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Difficult question.  This response is based on Waterfall trial that compared moderate resucitation (1.5ml per Kg) vs aggressive (3ml per Kg) and showed no difference in worsening pancreatitis  but a tendency of fluid overload in the aggresive group (20.5% vs. 6.3%).

Ringer lactate or Hartmanns have been proved to have benefit ovver saline due to an anti-inflammatory effect which was attributed to the properties of lactate and to have a higher pH that can help counteract acidosis.

This indeed is a subject of debate. American guidelines still mentions that most patients with acute pancreatitis & hypovolaemia could have a deficit of 3-4 L to replace in 24h (Like it is our patient with vomiting and  mild hypotension and tachycardia) . If patient has no evidence of hypovolemia, an initial resuscitation rate of no more than 1.5 mL/kg of body weight per hour should be administered. However, in patients with hypovolemia, clinicians should administer a bolus of 10 mL/kg which in this case is 750ml per hour (1500ml in 2 hours)

So, the answer is  Goal-directed rehydration with Ringer’s lactate solution (or Hartmann’s).  In this case of Hypovolemia, our first step should be resucitate until volume is stable (normal BP, HR and clinical status) looking closely to avoid overfluid, and once patient is stable, keep her on 1.5ml per Kg per 24 h with clinical re-checking every few hours to ensure she is not hyper or overhydrated.

Solid pseudopapillary neoplasm account for around 5% of pancreatic neoplasm. They are almost exclusively found in females (f:m ratio 10:1) and usually appear in their 20s.  CT and EUS can show well-encapsulated mass with varying solid and cystic components, caused by hemorrhagic degeneration. Peripheral calcification may occur.  They appearance can vary from solid to purely cystic- therefore even a small cystic lesion in a young female without previous pancreatitis episodes must make us consider this diagnosis

These lesion have a potential for malignant degeneration (Around 15%) therefore surgical removal is recommended . Cytology can show cluster  or sheets of papillary cells, PAS + and Vimentin.

• CLINICAL CASE AND Image: Dr Hajar Adil
• Source: Endosonography, 5th Edition by Shyam Varadarajulu, MD, Paul Fockens, MD, PhD and Robert H. Hawes, MD.
• Learning point brought by Dr Sarto Paquin

The proportion of AST to ALT in hepatocytes is about 2.5:1, but because AST is removed from serum by the liver sinusoidal cells twice as quickly (serum half-life t1/2 = 18 hr) compared to ALT (t1/2 = 36 hr), so the resulting serum levels of AST and ALT are about equal in healthy individuals, resulting in a normal AST/ALT ratio around 1. See here.

B6 is more essencial for ALT synthesis than AST, that is why in chronic alcohol (low B6) we will see a reduction of ALT in proportion to AST, increasing the AST/ALT ratio>2

ESGE recommends offering treatment to all the patients with CBD stones (symptomatic or not) who are fit enough to undergo procedure.
This is true that we should explain always the option of intervention, and we should at least talk about risks of complication from leaving untreated biliary stones (Roughly about 25%  - biliary colic, pancreatitis, cholangitis- vs 12% if we clear the bile stones) this is  based on this  Gallrisk sweddish cohort   where they followed 3969 patients with untreated CBD stones, during follow-up ranging from 0 to 4 years. 

In summary: Explain why there is an indication to treat, which risks ERCP associates, what the alternatives may be  (ie Cholecystectomy plus surgical bile duct exploration in the same setting when approppriate) and their own risks.  And last but not least, explain the alternative of not treating and only monitoring, and the risks of this approach as well.

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

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)

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.

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)