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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)

Check the guidelines

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.

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

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.

They recommend dual therapy in bleeding ulcers- Forrest Ia, Ib -(except selected cases of big excavated vascular ulcers that can be considered straight for cap-mounted clip).   In Forrest IIa (non bleeding vessel) they recommend thermal therapy, mechanical therapy, or injection of a sclerosing agent, each as monotherapy or in combination with epinephrine injection

DOI: 10.1055/a-1369-5274

Endoscopy 2021; 53(03): 300 - 332

Check guidelines 

-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.

-Sporadic Pancreatitis: Episode of acute pancreatitis from any ethiology (Ethanol, Obstructive, drug-related..)  There is no strong identified genetic factors. Incidence is 5-12 per 100000

-Idiopathic Pancreatitis: When Acute recurrent pancreatitis (ARP)  on more than one occasion and no cause identified. SPINK1 and CFTR mutations predispose the pancreas to develop pancreatitis from other genetic or environmental factors. It has been  shown that 16%-23% of patients with apparent idiopathic pancreatitis have SPINK1 mutations, compared with only about 2% of healthy controls. Heterozygotes for CFTR mutations are generally healthy but still have a 3 to 4-fold risk over the general population for pancreatitis.

-Autoimmune pancreatitis: THis is an autoimmune condition with type 1 (lymphoplamocytic infiltrate, IgG 4 associated) and 2 segmental or focal narrowing)  As many autoimune conditions, some multi-gene mutations have been described but no specific strong association genetics proved.

-Hereditary pancreatitis :Rare entity that tends to manifest in early ages. HP is a rare cause of acute, recurrent acute, and chronic pancreatitis. Up to 80% of patients with HP have been found to have a mutation in the PRSS1 gene.  A diagnosis  requires (a) demonstration of a clear pattern of autosomal dominant inheritance in a family and/or (b) finding a known disease-causing variant in the PRSS1 gene. This presentation of disease in a family should be consistent with autosomal dominant inheritance – i.e. two or more individuals with recurrent acute or chronic pancreatitis across two or more generations of a family.   Do not confuse with familial pancreatitis, in which  families with a higher incidence of pancreatitis than expected by chance (2 or more 1st or 2nd degree relative with idiophatic pancreatitis)  but no autosomal dominant pattern or PRSS1 is found

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 )