Digestive System
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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.

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

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)

Mucosal xantoma - benign lesion composed of foamy macrophages within the lamina propria. fibrovascular. They presents as discrete single to multiple yellowish-white patches, most commonly in the antrum or pyloric region of the stomach . Endoscopically it sometimes can resemble candidiasis, polyp, lymphangiectasia, Russell body gastritis, and Pseudoxanthoma elastic or gastric malignancy.

Lymphangiectasia would have showed prominent dilated lymphatics in the lamina propria region of the villous structure, often with extension into submucosa . These are more commonly seen in duodenum or terminal ileum

Pancreatic cancer tends to have an ominous character, partly cause disease is a) advanced age, so even in resectable cases many patients are unfit for surgery and b) most cancers are borderline resecable, irresectable or metastatic. (80% of the pancreatic cancers are diagnosed in advanced stages)

Even in patient with surgical resection, the 5-year survival is quoted as 27%

A recent review showed that 5-year survival is 30% in Ia (T1 N0 M0- single 2cm or less panc mass)  dropping to 11.8% in Ib ( T2 N0 M0, this is single mass 2-4cm). When putting all the stages together, the 5 year survival is only 5%.

The best possible outcome would theorically be in an early cancer, 2cm or less (T1), found either incidentally (or if it gives symptoms very early), resectable (non conctacting vessels and not involving other anatomical structures, as well as surgically accesible)  and in a fit patient amenable for surgery.

Check the 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

Whenever an HCC (Hepatocelullar carcinoma) is resected in an early starge, 5-year recurrence occurs in up to 60-70% of the cases,  either as a result of intrahepatic metastases (true recurrent disease) or de novo cancer in the remaining cirrhotic liver .  However, similar rates of reccurence occurs if we use ablation instead of surgical resection (  between 60% and 85% recurrence with ablation) via the same mechanisms (either incomplete tumor erradication, or new tumor formation)

5-year recurrence after liver transplant is way lower (8-20%) and of course varies depending on the tumoral burden --> potential microvascular invasion at the time of the transplant.

See BSG 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.

This is a case of Clostridioides (Clostridium) difficile colitis with typical pseudomembranes on the colonic mucosa.  Elderly and nursing home patients are risk factors. We should take biopsies and ask for faecal sample (GDH and /or culture for toxigenic C.diff) because pseudomembrane rarely can have other causes (Staphylococcus aureus, CMV, radiation, ischemic, chemotherapy)

Patient does not meet the definition of Severe (>15000 leucocytes or deranged Creatinin) or fulminant (hypotension, septic shock, megacolon)

Most guidelines no longer recommend Metronidazole for C.diff as first line unless no other alternative available.  Despite ACG recommends either Vancomycin or Fidaxomicin as first line, (Fidaxomicin is more expensive) the European guidelines recommend Fidaxomicin over Vancomycin (Vancomycin is a perfect acceptable good choice , however despite both curing the infection in about the same rates (76.2% vs 70.5%),  lower recurrence rates with fidaxomicin are described (8.3% vs 32.6%) which could justify its higher cost.