Digestive System
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If someone has IgA deficiency and celiac disease, the IgA deficiency can cause a false negative on a celiac disease antibody test.  (As IgA anti transglutaminase antibodies may be falsely normal) In this case it is important to perform IgG-specific antibody tests for endomysium, gliadin, and tissue transglutaminase

-Sporadic Pancreatitis: Episode of acute pancreatitis from any ethiology (Ethanol, Obstructive, drug-related..)  There is no strong identified genetic factors. Incidence is 5-12 per 100000

-Idiopathic Pancreatitis: When Acute recurrent pancreatitis (ARP)  on more than one occasion and no cause identified. SPINK1 and CFTR mutations predispose the pancreas to develop pancreatitis from other genetic or environmental factors. It has been  shown that 16%-23% of patients with apparent idiopathic pancreatitis have SPINK1 mutations, compared with only about 2% of healthy controls. Heterozygotes for CFTR mutations are generally healthy but still have a 3 to 4-fold risk over the general population for pancreatitis.

-Autoimmune pancreatitis: THis is an autoimmune condition with type 1 (lymphoplamocytic infiltrate, IgG 4 associated) and 2 segmental or focal narrowing)  As many autoimune conditions, some multi-gene mutations have been described but no specific strong association genetics proved.

-Hereditary pancreatitis :Rare entity that tends to manifest in early ages. HP is a rare cause of acute, recurrent acute, and chronic pancreatitis. Up to 80% of patients with HP have been found to have a mutation in the PRSS1 gene.  A diagnosis  requires (a) demonstration of a clear pattern of autosomal dominant inheritance in a family and/or (b) finding a known disease-causing variant in the PRSS1 gene. This presentation of disease in a family should be consistent with autosomal dominant inheritance – i.e. two or more individuals with recurrent acute or chronic pancreatitis across two or more generations of a family.   Do not confuse with familial pancreatitis, in which  families with a higher incidence of pancreatitis than expected by chance (2 or more 1st or 2nd degree relative with idiophatic pancreatitis)  but no autosomal dominant pattern or PRSS1 is found

This is a case of Clostridioides (Clostridium) difficile colitis with typical pseudomembranes on the colonic mucosa.  Elderly and nursing home patients are risk factors. We should take biopsies and ask for faecal sample (GDH and /or culture for toxigenic C.diff) because pseudomembrane rarely can have other causes (Staphylococcus aureus, CMV, radiation, ischemic, chemotherapy)

Patient does not meet the definition of Severe (>15000 leucocytes or deranged Creatinin) or fulminant (hypotension, septic shock, megacolon)

Most guidelines no longer recommend Metronidazole for C.diff as first line unless no other alternative available.  Despite ACG recommends either Vancomycin or Fidaxomicin as first line, (Fidaxomicin is more expensive) the European guidelines recommend Fidaxomicin over Vancomycin (Vancomycin is a perfect acceptable good choice , however despite both curing the infection in about the same rates (76.2% vs 70.5%),  lower recurrence rates with fidaxomicin are described (8.3% vs 32.6%) which could justify its higher cost.

Alcohol intake is a strong and well-established risk factor for esophageal squamous cell carcinoma (SCC), but the association with esophageal adenocarcinoma  or adjacent tumors of the esophagogastric junction (EGJA), is not clear.

There is evidence of dietary factors being protective against both adenocarcinoma and squamous cell.  This seems to have a protective effect in both, and probably reduces obesity which is a known  risk factor for adenocarcinoma

Chronic GERD can lead to Barrett´s oesophagus which is a factor for adenocarcinoma, but not for SCC.

High compsumption of hot beverages have been linked to SCC, not adenoca.

Interestingly, Mate te (very common in Argentina) seems to have a increased risk for SCC.

For standard colonoscopies,  ASGE  and ESGE  agree that it should be an overall > 25% (for men ≥30%, for women ≥20%)

The  BSG minimum standard is slightly lower to > 15% (aspirational 20%)

Based on this metanalysis of real life Colonoscopy findings in >3.5 million patients, this percentage are pooled to real life colonoscopies

This rate is for standard colonoscopies, does not take into account FIT/FOBT  positive patients (Positive faecal blood patients in bowel screening) in which the aspirational should be at least 40-50% of adenoma or cancer detection. (See report from bowel screening in the UK)

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)

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%

See AASLD  and BSG guidelines

Difficult case. In this patient, option A is false- This is a very early stage ≤2cm (BCLC 0)

HCC requieres always an individualised treatment. Knowing that patient is fit and wihtout portal hypertension, he could be amenable for resection. However ablation has been proved to be as effective as surgery with less adverse events, so it would probably be indicated in such as small lesion as first line. The bigger the lesions, the less efficacious ablation is as can leave tumoral tissue untreated. In this case, transplant  certainly could be considered but would not be an ideal first line option as still is <2cm and Child A does not warrant the inclusion in list.

If this HCC was between 2-5cm, treatment could be trasplant (however Child A has per se no indication for transplant, being in the list with modify MELD can be tricky and has risk of tumour progression) surgical resection or ablation, based on radiological features , patient background and preferences

If multifocal HCC,  transplant is ususally the recommended 1st line therapy, whereas TACE/SIRT would be an option in non transplant candidates, unless the lesions are in the same lobe and accesible, in which case occasionally surgical resection can be offered.

If mass>7cm, this surpasses even the Expanded Milan criteria, and we know the risks of HCC invasion, recurrence and mortality after transplant are too high, therefore TACE/ SIRT/ Stereotactic resection or surgical resection are options based on patients features.

Check the ESGE  guidelines

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

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.