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Hi, everyone. Thanks for joining. We'll just give it a couple of minutes. Um, give people time to join and then we'll get started. Ok. So we'll get, um, started. Hopefully everyone can hear me just, um, I've got my, I'm logged in on my phone as well, so I can see the chart. So if anyone's got any questions at any point, I'll try and make it as interactive as possible. So, um, just pop your answers and things in the chat and if you've got any questions, feel free to unmute and ask them or you can pop them in the chat as well and I'll try and keep an eye on them. If anyone sort of can't hear me at any point or the connection goes a bit dodgy, please just try and let me know on the chat and I'll see if there's anything I can do. Um, to sort it. I do kind of have a rubbish wi fi. So hopefully everyone can hear me. Ok. So today we're gonna cover the a da number of different bowel pathologies. It's impossible to sort of cover them all in an hour. So I've kind of picked the ones that I see the most in the hospital, um, and trying to do sort of a whistlestop tour of them. So, we'll see how it goes. Uh, so first we're gonna cover bowel obstruction. Um, so does anyone know what a bowel obstruction is, how it might sort of occur, um, sort of what's going on in the bowel when there is a bowel obstruction. So, really? Yeah, perfect. So, essentially, it is exactly what's in the name. There is an obstruction somewhere in the bowel. It can be small bowel or large bowel, which means that the contents are not getting through the bowel, um, and being able to pass out through the rectum. So if they're distal to the obstruction, they get passed and proximal to it and they accumulate. It's not always a complete obstruction. It can be a partial or a complete obstruction. It might be that some gas is getting passed. Um, you can also get sort of overflow, um, if there is a sort of obstruction. Um, so you might end up getting constipation and then diarrhea if there's sort of overflow, diarrhea. So what tends to happen is the bowel dilates and the tummy starts to distend. The pressure in obviously, the bowel increases and contents are pushed more towards the intestinal wall which compresses the blood vessels in the intestinal wall which can cause, um, perforation. So, obstructions tend to be either mechanical or functional. Does anyone know any anything that might cause a bowel obstruction at all. It can be mechanical or functional. A tumor. Yeah, adhesions. That's a really, really common one we see in the hospital often it's, someone's had some sort of surgery in the past, whether that's ac section or a previous sort of laparotomy or anything like that. It's quite rare that we see people with, um, virgin abdomens as they call them. So people that haven't had any surgery previously, um, get a bowel obstruction. Most people I've seen have been a bowel obstruction. See ius, very good, often go into that after surgery. It's very, very common after surgery. The bowel just gets a bit sleepy with all the medications and all the handling strictures. Yep. And volvulus. Yep. Another good one. So, go through so mechanical. Yeah, things like adhesions can be, things like malignancy often. I think it's like more, um, the right sided tumors, um, can be sort of really quiet and not presenting and then they can present sort of a big bowel obstruction or perforation. So that's something that we always look in, especially in older people. If they're having a, a small bowel, any bowel obstruction, have they got some sort of malignancy, uh, inflammation and strictures? You can also get gallstone elis. We talked a little bit about this last week, could also get incarcerated hernias. Um, so we're going to go into hernias a bit more in, um, a bit further on and interception and volvulus as well. And then functional is sort of where peristalsis is, uh, interrupted, common after surgery. Often to do with the handling of the bowel and things like the medications we give, including opiates and things. Also, their electrolytes can often be quite deranged after surgery. So, it's important to make sure you've got the ene and things like hyperthyroidism as well. So, a presentation we already touched on this a tiny bit. Um, does anyone know how a bowel obstruction might present? Nausea and vomiting? Yeah. Very good. Not passing stool. Yeah. Abdominal pain and constipated. Yeah. So anyone what might know might happen to the stomach, what that might look like? Distension? Yeah. Very good. The abdominal distension sort of a colicky pain because nothing's getting past that point, not opening your bowels with small bowels. You can, uh, tend to get sort of more, more vomiting, um, which can be bilious, which large bowel vomiting tends to be less common and it's more sort of the constipation and abdominal pain. You can get either absent bowel sounds or high pitched tingling bs bowel sounds and, um, in terms of complications, obviously, we had a bit of a chat about, um, the perforation and things and when we were talking about what is a bowel obstruction. Does anyone have any idea of any other complications that there might be with bowel obstructions, ischemia? Yeah. Perforation. Yep. So we, we're obviously trying to avoid getting to that point when they come into surgery. Sepsis. Yep. So, perforation, sepsis, death retinitis, you can also get aspiration, which is often why we stick an NG tube down. Um, because if they're that extended, we don't want them to then aspirate get pneumonia and that obviously leads to worse outcomes. So, investigations, we talked a bit last week about how it is good to sort of, um, in your OSC especially and also in life, um, to sort of split your tests into sort of bedside tests, blood tests, scans and special tests. Does anyone know anything we would do by the bedside, if someone comes in with bowel obstruction or any blood tests as well, we can move on to blood tests as well because the bedside ones are always gonna be quite similar drip and suck. Yeah. Auscultation. Yes, you do want to do a full examination. Um, so drip and so I would say is probably more of a treatment than an investigation. But obviously if it does, what if you put a, um, an NG tube in and loads of stuff comes out, it's quite a good indication that there is a blockage somewhere. So bedside, you always want to do observations and normally would get an ECG done as well because they quite often like pre op ECG S because of all the medication and things we give to people and just to identify if there's gonna be any risks if they're going into surgery so any blood tests, considering the, um, causes that we talked about earlier that you think is really important to get C RP. Yeah. I mean CRP is good in everyone to see if there is any sort of inflammation and infection. Um, good if it's, uh, sort of maybe a stricture and things for blood count. Yeah. So, yeah, I was thinking more along the lines of, sort of using knees, um, because often, um if their electrolytes are deranged, that can sort of cause an ileus as well. But you always want to get sort of full blood count using knees. LF TSI. Always do sort of a VBG or an ABG depending on how sick they are and also always get a group and save if they're being admitted into a surgical ward. Um, because it's potentially they might go to theater. Um, anyone know what scans, you might be able to see a bowel obstruction on or what we would do to sort of investigate a bowel obstruction, abdominal X ray. Yeah, you can also, we often do a lot of, um, give people gastrograph in and then do an abdominal X ray to see if things are getting through. Yep. Great. And right chest X ray is really good just to see if there's any uh pneumoperitoneum to check. They hasn't, um, had a perforation. So, yeah, you'd see dilated the bowel loops with multiple fluid levels or either a uniform distension of the bowel depending on if it's, um, mechanical or functional. Also get what I was talking about if you give them gastrograph in and see, see sort of how far it's getting through the bowel. See, see if we can find that, um, sort of the point of where the obstruction is e chest X ray we talk about and also a CT scan to potentially, if they're gonna think about taking this person to surgery, we might want to look at where the obstructing point is, um, which you might get more information from a CT. So, can anyone have a guess whether this is a small or a large bowel obstruction and how we might know that I've seen quite a lot of questions. Yeah. So good. Yeah, small bowel obstruction. There's quite a lot of question, um, on past med and things, trying, giving you X rays and trying to get you to decide which it is. So, if you can see the lines running across, that means it's a small bowel obstruction. And this one obviously is a, a large bowel obstruction. So this is just a picture of sort of the dilated loops. And also this is a, a hernia which is causing, um, obstruction. So you got obviously dilated loops before the point of obstruction and then, um, sort of collapsed loops, um, distal to the obstruction and just another CT scan here. So, treatment we have already spoke about, um, a little bit about the treatment. And what's the first thing you want to do in a patient? Um, before you sort of do any fancy treatment. What's the main things you would want to make sure that they've got? Yeah. So, I think especially in surgery as a junior. Um, yeah, antiemetics. Really good when you're first seeing the patient, even if you've got no idea what's going on, always make sure they've got pain relief. Always make sure they've got anti sickness. Have a look at all of the regular medications. Is there anything that needs suspending, such as kind of Apixaban or Warfarin and change into maybe a um low, low molecular weight heparin such as Darin. Um if you're thinking they might go to surgery at some point in the future so that it's easier to reverse or to um stop and let the effects go away. Um Once you're having a look at the blood, is there any electrolyte replacement you need to start? Do they need fluids? Are they quite dry? So, just making sure you've got the basics in before you speak to a senior and then they can, if you're not sure what's going on. Um and just making sure that if they are unwell that you notice that and do your a and sort of treat anything that you find, including whether you need to start the sepsis six and give them um antibiotics. So, yeah, the first thing is always resuscitation and then um if they're a surgical patient. I'd like to keep them nil by mouth until senior review, um, because they should be seeing them within, you know, a couple of hours. So making sure they've got analgesia antiemetics. So, keeping them all by mouth. And so we spoke earlier about the drip and suck. So I'd put a Ryles tube in aspirate it, um, obviously to check it's in the right place and see how much, um, is coming off and then often leave it on free drainage, um, to drain whatever's in the stomach to prevent them aspirating. Um, often what they do is they keep it on free drainage for a bit and then they'll put a spigot in it just, and we like to monitor the output and make sure that if someone's got a really high output NG, make sure you're balancing that with, um, fluids going in otherwise or going into an AK I so fluid and electrolyte replacement. And sometimes they might take them to surgery if it's, um, not been, um, conservatively managed. There's been a few additional ones that we've took to the surgery. So they just, um, did it with a laparotomy and just found the adhesions and just, um, but there, and then the obstruction resolved. So, any questions on bowel obstructions, um, before we move on to hernias, all of, most of the things today are often quite interrelated because obviously hernias can cause bowel obstructions. I've tried to split them up as much as possible. What antiemetic would you use in a bowel obstruction? So, we normally just at, um, Doncaster, we give, um, cyclizine and Ondansetron. If it's a complete bowel obstruction, you're gonna wanna, um, avoid metoclopramide because that can obviously make it worse. To be honest, it depends how nauseous they're feeling. Often by the time you've got an NG tube in them, it really completely makes a whole world of difference. They feel completely different because you just drain in all of that nasty stuff that's been sat in the stomach. Um, often sort of gives them quite instant relief. NG tubes were definitely something I was quite anxious about going into the first job. I'd never done an NG tube on a person as a medical student. Um, so definitely, if you're not feeling confident about it, I got the registrar to help me the first time. Um, but a tube for drainage is definitely much easier than a, um, a feeding NG tube. Um, so, yeah, don't, um, if you don't feel comfortable about it, make sure you ask someone just to observe you just the one time and then you'll feel a lot better about it and it really does help people out a lot of the time the nurses do put them in as well on our, on surgical wards. Um, yeah, hernias. So we're gonna go through and see if people can be if they know what, um, which one is which, in terms of the hernias I'm only going to cover, um, I think it's the four, sort of main ones. There is obviously so many different types of hernias and I just don't have the time to, um, cover them today. So they all know what this top hernia is here. So, not quite the top one. It's an epigastric hernia. The next one. What do people think this one is? Yeah. So that one's umbilical. Um what do people think this one is maybe giving it away like by this a little bit on the top? Incisional? Yeah. Well done. So you get quite a lot of questions on differentiating between the next two. And I'm gonna go into how you do that in the future slides. But does anyone know before we start which one? This one is inguinal? Yeah. So this one is inguinal and this one is femoral. Ok. So path physiology. Does anyone know the sort of definition of a hernia? Um Yeah. Really good. It's protrusion of viscous through wall defect or an area of weakness? So, it can be reducible, which is where the sac returns to the abdominal cavity spontaneously or with um manipulation, irreducible where the sac can't be reduced, strangulated, which is where the blood supply of the contents of the sac are compromised or obstruction. So there's bowel in the hernia which is causing a bowel obstruction. Does anyone know what symptoms we would be worried about with the hernia, if we were concerned that it might be strangulated, which would mean they would obviously need to come in, into, into the hospital and go to theater quite rapidly. Yeah. Vomiting feces, I would be worried about that. I would probably think there's some sort of obstruction going on pain out of proportion. Yeah. So if there's an increase in pain, so a lot of people might have a hernia that is asymptomatic. If there is sort of an increase in pain, anything about what the hernia looks like we might be concerned. Yeah. Well, see if there's any sort of skin changes, changes to the color of the sort of hernia. Yeah, if it's kind of purple or blue, um, we've had a couple that have come in that the GPS are being concerned about, but it's just a bruise. Um, because obviously people do get bruises as well. It's not just because there is sort of change in color doesn't necessarily mean that there's strangulation, but that is kind of what we look for. So, causes either sort of an increased intra abdominal pressure. So it can be from chronic cough from things like COPD smoking, bronchiectasis, cystic fibrosis, abdominal distension. So often after pregnancy, people with ascites, obesity, if they've had chronic constipation or if it can be things if they've got sort of a naturally weakened, um, tissue. So things like congenital defects, congenital disorders, such as cells down loss, trauma, which is where you get your incisional hernias, aging, if there's steroid use and sort of things like chronic malnutrition as well, sir. Inguinal hernia, try to do these in tables because otherwise it would just be a million slides. Um So the right side is more common than the left they have. So there's two different types. So either direct, which is through the posterior wall of the inguinal canal or indirect, um which is actually through the internal inguinal ring. I'll just go to the next slide just so I can show you a picture. So it's a tiny bit blurry but so direct is through actually through the wall and then indirect is through the ring. So the deep from the deep ring, so direct hernias are medial to the inferior epigastric artery and indirect are lateral to the inferior epigastric artery. I think you don't really know, you don't really need to know the difference between indirect and direct because essentially the management is the same anyway. Um but the causes are just slightly different. So direct can be from chronic intraabdominal increased pressure from things like obesity, chronic cough, constipation and indirect are from the processes, vaginalis closure, um failure or late testicular descent. So essentially, you'll often get questions between knowing whether it's an inguinal and or a femoral hernia because the management is slightly different. Um So an inguinal hernia, there's a groin lump which is superior and medial to the pubic cubicle as shown in the um the first picture. So this one is superior and medial and femoral hernias are inferior and lateral. So you can e it can either be asymptomatic and they just notice a lump or it can be that they've got a bit of discomfort in it um Of how you can tell whether it's a direct or indirect. So you reduce the hernia. So essentially shove it back in and then occlude the deep ring with two fingers. And then if you ask the patient to cough or if you ask them to stand, if the hernia is doesn't reappear, then you know, it's indirect because it's coming, it can't get through the deep watering, it still protrudes, then it's direct and then you can do an ultrasound or a CT to investigate. So the recommendation is you can observe them. It's obviously a patient choice. Um But they would often treat them. Um Even if they're asymptomatic sort of mesh repair, it's not something that needs to be done urgently because they're not high risk of becoming strangulated. Um But it's definitely something that should be considered. Um Obviously, if they're symptomatic, they're going to be treated more urgently than if they're asymptomatic. And um if it's a child presenting in the first few months of life, they've got quite a high risk of strangulation. So the hernia is repaired urgently. If they're over one, it's lower risk. Um So the surgery is then elective. So we've just gone through that as well. Just to show you the difference between direct and indirect. So, femoral hernias is across the femoral canal through the femoral ring. Um so they are lateral and inferior to the pubic two because I showed you in the picture. So females have it more commonly in males because they have a wider pelvis. Um So it can be caused by congenital, it can be congenital due to failed obliteration of the processes, vaginalis. It can be a weakness, sort of abnormal fascial opening or it can be the other causes that we've already discussed. Um So with femoral hernias, the surgery is more urgent because they're high risk of strangulation. So don't ever use sort of a hernia support bell or resus because it um increases the risk of strangulation often as well. The cough impulse can actually not be a, not be there because the femoral ring is quite small, the umbilical hernias. Um So some risk factors for umbilical hernias are afro caribbean infants seems to have them more commonly and things like Down Syndrome and beck with Wide Syndrome as well in adults. It can be things that we've already discussed such as obesity pregnancy. Um It's more common in females because it's especially common after pregnancy. Um It's often in young Children because um the opening for the umbilical cord blood vessels don't fully close. Um So if it's um asymptomatic, it's quite a low risk for complications. So it can be managed conservatively if it's symptomatic or the patient doesn't like the sort of look of it, it can have a repair with mesh. Um So in terms of newborns, um they might be born with them and they most likely will resolve spontaneously sort of by age of 2 to 3. So it's not something that they sort of rush into, um, into doing is repairing in newborn hernias. So just the last one we're gonna cover is incisional hernias. Um So that's when there's protrusion um through the site of a previous surgical incision. It's most common in the midline and per port site. Hernias obviously becoming increasingly common with the increase in use of laparoscopic surgery of open surgery. Um of quite a high risk of strangulation if the bowel actually gets stuck in them because the incision site is obviously much smaller than an open incision. Uh You can also get hernias with stoma, uh more likely with the colostomy than an ileostomy. So, some ri risk factors for them is if there's suboptimal closure after the operation, there's patient factors such as obesity, coughing, vomiting, eyes increases the risk smoking, peripheral arterial disease. And if it's been sort of emergency surgery or there's some sort of inflammatory process going on such as Crohn's. Um So it presents much the same. Um and also manage all hernias are kind of managed the same. It just depends femoral hernias tend to be managed more urgently and obviously, if they come in with any of the investigations, they're also going to be managed more urgently as well. So, appendicitis, such a common presentation, often people that we think of appendicitis don't turn out to be appendicitis because, you know, there's a lot of different things sort of going on, uh, in that area. Um, so pathophysiology does anyone know sort of what happens with appendicitis and why sort of the series events occur and why we need to remove the appendix? Yes, essentially um become blocked. Um either by sort of a lymphoid follicle hyperplasia of the lymphoid follicle. A Fali is often quite common could be a foreign body. There's also been cases of pinworms that have caused it and tumors or infection as well. Yeah, it could be af yeah. So then because there's a blockage there, stasis in the lumen mucus gets secreted into the lumen and the pressure in the lumen increases the appendix swells which causes stimulation of the nerves which causes the pain and um sort of localized peritonitis. Uh The appendiceal artery doesn't actually reach the distal appendix, it gives off capillaries and the pressure causes ischemia which leads to necrosis and then obviously, perforation, which is why if it's getting increasingly inflamed and swollen, we need to take it out. Otherwise it will perforate. Um So yeah, and obviously, if there's that stasis there, there's more for bacteria to sort of feed off and then they can multiply obviously pasta presentation. Does anyone know how appendicitis presents where the pain starts where it then moves to. Um, and what a patient with appendicitis might look like when they come to see you pain in the right iliac fossa. Yeah. Umbilical pain that moves to the right iliac fossa. Yeah. Great. And then obviously if the pain, if the appendix imperforate, it can then get more generalized peritonitis and garden and things. So you can also get a fever, uh, nausea and vomiting, diarrhea or constipation. Pain tends to be worse when moving, breathing, coughing. So they tend to want to lie very still rebound, tenderness at Bernie's Point and Garden. So Rosnick sign, which is palpation of the left, lower quadrant causes right iliac foci. So, yeah, so then we want to sort of get them at the point before it's perforated because it becomes a very nasty operation with um, obviously increased risks. We had a patient at the hospital who his appendix by the time we had got into surgery was essentially eroded. There was no appendix to remove, it was just clearing everything up and he was also HIV positive. So obviously he was immunosuppressed. Um So we were really quite worried that he was gonna become very septic because he had all the fecal matter all inside his abdomen. Um I don't think from what I've spoken to the surgeons about, there seems to be a way of knowing whether it's gonna perforate or not based on CT findings, there's been a few that we've took the, took surgery and it's been classed as sort of minor appendicitis on a CT. But we've got there and they've already had a perforation. So, based on what we've been talking about, any complications of appendicitis, sepsis. Yup, retinitis. Yup. So, yeah, you can get, um, abscesses. Um, you can get obviously chest infection when people have had surgery, um, often because of the abdominal pain, it and um, when they've been on um, ventilation, it means that the sort of the bases of their lungs might collapse a little bit. So I get ATPs and then because they're not doing deep breathing, they're not coughing because they're in so much abdominal pain, they're not clearing all the gunk outside, out of their um, chest and then you can often get um chest infections due to that. And so that's why we really try and keep control of patients pain and also get them chest physio, get incentive spirometer and really try to make sure that they don't get a chest infection. So when the, um, and so I've just got asked how would the lower legs of the lung be affected by appendicitis? So it's essentially when we take them to theater. Um, because of the pressure with the ventilation, it can be that um, the sort of the bases of the lung then collapse because of the ventilation. So, atelectasis is quite common after surgery. Um, which is often why we keep them on oxygen, um, for a couple of hours and things after surgery. And then because of that, that's what can lead to. Um, so it's not the actual appendicitis. It's just a complication of surgery, get collection formation, the investigations. Um, if there is a young gentleman or a young lady that's presenting with absolutely classic appendicitis, they've had their bloods done and things which is, um, leading you towards appendicitis. Do you think that we still need to do a scan on them before we take them to theater or not? What are people's opinions about it? So, yeah, it doesn't, you don't actually always need to give them a scan. It can be sort of based on clinical judgment by the time most people get surgery, they've had a scan because obviously the way like even emergency surgeries, unless they literally about to die without the surgery in half an hour, it's gonna be a couple of hours at least before we get them a surgery. But if it's someone that is, it is a very, very likely diagnosis that they have appendicitis, you can actually take them for sort of a diagnostic, um, laparoscopy and removal of the appendix. It's not, um, something that you have to do a scan for often, even if they find that there is um, no appendicitis, they will still remove the appendix because by doing the laparoscopy and possibly causing adhesions, it will increase the risk of appendicitis in the future. Um, so we always, we keep doing sort of beds bloods, that kind of thing. Is there anything that you would, especially in a sort of a younger woman you would really want to do before? Um, yeah, be very good. And what is, what is it that you're looking for potentially in a lady that might be presenting with, um, sort of rightly proserin, ectopic pregnancy? Yeah. So it's definitely the surgeons definitely like Gyne causes, um, to, um, be ruled out before we take them because it's possible either they've got a ruptured cyst. Um, it could be that they've got an ectopic pregnancy. It could be, they're having a miscarriage. Most likely there will be other symptoms to point towards that as well. But it's just something to keep in mind, especially for your oy um, that any sort of younger woman. So that's so you do ob sec g, urine dipstick and pregnancy test. You'd wanna do all the sort of classic bloods. Um, you obviously get, most likely get increased white cell count, increased neutrophils C RP would be raised very, possibly might have, um, an AK I if they've been vomiting. Um, I also want to do group and save do V VG to get the lactate. Um, because obviously if it's really high, they're gonna be first in the queue to go into theater. Um, you might want to do blood cultures as well as they're looking that this could potentially be a septic picture. So we've already sort of discussed the scans you can do ultrasound scan, um, should be what is done for appendicitis. It's obviously the sort of least risky scan we can do. Um, because CT obviously does come with risks but often in a, in a, everyone just seems to get a CT scan, um, sort of regardless. So most people will have had a CT scan. Um, by the time they get to use the sort of F one on the surgical ward. So just having a look at sort of just like a nasty swollen appendix compared to a normal appendix. So treatment, um obviously all treatment, like we said, of an unwell patient starts the same A two e stabilize sepsis. Six. Um Does everyone know the components of the sepsis? Six? I think we went over it last week. Well, it's, it's a question you will get asked every single day. Probably so. Yeah, it's three in and three out. If anyone knows any of the three on three in or the three out good cultures. Yeah, lactate. Yup. And urine output. Yeah. So they are the three out blood cultures and urine output and then the three in a fluids, antibiotics and oxygen. So, always do the same analgesia antiemetics. Keep them nil by mouth because they might take them to surgery. If they've got a gap on the emergency theater list, often they'll probably wait until the next morning, give them some antibiotics in the meantime, if you need VT prophylaxis. So, Ted Stockings and Delta par antibiotics as per guidelines. There's a lot of questions on past me about what antibiotics to give in a certain situation. There are obviously gu antibiotics that are given sort of more nationwide, but always just say I would give antibiotics as per guidelines because it is different from trust to trust. And that is based on the sensitivities in the local area. Um, so don't sort of be fooled by going on the BNF or whatever when you're working as a doctor, make sure you trust will have guidelines for them. So then you're gonna remove the appendix, um, and, um, always send it off, um, to see if there's any sort of malignancy or anything. Um, I have seen a few patients who have been really, really unfit for surgery that are being managed conservatively. So with, um, just with antibiotics and very strict observation. Um, but most people who are fit for surgery will have an app will have their appendix out. Um, and then if there's been a perforation, they're probably gonna leave a drain inside, um, for a couple of days to just remove anything that's not being sort of washed out. Um, because obviously if it gets stayed in there, it's just gonna form a collection or an abscess and they're gonna, you might send them home and they'll come back as just equally as unwell. So any questions on appendicitis or anything before we move on to diverticular disease. So, it's just any sort of like colorectal cancer, you can get the, um, carcinoid tumors can also be in the appendix as well, but it can, it can possibly be um, in older people, especially if someone's coming in with appendicitis, we're very, very suspicious that is, this is the, this is the colorectal tumor that's causing obstruction, which is leading to appendicitis. Um, so we definitely would want to sort of be looking out for that and sending it off to pathology. It's the same when we remove a gallbladder as well. Um, send it off for pathology. If it ruptures when it's time for surgery, would you play in the contest? So, yeah, you would, if it ruptures when you've, um, obviously had bef before you've had surgery and before you've taken it out what you do, you'd obviously remove the appendix, wash everything out and remove everything that you can do to sort of prevent any infection and then leave a drain, um, in for a couple of days, um, to hopefully drain anything that's kind of been left behind. So we move on to diverticular disease. So, does anyone know the pathology of why diverticular form? What a diverticula is? So, as you get older, the bowel does weaken over time. So that with abnormal or exaggerated smooth muscle contraction, there's unequal intraluminal pressure and then this causes pressure, which pushes out the um wall, causing out pouchings. So, essentially diverticula are out pouchings in the bowel wall. So they often form where supplying muscles transfers the muscle layer, uh trans supplying blood vessels transfers the muscle layer because the muscle as the wall there is weaker and the most common in the sigmoid colon. Um because this has the smallest diameter. So the highest pressure, anyone know any risk factors for diverticular disease. We're seeing it more and more commonly in younger people as well because of a particular risk factor. Yep. So, constipation um and sort of a low fiber diet, that's a big risk factor. So, low fiber diet and constipation, that's a big one increase in age because obviously, as you increase in age, the um the bowel wall gets um weaker, more common in men. So they've got a family history. Obesity is a big one that we're now seeing it a lot. Um, more in younger people, things like fatty food and red meat, connective tissue disorders such as Marfans S Danlos Polycystic kidney disease because obviously the, the wall is then uh weaker. So we're gonna go into complications before presentation because um I just think that would be an easier way to talk about the presentation. So, is there any complications that you can think that might happen? Because a person has diverticula, diverticulitis. Yep, perforation. Yep, sepsis. Yep, peritonitis. Yeah. So, yeah, there's a difference between, there's diverticulosis which is just the presence of diverticula. People can have them without knowing about them. They might not ever be aware that they've got them. And then you can get diverticulitis, which is obviously inflammation of the diverticula. It can lead to perforation and things like that as well. So, bleeding can be another one that can be a cause of pr bleeding. So, inflammation of the diverticula often due to a lodged fecalith which obstructs the neck of the diverticula stagnant bacterial multiplication. Very similar to what we were just talking about with appendicitis, perforation. Very similar. Again to what we were just talking about fistula formation. So you can get um sort of a color vaginal fistula or a color vesicular um fistula as well, abscess formation, sepsis, strictures obstruction. So, yeah, I wanted to do that before because then we can talk about the presentation of why someone might come into hospital. Um If they've got diverticular disease, does anyone know what most commonly is the sort of where is the abdominal pain in diverticular disease? Pr bleeding? Yeah, that was definitely a presentation of it. So, yeah, left iliac fossa. So there is evidence that um in sort of more in Asian patients that it is more in the right iliac fossa to just make sure that you're fully aware of um of your patient and just make sure that you're not missing things because they can sort of, they're not just in the left iliac fossa, blurting, diarrhea and constipation, pr bleeding. If they've got, if they've got inflammation, they might have fever, tachycardia, tiredness, the classic sort of infection signs, um, guard and rebound tenderness, nausea and vomiting. You can also get um increased urinary frequency urgency, diarrhea because of irritation of the bladder by inflamed bowel. And you can also get um sort of the presentation of the fistula. So if you've got um, like fecal matter coming out of the vagina, if there is um quite bubbly urine, that can be a presentation of a fistula. So you can classify um diverticula as uncomplicated. So that's just inflammation that doesn't extend to the peritoneum or complicated, which is diverticulitis associated with complications that we've just spoke about. So true, you can have either true of diverticula which are all layers such as knuckles or false, which is just a subur and submural false diverticula are much more common. So this is the hinge she um classification of diverticular disease. So it's from stage zero to stage four. So it sort of goes from mild diverticulitis, the CT findings, they're more, it sort of gets worse, obviously as you go down. Um, and this can sort of impact on how we treat it whether they need, not everyone needs antibiotics. Most people do tend to get them there, but they don't always sort of, they present to GP they might just not need them. Um, or if we potentially take them to surgery to remove the um sort of perforated section. Yeah, this is just another sort of um where we can have a look at the um complications so that an abscess. Ok. So a false diverticulum that is just where it's just the mucosa and the submucosa, whereas a true diverticulum like meckels is all the layers. Um So in terms of perforation and peritonitis, you get rigid abdomen with garden sepsis. Um I think we'll probably, hopefully we're all quite aware of the presentation of sepsis. Um So high new scores, meaning low BP, raised, heart rate, raised, rests, low urine output, you can get fistulas into the bladder or vagina. So feces in the urine, um like the bubbly, urine passes of feces through the vagina and obviously obstruction as well, which we've already talked about. So, investigations, anyone know what investigations we might do looking for someone with diverticular disease, but sort of long term and sort of in the acute phase where the bowel is all inflamed. Yeah. So CT and colonoscopy, they often don't get colonoscopy while inpatient because of the risk of perforation due to the inflammation of the bowel. Yeah. So you do sort of observations beds, uh bedside tests such as ECG or in the pregnancy test because again, obviously, it could be um sort of the next topic, pregnancy as well. So you can do CT S or also you can do chest x rays, abdominal x rays, CT, you'll obviously see the outpouchings much better. Um Yeah, you can do a colonoscopy as outpatient today just so you can see the little outpouchings of the diverticula. This is pneumoperitoneum and you can just see that pouchings. So treatment for diverticulitis, obviously, you're gonna start much the same as we have talked about, sort of over and over again. Um stabilizing the patient, giving them analgesia, giving them antiemetics, doing the VT prophylaxis, keep them know by mouth in case either they're gonna want to sort of put them on bowel rest or take them to theater antibiotics as per guidelines. Um, if uncomplicated can give them oral antibiotics if the symptoms don't resolve in sort of 72 hours or they've got severe symptoms, start them on IV antibiotics. You can always step them back down to oral antibiotics. If it's not appropriate to be on IV, you might want to tell them surgery to resect the section with diverticula and then sort of in the long term, you're gonna want them to reduce their risk factors. So things like increasing fiber in the diet, increasing physical exercise, stopping smoking, trying to lose some weight, all the modifiable risk factors that they've got, hopefully, um, get them to change that. So that's, you might need to prescribe, like give them smoking cessation advice, refer them to the smoking cessation team. What complication will lead to the. So, in terms of, so I've just been asked what complication would lead to the need of resuscitating. So, if a patient is septic, um, if they've, if they've got ap, um, if they're in bowel obstruction and it might be that if they've had quite a lot of diarrhea or quite a lot of vomiting, they might just be having an achy, they might be a bit dry, which needs resuscitating. Um, because often, you know, if it's more common in elderly people, they're often that bit more frailer and got an increased, um, sort of risk to any sort of insult, whether that's just a bit of vomiting, they might just need some fluids just to top them back up. Uh I hope that made it a bit more clear for you. Um, so, yeah, so that might be getting them to see the GP when they're, um, out of hospital to get them to see a dietician. Um, because obviously when people are elderly, they tend to be on the tea and t diet if they live alone. And so they might not have the best nutrition. So trying to really optimize their nutrition while they're in the hospital and putting things in place for when they leave laxatives as well if they're constipated. Um, often try and avoid nsaids, opioids, nicorandil as increases the risk of perforation with people with acute diverticulitis. So I appreciate this is a very whistle stop tour of everything. Um, and I'm sorry if I'm going too fast, but I will obviously, um, send the slides out and things um later on. So you'll have more time to sort of review the slides and please do contact me with any questions and things. So, ischemic colitis, I just run through that really quickly. So, does anyone know um, what area of the bowel is more vulnerable to ischemia? Yes. Very good. And we do, do we know why it's more vulnerable to ischemic colitis? Yeah. So it's, there's a watershed area between the S MA and the LA I MA. Yeah. S it's essentially decreased blood flow leading into ischemia, inflammation and necrosis. Risk factors are increase in age hypercoagulation disorders such as Factor Five Leiden AF is a really, really big one. So if you've got someone with um a patient with a history of AF and they're presenting with symptoms of ischemic colitis, which we will go through in just a minute. Have a very, very low suspicion and get a senior involved. Yeah, swell in fracture is most at risk because it's the watershed um area. So it's um where the blood supply changes from the S MA to the I MA. The presentation. Does anyone know how patient might present with ischemic colitis? Severe abdomal pain, especially after eating? Yeah, often it's abdominal pain that is completely out of proportion to any of the exam findings. So they might have quite a normal abdomen but just being absolutely in agony, sort of riding around on the table. Any change to the stool. Yeah, blood in stools. Really good abdominal pain, out keeping physical exam, pr bleeding with loose stools can get decreased or absent. Bowel sounds distension of the tummy garden and rebound tenderness might be very hemodynamically unstable. It's often something that is quite under diagnosed until it's kind of too late. Um, it's got quite a high mortality. So, if you just keep it sort of all, always in the back of your mind, um, it's definitely something that could, I've seen it a couple of times while I've been working. So, any complications, I know they've all very much been very similar complications for all the pathologies we've kind of discussed, but it's because they all kind of all interrelated in a certain way. Yeah. Necrosis, rupture, peritonitis, perforation, sepsis, organ failure. So that should say reperfusion injury. So it can be when we, um, sort of cause get reperfuse the bowel that can cause injury to the bowel ak investigations. Does anyone know what investigations we might do in if we're querying someone might have? Ischemic colitis? Yes. An ECG. Very good BG. Yep. And G. Yep. So I just pop all these on. So S ECG very important because if they've got af that's sort of another tick on the box of, it's quite likely to be ischemic colitis, you want to have a look at the lactate we were told definitely do not use this as a rule out test. Someone can have ischemic colitis. With a normal lactate. But if they do have a high lactate, that obviously increases the chance that they're gonna have it, raise white blood cell count. So you can do a CT or an MRI with angiogram or you can do an abdominal X ray, um which is um dilated bowel loops with thumbprinting cancer, pneumoperitoneum. If we've got um hair perforation, you can also do um a diagnostic lap. So having a look, see if the bowel looks dead and removing the bowel. Um, that is dead management. Obviously, we always start with resuscitation and, and it's very boring to keep constantly saying that. But if you've not resuscitated the patient, there's no way they can take them to theater because they'll just be way too unwell. So making sure that patient is optimized for theater really does increase the um outcomes. So, starting the sepsis six, making sure they've got antibiotics and keeping them nil by mouth. They're going to want to take them urgently to theater to resect any infected or dead tissue can also do thrombolysis at the same time. Um But we, when we got taught about this quite recently in the department, they said, you know, we would obviously speak to the vascular team. But the most important thing is sort of getting that dead bowel removed because even if you can restore the blood flow, if the bowel is already part of the bowel is already dead, it's going to need to be resected. So we're gonna do a very whistle stop to pr bleeding as well because we've covered already a lot of the things, um, that could cause pr bleeding. Um, but I just wanted to sort of let you guys know what it is we kind of do for people with pr bleeds. So anyone know any causes of pr bleeds, we've already gone through a few of them this evening. Fisher hemorrhoids. Yeah, that's really good. Hemorrhoids are probably one of the most common things that's gonna cause pr bleeding that will probably come to the GP. Yep. So, Crohn's can also cause um pr bleeding but it is more common with UC diverticulitis. Yeah. Colitis. Yeah. F Yeah. So it's really useful to know sort of where the, the most vulnerable area is for ischemic colitis because then you can sort of try and if that's where the ischemia is on a CT scan, you can think that most likely etiology is colitis is ischemic colitis rather than maybe infective or more like a uh IBD sort of picture. So, fis fistulas diverticular. Yeah. So like a blood disorder. Yeah, definitely IBD ischemic colitis, polyps, upper gi bleeds can also if they're quite severe, can cause pr bleeding infection, meles rectal ulcer, colorectal cancer, angiodysplasia. I mean, that's not even the exhaustive list. They're just kind of the most common things most commonly if it's in GP, it probably is going to be a hemorrhoid and we had hemorrhoids as one of our final year. Um osk A two E stations. We had a patient with an sort of hemodynamically unstable pr bleeding. And on pr examination you found a hemorrhoid. So what are the things if patients presenting with pr bleeding that you want to know about this pr bleeding? Because often the way it presents can kind of tell us where it's coming from. Yeah. All the tissue are mixed in. Good. What color is it? Yeah. Good. Is it fresh? Yeah. Amount of it? Yeah. Good. How long it's been going on? Good. Any mucus. Yep. Good. Weight loss. Yeah. So you definitely, or if they're in hospital or even in the GP, you want to know if they're stable. Um, yeah, painful and painless. Good with fever, night sweats. Yeah. Really good. So, if they're unstable you're obviously then going to want to, um, get them stabilized by giving them a fluid challenge, deciding whether you need to activate the major hemorrhage protocol and getting some blood in them. Um, because that's the sort of the most important thing is sort of stabilizing them immediately. So, yeah. Is it mixed in with the stool? Is it dripping into the pan? Is it only when they're wiping? What color is the blood? Is it fresh blood? Is it dark brown? How long has it been happening? Has there been a change of bowel habits? Are they going more commonly? Is it like really large? Volumes of sort of bloody diarrhea, sort of maybe leading towards more of like a ulcerative colitis picture. Is there sort of a shape difference in the shape of the stools, um, which might lead to sort of a, you might be thinking of more of like an obstructing tumor kind of thing. Has it been happening for a really long time which might maybe make you think more sort of, um, colorectal cancer? I like to always ask, is there any actual change that the patient has noticed? They might not actually think to say it, or maybe too embarrassed to say it unless you directly ask them. So, is there a lump that protrudes? Um, and if so does this lump go back in, does it stay out? Can they push it back in? Um, is there any mucus in the stool? Have they had any weight loss? Is there any painful? Is it painful when they pass stool? Is anyone unwell in the house? Um, is it, have they had any vomiting? They had any recent travel? What do they do for work that might sort of make you think more of an infective picture? Have you got any family history or any past medical history of bowel cancer? Um, or IBD? Yeah. Just making sure, especially if someone's coming in with pr bleeding or a change in bowel habit that you're just getting a really, sort of, it's can be quite awkward to ask people about especially if they're uncomfortable but making sure you're quite to the point and getting a really fixed picture of what's actually happening will help you before you've even done any scans. Have an idea what you think it is. If it's just someone that's getting sort of bleeding when they're wiping, they've maybe noticed that it's a bit itchy down there. Hopefully it's just kind of a hemorrhoid. If it's someone that has been sort of noticing a bit of blood in the stool for a while have been too scared to come and do anything about it. No, it's a bit of weight loss, a change of bowel habit and they're a bit older, you're more likely gonna be thinking this is some sort of cancer. So, what do we do about it when they're in the hospital? So we don't actually do loads about it while they're in hospital pr bleeding, we often just admit them resuscitate them if they need, observe them, correct anything that we can and sort of try and find the cause of it and we'll often do things about it kind of in the long run. So you have a stabilized patient, investigate do fecal car protecting, flexible sigmoidoscopy or colonoscopy. Often as an outpatient or sort of, um, you can do a flexible sig as an inpatient, but often they wait until they've been sort of stabilized and discharged because if someone's already a bit unstable because they've been bleeding, we don't want to get in there and give them loads of bowel prep and it's going to possibly set the kidneys off a bit more. So you can do act to see if there's any diverticula or any colitis. You can do an O GD if, um, suspecting an upper gi bleed. But these actually, I don't know if it's the same in every trust they're treated by the medics in our trust and then try and find the cause of it and treat the cause. So see if it's hemorrhoids, um, treat the hemorrhoids, get a patient to sort of try and increase the fiber in the diet, lose a bit of weight, that kind of thing. So, yeah, I'm very sorry. That was a very sort of whistlestop tour of everything. Um If you guys wouldn't mind filling out the feedback form for me and then I can get the, um, the slides and the certificates sent over. Um, don't hesitate to sort of email me any questions. Um, hopefully you should have my email by now. Um I'll pop it in the chat very quickly if you don't. And yeah, thank you guys for coming. If you've got any questions, just either email me or just pop them in the chat now and I'll try to ask them the best I can. Yeah. So if there's no questions, we'll end it there and um, hopefully see you all same time next week. Do you put a feedback form? To the link. Yeah, hi. Yes, there is. So I have a, um, I've got a contact, um, list for people that have signed up. So let me send you the link to sign up and I'll be able to contact you sort of every week with the time and the links and things. It's always on a Monday at half past seven. If that helps, uh, the link that's going through now is if you haven't already signed up and then I can send you an email. Ok. So we'll leave it there if no one's got any more questions, obviously, just send me an email if you need anything. And thank you so much for coming.