Digestive System
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Mucosal xantoma - benign lesion composed of foamy macrophages within the lamina propria. fibrovascular. They presents as discrete single to multiple yellowish-white patches, most commonly in the antrum or pyloric region of the stomach . Endoscopically it sometimes can resemble candidiasis, polyp, lymphangiectasia, Russell body gastritis, and Pseudoxanthoma elastic or gastric malignancy.

Lymphangiectasia would have showed prominent dilated lymphatics in the lamina propria region of the villous structure, often with extension into submucosa . These are more commonly seen in duodenum or terminal ileum

both Left main bronchus and left atrium are compressions   visualized anterior to the oesophagus. See image

Even in 2019, 38.9% of the HCC- liver transplant  had Hepatitis C etiology (vs 24% NASH and 16.3% ALD) . This is completely different in patients without HCC (the majority of liver transplant candidates, which only 7% had hepatitis C , 28% NASH and the leading cause with 37.7 %  was ALD.  https://doi.org/10.1016/j.cgh.2020.05.0

Check AGA guidelines and ESGE, BSG  and Asia Pacific and  international consensus group

This is a Forrest III (clean based) duodenal ulcer in a healthy and stable patient. (Rebleeding risk <5% )

Patient could be discharged if stable and toleranting oral diet (AGA recommends in low risk endoscopic findings considerning discharge in stable cases with stable vitals and Hb and  no other reason for hospitalization).  PPI should be initiated orally, but given it is a low risk finding (F-III) only standard dose would be enough.  If it was a high risk such as Forrest I-IIa, then 72h of  IV PPI (Or oral high dose PPI in selected cases) is recommended as well as keeping the patient under observation.

In high risk (Forrest I-IIb) American and International guidelines advise commencing a two week course of twice daily high dose PPI,  based on a trial that showed 40 mg esomeprazole BD significantly reduced rebleeding compared  40 mg esomeprazole once daily  ( 10.8% v 28.7%,)

So the endoscopist gave good advice in general. So why is it false then? Because:

•  ESGE recommends in bleeding secondary to peptic ulceration,H pylori test at index endoscopy.   In the event of a negative result,  like this case, advise  retesting within four weeks and eradication of H pylori if positive (given the low-ish sensitivity of clotest or histology in acute bleeding, about 0.7)
• Do not forget iron replacement, either orally or if patient does not tolerate, then iron infusion to correct the anaemia.
• Smoke cessation is advised too!  Especially if Hpylori is really negative, then smoking could be a main trigger factor.

ESGE recommends offering treatment to all the patients with CBD stones (symptomatic or not) who are fit enough to undergo procedure.
This is true that we should explain always the option of intervention, and we should at least talk about risks of complication from leaving untreated biliary stones (Roughly about 25%  - biliary colic, pancreatitis, cholangitis- vs 12% if we clear the bile stones) this is  based on this  Gallrisk sweddish cohort   where they followed 3969 patients with untreated CBD stones, during follow-up ranging from 0 to 4 years. 

In summary: Explain why there is an indication to treat, which risks ERCP associates, what the alternatives may be  (ie Cholecystectomy plus surgical bile duct exploration in the same setting when approppriate) and their own risks.  And last but not least, explain the alternative of not treating and only monitoring, and the risks of this approach as well.

The protective effect on colon cancer has been suggested in <70 yo. A meta-analysis of five RCTs showed a 24% decrease in the risk for developing CRC (HR 0.76, CI 95% 0.60–0.96). Daily low-dose aspirin also showed a 40% reduction for the risk of CRC mortality (HR 0.60, CI 95% 0.42–0.86). However, the ASPREE trial studied low-dose aspirin among >70yo without cardiovascular disease. Secondary analyses demonstrated that aspirin use was associated with a higher risk for cancer-related mortality (HR 1.31, CI 95% 1.10–1.56) and colorectal cancer-related mortality.  This significance is uncertain and we should be cautious. Check preliminary results here. DOI: 10.1056/NEJMoa1803955

The protective effect preventing HGD and adenocarcinoma in Barrett’s was seen in several studies such as Aspect trial (DOI:https://doi.org/10.1016/S0140-6736(18)31388-)

This is likely a lower GI bleed, however, the fact that is so abrupt and has caused   haemorrhagic shock makes us wonder if he is not having a severe upper GI bleed – frail patient taking clopidogrel - Severe upper GI bleed sometimes can be so brisk and profuse that blood travels the intestine fast wihtout being digested, so patient passes per rectum red bright blood instead of black melaena. (Blood is laxative too) As many as 10–15% of patients suspected initially to have lower GI bleed are ultimately found to have an UGI source.

Once OGD is done and clear, the next step should be depending on the clinical and hemodinamic status. Either prepare the patient for colonoscopy/ video capsule (If clinically stable)  or repeat CT angio (If clinically worse)-->If bleeding point is located and there is no access to IR (interventional radiology) the surgeons may want to proceed with exploration and colectomy but this is the last resource as obviously this is an elderly patient with cardiovascular factors (Clopidogrel) whose surgery would be high risk of mortality and morbidity.

Difficult question, but summarizes the (sometimes) difficult scores.
Montreal classification is easy - A for Age  L for location and B for phenotype.  There is ileal and colonic involvement so it is L3 (Ileocolonic) Small p is added when it is perianal disease (abscesses, ulcers or fistulae , but not skin tags or fissures)

The HBI takes into account the general well being , Abdominal pain   Number of liquid stools per day, Abdominal mass and extrainestinal Complications ( arthralgia, uveitis, erythema nodosum, aphthous ulcers, pyoderma gangrenosum ,anal fissure , new fistula or abscess)

<5 Remission   5-7 Mild disease  8-16 Moderate disease  >16 Severe disease

Her score is 9 (Moderate) But this could be guessed based on her level of pain, stools and absence of systemic inflamamtory reponse.

Check the HBI score

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