Digestive System
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Underwater EMR offers the advantage of keeping the polyp surface small in flat polyps (opposite to when we inject lifting solution where the polyp keeps spreading and this makes grabbing the polyp en bloc more difficult) this explains why is a good method to remove en bloc lesions bigger than 10mm (Ideally even bigger than 20mm, although even with U-EMR the bigger the polyp, the more difficult to obtain full resected piece en bloc. This results are published in endoscopy in this meta analysis

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

 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. 

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.

Difficult question, but summarizes the (sometimes) difficult scores.
Montreal classification is easy - A for Age  L for location and B for phenotype.  There is ileal and colonic involvement so it is L3 (Ileocolonic) Small p is added when it is perianal disease (abscesses, ulcers or fistulae , but not skin tags or fissures)

The HBI takes into account the general well being , Abdominal pain   Number of liquid stools per day, Abdominal mass and extrainestinal Complications ( arthralgia, uveitis, erythema nodosum, aphthous ulcers, pyoderma gangrenosum ,anal fissure , new fistula or abscess)

<5 Remission   5-7 Mild disease  8-16 Moderate disease  >16 Severe disease

Her score is 9 (Moderate) But this could be guessed based on her level of pain, stools and absence of systemic inflamamtory reponse.

Check the HBI score

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.

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.

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.

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. 

Kudo II (asteroid or stellate pits) which are star or cross-shaped.  This is very typical of hyperplastic polyps (non neoplastic)  or serrated lesions.