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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. 

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

Based on the KSGE (Korean society of GI endoscopy) 2021 guidelines : Repeat EUS-guided acquisition provides a conclusive diagnosis in the majority of cases with indeterminate cytopathological diagnoses and, therefore, should be strongly recommended ahead of other modalities, such as biopsy under computed tomography-guidance or diagnostic surgical exploration.

Also common sense will tell us repeating EUS is the less invasive option and has high chances of being successful in tissue adquisition. If persisting negative/inconclusive material, MDT re-discussion should take place and possibly surgical team should speak to the patient regarding risks and benefits of  laparoscopic examination or even proceeding to pancreatectomy -the incidence of benign disease among patients undergoing pancreatic resection for suspicion of malignancy is extremely variable, ranging  from roughly 4-13% , but in some series has been reported up to 35%.

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 

Andexanet is factor Xa inhibitor which is approved to reverse Rivaroxaban and Apixaban. However, it has not being proved to be efficacious against Edoxaban. Dabigatran is  a direct thrombin (factor IIa) inhibitor, not a Xa inhibitor.

Despite they all are good options that could be considered. We need to see:

• Size (abut 12-13mm in size)
• Mucosal pattern (looks like sessile serrated lession or SSP-  with clouded surface and indistictive borders - see  WASP classification - : The lesion has NO suspicious areas of submucosal invasion
• Shape- 0-IIa of Paris classification (despite the name sessile serrated lesion, this is the nomenclature for that type of serrated lesions, although the majority of them are in fact flat, not sessile)
• Position- Right vs left colon (risk of perforation,  lesion is easy accesible or not in case of delayed bleed)

With all in mind, the most difficult option would be cold snare as >10mm and having broad base, it would be difficult to fully grasp the tissue, close and cut through with cold snare. ESGE guidelines recommend cold snare in small (<10mm ) and in >10mm they suggest hot polypectomy or piecemeal cold snare resection.

So the options would be 1) Lifting and use the cold snare to resect either en bloc if feasible, or most likely piecemeal 2) Do the same but using diathermy with a hot snare or 3) do not lift and use underwater EMR, which probably would allow to grab the lesion en bloc, completely in one go with a 15mm snare. Despite ESGE recommends underwater EMR in selected cases >20mm, realistically if we want en bloc resection, it is either hot snare or underwater EMR.

Note that cold EMR is also a good option for SSL, has an excellent safety profile with less adverse events compared to hot EMR, and less residual rate (1% in cold vs 4.2% in hot) in serrated lesions, however requires some level of practice and getting used to a slighly more bleeding field.

For standard colonoscopies,  ASGE  and ESGE  agree that it should be an overall > 25% (for men ≥30%, for women ≥20%)

The  BSG minimum standard is slightly lower to > 15% (aspirational 20%)

Based on this metanalysis of real life Colonoscopy findings in >3.5 million patients, this percentage are pooled to real life colonoscopies

This rate is for standard colonoscopies, does not take into account FIT/FOBT  positive patients (Positive faecal blood patients in bowel screening) in which the aspirational should be at least 40-50% of adenoma or cancer detection. (See report from bowel screening in the UK)

1. True.  Around 80%  of AIH will be either ANA or ASMA+, 8% AMA+, 2% LKM+. 30% SLA+
2.  True. Less than 50% in reduction of transaminases in 4 weeks after treatment is considered Non-response. (Occurs in 17% of treated patients and assoiciates a 7-fold risk of liver related death )
3.  False. Previous guidedlines suggested this parameter, but now we consider response when complete normalisation of transmanisases and IgG.   Liver biopsy is very useful to asses histological response if Modified Ishak hepatitis activity index (mHAI) <4 /18, however histology response lags behind biochemical response by several months: in one  RCT, only 28% and 50% of patients receiving prednisolone±azathioprine achieved histological remission after 6 and 12 months, respectively. Thus, repeat biopsy to confirm remission is not recommended over the first 2 years

4.  True. Since the response criteria are more strict, there will be 20-30% who wont achieve complete biochemical remission.  These scenarios are tricky, we need to compare the overall response, patient adeherence to treatment, considering Azathioprine adeherence and metabolism:  Measuring Thioguanin nucleotides- TGN-  to see that they are in therapeutic range(>220 pmol/8×10) and  Metilmercaptoruine ( MeMP) > 5700 can confirm that the patient is taking the right dose,  Also there are specific situations in which transaminases can remain slightly abnormal due to other causes like MASLD or drug related, and IgG is commonly raised in conditions like cirrhosis.

Check BSG guidelines AIH

If someone has IgA deficiency and celiac disease, the IgA deficiency can cause a false negative on a celiac disease antibody test.  (As IgA anti transglutaminase antibodies may be falsely normal) In this case it is important to perform IgG-specific antibody tests for endomysium, gliadin, and tissue transglutaminase