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Even like even like a month before the exam. So please either use things like nice C KS or um resources like past medicine that kind of keep things up to date. Ok. And also realize if you are a junior doctor protocols, er, in hospitals can be quite old fashioned and not actually the nice guidelines. So that's something to be aware of as well. Ok. So let's start straight away uh with an SBA actually, we'll go thr briefly through this. So I'm sure you've heard of this, the regional abdominal pain, er, and this, you've probably seen a lot, but it's a good way of kind of er putting a diagnoses in different areas of the abdomen where someone kind of, er, is complaining of pain. Now, there's a lot of overlap with these different areas, but it's a very good thing to use for kind of exam presentations. So if someone presents with epigastric pain, most likely it's one of these kind of key conditions like heartburn, pancreatitis, et cetera. Uh in clinical practice, this isn't, isn't as reliable, but a lot of the times in OSC S and exams, they'll kind of use these use these areas when they're talking about conditions. So it's a very good clue and it's a good thing to go through. Ok? And you'll get the slides. So don't worry, I'm not gonna go through every single one. All right. So starting with an SBA uh Sylvia 64 year old woman presents to A&E with abdo distension and green bill. Vomiting on examination, tingling, bowel sounds are heard. ABDO X ray is taken to confirm the diagnosis. So there's the image, uh I'll give you like 30 seconds. Uh, just so you can think about it or put it in the chart if you want. Uh, and then we can take it from there. Ok? I think that's everyone so we'll move on. Er, so we've got d large bowel and c small bowel obstruction. Ok. So this one's actually quite a tricky one and the ac the answer is actually a sigmoid volvulus and there's something very characteristic called the coffee bean sign. If you can try and orientate it, you can see it kind of looks like a coffee bean and that's a very, very like exam style, er, question. And once you see that kind of picture, once you see that shape, always think of a volvulus, specifically sigmoid. And you can usually tell, er, if it's a cecal or sigmoid from kind of the kind of area of the abdomen is coming from small and large bowel obstructions, um, will look different on x rays and we'll go through that in a second. Ok. But by the end of this, you should know confidently how to diagnose these on X ray. So firstly, we'll go through the pathophysiology. So it's a surgical emergency in a lot of cases. And it involves the obstruction of food and, or fluid and, or gas complete obstruction is when there's, there's obstruction of all three of these. So, uh the key thing to remember is is that it's ultimately just a blockage somewhere in the gi tract and that causes back pressure and then that causes dilation of the gi tract. Above that. Above that blockage, there's a concept called third spacing, which used to um it used to confuse me a lot and it, it essentially leads to hypervolemia. And the way someone explained this to me is it very simply the gi tract produces a lot of digestive juices and it slowly is reabsorbed down down the line in the gi tract. So imagine all these juices are being produced, but then there's a blockage, you're not gonna get it reabsorbed, but it's gonna continue to be produced. So that's why people can get huge amounts of vomiting or energy aspirates, er and also become very hypervolemic. People can lose liters in this way. So it's very important to fluid resuscitate them, for example. And that we'll discuss that in a second, the three key causes you need to know for exams especially are adhesions, hernias and malignancies. There is other causes, uh, like interception volvulus, which is one of the ones I put in. Uh, but these are the three key ones that you should always think of, uh, in exams. So the way it presents this is, is in an exam, er, style, it will be very classic. You'll get the distention, you'll get central abdominal pain and it usually is diffuse, it's not localized to one area. Er, you'll get vomiting, you'll get constipation. And the key thing we ask in Aussies, for example is if they're passing, um, gas cos, if they're not, then, then we're a bit more worried. That means there could be complete, um, obstruction and tingling bowel sounds is another clue I put in the, er, in the, in the questions, then investigations a X ray, er, always, always the first line, even though it's not as good as CT CT will tell you exactly where it is. Um, however, a lot of guidelines, always say you get an Abdo x-ray first to make sure it is obstruction and then they move on to ct good rule. A good rule to remember is a 369 rule. So that's the upper limits of how di dilated each part of the bowel should be. So the small bowel should be no bigger than three, the large, no bigger than six centimeters and the cecum no bigger than nine. And obviously, it's important to ask for a erect chest, X ray as well. If we're suspecting a perforation, cos if there's a perforation, there will be gas released and that will settle just under the diaphragm. Ok. So, um, does anyone wanna put in the chart or at least think about what this x-ray looks like? I'll give you some hints. It's kind of central. These are dilated loops of bell. Ok. So we've got large bowel from both, any other guesses. Ok. So this is actually small bowel obstruction and a very, very easy way of telling this that it is small bowel is if you look very closely in the dilated loops, let me actually a point to it. Yeah, we can see that there's a radio opaque line ie the white lines extend all the way from one side to the other side of the bar. Ok? And that signifies something called the valve contes or however you say it and thus just basically represents the mucosal fs in the small bowel in the small bowel. And this isn't found in the large bowel. So if there's a white line stretching all the way across, it's small bowel, that's a very easy way of knowing it. Ok. And it's called this All right. So hopefully you'll never get that wrong again. Let's contrast it with this x-ray. So what do you think this is now that I've told you what a small bowel looks like bowel obstruction looks like exactly large bowel, large bowel. So we can see here that the lines, they're not extending all the way across, it just kind of, it's kind of like just punching in and this represents something called the Haustra. Ok. And it's just how the Mucosa looks like, uh, in the large bowel. Ok. So very simple. If the line's all the way across, it's small bowel. If it's just like this kind of peeking in, then it's a large bowel. All right. And also you can, you can kind of tell this is peripheral, it's kind of bent here, but you can tell that it's mainly peripheral in the, in the other, in the other side, it was mainly central. So that's also another clue. Ok. So what does this signify? I've kind of helped it with the arrow here, but there's something abnormal going on here. Does anyone know what this is or at least what it, or what it's called? Give me a few seconds. Yeah. Air under the diaphragm. Exactly. Neo peritoneum. So this is what I was talking about earlier. So when a bowel, when the bowel ruptures, then the air will, will travel up just because of densities and you'll see it just under the diaphragm there. So it's a very key and now be very careful not to confuse it with this. This is a gastric bubble. So it's, this is an air bubble in the stomach, but you can see how it's, it presents slightly differently to the Neer Peritoneum here. Here, it's a very clear kind of level and you can see like the air here, here, it's more circular and it's not necessarily at the very top of the diaphragm. Ok. All right. This is another course of bile destruction, er, called interception, otherwise known as telescoping. And this is a common peds, er, presentation and another very common exam, uh, kind of buzzword is what's happening in this ultrasound scan here. Does anyone know what this is or if they don't, what does it look like to you? Can, you, does it look like something else? A sign you've seen somewhere? Target sign perfectly. So sometimes it's called target sign. Sometimes it's called donut sign even, but that's, that'll come up. So in the stem it'll be like ultrasound shows target sign and he already knows interception. Ok. So it's very good to know these buzzwords. All right. So the key management is something called drip and suck. And what basically that means is, is you, you give them fluids and you also suck out all the digestive fluid, digestive juices. That's, um, that's piling up in the gi tract as well. So you'd keep them nil by mouth, you wouldn't give them anything, you tell them you're not allowed to drink or eat, you give them IV fluids and you'd also put an NG tube as well for free drainage. Now, a lot of the time bowel obstruction is actually partial. So this can actually relieve this can actually relieve a lot of, um, the symptoms and eventually relieve the obstruction if it does not. And if the symptoms are worsening, then, uh, then they may actually go for surgery to treat the underlying cause. So, if it's a hernia to put the hernia back to where it's supposed to be, it's the tumor to resect, et cetera. Ok. Paralytic ileus is basically when the bowel. So usually there's smooth Rhys, um, rhythmic contractions throughout the bowel. That's what's propelling your food. Now, if something stops those muscles from moving as much, then the food just stops there. The bowel dilates and it, it mimics the same, the same, er, presentation as an obstruction and there's a lot of causes for this. One of the most common ones is POSTOP. When you're in, you're, when you're in surgery, you might not see this, but a lot of the surgeons, if they're looking for something for, um, key, they might go through the whole length of the bowel, literally handling it with their hands. And that, that's a lot of, that's a lot of movement for the bowel and think of it, of the bowel just being shocked. It shouldn't be handled that much. So, even that can cause an, er, paralytic illness, electrolyte, imbalances can be a subtle cause as well as well as infection and injury. So, the management is very similar to bowel obstruction, drip and sac, but also trying to actually, er, get the cause, find the cause and actually treat the cause of it. Um And people sometimes may even have to go into TPN, which is when they just give all the nut nutrients through, uh, through IV. Uh, instead of inter until the, the bowel regains function. So another question, Ali 47 year old man presents his GP with a lump in his groin that disappears when he lies down. He's diagnosed with an inguinal hernia, which of the following statements about an ual hernia is false. So I'll leave you, I'll leave you some time to read this because this is a little bit longer. Wait 10 more seconds. There's no harm. Imagine this is an exam scenario. A we've got a and you've got D as well. Ok. So the answer is actually Sikh and that ST and strangulation is relatively uh oh yeah, it is relatively common. So that is false because it's actually uncommon in inguinal hernia. Specifically, the others are actually true, but we'll go through that in a second. Ok. So abdominal hernias. So there's a lot of type of hernias. But the key thing you need to know is just a weak point uh in the cavity wall and it just allows the, the bowel underneath that cavity to protrude. And the key thing is to remember is a word called reduce ability. And that's the ability for, for you to, to push that uh to push that herniation back into where it's supposed to be. Uh and we'll come on to why that's important. Next in the next slide. Uh Key symptom is protrudes, coughing uh when coughing or standing. And also a lot of patients will say it's an aching, pulling or dragging sensation as well. So it can see, seem quite abnormal to the patient. And there's three key complications you need to know about incarceration is when, when you try and push the protrusion back in, but you can't. Ok. And that's called incarceration. And that's important. It's not necessarily in an emergency because if the food's going through normally and if the blood supply is fine, then it's not a big deal unless the patient, unless it's unless the patient um is quite distressed about it. A lot of people live with incarcerated hernias and I'm totally fine with it. Obstruction is when the food can't go through. So we get the symptoms of obstruction and obviously that's, that should, that needs to be treated. Strangulation specifically refers to ischemia. So as you can see from the picture here, so when the blood vessels, when it's so tight that it's, it's constricting the blood vessels, that's when it's a surgical emergency. Cos obviously that bile that bowel can die off can become necrotic, patient can become septic, et cetera. So it can be very dangerous. And as you can imagine, uh a hernia that is in incarcerated is more likely to be strangulated. So that's why even though we don't have to do anything if they're incarcerated, we have to keep an eye and we have to safely net the patient uh to know about the symptoms of strangulation. Two key hernias, we need to know about inguinal and femoral and with inguinal, it can be split into direct and indirect. Now, originally in this, I actually went through the whole embryology, explaining direct, indirect, but a lot of people complained because firstly, embryology is horrible but it's not actually that relevant in exams. Er, and I could have spent time talking about something else more. So I'm gonna keep the slides and you can have a look at it in your own time, um, because people can get lost. But the key thing to remember about all this, er, lecture I was gonna give is a, is when you reduce a hernia is when you reduce a inguinal hernia by pressing on the deep ring, which is somewhere in the middle of the inguinal ligament just underneath, er, if it protrudes when you cough, it's a direct. If you're pressing on the deep ring and you cough and it doesn't protrude, then it's indirect. Ok? And I'll leave it at that because I don't wanna get, get too complex. And again, this is more about the embryology and this is more about the anatomy itself. Um I'm just gonna give you an example. So viewer discretion is advised if you're squeamish et cetera and this is quite a sensitive body part. This is what kind of hernias can even look like sometimes. And you can imagine this patient wasn't bothered by it for a long time until it became significantly debilitating. So, this is an example of how an incarcerated hernia can stay um for a long time until the patient actually wants to do something about it. Femoral hernia is just in the femoral canal. And the key thing to know about this is it's a higher risk of strangulation, er and it is more common in females. So this is what was wrong in the questions stem because I said that inguinal hernias are more common are more commonly strangulated and that's not correct. So, what I've done is is kind of summarized all this in a, in a table and this is the key things you need to know for exams basically. Uh that the that the strangulation risk is high for femoral hernias, it's more likely in females and indirect hernias is more mostly occurs in infants. It's good to know the anatomy as well, less tested. Um But as I said, I don't wanna go through it because a lot of people complain last time because it's not that relevant, but for your interest and for your understanding, uh so you can work out in the exam if you do forget, have a look at the slides. Ok? And these are just some other hernias to be aware of, usually named from where the protrusion is coming from, umbilical, from the umbilicus incisional, from a previous incision site, usually from a previous surgery. Um, an epigastric just in the top part of the abdomen. Another one which has some examples, words as well. So, obturator hernias, if you get pain when you're extending the, er, when extending from the inner thigh to the knee, um, then it's something called the hausch Romberg sign and that's because of the compression of the obturator nerves. So if you ever get someone presenting like that, er, the knee, it kind of gives you a clue, hiatus, hernias, it's probably one of the most common hernias you'll see in clinical practice, you'll see on literally half the chest X ray reports when you start working and these are the different types. Sometimes you'll get tested about this in exams, type one. So looking at the diagram, the black, the small black ring. So yeah, the small black ring represents the G OJ, the gastroesophageal junction. So type one is when that junction is above the diaphragm. And then so a bit of the stomach is behind it. Type two is when the G OJ is at the diaphragm where it should be, but a bit of the stomach is protruding. Type three is both of one and two is a combination of one and two. And type four is just when the hole is so big or when the protruding is so big, then other other abdominal organs are going through. So that's, that's a bit of small bowel as well. Ok. And the recti, if you ever look at any bodybuilding shows a lot of these, a lot of people who have very distended abdomens, their six pack, er, there's like a big, there's a, like a big, um, gap in between their two kind of, er, in their six pack. And that's what dire is basically widening of the linear. Ok. So hernias, the management, as I said, a lot of the time is conservative, depends on how, how symptomatic the patient is. Um, there's even something called a hernia truss, which is just a waist strap that p patients can put in if they're not fit for surgery if they don't want it. And finally, there's something called surgical mesh repair and that's usually, uh, the thing that's has the lowest recurrence rate and it just involves repairing the defect using, uh, a bit of surgical mesh. All right. Let's go into another question. So, Niel, 45 year old woman with a background of bilary colic is complaining of severe epigastric pain serum amylase is found to be 1200 which of the following features are not associated with the likely diagnosis. Again, this is very hard because you need to know is, and you'll get a lot of these questions like what's not. So, give me about 20 seconds. All right. So we've got answer e the answer is actually ci can see why you would have thought that cos what's it got to do with the eyes but never discount it if it seems odd. Cos there's a lot of rare complications of things. Ok. So pancreatitis, let's go through it. So it's inflammation of the pancreas, the itis and pancreas, it can be acute or chronic. Acute is when it happens suddenly. Uh and usually the normal function of the pancreas returns later on. And that's very key because chronic, it's a longer term, but usually it causes permanent deterioration of the function of the pancreas. So we, we, we talk about exocrine and endocrine exocrine um is reserved for kind of like the digestive juices. The enzymes, endocrine usually refers to the insulin that's produced by the pancreas. Uh three two, he cause is very important. OK? And there obviously is a lot more causes and there's a lot of acronyms that you can use. Um but whatever works for you just use it. A lot of people get the Scorpion thing. There's a, it's not the best acronym. Cos obviously, when you go to other drugs, there's like a million other drugs. So whatever works for you try and memorize it. But the key things you need to know, the ones you need to know is gallstones and, and uh and alcohol, OK. Presentation presents as epigastric pain, quite severe and sometimes radiating to the back as well. So a bit of an unusual and that's just to do with kind of referred pain. You'll get vomiting, which is very, very common. Some people get tachycardia, some people get low grade fever as well. Two exam buzz words, colon sign and Gray Turner signs. The colon sign is when there's periumbilical er discoloration. Gray turners is when this flank discoloration. When I talk about discoloration, it kind of looks like bruises and retinopathy as well. So very a bit random, but hopefully now you've got it wrong. You won't remember this. You'll remember this. OK. Investigation. So you're probably so we look at the digestive enzymes that the pancreas produces and the two key ones are amylase and lipase, amylase is a very common one. But please remember that even if it is raised, it doesn't mean it's pancreatitis. It has to be raised by a lot up to three, more than three times the upper limit. OK? Um but it's not a perfect marker can be raised in a lot of other things as listed here. Lipase is more sensitive and more specific and has a longer half life. OK? And early ultrasound imaging again is quite important as well and useful. There's a lot of scoring systems to kind of grade how bad the pancreas is as well in terms of severity. This these are the parameters used in something called the Glasgow score, but there are a lot of other ones like Ranson er or Apache or Apache or whatever or however, you say it. Um but it also helps you kind of remember what to interpret in blood test results. So, like neutrophils, uh the urea is quite important as well and the hypoglycemia uh that you can get uh OK. And yeah, so every, every, every single, every single scoring system has its own scoring system that those scoring systems, although you might think they're not relevant, it's good to know because you might get these parameters in like an exam or blood test and you need to interpret them. So it's quite good and it sometimes it's the only clue in the, in the questions then and management. Um because there's so much third spacing, we it always, it always involves a lot of fluid resuscitation and obviously, a lot of vomiting happens in these cases as well. So aggressive fluid resuscitation, fluids, fluids, fluids, um and obviously a lot of painkillers as well cause it can be very, it can be very painful and gallstones. So all the causes that we mention for pancre for pancreatitis. Obviously, we wanna treat those as well. So it's important to kind of investigate what's caused the pancreatitis. And the very key thing here, antibiotics, people's inflammatory markers will be raised in pancreatitis, but it doesn't always mean there's infection. Ok. So that you only give antibiotics if there's evidence of infection. And a lot of people even in clinical scenarios, give antibiotics when it's not warranted complications. Key ones are necrosis infection. There's a lot of other, um there's a lot of other things like pseudocysts as well and that's just to be aware of and you can get chronic pancreatitis. So, II said before that normally returns to the function, normally returns, but it doesn't always and it can develop into chronic, especially if you've had multiple bouts of acute pancreatitis. So, chronic microtitis, uh alcohol as well is a, is a common cause similar kind of pain, er, but not as not as severe. It's still in the upper gastric area, loss of the exocrine and endocrine function. We talked about earlier an investigation. ABDO x-rays can see. So the key thing you're looking for in chronic pancreatitis is actually calcifications. It's not that it's not that good, it's not that good at picking it up on ABDO x-rays, but CT S are very sensitive and a lot of most people in the liver surgery department will get CT S. Uh and fecal elastase is good as well to measure kind of exocrine function and similar management analgesia. But obviously, if you're losing that function of the pancreas, you need to replace it. So there's something called Creon, which is just a, a lot, just a group of enzymes that you can give the patient if they're obviously lacking it cos they can't produce it and it helps them digest food better. Um, and then also if it develops into kind of diabetes, uh you may have to kind of supplement insulin even when, when the endocrine function is that, is that kind of debilitating? Ok. So let's move to another question. Karen, 46 year old female has been diagnosed with ascending cholangitis. Your consultant tells you that rarely these patients can present with a collection of symptoms called the Raynaud's Pentad. Which of the following statements uh about this are true. This is very hard, but I thought it's good to have hard questions to kind of challenge. But I'll, I'll, I'll leave a minute for this. This is quite long. Tell me a suggestion and more seconds. All right, we've got you. Ok. So the answer is actually er d but you're very close, you're very close. So the way I remember it is, it's just shock odds, triad plus shock and confusion. And so you nearly got it with the ultimate meta stasis, but it's hard to remember that. So I'll go through that in a second watch how con try it is. So let's go through it. So acute cholangitis, acute, meaning sudden itis, there's an infection somewhere col it's in the biliary tree. So it's an infection of the biliary tree common. Um, buzzword common cause in exams is E coli then is followed by esa then enterococcus, er, and most common predisposing factor gallstones and also can occur post er CPA bit like post E RC pancreatitis as well. So E RCP, although it can help with diagnosis and relieve it can cause a lot of these problems as well. Presentations of charco triads. So sha arthritis composed of three things. You get fever, you get jaundice and you get right upper quadrant pain. If you get another two features, hypertension and confusion, you get Raynaud's and pentad. OK. So that's how you remember it. So first line investigation is ultrasound. You can see bile duct dilation in this, you can see stones. Um and another important marker is obviously kind of inflammatory markers like CRP management is quite simple. Keep them nil by mouth, antibiotics, fluids and then E RCP as well, but usually the infection is treated first. Ok. So let's move on. So a 58 year old man presents with vomiting and a fever. All liver function tests are normal on palpation of his right upper quadrant. You realize he suddenly stops inspiring oceans 20 seconds for it. Ok. So your a all right and well done. The answer is a. So there's a very important and the key thing for me when I'm just looking at this question is the LFT S, the liver function tests are all normal and that's a huge indicator towards the um the answer. Ok. So I always get confused with these cholecystis cholangitis, cholestasis, cholelithiasis, cholic cholelithiasis cholest. So it's very, so I just made this slide. So you know the difference between each one. So going through it bilary colic, that's just kind of the in the actual intermittent right up Chondron pain that you get with the gallstones. And that's because of the irritation because, uh, like, like the bowel, like the gi tract, there's kind of peristalsis, there's that movement of smooth muscle, but it's rhythmic. It's not all the time. And that's why it's intermittent because it's kind of pushing things along. And if you have stones in there it's gonna hurt when it does that. Ok, cholecystitis. So, anything with cholic cyst, that's just, that just means gallbladder, itis means inflammation. So, gallbladder, inflammation of gallbladder. Again, cholene, that's referring to the bile duct. So, um, cholangitis. Ok. So that's the easy bit. This is where it gets a bit more confusing. Co so cholecyst status. So collie something to do with the bile stasis when it's still in case. So there's a blockage of the flow of the bile cholelithiasis, anything lithiasis. And this, uh this is, uh, this goes with renal things as well, like nephrolithiasis, anything lithiasis just means a stone. So choli, you know, it's something to do with bile, you know, it's something to do with kind of like the bilary tree. So it's gallstones are present, choledocholithiasis that's specifically referring to the gallstone because of the lithiasis. But in the bile duct, empyema, self-explanatory and anything ectomy means the removal of anything ostomy means making a hole in something. Ok. So cholecyst we know is a gallbladder. So, removal of gallbladder, drain into gallbladder. Hopefully, that isn't confusing if it doesn't go through through your own time. But this is a good slide. OK? And for the conditions that we're not kind of covering today, I have put something like this uh at the end of the presentation just to make you aware, just the key things uh to learn for the exam. All right. So let's just go through acute cystitis. So we've talked about it, inflammation of the gallbladder. Um and it's mostly caused by gall gallstones as well. There's, there's a lot of kind of minor detail, but they're not so important, but it is associated with high morbidity and mortality. So it is a serious condition and the key presentation again, right, quadrant pain fever, you realize we've got two of the shot shots fired. However, there's no jaundice cos there's no, there's no obstruction of that bile. So you're not gonna get jaundice. That's the very key thing cos even if there's inflammation called cystitis, there's no pressure anywhere in the biliary tree. So it's not gonna block and it's not gonna cause jaundice. So that's, that's what I was referring to. What you saw in the, what you heard about in the questions to them is something called Murphy sign. So that's inspiratory arrest upon palpation of the right upper quadrant. Ok. Very classic. And there should not be jaundice. However, there's exceptions and everything and the only exception in ocular cystitis, is it something called Marii syndrome? So, Mai syndrome, think of it as if you have an impacted gallstone. It's so inflamed that actually it's putting pressure on the bilary tree next to it, for example. And that's, that's the only time you'll get, uh, you'll get kind of LFT derangement, uh, with cholecystitis. Uh, and it's usually what happens when there's kind of compression there. But it's, it's very, it's quite rare that, you know, a surgical consultant might crazy on it. Uh, ultrasound first line, there's other ways you can have a look through your M RCP, for example. And the management is quite simple IV antibiotics. Uh and an early cholecystectomy within a week of diagnosis. OK. And a and a lot of the times you'll see the trend that we want this kind of infection, we want this inflammation to subside before we operate. OK. Another question. Um Marriam is a 67 year old female presents with jaundice, anorexia and weight loss on examination. She has the palpable gallbladder. Give me 20 seconds. B this is a hard one cos I just put cancer in all of these. Um just to be annoying. But yeah, it's specifically pancreatic cancer and we'll discuss why and we'll see, we'll see now it's actually a, a sign that comes up in exams and it's got, you'll see, you'll see how obvious it is when I go through it. So, pancreatic cancer often diagnosed quite late. Um And the main kind of type of cancer is adenocarcinoma and the classic presentation is pale stools, dark urine and purges. So kind of itching and that has to do with kind of the bile metabolism. Cavo law is what was kind of mentioned in the stem. So painless obstructive jaundice and a palpable gallbladder is unlikely to be due due to gallstones, most likely pancreatic cancer. It obviously it could be the other types of cancers, but it's an SBA it's the most likely. So you're not wrong in that sense. Uh You get lots of exocrine and endocrine function. For example, I saw a patient in GP who had very bad, badly controlled diabetes and it's suddenly gotten really worse. And I was actually tasked with calling them to discuss his options. And he'd actually told me he'd recently been diagnosed with pancreatic cancer. So it can actually suddenly it can cause a significant drop in endocrine function. And that's, and you can imagine that it was probably quite late when you kind of picked that up and it could have been the cause of endocrine dysfunction from the start. Terza sign refers to something called migratory thrombophlebitis, uh which is a bit more common with this type of cancer as well. So, referral uh these, I'm not gonna go through that much because it's kind of like an algorithmic thing. They're over 40 jaundice two week, wait. And if they're over 60 with these kind of symptoms with weight loss, then it's uh then it's not as urgent. It's more kind of like a direct access CT abdomen. So these are kind of guidelines that I'd advise you to have a look at. Make sure it's up to date just um like when you're looking at it for the exam and just memorize kind of like these algorithms. Uh but you can see that the the symptoms can be very nonspecific, you can get loads of things, which is basically all you'd ask for in a, in a gi kind of history investigation. Like, like anything to do with the pancreas CT is probably the best choice. And another exam is something called the double duct sign, which is the presence of simultaneous dilation of the common bile duct and the pancreatic ducts. Uh So sometimes I'll just throw that in the stem and you already know that it's pancreatic cancer. Say in 99 again, a very good thing to know tumor marker, specifically raising this kind of cancer management, less than 20% is suitable for surgery, unfortunately, because it's so late. Uh And there's something called a whipple resection, which is a huge surgery and it's a technically a pancre pancreatico either that one, but it's a very big surgery and you need to be quite fit to have it. And it obviously you need to be supplemented with a lot of medication after to kind of supplement the kind of function of the pancreas kind of endocrine exocrine function. We talked about chronic. Um And there are palliation options as well like um chemotherapy sometimes and actual stenting of the bile ducts. So people aren't as jaundiced, for example. Ok. Um Ali 61 year old man presents to his GP with weight loss change in bowel habit and a full blood count is taken given the likely diagnosis. What would be the best course of action and sometimes they're not very nice and they won't give you the diagnosis. So I'll, I'll, I'll leave a minute for this. OK? OK. So we have B All right. Yeah, this is quite hard. Hopefully in the exam, they're not gonna be this hard by the way. Um As I said, I want, I want to challenge you guys. All right. So the answer is actually urgent two week wait referral. So this is how you need to know kind of the algorithm exactly what meets what criteria from the stem, et cetera. So let's go through it. So bowel cancer most prevalent. Fourth, most prevalent in the UK, it's probably changing all the time. But the key thing is, is very prevalent, especially it's becoming more prevalent even in the younger population as well. Unfortunately, key risk factor again, the exam stuff all highlighted in red F AP and HN PC as well and other things like diet, low fiber, red meat, processed meat, smoking, obesity, of course, alcohol, that kind of thing. All the key ones and the presentation change in bowel habit, something that you'll always ask in kind of gi histories as a red flag, unexplained weight loss, very nonspecific. It ties in with a bowel habit and a microcytic anemia as well. Uh can be uh if you're losing blood cos, cancers tend to bleed. And a mass, obviously, if you feel on examination. So, referral criteria. So again, this is very algorithmic and I got some feedback that this was a bit more. There's kind of, again, it was a waste of time. Cos this is how I remember it, but I'm just gonna leave it on here for a bit. So you can appreciate there's several ways of remembering kind of the pathways recommended by nice and I literally took it through letters and words, but this is just a combination of ways of how I remembered it. Um But there's no easy way. Unfortunately, uh try to do what works best for you. I like to play a story in my mind. This is kind of like something I used. OK. Uh But it just basically combine, it combines the red flag symptoms, weight loss, a pain, the bleeding, and it's kind of like a severity. It's kind of on a scale of severity, er the weight loss and a pain being something we're more concerned about. So we'll consider it at younger ages and then for the others, you have to be a bit older because you're more likely to have the cancer, you're less likely to have the cancer if you have the symptom at a younger age, think of it like that. Ok. We're reaching around an hour. Uh, we should be finished soon. I'll, I'll try and stop around an hour because your attention span probably isn't that long. Ok. So I'll finish around seven. Ok. Screening. Uh, so we, we, we use something called the fit test. It's very um the ranges for the ages again, changes all the time. So please check, uh please check at the time of your exam or in your clinical practice that it's actually up to date. And there's certain criteria even for like people who are eligible for the fit test as well. And there's even things like flexible sigmoidoscopies that have been offered in the past. So there's a lot of research going into this. Hence why please look up the latest thing that's happening. Ok, investigations colonoscopy is obviously gold standard. Um a as a histopathologist or as a trainee who's just started, we get a lot of these biopsies from colonoscopies and we get to see it under the microscope and it's very, it's very, it's a very good way of diagnosing uh abnormal polyps, for example, uh CT scans are obviously very good uh and realize a lot of people can't tolerate colonoscopies. So sometimes CT is the only way and again, a a very important tumor marker is C EA it's kind of the equivalent C 19 9 for pancreatic cancer. But it's for b uh, and management. Obviously we wanna take the cancer out.