Digestive System
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Hb needs to be kept 7-8g/dl at least,  and a target of >9-10g/dl  if significant cardiovascular disease.  Andenaxet is recommended if life threatening or uncontrolled bleeding, like this case which is responding only partially to resucitation with fluids and continues to pass blood, so it could be prescribed.  If not available, 4-F PCC can be used instead.  Urgent sigmoidoscopy in general has no role and it would likely be useless without an adequate bowel preparation as we would expect to have very poor visibility due to stool and blood remains.

Unprepped colonoscopy or any form of sigmoidoscopy is NOT recommended in acute lower GI Bleeding unless very clear that the source is known to be anorectal or very distal colon (see American Guidelines) BSG guidelines also recommneds Colonoscopy as  inpatient with adequate bowel preparation, not urgently but  ideally after stabilising the patient.

If after resucitation and transfusion the patient remains unstable, then a joined plan with intensivist and surgical colleagues should be made (i.e, Interventional radiology, vs quick preparation with movicol, vs enema and salvage lower endoscopy, vs surgical approach)

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 )

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.

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)

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 .

Misty mesentery refers to a non-specific radiological finding characterized by increased attenuation within the mesenteric fat on computed tomography  imaging.  It mimics mistiness as localised fat stranding in the mesentery.  Many processes can lead to the appearance including infiltration by inflammatory cells, oedema, lymphatic accumulation, haemorrhage, tumour infiltration, and fibrosis.  Tipically reflects mesentery panniculitis  ( rare  benign condition characterized by chronic inflammation  of adipose tissue mainly of the small bowel mesentery) But can be the results of any inflammatory or neoplasic process. That is why it is needed to consider also vasculitis, lymphomas, inflammatory process or GI neoplasia.

Check the 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.

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.

If patient had HGD / Adenoca on a Barrett´s oesophagus, then the lesion is removed or ablated and afterwards the Barretts is fully ablated, we should perform regular gastroscopies for surveillance after Barretts eradication- yearly for 5 years and then at year 7 and 10-  Check the guidelines

If the reason for the ablation was only low grade dysplasia, then the surveillance can be 1,3 and 5 years and than surveillance can be stopped.