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Can anyone hear me or see me? Can anyone hear me? If you can hear me, put something in the chart box. Yeah. So it's live now. Yeah. You can't because my camera is off. Um, let me see. Can you see now? Yeah, I can see you, Danny. Yeah, so? So the event is live. Now, as I suppose. I think the person who joined did not click the Supposed to broadcast live? Yeah. I can't even see the moderate and the presenter. Both of them are not on stage. Um, just give me one second. Let me communicate with them. So who's the Who's the Who is this? Picker? Speakers. Jokes? Yeah, the spirit to invite. Invite him to stage. So I've invited into this stage we should be able to I'm not sure if he's on his medicine now. Okay, but rather than to the stage, we want to come to the stage. Now. Can you invite a bit as well? Well, I only had a quitter. He's not. He's not currently he hasn't changed at all. Let let him join. Okay, one second. Um, apologies that we're starting a bit late. Um, okay. Yeah. Uh, okay. You're welcome. Thank you. Yeah. Good evening, everyone. Sorry for the technical, Um, in the difficulties. Oh, that's right. Um uh, so she said I should invite one more person. So once you do that, you know, we can just start this session and I'll start recording. Let me. Okay. Yeah, I can see them that you have about 15 people, okay. And decisions will be recorded as well. Mhm. Hi. Damn it. Can we just start? Um, I'll just standing for him and moderate. Uh, just just give me one minute, please. Okay. Okay. Uh huh. Yeah. Uh, okay. What are you doing? Your radio. You still there? Good evening, everybody. Can you hear me? You can hear me. Just type in chat box. All right? No. All right, so So we'll be starting soon. All right, so we're starting soon. We apologize for the delay. There been some technical issues. Um, so without further ado would invite, uh, the, uh the teacher for today is Dr uh, Botox. Uh, we We sincerely apologize for the delay anyways, so I would invite Doctor Abu trucks to common stage and and go on, which is teaching doctor troops, please. Yeah, before. Oh, yeah. Sorry about that. Sorry for the delay. Uh, let me just share my slides now. Oh, okay. Can we all see? Um, not yet. So they did. You quit the share bottom in the center? Yeah. You can't see at all. No, no, we can't. We can't see the screen. Uh um, you should press, press, share your entire screen, not just the slides. Try to, um I went to to share your skin and your entire skin. Okay, That's what I'm going to. And then, um, yeah. Can you go see No, no, no, no, not yet. Not yet. Uh, what can we do about this? Mhm? Uh huh. Shit. Just just try both of them straight. Um, I tried the 1st and 2nd, if that's possible. Uh, the other one is telling me to shame. Pdf, my stuff is in power point. Shh. Uh huh. Who's Who's moderate? Um, I had a moderator for this session. Yes. Yes, I am trying to share the screen. Let's let's say that work. Yeah, Yeah. Okay. Yeah. Uh huh. Mhm. Well, let me try for my and can get some ice cream. Yeah, you can see your screen So you're not working. So you went to entire screen, right? Yes. I just press the middle button that present now. There should be a middle button. You see that? Immediate present. Now they want to click in addition to options. Just live. Yeah, suppression. So share screen. Then it gives me an entire scream window from tablets, right? Yes. And actually, and then we can share. Okay, I see. No, no, you can't. No, I can't see. So what's happening? Okay. No, I think I think I know what the problem is. Yeah, uh, let me make it more Xarelto. Okay. Uh, can you dictate your email for me? Um, tricky dot ago at NHS of net. See, that's your middle. That's your middle email. Yes, that's a lot. Okay. Able to just quickly check your meal. Uh, not enough. Okay. All right. You accepted to request. Yeah, let me refresh. I know you're not accepted yet and I can see from my end, So if you use this to join, right, so I click Join. It is such a signing. Yeah. Okay, so I said, can we go to the lessons and share slides later? Okay, if this doesn't work. That would be an exception. Now, try to I I logged in with the account, so I think you should maybe look at I'm looking again. Okay. Um, if you accepted, let me see. Yeah, you've accepted. Just look out and then looking again contribute to share your screen now. Okay. Yeah. So if this doesn't work, we'll just go ahead, and then we'll share the slides, actually slide later. Um, sorry. Sorry. Yes. Okay. Welcome back. Thank you dot So can you try and get your screen now? You should, uh, should work. Okay. I see. Have you see the screen? Yes. Yes. Uh, you can, you know, maybe just go ahead, go ahead and go ahead, and maybe she slides later, okay? And we'll look into the next time. I'll probably just practice. We have our session maybe 10 minutes before the time. All right. Um all right. Good evening, everyone. I'm sorry about the delay and starting due to technical error. Uh, my name is to do the album. Um, it was a doctor with the department of General surgery at the you can ask about tetanus between the chest condition trust. Um, I'm also a trust doctor with the Lasix and the Valium. You just transition trust, obviously. The winter I have trust. So today we'll be talking about your colitis. Is, um which is, um, colloquially known as a ghost and disease. The PT. I can't share my slides about our two most talking as possible. So I have a couple of outlines. Um, so obviously I'll be talking on introduction. Epidemiology, um, courses. Um, then we'll look at the presentation, how disease is still present. And then, uh, we'll look a little about diagnosis. How do we diagnose this condition? Um, then we'll talk about the treatment options. Um, what are the treatment options? Um, really? Generally, we look at the management of it. Um, since we look about courses, we also talk about prevention, and then we'll end this session with a case presentation. All right, Um, So, um, which also the do let's start. Um, So gallstone disease basically refers to, um when we have had fatty or mineral deposits. Um, when they're forming the gall bladder. So when you have these mineral deposits, that's the reverse of the gall stones. Formally, gall bladder. Um, I have a nice picture of, um, leave the gallbladder with some Nice to, um, I can share this because I want to share this light. And I guess I was just like, some other time, um, looking at epidemiology, wise, about 15% of the population. Generally, I thought to have a ghost. And so it's a bit around there in the population. 15%. All right, Um, then we look at the courses. Um, So generally, um, what are the risk factors? Things to know that predisposed to this. Um, So we have obesity there When you do know that overweight and obese obesity, uh, predispose people to form gallstones because the fact has been broken and you have tried Crestor and all that. Okay, then, um, we'll talk about diabetes. Um, you know, because of the condition, they have a higher amount of triglyceride again. So wish lists breakdown the liver, and then you have gall stones from it. Um, generally, we tend to see that women are more likely to have costumes than men. The deviation is basically more like 2221. So we have twice, uh, you said it's a voiding women than a meal. Then I'm looking at age. Um, most people over the age of 60 years old, they have gallstones, and it does get worse for a few of them who doesn't know about it. And, uh, maybe they have other risk factors with heritage diet and regular exercise medications. Yes, some medications are known to be predisposed to that, which is amazing. And it's Elaine. Um um, cyclosporin that soon and some antinarcotics we know. We do know that can cause that. Okay, um, with regards to out of the starting, um, the the statins, generally it is controversial. Some studies, um, says, um, it tends to reduce the possibility of you having goals since where somebody say, because it's a bit increased. So generally it's a bit controversial with the statins. Okay, then. Rapid with loss. Yes. So rapidly is no sense of this high amount of cholesterol in the bile. And that tends to change the Constitution, the Constitution of the bile, which precipitate as Constance. All right, then. Fasting. Yes, Fasting. Um, when you first and don't eat timely, it also leads to degrees. Um, gall bladder movement. Um, when you have the intensity, uh, the biting. Still completing the goal blood. They tend to have been very sludge from the stone. Can call. Um, lastly, I wouldn't want to forget about the genetic predisposition and some familiar illnesses, and that could be supposed to go stones to inform some metabolic diseases. Okay, so that's generally about a refill of your overview of the present of the courses. So now let's talk about the presentation. Um, So, generally, how do, um, individual will go some present. Firstly, it is interesting to note that most of these people, they don't have any symptoms at all. It might just be due to and ask them to make an incidental finding. And you're checking for something else. And then you just find the ghost today, however, a small proportion of individuals with a gallstone um, they tend to have these gallstones if it is the wall of the gallbladder or, um, the lining of the be our system, and then it gives them with pains. So, um, the General common um, presentation you have is, um you present with upper abdominal pain, which is increasing in nature tends to be constant. Last for about a few minutes to a few hours and usually was Which meal intake? Um, usually the fat if it's, um so this pain also, could you get to the back or classically to the right, Um, show that it's the right shoulder? Yeah. Bought some for some persons they might not present with a problem that they might just present with, um, severe pain in the right show that also, there's a company nausea and vomiting. This must not be present. But these are some of the things we see. Um, sweating, Yes, Um, low grade fever and chills. Some my present with John just, um it might not be obvious, but, um, some of them might actually present with an obvious, um, joined this bloating in the abdomen. Um, feeling of indigestion? Um, clear color is to, um these are rare cases, but generally these are the representing fever. It tends to say so commonly. What you say is, um, you see a patient you are representing most likely female in our forties, presenting with an upper abdominal pain. Um, constantly nature related to the back of the right show that, um with associated nausea and vomiting, bit of fever or choose and generally was with intake of fatty foods. That's generally how they present. All right, uh, so move to diagnosis. How do we diagnose this condition? Um, generally, um, when the patient comes to the hospital, Obviously, um, we start with the general physical examination, and after the general physical examination, you go to, um, the blood. So generally, when you do the liver function test, you see a holistic pattern on liver function. Test ultrasound. Um, usually, it's preferred because of its, um, high, uh, specificity and picking up stones or bladder stones. So, uh, the liver function test ultrasound speaking that up, she tends to, uh, um, make that diagnosis according to the nice guideline, it is recommended liver function, test ultrasound. And then, if you were able to get this, if it isn't gonna get that and you are observed in the common bile duct is dilated. You want to go for an MRI? C p. Why? Because the biliary duct is dilated. You want to be sure that there's no stones in the gallbladder because that will affect your management options. So that's treating. We should note liver function, test ultrasound, abdominal ultrasound and um, M R S E p. That's magnetic resonance cholangiopancreatography okay. Um, nines went on to for the advice that, um we should consider an endoscopic ultrasound if MRCB does not allow a diagnosis to make. So usually this should give you a diagnosis of Boston. If after the you know, these investigations and you're not able to pick, um, been able to detect the gallstones, um, this advice that you should refer for further investigations other than Gustines as it might be something else you're dealing with. All right, um, So, management, how do we manage this condition? Um, so generally, um, I want to reassure people that when you have a patient with a symptomatic Goldstone's, which is just found it no more gall bladder and the Mobic territory. You don't need to give any treatment unless develop symptoms. So most times the situation will come in. Um, I was using it within 50 contamination, and I have a gallstone that was picked up. So I need to have surgery. No lines recommend generally if they are symptomatic with the gall stones and the biliary tree and the tractors Okay, is fine. They don't require symptoms. Otherwise, if they are symptomatic, will offer them a laparoscopic cholecystectomy That's the key hole surgery down to move the gall bladder. But then, um, for some persons, we do know that, um, this tends to have complications if gallstone is left untreated. Initially, I mentioned that the gallstones can irritate the wall of the gall bladder. And when it does that, um, cause inflammation of the wall of the gallbladder that some cold societies, um, that's for the That's for the ascending the tree to give you cholangitis. And, um, the gall stones can track down and give you a coupon for charities. Um, generally joined this gall stone area, so these are other complications that you tend to have. But then also, there's all the complications which we tend to see in some individuals. And that's what we call a gallstone empyema. Um, so basically, they tend to have possibly one of the gall bladder. Maybe it's a long standing, um, um, inflammation of the world. But generally, when these patients, they come, uh, come in. And you've seen these patients have gall bladder empyema. And for some reasons, um, surgeries country indicated, and when they present, what you do is they would do like a scope in school um um the percutaneous um cholecystectomy. So, basically, you take them in the theater, um, this procedure here and then just past, um, a catheter, um, Children to dream that. And after that, if they are well enough, a surgery, you might consider laparoscopic cholecystectomy. Um, um, some surgeons choose to just go ahead with some conservative management for the gallbladder empyema, which for something that might resolve, uh, full and conservative management. But if it doesn't resolve a conservative management, you want to be putting a school systems to me, and after you had not been buried during the revolutionary inflammation, you can then, um, visit the idea of a laparoscopic cholecystectomy. Okay, um, so after that, now we want now to talk about how do we manage? Um, Gallbladder stones? Yes. So sorry. Coming by dot Stones like we mentioned. Um, when they come in, they did the gallbladder ultrasound. Get the stones. You bye dot is deleted. CBD is deleted. You want to check for stones? So if you check on their stones, what do you do? Nice for the nice guideline for the gifts that you offer bye dot clearance and laparoscopic cholecystectomy to do those with symptomatic or asymptomatic Common by distance. That's the the guideline. So how do you clear this bio duct? Um, is really, um when? If you're taking them for a laparoscopic cholecystectomy, um, you can clear the bye dot at the point at subject, so you want it down. Take the stone, uh, declare it down to the gallbladder before you remove it. Also, he could also revisit the idea of, um, and the scope which will get cool and you back in photographic as the ercp before or at the time of your laparoscopic cholecystectomy to help clear the bio duct. Um, I think there's there's a study going on in in North Yorkshire and discovered the sunflower study, which basically is assessing. Um, if you're going from a r c e p a t h on it before, um, like possibly cause steps. I mean, if it changes the overall out of the picture, so you might want to check that out on Twitter. It's called some flour study. Okay, Um, so if the gold plan, if the bye dot cannot be collect on e ercp, the advice is to use. Bladder is standing to actually been doing it only a temporary measure until you have a definitive endoscopic or surgical clearance. That's that's so That's generally direct review of, uh, Goldstone's. Generally you get symptomatic. We don't do anything. You're symptomatic. You go ahead and manage them. Um, we do know that if they're having a clinical societies, the management is different for them. Um, we will get that inflammation, and the white cells is raised with CRP and lactic. Um, want to give some antibiotics for that or preferability the cycling? And then you also have to do, um, the school pick a cholecystectomy usually within 72 hours of commission. Okay, Um, so what is the advice? Generally, we give patients, um, with all the patients and also the carers, uh, to avoid food and during that triggers the symptoms until they have their gallbladder or the gallstone removed. Interviewers With these conditions, we mentioned that intake of mutants of watching usually fatty food and wine. Um, advise people that they should not need to avoid food, and during their trigger their symptoms after they have their gallbladder or got some remote, it's already out. It's already out. There's no point in avoiding it because it won't cause them anything. Um, you also go ahead to advise them to meet the GP. If it's not drinking triggers for the symptoms after they've had a global they removed. Because obviously, we have to look for something else other than your big brother because that will only be the cause of it. Because it was because of their problems. Um, they should tuned to be having the symptoms again. Okay, let's look about, Let's look at some, um, prevent chief strategies. Okay, so, one. We generally advise that individuals to strive to maintain a healthy body weight, exercising regularly and measuring a bm I because we tend to see a high occurrence of high incidence of gallstone disease in the, um, the IBM I range, um also advised to eat balanced meals at regular intervals, including fibers who green and calcium. Um, limit fatty food consumption of foods that are high in cholesterol as you know, because, uh, you just need to deliver and then increase your, um, your likelihood of developing a ghost do not diet to lose weight hastily, um, directed with loss. Um, it's generally, um, generally cancer against that. Don't do that because um, to affect you Do not fast too often. And do not skip meals. Uh, frequently monitor your cholesterol levels just to keep them under control. Um, so that's basically, uh, the preventive measures. So So I think that, uh, that's the most you can take in terms of the clinical information we have about ghost. And we've looked about Look at the introduction. Told you what's upset, what the gallstone is. Um, we talked about the epidemiology occurring about 15%. We looked at the course, is how they present common presentation, how to make a diagnosis and generally the management strategies and involved. And then we'll talk about other things. We need to look about by stone common bile, duct stone management also advised to give the patient, and we'll get some use avoidance and be fine after surgery. And also general preventative strategies. Uh, individual population can take to avoid, um, or to try to reduce the risks of development. This condition. Okay, um, so let's take our presentation. So, um, I'm going to take this presentation, so this is generally a lead. She came in. Um, so she's 42 years old. She's a teacher of course she's local. Yeah, And she presented to the ascent an emergency of the hospital with a four hour history of, um, upper right abdominal pain. Um, so she woke up with this pain about two. AM in the morning. And the pain is just there is constant. Um, it's 80 nature related to the back associated nausea and vomiting. She waited this pain to be about 9 to 10 to try to keep up with the more it did help initially, but, um, later, it didn't really help at all. Um, sorry about the non sedating. Have something. Uh, okay, So that's generally about one important interesting thing about this history was that she did have a bottle of wine with cheese the night before. Um, the event happened. Um, Anyway, um, she is a nonsmoker. Otherwise feet and well, um, um, she doesn't have any past history other than hypertension. Okay, Um, So when she came in, um did a physical examination on her. Um, knew she was using that one. Um, she was psychotic. Bit at some 103. Um, she was just aching right there. Abdomen is soft. Um, quite a bit tender at the right upper quadrant. No guarding. Um, no rebound tenderness. Um, we did a blood blood came back. Um, lft obviously was deranged, obviously. The holistic pattern, alkaline phosphatase and a little bit raised, um, quest and CRP, um, white cell count and liked it. Um um, they were bit normal, so they were actually normal. So we're not really worried about any inflammatory process going on. Um, so obviously we give her a Magesium to help with the pain. And then we did an ultrasound ultrasound identified multiple gall stones in the gallbladder, you know, inflammation of the gallbladder wall, and the common by that was not dilated. So other than the analgesia, she was admitted. And then, um, she had a street for laparoscopic cholecystectomy. Um, within 24 hours, and she was out and about, um, within one day and she was discharged home the next day. You know, complications at all. Um, so this is basically a classical case of, um um biliary colic. So they have the gallstones tend to give the biliary colleague they come in, and it was quite straightforward for them. Um, So, um, that's about it. And yes, I have my references. Um, which I I got most of my work from the National Institute of Health Care Excellence. And they have a clinical guidance that was published in October 2014 on the diagnosis and management of gallstone. This is and that's about it. So I will leave the floor now for any questions. All right. Thank you so much, Doctor. Shucks. Um, all right, we'll be taking questions. Now, if you have any questions so far on the lecture, you can just drop them in the chat box. You can just drop them in the chat box. They'll be attended to have any questions. Yeah. Yeah. All right. It seems seems to have no questions, but any questions? Um, what was, like, the classical patient that you would say that Okay, if a patient just comes into your consultants, what? As a general surgeon, what was like it was like the classical patient, like, most likely to have them call it psoriasis. Is there, like, a Is that, like, maybe is it common in some certain set of people? Or that's my That's my That's my question, actually. Okay. Okay. Um, so yeah, so we have the classic, uh, things we learned in medical school. Um um, the fat lady. And she's not 14. She's light scared. So, um, so usually that's how basically, what you see when you go to the emergency room and having, um, and overweight or obese, um, leading or forties. And so this general population, you tend to, um, you know, yes. Um, that's that's why you see them more of a gall stones. I don't want to answer your question. Yes, you did. Thank you, sir. So I also have another question. Sorry. Sorry. Since I don't exactly questions, uh, medical interventions for political purposes, Um, just like like I mentioned, um, the the guidance generally, according to the national city. Okay. And incidence is that, um, when they come in, um, the management depends on how they present. So if it was an incidental finding of gallstones, they don't have any symptoms. That's fine. No problem. Um, but then, um, if they are coming in with accurately presenting accurately, it's advisable to get it removed. Um, but there are some medical interventions which have been positive already. Tried some persons Have you started to try to reduce constant? Um, there are also um, medical other medications try to use. Um I think it's it's in my purse and other person they try to use to reduce the incidents of the gallstones, but it has not been, um, if you look at the overall picture of it, um, it tends the surgery. It tends more favor than the medications, because, um, some persons go for lipid lowering agent to lower the lipids century, the side of the gallstones. But then if it works for some persons, but some other person is still go ahead to have biliary colic, I'm obstructed. Um, common bye dot And they're presenting with with the big metastasis, so you have to have the gallbladder. All right. Thank you very much, sir. Um, I did any other questions. If you have questions because send them here. Well, in the absence of I think that's the question and someone is actually, there's any long term complications after the removal of the problem. Um, so in terms of our complications, we don't really get that much, because obviously, if you look at the anatomy of the the liver and the biliary system and all that, so once you have, um, the gallbladder removed. There's still some elements of biliary drainage. Um, notable. Um, other complication that tends to be common is that they might have some diarrhea, but that tends to do better when, um, just give them an education. Uh, and then that's their fine with that. But in long term complication, No, um, they usually find one single day go up like that, and that's the problem they are having. Um, they are fine. They're fine. Although we do know there are other some other syndromes we need to be aware of, um, individual presenting with symptoms of, um, biliary colic after the gallbladder's been removed. And then but usually when you scanned, um, you noticed that maybe some stones have been was left in the gall bladder become a by that. So that is causing the obstruction. So with the adverts of ercp and MRCB to, um, check for gallbladder, um, common bile duct stones that tends to use, um that. But they say that, but generally overall complications in terms of health, no. Since I want to apologize like I think, you know, I apologize, but I want to apologize for the delay, and we hope that or we assure you that the next time we'll be having a an event like this. Well, sure you do. Better. So you could, um, take the You can still feel the feedback, um, forms in the in the chart box. And Okay, you can get feedback from the chatter box and your certificate will be sent to you sent to your meal. Uh, doctor, thank you so much for the teaching. It was such a wonderful session. Surely appreciate you for taking the time to to teach us this evening. And they want to appreciate the people that stayed with us. Even when everything everything seems as though it wasn't It wasn't, um I was looking with and all that. So once you're essentially I appreciate you and want to appreciate the everybody that, uh, contributed in making this event in structures. Doctor Pulaski, No data and the president of Siggraph. Um, Doctor. Dermatologist? Yeah. Yeah, and, um also the teaching head. So I want to essentially appreciate everybody. We are. We are very grateful. Okay. Yeah, I think I think someone was somebody mentioned. That box about bile can stop blood. Okay. You already mentioned that. Yes, those are just immediately post of complications. Um, just like you tend to have some bleeding infection. Um, then delayed wound healing. Um, that tends to be, um, injury to surrounding structures like, um, the liver. And the power was, um they tend to be there's an immediate post of not long term complications. All right. Thank you, sir. So, um, should we call the D now? Uh, yeah, I think so. I don't I don't see any of the questions here. All right. Thank you very much. Everyone for joining. Good night. Thank you, everyone. Yeah, the recording we made available, actually. Good night. All right, thanks.