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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)

Scores of 8-14 represent Hazardous or Harmful range. In those cases, the recommendation is to explain to the patient that they may be drinking too much on occasions, and the likely negative impact the alcohol can cause as it is carcinogenic, can help developing cardiovascular disease, can cause dependence and can put you or others at risk.

Any  score of 15 or above associates high risk (drinking could cause harm and it is important a clear determination to cut down or stop alcohol). Any score of 20 or above indicates likely dependence and needs referral to specialist and supervised detoxification

Even in 2019, 38.9% of the HCC- liver transplant  had Hepatitis C etiology (vs 24% NASH and 16.3% ALD) . This is completely different in patients without HCC (the majority of liver transplant candidates, which only 7% had hepatitis C , 28% NASH and the leading cause with 37.7 %  was ALD.  https://doi.org/10.1016/j.cgh.2020.05.0

Check AGA guidelines and ESGE, BSG  and Asia Pacific and  international consensus group

This is a Forrest III (clean based) duodenal ulcer in a healthy and stable patient. (Rebleeding risk <5% )

Patient could be discharged if stable and toleranting oral diet (AGA recommends in low risk endoscopic findings considerning discharge in stable cases with stable vitals and Hb and  no other reason for hospitalization).  PPI should be initiated orally, but given it is a low risk finding (F-III) only standard dose would be enough.  If it was a high risk such as Forrest I-IIa, then 72h of  IV PPI (Or oral high dose PPI in selected cases) is recommended as well as keeping the patient under observation.

In high risk (Forrest I-IIb) American and International guidelines advise commencing a two week course of twice daily high dose PPI,  based on a trial that showed 40 mg esomeprazole BD significantly reduced rebleeding compared  40 mg esomeprazole once daily  ( 10.8% v 28.7%,)

So the endoscopist gave good advice in general. So why is it false then? Because:

•  ESGE recommends in bleeding secondary to peptic ulceration,H pylori test at index endoscopy.   In the event of a negative result,  like this case, advise  retesting within four weeks and eradication of H pylori if positive (given the low-ish sensitivity of clotest or histology in acute bleeding, about 0.7)
• Do not forget iron replacement, either orally or if patient does not tolerate, then iron infusion to correct the anaemia.
• Smoke cessation is advised too!  Especially if Hpylori is really negative, then smoking could be a main trigger factor.

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

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.

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 .

According to the  2020 BSG  post-polypectomy surveillance guidelines   we recommend no surveillance if life expectancy is less than 10 y or patient older than 75 yo.  However this can be flexible depending on the patient situation. For example, if histology show incomplete resection margins or colonoscopy was suboptimally prepared then it could be reasonable to repeat the test in 1 year.

If this same case was in a fit and younger patient (e.g  65 yo patient ) then given that we removed 5  adenomas (premalignant) - this would be the cutoff to have another colonoscopy in 3 years

In fact, the majority of the guidelines suggest 3 year follow up if 5 or more small(<10mm)  adenomas are removed.  2020 AGA recommend 3 years followup if 5-10 adenomas, 5 years if 3-4 adenomas and up to 7-10 years if only 1-2 adenomas (or SSL).

For example, if a 65 yo patient had only 4 small adenomas with en bloc resection and good bowel cleaning,  no further surveillance and return to bowel screening according to the British guidelines but would need 5 year colonoscopy according to the AGA guidelines. 

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.