Digestive System
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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)

This is a healthy patient wihout history of mental health illness or impaired cognitive issues.  Age and sex may suggest EoE or peptic stricture as possible etiology.

As there is no suspicion of intentional multiple foreing body ingestions, x ray would not be necessary. (Xray can be very useful to guide us when radiopaque objects have been ingested, to see whereabouts in the GI tract they may be lying)  As there is no subcutaneous emphysema or abdominal pain or guarding to suggest any perforation , a CT scan would not be needed.

As per the timing, ASGE  recommends emergent endoscopy for complete esophageal obstruction. ESGE   recommends emergent (preferably within 2 hours, but at the latest within 6 hours) gastroduodenoscopy for foreign bodies inducing complete esophageal obstruction, and for sharp-pointed objects or batteries in the esophagus. The cough and sialorrhaea suggest a complete obstruction.

They recommend urgent (within 24 hours)  for other esophageal foreign bodies without complete obstruction 

AGA-For patients with suspected non bony food bolus impaction without complications (eg,no evidence of perforation or respiratory distress),endoscopy may be performed without obtaining radiographs.

Glucagon 1mg iv can be given to induce esophageal relaxation and try and avoid urgent endoscopy, however it should not delay endoscopy and definetely we do not need 6-10 hours to see if it works.

According to the US Hpylori Guidelines, BQT  is the first option for both standard and penicillin allergic patients.  This is a PPI (standard dose)  b.i.d.   Bismuth subcitrate (120–300 mg) or subsalicylate (300 mg) q.i.d. Tetracycline (500 mg)e q.i.d. and Metronidazole (500 mg) t.i.d. or q.i.d

In treatment-experienced patients with persistent H. pylori infection  , they recommend O+L+  either Amoxicillin or Metronidazole

High Amplitude propagating contractions (HAPC)

• HAPC, Defined by high amplitude (variable threshold among studies) and presence of propagation; amplitude is higher in the prepped than unprepped colon
•  from 50-100, can reach up  to 200 mm Hg, they last 20 to 30 seconds, approximately 6 times a day, with a range of 2 to 24 daily.
• Occur spontaneously, in response to pharmacological agents or colonic distention
• Increase upon awakening, are much more common during the day, and increase after meals
• A majority originate in the proximal colon; most do not propagate beyond the midcolon and fewer than 5% reach the rectum
• Can transfer colonic contents over long distances, can be associated with internal anal sphincter relaxation, and can precede defecation

Low amplitude (Haustral Contractions)

• Slow, segmenting movements that further mix chyme.
• About every 30 minutes.
• (5 to 40 mm Hg) 3 seconds
• Occur in haustra: small pouches caused by the teniae coli (longitudinal smooth muscle ribbons that run along outside the entire length of the colon). Because they are shorter than the large intestine, the large intestine tucks between the teniae and form sacs
• Primarily occur in ascending and transverse colons.
• Produced by contractions of smooth muscle layer

Both the low- and high-amplitude contractions are promoted by physical exercise as well as by emotional stress.

It is known that HAPC reduce  over time in elderly patients, and also are notoriously reduced in frequency in those wih chronic constipation. Opposingly they are increased in diarrhoea type IBS.  Low amplitude are worse understood, and despite increasing with age, they do not usually change the transit time.

Source

Source 2

Anatomy and Physiology of the Pelvic Digestive Organs
Ursula Szmulowicz MD, in
Posterior Pelvic Floor Abnormalities
, 2011

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.

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.

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

 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. 

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