would be 1) Lifting and use the cold snare to resect either en bloc if feasible, or most likely piecemeal 2) Do the same but using diathermy with a hot snare or 3) do not lift and use underwater EMR, which probably would allow to grab the lesion en bloc, completely in one go with a 15mm snare. Despite ESGE recommends underwater EMR in selected cases >20mm, realistically if we want en bloc resection, it is either hot snare or underwater EMR.

Note that cold EMR is also a good option for SSL, has an excellent safety profile with less adverse events compared to hot EMR, and less residual rate (1% in cold vs 4.2% in hot) in serrated lesions, however requires some level of practice and getting used to a slighly more bleeding field.

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