Digestive System
Online Learning Platform

According to the Haraldsson  classification, Type 2 and 3 are usually the most difficult- Type 3 is normally quite challenging as papilla is  protruding or bulging into the duodenal lumen or sometimes hanging down, pendulous , mobile and with the orifice oriented caudally. This papilla asociates a higher risk of failure OR 7.4 compared to type 1, followed closely by type 2 which is flat and small and associates also more risk of pancreatitis.
See image and data from retrospective database

Difficult question, but summarizes the (sometimes) difficult scores.
Montreal classification is easy - A for Age  L for location and B for phenotype.  There is ileal and colonic involvement so it is L3 (Ileocolonic) Small p is added when it is perianal disease (abscesses, ulcers or fistulae , but not skin tags or fissures)

The HBI takes into account the general well being , Abdominal pain   Number of liquid stools per day, Abdominal mass and extrainestinal Complications ( arthralgia, uveitis, erythema nodosum, aphthous ulcers, pyoderma gangrenosum ,anal fissure , new fistula or abscess)

<5 Remission   5-7 Mild disease  8-16 Moderate disease  >16 Severe disease

Her score is 9 (Moderate) But this could be guessed based on her level of pain, stools and absence of systemic inflamamtory reponse.

Check the HBI score

The caliber of the duodenoscope is 11.3mm  (shaft) with a 13.5mm distal end outer diameter.

This can help us  estimating the size of the biliary duct and the stones. We should use a balloon no bigger than  the size of the biliary duct at level of the trapped  stone, and ideally no  bigger than the duct diameter proximal to the ampullary segment.

In this case  biliary duct is approx the same size as the shaft , perhaps slightly less(10-11mm) therefore it is reasonable to start with the size balloon of 10mm (for 30-60 secs, although this is not well stablished) and keep inflating in ranges of 1mm per minute, until the waist of the balloon (see arrow)  disappears completely on fluoroscopic examination (see added picture  of a real balloon at the right to see how it should look at the end of the procedure) . Once balloon waist is gone, sphincter is considered to be adequately dilated .

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)

Underwater EMR is a technique in which instead of gas, the colon is insuflated with liquid (usually water, less common saline). The water makes the mucosa 'float' by reducing the wall tension and this separates the layers of the mucosa-submucosa naturally without injecting lifting solution.  This makes flat polyps easy to get grasped. Scar appears small after resection, but when water is aspirated and air insuflatted, one can see the scars are usually much bigger than they appear with water.  See this image from Spadaccini et al 

Should be endoscopic ablation (Radiofrequency or similar).  We cannot resect endoscopically a lesion that we cannot see.  Check the guidelines

In grade C-D reflux oesophagitis we should initiate PPI longlife (or increase the dose if patient already taking) and repeat endoscopy in 6-8 weeks to confirm healing and rule out underlying Barrett's (British recommend 6 weeks, american recommend 8weeks)

Biopsies, however, are controversial. ASGE  recommends bx  of irregular or deep oesophageal ulcerations or nodularity. ESGE does not mention them, whereas BSG recommends taking samples of any oesophageal ulcer or severe grade D oesophagitis.

Is the opinion of the author that any suspicious ulcer (despite of the grade of esophagitis) should be biopsied in the moment, whereas in  typical grade D oesophagitis biopsies might have a low diagnostic yield, atypia is difficult to assess due acute inflammation, and samples will be best targeted after improvement of the inflammation.

 Low amplitude propagated contractions (LAPC) Haustral contractions, triggered by chyme, facilitate the slow movement and mixing of food to enhance water absorption. Those are slow, segmenting movements that further mix chyme, most comoon in proximal colon.  (5 to 40 mm Hg) and last about 3  seconds.They happen  about every 30 minutes. 

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