Digestive System
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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)

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.

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.

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.

Paquet (Or Modified Paquet that contains 3 categories insted of 4) is the classification used for esophageal varices. Zargar is used for caustic injury

EREFS (EoE reference endoscopic score) is used to grade Eosinophilic esophagitis.

Kodsi is used for staging Candidiasis:

Grade I, a few raised white plaques up to 2 mm in size without edema or ulceration.

Grade II, multiple raised white plaques greater than 2 mm in size without ulceration.

Grade III, confluent, linear, and nodular elevated plaques.

Grade IV, finding of grade III with increased friability of the mucous membranes and occasional narrowing of the lumen

The proportion of AST to ALT in hepatocytes is about 2.5:1, but because AST is removed from serum by the liver sinusoidal cells twice as quickly (serum half-life t1/2 = 18 hr) compared to ALT (t1/2 = 36 hr), so the resulting serum levels of AST and ALT are about equal in healthy individuals, resulting in a normal AST/ALT ratio around 1. See here.

B6 is more essencial for ALT synthesis than AST, that is why in chronic alcohol (low B6) we will see a reduction of ALT in proportion to AST, increasing the AST/ALT ratio>2

Check the ESGE  guidelines

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

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

This is likely a lower GI bleed, however, the fact that is so abrupt and has caused   haemorrhagic shock makes us wonder if he is not having a severe upper GI bleed – frail patient taking clopidogrel - Severe upper GI bleed sometimes can be so brisk and profuse that blood travels the intestine fast wihtout being digested, so patient passes per rectum red bright blood instead of black melaena. (Blood is laxative too) As many as 10–15% of patients suspected initially to have lower GI bleed are ultimately found to have an UGI source.

Once OGD is done and clear, the next step should be depending on the clinical and hemodinamic status. Either prepare the patient for colonoscopy/ video capsule (If clinically stable)  or repeat CT angio (If clinically worse)-->If bleeding point is located and there is no access to IR (interventional radiology) the surgeons may want to proceed with exploration and colectomy but this is the last resource as obviously this is an elderly patient with cardiovascular factors (Clopidogrel) whose surgery would be high risk of mortality and morbidity.

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.