Digestive System
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Smoking and obesity are probably the most important modifiable risk factors for panc cancer (Smoking 74% higher risk, whereas every 5 points of increased BMI  increases risk in 10% )

Diabetes is an independent factor associated with higer risk of pancreatic cancer.

Alcohol is known to increase the risk although there is different evidence in regards of the association (It is known to be dose dependant, plus also alcohol can increase the risk of adquired chronic pancreatitis, which in itself increases the overal risk of cancer in about 4%)

The evidence of Hpylori is controversia, it was described in this review however further evidence fails to suppor this. It is thought to be  through secondary mucosal inflammation and immune evasion rather than Hpylori per se.

However it is known that there is an association with ABO blood groups in several large epidemiological studies. Non 0 blood types have a higher risk of developing pancreatic cancer compared to A/B/AB

In this article they summarised the current evidence.

According to the Haraldsson  classification, Type 2 and 3 are usually the most difficult- Type 3 is normally quite challenging as papilla is  protruding or bulging into the duodenal lumen or sometimes hanging down, pendulous , mobile and with the orifice oriented caudally. This papilla asociates a higher risk of failure OR 7.4 compared to type 1, followed closely by type 2 which is flat and small and associates also more risk of pancreatitis.
See image and data from retrospective database

High Amplitude propagating contractions (HAPC)

• HAPC, Defined by high amplitude (variable threshold among studies) and presence of propagation; amplitude is higher in the prepped than unprepped colon
•  from 50-100, can reach up  to 200 mm Hg, they last 20 to 30 seconds, approximately 6 times a day, with a range of 2 to 24 daily.
• Occur spontaneously, in response to pharmacological agents or colonic distention
• Increase upon awakening, are much more common during the day, and increase after meals
• A majority originate in the proximal colon; most do not propagate beyond the midcolon and fewer than 5% reach the rectum
• Can transfer colonic contents over long distances, can be associated with internal anal sphincter relaxation, and can precede defecation

Low amplitude (Haustral Contractions)

• Slow, segmenting movements that further mix chyme.
• About every 30 minutes.
• (5 to 40 mm Hg) 3 seconds
• Occur in haustra: small pouches caused by the teniae coli (longitudinal smooth muscle ribbons that run along outside the entire length of the colon). Because they are shorter than the large intestine, the large intestine tucks between the teniae and form sacs
• Primarily occur in ascending and transverse colons.
• Produced by contractions of smooth muscle layer

Both the low- and high-amplitude contractions are promoted by physical exercise as well as by emotional stress.

It is known that HAPC reduce  over time in elderly patients, and also are notoriously reduced in frequency in those wih chronic constipation. Opposingly they are increased in diarrhoea type IBS.  Low amplitude are worse understood, and despite increasing with age, they do not usually change the transit time.

Source

Source 2

Anatomy and Physiology of the Pelvic Digestive Organs
Ursula Szmulowicz MD, in
Posterior Pelvic Floor Abnormalities
, 2011

They recommend dual therapy in bleeding ulcers- Forrest Ia, Ib -(except selected cases of big excavated vascular ulcers that can be considered straight for cap-mounted clip).   In Forrest IIa (non bleeding vessel) they recommend thermal therapy, mechanical therapy, or injection of a sclerosing agent, each as monotherapy or in combination with epinephrine injection

DOI: 10.1055/a-1369-5274

Endoscopy 2021; 53(03): 300 - 332

Check guidelines 

Based on the KSGE (Korean society of GI endoscopy) 2021 guidelines : Repeat EUS-guided acquisition provides a conclusive diagnosis in the majority of cases with indeterminate cytopathological diagnoses and, therefore, should be strongly recommended ahead of other modalities, such as biopsy under computed tomography-guidance or diagnostic surgical exploration.

Also common sense will tell us repeating EUS is the less invasive option and has high chances of being successful in tissue adquisition. If persisting negative/inconclusive material, MDT re-discussion should take place and possibly surgical team should speak to the patient regarding risks and benefits of  laparoscopic examination or even proceeding to pancreatectomy -the incidence of benign disease among patients undergoing pancreatic resection for suspicion of malignancy is extremely variable, ranging  from roughly 4-13% , but in some series has been reported up to 35%.

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.

It has always been agreed that High grade dysplasia should merit ablation, however clasically LGD would be offered endoscopic surveillance until progressed to HGD. This approach has changed over the last years to the point that Both ESGE and AGA suggest eradication with ablation to prevent progression to HGD/cancer. BSG recommends repeating endoscopy in 6 months and if confirmed again, offering eradication vs 6 -monthly surveillance.  The AGA 2024 guidelines favous ablation over surveillance.

All societies agree that he biopsies should be reviewed by an expert pathologist (ESGE suggest 2 experts) before embarking into eradication.  Remember that the incidence of progression (to HGD or adenoca) is estimated around   9.1%/year  with reported incidence of adenocarcinoma of 0.54% per year. The overall yearly incidence of Eosphageal adenocarcinoma is 0.3% (0.19 in short segment )

Many chronic pancreatitis causing biliary stricture are asymptomatic or associate minimal changes in liver blood tests particularly ALP. In order to call cholestasis we have to see an increase in of usually >3 times ULN of alkaline phosphate (this is about >350-400 U/L)  As long as it does not cause significant cholestasis or cholangitis, there is no indication of biliary draining. IF they associate biliary stones , episodes of repeating infection or biliary pain (his pain seems more due to chronic pancreatitis) then it is justifed to drain the biliary tree.

Despite some increases in ALP, Conservative management with close monitoring is still adequate in this case, as well as recommend complete alcohol abstinence. If his bloods worsen or the bile dilation progresses during the next months, ERCP could be dicussed in a multidisciplinary meeting (risk of stenosis progression and cholestasis vs risk of ERCP adverse events)

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.

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