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Difficult case with patient older than 65 and comorbidities with moderately to severely active ulcerative colitis.

Vedolizumab should be indicated in his case as it performs better than anti TNFs in ulcerative colitis, confirming the results of the Varsity study.   ( Over a 5 year period, drug persistence is higher in patients treated with vedolizumab as compared to anti-TNF therapies and loss of response is less frequent again in the vedolizumab group). Age or previous TIA /AV block are not contraindications for anti-TNF (only Moderate-severe heart failure, which is not the case) So even though Adalimumab would be a valid option, it should be ideally used if Vedolizumab fails.

JAK inhibitor (Tofacitinib) should not be prescribed in people with a history of cardiovascular disease (eg. heart attack or stroke) at increased risk of cardiovascular problems (eg. current or past long-time smokers) at increased risk of cancer or aged 65 years and over unless no suitable alternative

Ozanibod could be an oral alternative , however second-degree Mobitz type II atrioventricular (AV) bloc and TIA within the previous 6 months contraindicates its use.

Off the quizz options, another good one would be Ustekinumab (interleukin 12&23 antagonist drug ) as not contraindicated here and equally valid to Vedolizumab.

ALD is the most common diagnose on referral for liver transplant in men but the second for women after MASLD.  MASLD is the most rapidly increasing indication for liver transplant worldwide.

Smoking and obesity are probably the most important modifiable risk factors for panc cancer (Smoking 74% higher risk, whereas every 5 points of increased BMI  increases risk in 10% )

Diabetes is an independent factor associated with higer risk of pancreatic cancer.

Alcohol is known to increase the risk although there is different evidence in regards of the association (It is known to be dose dependant, plus also alcohol can increase the risk of adquired chronic pancreatitis, which in itself increases the overal risk of cancer in about 4%)

The evidence of Hpylori is controversia, it was described in this review however further evidence fails to suppor this. It is thought to be  through secondary mucosal inflammation and immune evasion rather than Hpylori per se.

However it is known that there is an association with ABO blood groups in several large epidemiological studies. Non 0 blood types have a higher risk of developing pancreatic cancer compared to A/B/AB

In this article they summarised the current evidence.

Check the ESGE  guidelines

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

In grade C-D reflux oesophagitis we should initiate PPI longlife (or increase the dose if patient already taking) and repeat endoscopy in 6-8 weeks to confirm healing and rule out underlying Barrett's (British recommend 6 weeks, american recommend 8weeks)

Biopsies, however, are controversial. ASGE  recommends bx  of irregular or deep oesophageal ulcerations or nodularity. ESGE does not mention them, whereas BSG recommends taking samples of any oesophageal ulcer or severe grade D oesophagitis.

Is the opinion of the author that any suspicious ulcer (despite of the grade of esophagitis) should be biopsied in the moment, whereas in  typical grade D oesophagitis biopsies might have a low diagnostic yield, atypia is difficult to assess due acute inflammation, and samples will be best targeted after improvement of the inflammation.

Even though only 10% of hep B infections will become chronic and we have an effective vaccination that can virtually prevent infection, the reality is that hepatitis B incidence and prevalence is very high.  WHO estimates that 254 million people were living with chronic hepatitis B infection in 2022, with 1.2 million new infections each year. Maternal-to-newborn perinatal transmission of the virus can be high (70 to 90% in HBeAg-positive-indicating high viral replication-, or 10% to 30% if the mother is HBeAg-negative )

Hepatitis C , despite easy to become chronic (80% of infections) and no effective vaccine, is less common, (Estimated 50 million worldwide) partly because the vertical transmission is low and also because the new  direct-acting antiviral (DAA) tablets are highly effective at clearing the infection in more than 90% , reducing transmission.

Pancreatic cancer tends to have an ominous character, partly cause disease is a) advanced age, so even in resectable cases many patients are unfit for surgery and b) most cancers are borderline resecable, irresectable or metastatic. (80% of the pancreatic cancers are diagnosed in advanced stages)

Even in patient with surgical resection, the 5-year survival is quoted as 27%

A recent review showed that 5-year survival is 30% in Ia (T1 N0 M0- single 2cm or less panc mass)  dropping to 11.8% in Ib ( T2 N0 M0, this is single mass 2-4cm). When putting all the stages together, the 5 year survival is only 5%.

The best possible outcome would theorically be in an early cancer, 2cm or less (T1), found either incidentally (or if it gives symptoms very early), resectable (non conctacting vessels and not involving other anatomical structures, as well as surgically accesible)  and in a fit patient amenable for surgery.

The lower cutoff for FIB 4   >1.3.  Less than 1.3 rules out advanced fibrosis, and >1.3 needs further investigations.

In elderly patients (>65 yo) this threlsholds has low especificity (many false positive patients who do not really have advanced fibrosis) therefore the cutoff proposed in those is 2 (Fib 4 <2 rules out significant fibrosis)

>2.67 is the upper threshold for advanced fibrosis. Patients scoring this have high chance of advance fibrosis and should be referred to liver clinic

They recommend dual therapy in bleeding ulcers- Forrest Ia, Ib -(except selected cases of big excavated vascular ulcers that can be considered straight for cap-mounted clip).   In Forrest IIa (non bleeding vessel) they recommend thermal therapy, mechanical therapy, or injection of a sclerosing agent, each as monotherapy or in combination with epinephrine injection

DOI: 10.1055/a-1369-5274

Endoscopy 2021; 53(03): 300 - 332

Check guidelines