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 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. 

<2cm visible lesion without deep invasion: Offer EMR first and then ablation for Barretts eradication if lesion has been cured

Low grade dysplasia is a difficult diagnosis and should be always  confirmed by at second endoscopy and ideally by two pathologist (sometime LGD is actually downgraded to non displasia , or sometimes when reviewed can be upgraded to HGD)

HGD, on the contrary, does not necessarily need repeating endoscopy but always needs to be confirmed by a expert GI pathologist.  If any doubt, it is always reasonable to repeat endoscopy.

Patients with early-stage esophageal adenocarcinoma need treatment depending on many factors ( EMR, ESD, surgery or Radio-chemotherapy , discuss in the MDT)

If Check the guidelines

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.

This image  impedance pH study showing a proximal then distal increase in impedance with air clearing from the esophagus orally. Arrows indicate direction of air flow down and then up. This is supragastric Belching. (B) High-resolution manometry showing repetitive supragastic belching with upper esophageal sphincter opening then air propagating through the esophagus, contraction of diaphragm with aborad (away from the mouth) movement of lower esophageal sphincter.   The treatment for this is behavioural therapy and adding central neuromodulators in cases of linked psychological disorders

Calcium channel inhibitors and other antispasmodic therapy has been used for spastic disorders such as diffuse oesophageal spasm and nutcracker (hypercontractile) oesophagus.

POEM and Hellers myotomy are well known treatments for Achalasia.

EGJOO(Esophagogastric junction outflow obstruction )  can respond well to balloon dilation or botox (63-70%, although POEM is not commonly used it has been described very effective)

-MRCP does not usually require contrast.  The technique enhances any fluid  (the normal fluid which is present in the biliary and pancreatic ducts) as an intrinsic contrast medium by using heavily T2-weighted sequences. T2 potentiate water , therefore this structures will appear hyperintense against the surrounding non-fluid-containing tissues. We can see structures like stomach or duodenum being also bright due to the fluid content.

-Gadolinum is the typical MRI contrast causing brigher T1-weighted images , helping detection of focal lesions (e.g. tumor, abscess, metastasis) venography or calculating MR perfusion parameters.

-Omnipaque® is a low-osmolar iodinated contrast media is indicated for intravenous, intra-arterial or  oral use. Iodine-based contrast are often used in CT scan.

-SonoVue ® is a constrast based on sulphur hexafluoride microbubbles , which used is mainly on contrast-enhanced ultrasound imaging. Bubbles are extremely small—smaller than a red blood cell—and have a high degree of "echogenicity", reflecting ultrasound waves. Structures with higher echogenicity will be brighter on ultrasound.  The microbubbles dissolve, usually within 10 to 15 minutes, and the gas within them is cleared from the body through exhalation.

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.

Despite they all are good options that could be considered. We need to see:

• Size (abut 12-13mm in size)
• Mucosal pattern (looks like sessile serrated lession or SSP-  with clouded surface and indistictive borders - see  WASP classification - : The lesion has NO suspicious areas of submucosal invasion
• Shape- 0-IIa of Paris classification (despite the name sessile serrated lesion, this is the nomenclature for that type of serrated lesions, although the majority of them are in fact flat, not sessile)
• Position- Right vs left colon (risk of perforation,  lesion is easy accesible or not in case of delayed bleed)

With all in mind, the most difficult option would be cold snare as >10mm and having broad base, it would be difficult to fully grasp the tissue, close and cut through with cold snare. ESGE guidelines recommend cold snare in small (<10mm ) and in >10mm they suggest hot polypectomy or piecemeal cold snare resection.

So the options would be 1) Lifting and use the cold snare to resect either en bloc if feasible, or most likely piecemeal 2) Do the same but using diathermy with a hot snare or 3) do not lift and use underwater EMR, which probably would allow to grab the lesion en bloc, completely in one go with a 15mm snare. Despite ESGE recommends underwater EMR in selected cases >20mm, realistically if we want en bloc resection, it is either hot snare or underwater EMR.

Note that cold EMR is also a good option for SSL, has an excellent safety profile with less adverse events compared to hot EMR, and less residual rate (1% in cold vs 4.2% in hot) in serrated lesions, however requires some level of practice and getting used to a slighly more bleeding field.

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 )

both Left main bronchus and left atrium are compressions   visualized anterior to the oesophagus. See image

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.