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Based on this study by O Sullivan et al where 2451 LNPCPs (Large non pedunculated colonic polyps)  were analyzed after resection and found and average of 10% had submucosal invasive cancer (SMIC).  Previously, overall described SMIC had been reported around 7.6%–8.5% of endoscopically resected LNPCPs.   The higher risk were the depressed polyps ( 60%) followed by non granular (20%) or granular in rectosigmoid (20%)

Difficult question.  This response is based on Waterfall trial that compared moderate resucitation (1.5ml per Kg) vs aggressive (3ml per Kg) and showed no difference in worsening pancreatitis  but a tendency of fluid overload in the aggresive group (20.5% vs. 6.3%).

Ringer lactate or Hartmanns have been proved to have benefit ovver saline due to an anti-inflammatory effect which was attributed to the properties of lactate and to have a higher pH that can help counteract acidosis.

This indeed is a subject of debate. American guidelines still mentions that most patients with acute pancreatitis & hypovolaemia could have a deficit of 3-4 L to replace in 24h (Like it is our patient with vomiting and  mild hypotension and tachycardia) . If patient has no evidence of hypovolemia, an initial resuscitation rate of no more than 1.5 mL/kg of body weight per hour should be administered. However, in patients with hypovolemia, clinicians should administer a bolus of 10 mL/kg which in this case is 750ml per hour (1500ml in 2 hours)

So, the answer is  Goal-directed rehydration with Ringer’s lactate solution (or Hartmann’s).  In this case of Hypovolemia, our first step should be resucitate until volume is stable (normal BP, HR and clinical status) looking closely to avoid overfluid, and once patient is stable, keep her on 1.5ml per Kg per 24 h with clinical re-checking every few hours to ensure she is not hyper or overhydrated.

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 

Andexanet is factor Xa inhibitor which is approved to reverse Rivaroxaban and Apixaban. However, it has not being proved to be efficacious against Edoxaban. Dabigatran is  a direct thrombin (factor IIa) inhibitor, not a Xa inhibitor.

Whenever an HCC (Hepatocelullar carcinoma) is resected in an early starge, 5-year recurrence occurs in up to 60-70% of the cases,  either as a result of intrahepatic metastases (true recurrent disease) or de novo cancer in the remaining cirrhotic liver .  However, similar rates of reccurence occurs if we use ablation instead of surgical resection (  between 60% and 85% recurrence with ablation) via the same mechanisms (either incomplete tumor erradication, or new tumor formation)

5-year recurrence after liver transplant is way lower (8-20%) and of course varies depending on the tumoral burden --> potential microvascular invasion at the time of the transplant.

See BSG guidelines

In the guidelines they mention the increasing resistance of  Hpylori strains in the US to Clarithromycin (20-30%)  and Levofloxacin (approaching 40%) , therfore supporting antibiotics with much lower resistance rates (such as amoxicillin, tetracycline, and rifabutin that are all 5%)

That is why this guidelines say Clarithromycin- and levofloxacin-containing treatment regimens should be avoided in the absence of demonstrated macrolide and quinolone susceptibility, respectively.

Clarithromycin- and levofloxacincontaining treatment regimens remain an important option for selected patients, especially treatment-experienced patients with confirmed persistent H. pylori infection with strains that are known to be susceptible to these antibiotics

Vonoprazan is potassium-competitive acid blocker (PCAB) that inhibits the H⁺, K⁺-ATPase enzyme system in a potassium-competitive manner.    This is the same target as PPI but this class  of drugs  are acid-stable and thus do not require enteric coating or optimal dosing administration 30 minutes prior to meals , are more potent acid suppression, rapid onset of action, and long-lasting half-life.   Penicillin dual therapy was superior to lansoprazole-clarithromycin triple therapy among patients with clarithromycin-resistant H. pylori strains (70% vs 32%, P , 0.0001).

When treating with Vonoprazan + Amoxicillin, exceptionally we can add Clarithromycin as first line even in naive patients.

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

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%.

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.

 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.