Digestive System
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It is not 2 times higher, it is actually > 10 times higher!!

This is the reason ADR is probably  the most important surrogate marker of a good  quality colonoscopy, (others are bowel preparation, caecal intubation and withdrawal time) and we need to maintain ADR  at least >20%

We need to differenciate between non dysplastic (the majority of Barrett's do not have any dysplasia, just metaplasia) versus dysplastic changes (proliferative changes that is characterized by a loss in the uniformity of individual cells in a tissue and loss in the architectural orientation )

The overall yearly incidence of  eosphageal adenocarcinoma in non dysplasitc  is 0.3% (. This is approximate and based on a metanalysis, although we know that factors such a age, smoking or obesity increase the overall risk of adenocarcinoma in Barrett's patients, and equally, the risk lowers when short segment (<3cm) - down to 0.19 % per year)

9.1% is the overall incidence of progression (to either HGD or adenoca) in those who already present low grade dysplasia, up to   9.1% per patient/year  with pooled annual incidence of adenocarcinoma of 0.54% per year

See AASLD  and BSG guidelines

Difficult case. In this patient, option A is false- This is a very early stage ≤2cm (BCLC 0)

HCC requieres always an individualised treatment. Knowing that patient is fit and wihtout portal hypertension, he could be amenable for resection. However ablation has been proved to be as effective as surgery with less adverse events, so it would probably be indicated in such as small lesion as first line. The bigger the lesions, the less efficacious ablation is as can leave tumoral tissue untreated. In this case, transplant  certainly could be considered but would not be an ideal first line option as still is <2cm and Child A does not warrant the inclusion in list.

If this HCC was between 2-5cm, treatment could be trasplant (however Child A has per se no indication for transplant, being in the list with modify MELD can be tricky and has risk of tumour progression) surgical resection or ablation, based on radiological features , patient background and preferences

If multifocal HCC,  transplant is ususally the recommended 1st line therapy, whereas TACE/SIRT would be an option in non transplant candidates, unless the lesions are in the same lobe and accesible, in which case occasionally surgical resection can be offered.

If mass>7cm, this surpasses even the Expanded Milan criteria, and we know the risks of HCC invasion, recurrence and mortality after transplant are too high, therefore TACE/ SIRT/ Stereotactic resection or surgical resection are options based on patients features.

Many chronic pancreatitis causing biliary stricture are asymptomatic or associate minimal changes in liver blood tests particularly ALP. In order to call cholestasis we have to see an increase in of usually >3 times ULN of alkaline phosphate (this is about >350-400 U/L)  As long as it does not cause significant cholestasis or cholangitis, there is no indication of biliary draining. IF they associate biliary stones , episodes of repeating infection or biliary pain (his pain seems more due to chronic pancreatitis) then it is justifed to drain the biliary tree.

Despite some increases in ALP, Conservative management with close monitoring is still adequate in this case, as well as recommend complete alcohol abstinence. If his bloods worsen or the bile dilation progresses during the next months, ERCP could be dicussed in a multidisciplinary meeting (risk of stenosis progression and cholestasis vs risk of ERCP adverse events)

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.

Although Adenocarcinoma is the most rapidly growing esophageal cancer, still the most common type of esophageal cancer worldwide is esophageal squamous cell carcinoma (SCC). The highest-risk area, called the “esophageal cancer belt,” includes portions of northern Iran, southern Russia, central Asian countries, and northern China, where SCC dominates all cases by 90%. These are very dense populated areas.

However, in Western countries like the United States, esophageal adenocarcinoma has become more common in recent decades, particularly in the lower part of the esophagus and the gastroesophageal junction (GEJ). This increase in adenocarcinoma is often linked to conditions like Barrett esophagus and gastroesophageal reflux disease (GERD).

In summary:

• Worldwide: Esophageal squamous cell carcinoma (SCC) is the most common.
• Western countries (US and Europe): Esophageal adenocarcinoma has surpassed SCC in incidence.

The majority of pancreatic cancers are due to spontaneous mutations in a complex combination of usually several mutations ((KRAS) mutations are common in 90% of pancreatic cancers, but in combination with different other mutations, DNA damage and usually other risk factors.

There is however a very important percentage (5%-10%) of new PC which associate familial pancreatic cancer (Defined by two first-degree-relatives with pancreatic cancer), There are indeed genes involved such as BRCA2 gene  mutations  ( 3.5-fold increased risk of pancreatic cancer ).  Other inherited mutations in the STK11 gene cause the Peutz-Jeghers syndrome, and individuals with Peutz-Jeghers have a 130-fold increased risk of pancreatic cancer

To put in context,

One degree relative with PC  makes relative having an 80% increased risk of developing pancreatic adenocarcinoma (this is RR: 1.8)

individuals with 2 degree relatives with PC have a nine fold risk , and this rises to thirty-two times greater risk if three or more first degree relatives have been previously diagnosed

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.