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OK, so we'll make a start. Um, hopefully everyone can see and see the slides and hear me. Um, obviously just let me know if there's any issues and if there's any questions throughout, um, just pop it in the chat and I'll either try and answer them throughout or I'll keep a note of them and try and answer them at the end. Um, so I'm gonna try and make it sort of as interactive as possible. Um, if you guys can pop some stuff in the chat or feel free to sort of unmute, um, and answer, um, obviously the more interactive it'll be hopefully the more engaging for you guys, it'll be. So just to, so we're gonna start with, um, gallstone disease. So if everyone can see this, um, diagram here, just so that we sort of know the, the basic anatomy. Does anyone know what this label here? It would be, uh, if you want to pop in the chart, if anyone knows, I'm so this one of the gallbladder. Um, and then there's, um, this one here. Does anyone know what this level might be for? So it's the, the duct coming out of the liver. Does anyone know what it might be? Um, so it's where the two ducks join. Yeah, hepatic duct. So, it's the common hepatic duct from the, um, the left and right hepatic duct. Then there is one here coming from the gallbladder. Does anyone know what that duct is? Yeah. Cystic dot well done. And then there's just this one here, which is the, yeah, common hepatic duct and the cystic duct together. Do you know what that, um, mix up? Yeah. So the common bile duct very good. Um, so we'll start, um, sort of going through everything. So, um, there's different terms to sort of describe, um, things with gallstones. So you can either have gallstones that are in the duct, um, which are obstructing, um, outflow from the gallbladder or you can have gallstones that are just in the gallbladder don't always cause any problems. But obviously, if they're there, there is obviously that risk that at any point it could move into the duct. So the different types of gallstones, does anyone know what different types of gallstones there are and what the most common type of gallstone there would be. But everyone wants to pop in the chat if they have any idea, sort of what different types of gallstones. So you can have cholesterol stones, which is the most common type, um, where the bile super saturated with cholesterol or there inadequate salts to hold it in solution and they precipitate as solids, you can also get bilirubin stones. Um So there's extra excess um, hemolysis. Um, and there's um, increased, uh, unconjugated bilirubin, which is, there's too much to conjugate it then binds to calcium instead of bile salts, creating black pigmented stones. Or you can have brown gall stones which are built from b bilary tract infection. So, does anyone know what type of pathologies you can have um, with the gallbladder? There's like three main types that you probably will get quizzed on, um, to do with stones in your exams. And if anyone has any ideas of how, how it might present if you get any problems to do with the gallstones. Yeah. So, bilary colic is one and we'll go through all these in more detail and then bilary sort of going a bit further on from b bilary colic. Is there anything else anyone can think of? Yeah. So, cholecystitis very good. And then just sort of one extra one. That sort of the, the other thing that you might get quizzed on in your exams? Ascending cholangitis? Very good. So, does anyone know the three things that make up shaker's triad? This is sort of a really good one that can sort of help you figure out whether it's most likely just to be Bilary colic, whether it's most likely to be cholecystitis or whether it's most likely to be shaker, uh, to be, um, ascending cholangitis. So, yeah. Um, someone's popular, right. Upper quadrant pain, obstructive, jaundice and fever and chills. So, if you're just presenting with right upper quadrant pain and there's no, um, sort of LFT derangement, no jaundice. Um, it's possibly just, um, bilary colic then sort of going on if you're getting, um, deranged LFT S, um, it might be more likely to be something like acute cholecystitis. And then if you're also presenting with the, you know, quite unwell fever and chills infective kind of signs, then you could think maybe something like ascending cholangitis. So, does anyone know what the risk factors for gallstones are? There's a really easy way to sort of remember the, um, the sort of main ones if anyone knows, like what that might be. So a great way to remember the risk factors are FS. Um, so, um, if a patient is overweight female patients, they're in their fertile years or, um, if they're sort of over 40 there's also some other risks including diabetes. Um, Crohn's disease. If they've had either sort of rapid weight loss, um, for example, they've had bariatric surgery or if they've had rapid weight gain, there's also, um, different, uh, medications that can increase the risks such as the combined oral contraceptive pill and H RT. But Bilary Colic, we've already, um, discussed it a little bit, but these are sort of the, um, symptoms that you might get with that. So you might get a patient presenting with, um, you know, several episodes of right upper quadrant pain might be radiating towards the shoulder. Um, they might have noticed that it's related to if they've had, you know, particularly fatty meal. Um, often the one I seem to get is after they've had sort of like fish and chips or something, um, they might also get sort of nausea and vomiting, but normally sort of the, um, they don't have any fever or, um, sort of infection signs and the LFT S are normally normal. Um, because often with bilary colic, it's that they have, um, obviously gallstones in the gallbladder, bladder and then that fat is causing the gallbladder to contract, which is ca causing irritation. Obviously, that can then lead to a stone potentially going in the duct. Um, but at, with just with colic, um, either the stern might come out or it might, um, pass, it's not causing any sort of blockage or inflammation. So, cholecystitis, I think that's kind of the next one on Charcot triad. So you'd get the right quadrant pain, you know, quite a similar, um, sort of presentation to, um, bilary Colic, but you'll also get, um, like a jaundice patient. So they might have sort of a raised ap, raised bilirubin. You might also get raised inflammatory markers as well because obviously, it's um, inflammation of the gallbladder. So you can test for this with Murphys sign. So this is where you press, um, just over the gallbladder. So, in the right quadrant and you get them to stop breathing. And when the inflamed gallbladder reaches the examiner's fingers where you pressing in, they'll have a sudden, um, stop of breathing. So that's called Murphy sign. And then so, Acalculus cholecystitis, I'm not sure if, um, anyone's sort of heard too much about it. So this is where you can have cholecystitis, but there's no gallstones in the g bladder and it's often very, very poorly patients. Um, has sort of multi reasons why it happens to gallbladder, stasis hyperperfusion and infection. Um It's often sort of very immunosuppressed patients and like patients that are on, you know, critical care. Um and it's got a very high morbidity and high mortality as well. So, ascending cholangitis, that's when you have, you know, all three of chakra triad, these patients can be sort of really poorly. Um So what happens with this one is because you've got gallstones um in the common bile duct, um you get um obstruction of the bile. So that means that there's not sort of constant bile going down the duct, allowing bacteria to ascend from the duodenum to the bile duct and cause an infection and E coli is the um main cause of that. Um So does anyone know sort of what makes up of uh Raynaud's pentad? So that's um if obviously we've gone through Jacquet's trial, I didn't know if anyone knows what sort of makes up the five signs of um the pentad. So the pentad is where you've got a triad, which is the right upper quadrant colic, the obstructive jaundice and the fever and chills that we've already talked about. And then you also get sort of hypertension and shock with altered consciousness and confusion. Um, these patients can be really poorly and they can sort of go off. Um, so you've got to make sure you get them on, um, you know, get blood cultures done, get antibiotics in. So, investigations, does anyone know how is sort of a good way to structure? What if you're in an ak sort of situation, how you might want to structure what investigations you would tell the examiner that you might want to, um, sort of go for. Um, so I find, yes, very good. So I find if you go to bedside, what examinations you do at the bedside bloods, um, any scans and then sort of any special tests. So it can work whether you're a GP or sort of in an acute setting. So, bedside, um, you want to do things like, um, observations, ecg, um, you might want to do sort of a glucose, um, bedside test. Obviously, I would like to say, you know, I'm seeing a patient, I want to do a full a toe assessment to ensure that the patient is stable and act on any of those. And then these are the bedside tests that I would also do. Um, does anyone know what bloods we would particularly be looking out for in sort of gallbladder pathology. Yeah. LFT S and, you know. Yeah, cop disease. Yeah. Very good. And any imaging that is sort of the best type of imaging that we can get in, um, gallstone disease. It's not always the one that is completed, unfortunately, but it is the one that is most likely to pick up gallstones. Yes. Ultrasound. Very good. Um, yeah. So, I'd like to do sort of observations at the bedside, do an E CG. Um, I've had a couple of patients that have presented with query, um, cholecystitis, but then actually it's turned out that they've ended up having Mr S. Um, so yeah, I'd want to do your bloods. I'd wanna do full blood count using these LF TSC RP. Um, always do sort of a clotting screen in case people might be going for sort of E RCP or any potential surgery that they might need if they're coming in on the surgical ward also, make sure they've got two grip and saves on file and do a grip and save if you, they need it. I also like to do a V VG just to see. Um, obviously that's an immediate test. You can get a result of and have a look at the lab. Um, so you get sort of a raised ap, raised alt, you'd get raised bilirubin, raised CRP and white cell count potentially. Um, depending on how poorly the patient is, you might also want to do some blood cultures. Yeah, abdominal ultrasound is normally, hopefully the first one that patients get, it tends to be by the time I see them they've often had a CT in A&E which doesn't always pick up gallstones. Um, so if you haven't found any gallstones and you're querying, sort of a gallstone pancreatitis or cholecystitis. It's not necessarily, um, rules it out with the CT S to try and get them a gallstone as well. So you can see, um, a thick wall gallbladder with gallstones in it. You'd like to, I like to know where the gallstones are. Are they in a duct? Are the ducts dilated? Are they just in the gallbladder? Um You also need to make sure if you're wanting to have your patient to have an ultrasound, you need to be fasted because the gallbladder contracts with food. So it's not, um, as easy to sort of see everything. Um Then from an ultrasound, you can move on to getting an M RCP. Um So that's indicated if you can see stones in the duct or if there is duct dilation or if the ducts can't be visualized on ultrasound scan. Um So it's often quite good. There's quite a lot of debate about when they should be getting an M RCP because it's possible if they've had a positive M RCP. So stones in the duct and then they're sent for an E RCP. Um It can often be that by the time they get to the E RCP, the stones actually passed. Um So obviously, it's like kind of a waste of an E RCP and an E RCP doesn't come without risks. Um There's a patient that's been on my ward who's been very poorly that's had pancreatitis because of um an E RCP. So you do need to try and make sure that the E RCP is going to actually be beneficial. So, yeah, these are just some um sort of examples of things that you might uh so images sort of an M RCP, an ultrasound and a CT scan. So any anyone uh any sort of complications of gallstones and sort of cholecystitis and things like that that anyone can have a think about. Yeah, an abscess. Yeah. Very good. Yeah, you can get um acute pancreatitis. Yep, gallstone eyelids obviously. Yeah, recurrence of the um because obviously once you've got those gallstones in there, you can get repeated attacks um until you get your gallbladder out. And even then you can obviously get stones in the CBD once you've had um a cholecystectomy. So a lot of people are saying um gallstone eli. So I don't know if, if someone who said it wants to sort of explain um what it is from your understanding. So we go through the other ones just while people are having to think maybe about a lot of gallstone ili is obviously you can get sepsis. Um So you can get very unwell. Um I've had, you know, there's been a few patients that have gotten really unwell um and had to go to critical care. Um So perforation of the gallbladder. So it might be possible that if it perforates, you might need to pop a drain in there if there's a collection that needs draining um pancreatitis, as we said. So, yeah. Goldstone Alius. Um So, yeah, it's when um there's adhesions between the gallbladder and the gastrointestinal tract, um large gallstones can cause pressure, necrosis, um causing formations of fistula and it causes like a mechanical small bowel obstruction and the treatment is still quite up for debate. Um Sort of whether it and it depends on where the site of the fistula is. So they'll either do it as um a two stage repair or one stage repair. So, removing the stern and eradicating the fistula either as one or two steps and there are some patients that are too. Um You know, they've got a lot of comorbidities. So you might just try and treat them conservatively. So, you know, keeping them no, by mouth, getting them an NG tube and hoping that the bowel obstruction will sort of resolve by itself. Um And then obviously, you can get a cholangiocarcinoma. If you get, you know, recurrent, um inflammation of the gallbladder, it might lead to some mutations. So, treatment, um where would we start in terms of treatment? Um So if you say all the F one and you've clocked a patient, you're pretty sure they've got cholecystitis. Um, what kind of things would you want to be doing to try and help them get better? Make sure you sort of think from, especially in sys, think from the most simple things to, um, trying to get a specialist help. And, you know, if you're not sure in the time of oss, you can definitely say, you know, as you know, as the most junior person on the team, I would want to have sort of a senior review and ask for some advice from that as well. So don't feel as though you sort of have to have the answers for everything as long as you've got um something to say that makes sense, I think is good. So, yeah, fluids, analgesia and antiemetics are sort of really important ones, um which are often missed. Um at our trust, we like to make sure they've got regular paracetamol, regular codeine and um P RN either morphine or oxycodeine um to sort of get them covered. So yeah, I would always start with doing a full a assessment and obviously correcting anything that needs um correcting from that point of view. So if they need oxygen, if you need fluids, um and then obviously, if they're very unwell, you want to start thinking about activating the sepsis six, so that I is three in and three out. So give them some fluids give them IV antibiotics based on trust guidelines and um IV fluids and oxygen and then three out is get catheter in them. So you can monitor urine output, blood cultures and lactate. So that'll be from sort of either your ABG or BG. And if you can get some cultures before you give antibiotics, that's really good as well. Um Always make sure you're thinking about VT prophylaxis. So, in terms of teds, if there's no contraindications, like uh peripheral arterial disease and um par or whatever, low molecular weight, heparin your trust users. Um, so then thinking about sort of treatments, once you've done the investigations, we in our trust give, um, I have antibiotics for cholecystitis as well. Um, so you would get them if they've had an M RCP that, uh sort of or a ultrasound scan that demonstrates stones in the duct, you can get them an ERCP to relieve the obstruction. Um, you can, in, when I was at med school, it was always a thing you try and do a hot cholecystectomy. Um, so I know it definitely used to be that we used to wait a while, but now you're supposed to sort of do them as soon as you can. However, in my trust, they still like to wait sort of six weeks and get them for a cholecystectomy as an outpatient, I think if it's sort of a pancreatitis caused by gallstones, they get it sort of more, um, quickly rather than if it's just cholecystitis. Um and you can also get a cholecystostomy draw. For example, if there's been a perforation or if there is a patient that's not fit to undergo a cholecystectomy. Ok. Any questions about sort of gall stone disease before we move on to pancreatitis. If there's any just pop um pop them in the chat if there is any so acute pancreatitis. So that's inflammation of the pancreas due to autodigestion by pancreatic enzymes. Increased intracellular calcium causes early activation of trypsin. It can be associated with system systemic inflammatory response that can impair the function of other organs or systems. So causes, does anyone know any causes or a good way to sort of remember the causes of pancreatitis? I get smashed very good. And um anyone uh any of the um what any of the letters stand for at all? Yeah. Idiopathic. Very good gallstones. Yup. Ethanol. Yep. So alcohol trauma. Yeah. Very good. Anyone know? Oh, scorpion stings. Yeah. Very good. Definitely. Wouldn't be the one I would go for first if a consultant on the ward round asks you um unless they've got a good sense of humor. Um So yeah, the um scorpion sting steroid. Yeah. Correct. E RCP. Yep. Mumps. Yeah. Great. So we'll just pop it on. You're, you're very good at knowing sort of the causes of pancreatitis, which is really good. So you can also get autoimmune. Um you can get hypertriglyceridemia, hypercalcemia and hyp hypothermia could also cause it. I've seen a few stems sort of on past med where it's potentially like a homeless person has come in. Um, and they've got this epigastric pain and you're sort of thinking sort of what is the cause of the pancreatitis. And it can be hypothermia, there can also be, um, different medications that can cause it. So, azaTHIOprine, some of the, um, so sort of like mesalazine. Um, we had a lady come in that was on one of the biologics for multiple sclerosis and had had several episodes of pancreatitis. So, and some diuretics as well can cause it. So, does anyone know how pancreatitis presents? And if anyone knows what Collins sign might be as well? Epigastric pain radiating into the back. Yeah. So, yeah, colon sign is periumbilical bruising. There's also gray Turner's sign, which is bruising in the flanks and Fox's sign, which is, um, sort of bruising over the inguinal ligament. Um I found that it can be sort of very variable on how the patient presents. Some of them, you know, give them treatment and they're better sort of in a couple of days, some deteriorate and get really, really poorly with pancreatitis. And you can also have sort of vomiting as well. And obviously you can think, you know, depending what the causes are, um, how they're presenting might give you some clues. So they had, you know, several admissions with cholecystitis, are they sort of known um, a known alcoholic? Are they really important to get sort of a thorough history of whether, how, what is their alcohol intake? Is this something that we need to be treating them for withdrawals while they're in patient? Because obviously you can get really poorly if you don't. Um, if you just, so I get a cold turkey from on cold. So, yeah, we've got just a picture of Colin sign on the left and greater a sign on the right. I haven't actually ever seen any patients with these signs but, um, if they're, they're there that sort of points towards pancreatitis and they can be in a lot of the stems for, um, exams or they might ask you to sort of define what it is. So, it's good to sort of be aware of them. So, investigations. So, we went through what's a good system, sort of go through how you would structure your investigations, any investigations of particular interest in pancreatitis that anyone's aware of? Amylase? Yeah. Very good. So, you know, any other, it's not as sort of well used as Amylase. Any other test we could do that actually might be potentially a better test. Lipase. Yeah. Really good. Um, lipase is very, very expensive. Um, so I don't think it's done very often at all. Um, but yeah, I think it is sort of better and it's raised for longer so you can, um, potentially detect it. So, yeah. So I'd want to do, you know, um observations ecg um And also, you know, you, you can always do a sort of a urine dip if you want to do sort of a full septic screen, things like that. Um So blood, I want to do full blood count using these LF TSC RP. So amylase is, it's diagnostic but it's not prognostic. So whether they've got an amylase of just three times the upper limit or whether they've got an amylase, that's 10 times the upper limit. It doesn't necessarily mean that that person is gonna be more sick than the other person. It's just a way to see that they actually have um pancreatitis. So, lipase, um so it's more sensitive than amylase and it's got a longer half life. So say if someone's had the pain for sort of two weeks or um then you can sort of uh you can detect it for longer. I always want to do either you, we in our interest, do sort of the ABG for the Atlantis scoring and you can do calcium as well because hypercalcemia so low calcium and that can um that can be prognostic of someone that's gonna be more poorly. So, ultrasound should be the first investigation for acute pancreatitis. Um because gallstones is the most common cause in this country um with gallstones and so alcohol being the two most common causes and ultrasounds are more likely to pick up um gallstones than a CT scan is, you can do a CT scan to sort of evaluate the um complications of pancreatitis. But they, I mean, everyone in my trust tends to get a CT scan in A&E. Um but they tend to like it a little bit later on because the complications tend to take a couple of weeks to sort of develop. Um So, yeah, this can be. So the Glasgow score um sort of how severe um a patient's pancreatitis is likely to be. Um So you, you need the pa uh two, you need the age neutrophil count, calcium renal function and sort of the enzymes. So the LDH with the ast the albumin and the um the glucose. So if you try and remember it using the acronym pancreas and there's quite a lot of questions on password and things about um what is sort of gonna be um someone that's gonna be more poorly than the other. Um So you can also use the Atlanta um classification which classifies as mild, moderately severe, severe. Um So I think with pancreatitis, you need two out of the three criteria for diagnosis. So it's a sort of the presentation of the abdominal pain. So like the epi epigastric pain, a raised amylase and ultrasound imaging confirmed diagnosis. You only need two out of the three, don't necessarily need uh imaging confirmation if you've got a high enough clinical suspicion, but it's good to sort of figure out what is causing in the pancreatitis. Yeah. Just some images of sort of CT pancreatitis. So, complications of pancreatitis. Anyone sort of know any complications sort of in the acute phase and in the more um the later phases as well. Yeah. So, necrosis. Yeah. Sepsis and shark. Yeah. Very good. So, in pancreatitis you tend to get um quite, you can get achy eyes because you can get very dehydrated because we tend to get a lot of third spacing. And so we, we try to make sure that they get a lot of IV fluids on board. So yeah, you can get um fluid collections which are just collections of fluid that lack fibrous granulation tissue. Um AK I often due to the third space and dehydration pseudocyst. So it's a collection that is walled off by granulation tissue. So it's often sort of four weeks after your acute attack. So with pancreatic fluid collections and pseudocysts, often they can sort of resolve by themselves, but they can be aspirated as well. You just have to, it's sort of case by case, depending on what they decide to get. Necrosis, abscess, hemorrhage, um chronic pancreatitis, obviously, depending on the cause sepsis, organ failure, and D IC as well. So considering the complications we kind of had to talk about, does anyone know sort of what the main stay of treatment for pancreatitis is while they're inpatient? So we like to give aggressive fluid resuscitation. Um Obviously, he wants to take into account if they've got heart failure or if they're elderly, but often they get, um, very dehydrated because of the third space. So they need a lot of fluid resuscitation and they're not routinely kept all by mouth anymore. Um, you want to make sure, you know, they've got analgesia antiemetics and nutrition is really key because they can get a really low albumin and it's sort of really key to try and keep them nutritionally balanced, wanting to make sure if they're going to be sort of in alcohol withdrawal or also making sure they've got reducing regime of sort of whatever benzo diazepines you use in your trust and making sure they've got PEX and thiamine and referring them to the sort of drugs and alcohol um team in your trust, uh early cholecystectomy, if there is gallstones present, that are likely to be the cause of the pancreatitis. Um I've not often seen antibiotics used in the treatment of um pancreatitis, but if there's any evidence of sort of infection or necrosis, you can use it. Um but it would be something that you definitely want to con um consult a senior about because it's not something I've seen routinely used the chronic pancreatitis quickly, just sort of go through what that is. So it's a persistent chronic inflammation um due to autodigestion. So it's a progressive inflammatory disorder leads to irreversible destruction of exocrine and endocrine pancreas with atrophy and replacement with fibrotic tissue. The causes some of them are obviously quite similar to um acute pancreatitis, including sort of alcohol. Um, obviously, if you get recurrent acute pancreatitis because of gallstones that you don't have your gallbladder removed for. But there's also causes such as cystic fibrosis. Uh, hemochromatosis can be idiopathic, can also be sort of a genetic component or some sort of autoimmune um, reaction. There's also things like pancreatic head tumors which are causing obstructions. Does anyone know how pancreatic chronic pancreatitis might present? And what sort of um complications patients might be getting? Yeah, ta can get um diabetes. Um because of the loss of the um cells that are producing the insulin can get weight loss, edema due to malabsorption, steatorrhea and the pain often typically wears after 15 to 30 minutes. Um after a meal, does anyone know how we might investigate chronic pancreatitis in a way that's potentially different to acute pancreatitis? You know, we discussed that acute pancreatitis ultrasound is often the first scan that should be done. Um Does anyone know what scan or what sort of um test we can test for for chronic pancreatitis? You can do um an abdominal X ray which should show pancreatic calcification. Often a high resolution CT scan is the most sensitive test for pancreatitis. You can also do um fecal elastase which will test for chronic pancreatitis as well. So here you can see sort of the um calcifications in the pancreas and again on the CT scan as well So we've finished pancreatitis. If anyone's got any questions, um, feel free to let me know if not, we'll just, quickly, we're quickly just gonna cover cholangiocarcinoma and pancreatic cancer sort of in the last 20 minutes. If anyone's got any questions, we can go through them either now or at the end. Um, ok, so if no one's got any questions at the moment, we'll just move on quickly to angio carcinoma. Um So it's a cancer of the bile duct. Um 10% are intrahepatic with 90% being extrahepatic. So, risk factors include primary sclerosing, cholangitis, liver, fluke infections, liver cirrhosis, chronic viral infection, a congenital abnormality of the biliary tree, things like obesity and diabetes. Um Bile duct stones, also ulcerative colitis and cysts in the bile duct. Does anyone know how a angio carcinoma might present? Yeah. Very good. So, painless jaundice. Um You can also get a pattern egly with sort of a palpable mass. You might get nausea and vomiting, weight loss. You can also get the C mary joseph nerds and vers nerves. So, it's the periumbilical lymphadenopathy and supraclavicular uh lymphadenopathy as well. You can also get pruritus with dark urine and stay out as well. So, yeah, really good. Make sure you're asking sort of your red flags um at any presentation. Um So you're gonna want to know obviously, has there been any weight loss? Um depending sort of what presentation you're looking for. Has there been a change of bowel habit. Um, has there been any sort of blood in the urine stool? Um, and has there been any, um, sort of loss of appetite? How long has this kind of been going on for, you know, more acute presentations? We're thinking more likely something like cholecystitis if this has been going on for quite a long time thinking something potentially more like a malignancy. So, investigations. So we would want to do observations. Obviously, we want to do sort of um bloods, full blood count using these LFT S. You probably see a raise bilirubin and AP also do tumor markers such as ca 19 9 and C EA and wanna do a CT in screen as well. Um So, depending, obviously when you're seeing this patient, they might have already had a few things done. You'd want to have an ultrasound scan to see what um probably maybe invest investigating for gallstones, see if there's sort of any mass or anything there. You might want to see this further with an M RCP. So you can sort of evaluate the ducts and potentially you wanting to do a CT as well. Um And you might also want to do a sort of an E RCP with biopsy. So in terms of treatment for cholangiocarcinoma, um does anyone sort of know anything about the prognosis or what treatment we might um do for cholangiocarcinoma? Yeah. So surgery sort of a resection um is often quite a poorly survived um diagnosis. The average is about 12 to 18 months as most patients aren't able for resection. So you'd want to make sure that those patients, you know, have every bit of support that they need, that they're seeing sort of specialist nurses that they've, the symptoms are adequately um controlled. You might also want to do sort of palliative radiotherapy or palliative chemotherapy. You can also do E RCP um with stenting if there's any obstruction, um if we're not sort of doing a resection, um and just really making sure that um the family is involved that we've got, um you know, the really difficult conversations have taken place. Um It's not necessarily something that you guys have to do as an, an F one. But it's definitely something you should kind of try and be involved in whether that's just going to the discussions and seeing how your seniors are doing it. Um You know, because often we've got patients that are really sort of in the last days of their lives um with metastatic cancer on the wards that do and have a respect form filled in. Um And this needs to be filled in by someone's registrar or above. So it's definitely trying to have those conversations with your seniors and trying to make sure that people that, you know, are potentially going towards um their end of their life, making sure that if they're not for resuscitation that that's documented and that we're aware of what that patient values most, whether it's prolonging life or whether it's sort of getting comfort. Ok. So, moving on to the last thing, um, last sort of 10, 15 minutes. Um, so pancreatic cancer, does anyone know any risk factors for pancreatic cancer? Smoking. Yes, it's always a good one to go with smoking. It's often a risk factor for pretty much everything. Um, we'll just go on to risk factors first and then we'll go back. So obviously increase in age as well as one chronic pancreatitis. Very good diabetes. Very good. Often, if there's kind of things, you can't, if you're in an osk situation and you really can't think of what might be a risk factor, diabetes, age smoking, obesity, lack of exercise are often really good ones to sort of, most things are not gonna be helped by, um, those kind of things. Um, gallstones as well. So obviously that would maybe cause a chronic pancreatitis. You can also get, um, hereditary nonpolyposis. Colorectal cancer is a risk factor, multiple, multiple endocrine neoplasia, the BRCA two gene and the CRS gene mutation. So in terms of pancreatic cancer, 60% are in the head of the pancreas, um, 25% in the body and 15% in the tail, 95% are in the exocrine pancreas. But there are also different kinds, um, in the endocrine pancreas. And there, there, there are several questions I've seen in sort of past med and in exams where they give you sort of a few different symptoms and it's a, a specific sort of type of endocrine pancreatic cancer. So, an insulinoma that can present with either fasting or exercise, induced hypoglycemia with increased insulin and an increased C peptide. You can get a gastrinoma which secretes gastrin, which increases gastric acid. So you get presentation with sort of peptic ulcers and diarrhea, um, a glucagonoma. So these, it's like the D is how you can remember it. So, diarrhea, diabetes, DVT decrease in weight and often also present with a blistering rash and hair loss, uh with glossitis and angularis as well. So you can get a soma somatostatin as well. So, um that inhibits glucon insulin release and um pancreatic enzyme secretion, which can increase the risk of diabetes and gallstones. And you can also get a VIP um which is in the D cells causing high volume diarrhea, which is tea colored and less increased vasodilation, um and increased bone resorption as well. Um They aren't as important to know about, but just so that you're aware of them because there are definitely questions on them gone over the risk factors. So, presentation of pancreatic cancer, anyone got any ideas how it might present? There's often a lot of questions on this. Um sort of given sort of a vague history of a patient and how they present and trying to figure out if they've got cancer. Where is this cancer or is it sort of pancreatitis, that kind of thing? Ok. So we'll go through the presentation if no one's got any um ideas. So you can get painless jaundice. Very good. Um So you can also get pale stools, dark urine and pruritus, the classics of kind of loss of appetite, weight loss, generally unwell. Um You can also get um, recent onset diabetes. So there's a law called Co co Law. Um so painless obstructive jaundice with a palpable gallbladder is unlikely to do with gallstones. So, if you have a right upper quadrant mass with painless jaundice, think pancreatic cancer, um also can get steatorrhea and sign which is migratory thrombophlebitis. So anyone know about any investigation, if we do have pancreatic cancer or what sort of, um, markers that we look for? Pancreatic. Yeah, pancreatic cancer. Yeah. See you 19 9. Really good. So, again, if any patient that's presenting to hospital, you're always gonna do the basics first. Um, and you wanna, you're gonna wanna do obviously bedside observations. EK GSI wanna do a urine dip. You're still gonna wanna do all the, you know, full blood count using these LFT S um C RP clotting group and safe. Any, any patient that's admitted to a surgical ward, those are not wrong answers. Um Even if you think they potentially might not be, um, gonna be going for surgery, it's good to have a, um, group and save on file if you're gonna need to transfuse them as well. Um So ca 19 9 is uh the marker for pancreatic cancer. Um It's really good to try and sort of remember in your head, the markers for the different cancers because that can often come up as questions. Um You can also um do so on a high resolution CT scan. A classic thing you'll be asked about is the double duct sign, which is dilation of the common bile duct and the pancreatic duct. And that is a sign of pancreatic cancer. So there's loads and loads of questions about, you know, a patient presenting with painless jaundice mass in the right upper quadrant and a CT which shows a double duct sign. What is the presentation, you know, a mass in the right, right upper quadrant, you could definitely be forgiven for thinking, you know, cholangiocarcinoma or um something more to do with the gallbladder, but make sure you're always having pancreatic cancer in your head. If there is painless jaundice, that's gonna be the most likely explanation of that. Yeah, just some pictures of the. So this is a doubled up sign and obviously pictures of the um pancreatic head tumors. So yeah, that's everything that we're gonna go through um today. If anyone's got any questions um for anything we've discussed today or any questions about surgery in general, um or anything that I can help with really just either put them on the chart or mute yourself and it's just a QR code for the feedback form. Really appreciate if you guys fill that in for me and it with um that I'll be able to send you guys the slides for today and the certificate so that you guys are here. Um Yeah, any questions, fire away. I'm more than happy to sort of answer any questions you guys have about anything to do with surgery, anything to do with working in the hospital or any concerns you guys have. Yeah, but someone got a hand up but they wanted to ask a question. Yeah, I'll just stay on for a couple more minutes and if anyone's got any questions, just pop them in the chat or just unmute yourself and feel free to sort of an, I'll, I'm happy to answer anything, uh, or if anyone's got any questions they don't wanna ask on this, obviously, feel free to just email me. Um, any questions you guys have at all. Yeah, I'm gonna stop sharing now guys and if you fill up your feedback form, I'll get everything um, to you guys as soon as I can. Thank you so much for attending and hopefully see you guys next week.