Digestive System
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Kudo II (asteroid or stellate pits) which are star or cross-shaped.  This is very typical of hyperplastic polyps (non neoplastic)  or serrated lesions.

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.

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.

GERD is a well known risk factor for adenocarcinoma of esophagus, but not for squamous cell carcinoma.

Risk factors for SCC are low socioeconomic status, consumption of tobacco, alcohol, hot beverages, and nitrosamines (e.g cured or smoked) . Additionally, micronutrient deficiencies have also been linked to the development of esophageal squamous cell cancer. These include vitamin C, vitamin E, and folate

Plummer-Vinson syndrome (PVS) is a rare condition characterized by the classic triad of dysphagia, iron-deficiency anemia, and esophageal webbing.  Approximately 10% of patient can develop SCC.

Remember Achalasia as other importart pathology in which there is an increased risk of esophageal cancer, particularly SCC

The caliber of the duodenoscope is 11.3mm  (shaft) with a 13.5mm distal end outer diameter.

This can help us  estimating the size of the biliary duct and the stones. We should use a balloon no bigger than  the size of the biliary duct at level of the trapped  stone, and ideally no  bigger than the duct diameter proximal to the ampullary segment.

In this case  biliary duct is approx the same size as the shaft , perhaps slightly less(10-11mm) therefore it is reasonable to start with the size balloon of 10mm (for 30-60 secs, although this is not well stablished) and keep inflating in ranges of 1mm per minute, until the waist of the balloon (see arrow)  disappears completely on fluoroscopic examination (see added picture  of a real balloon at the right to see how it should look at the end of the procedure) . Once balloon waist is gone, sphincter is considered to be adequately dilated .

Check the guidelines

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 )

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