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Ok. All right. Um, good morning everyone. I am George doesn't know me. I haven't seen you in the previous ones. I am an f one. I'm a previous manage to graduate. I have just moved to acute medicine from Ortho. So it's been a pretty ii say chaotic. It's not been that chaotic but it's a different week compared to my normal Ortho stuff. So I feel like a bit tired. That's it. But I'm feeling very energized today. So, don't worry. Um, do you guys want to introduce yourself as well? Yeah. Hi guys. I'm Nam. Um, I've just found out that the block that we're currently on is formative. So I'm the happiest person in the world cos they will not be seeing me for like two weeks. But yeah. Pardon? What is that? Um It's, I'm on psychiatry so I'm, I'm so happy it's because of the junior doctor strikes. There's not enough people to sign us off. So. Oh, that was a, yeah, but anyway, they were straight. Um, and I'm Anna, I'm also very happy that it's formative for the next block. I just started Ortho. So lots to do. I'm sorry that really doesn't make sense either though. Cos the strikes are over the holidays mostly. Yeah. Happy days. Lucky. Ok. So to anyone, I'm gonna kind of zoom through this. Hopefully you will know what's called that is by now. Uh, disclaimer. Yeah. So this is created by us Zach. If you haven't met him before, he's made a lot of the slides, many of them have his own slang and some references to Zack. So if you get confused to blame Zach. Um, but yeah, obviously this is our own kind of curriculum mapping, but it's based on the Manchester stuff. Uh, blah, blah, blah. Uh So today we are going to do gastric cancer, gastric perforation, reflux, pancreatic cancer, peptic ulcer disease. It's not much. So you split it pretty evenly so you won't hopefully get bored of seeing one face for a while. Um, it should be all nice and relatively fast paced. So, um, nice thing. Do you wanna take over? Yeah. Sure. So, hi guys, I'm doing go today. So go is basically reflux or gastro um esophageal reflux disease. Um, it's quite common. Ok. So common is common. So in terms of uh what it actually is essentially, it's when your stomach contents or sort of stomach acid basically gets, well as a, as you use need to care, but it basically goes back up into the esophagus. Ok. Um And obviously that causes a bit of irritation in the stomach area. So patient, it will present with something called dyspepsia, which is basically this upper abdominal sort of pain, which is very persistent. Ok. So, um, in terms of symptoms or get indigestion after, after meals and it's a lot worse when they're lying or bending forwards. Um, they can potentially get some nausea, vomiting some chest pain, some regurgitation, sort of difficulty swallowing as well. Um, and there's a di aphasia as well which we can get, um, do they know what a di aas is? So, put it in the chart for me? What is a di aag di aphasia? Pain? Yeah. Brilliant. So, basically, pain on swallowing. Ok. Uh That's quite, I've not come across that in a lot of uh sort of questions, but a diasia is, again, it's a symptom that could happen with go. Ok. Um So in terms of risk factors, what are the risk factors for? Go? Can anyone tell me we have two main ones but can give some risk factors for God. Any idea? Obesity. Yeah. Brilliant. You've got obesity there any of those NSAID use. Yeah. Brilliant. Brilliant. Keep them coming guys. Obesity, nsaids, pregnancy. Amazing. Any others. Smoking. Yes. So, smoking is the biggest ones. Well, and Hannah, um, smoking is, is up there any others? I'll give you guys a pi uh yes, alcohol is one. Yeah. Brilliant. There's one of it. It's like a medical condition that you can get alcohol and caffeine. Yeah. Good. A medical condition. Hi. So brilliant. Robert. W ok. Yeah. Brilliant. So, yes, sir. George. Next time it's all right. Um, so risk factors. Yeah. So, cigarettes and high BM I and obesity are the top ones. Ok. And the others include sort of hiatus, hernia, uh, pregnancy, NSAID s caffeine and alcohol. Ok. So a hiatus hernia. What is a hiatus? Hernia? Does anyone know what is a hiatus? Hernia? Cos it's quite common sometimes even on past me and sort of questions or like past medical history wise. Um, they have a hiatus hernia. Um, a part of the stomach which moves up the diag, yeah, so brilliant. So, basically a part of your stomach sort of slides or rolls up into the chest cavity. Ok. So if you can imagine that you can imagine why that would cause sort of acid reflux. Ok. So brilliant. So, yeah, that risk factor is really good to remember that, especially for your oscopies. Ok. Um So, yeah, so, yes, you can just do the whole slide of this one. So, in terms of, um, you wanna rule out something a bit more sinister with God. Ok. Cos Dyspepsia in sort of, um, the elderly and maybe like above 55 can be something a bit more malignant, potentially. Ok. Um, so if a patient comes in with dyspepsia and weight loss, dyspepsia and anemia, um, dysphasia or sort of new onset dyspepsia, they are red flags. That could, could be something a little bit more sinister. Ok. So another one here, this is a big one. They love to ask about this. So, symptoms, refracture to treatment, um, you'll sort of get like a question most of the time where it's like, ok, patients come in with sort of dyspepsia, you know, we've given omeprazole, we've given lansoprazole, um, and nothing's happening. They've still got these treatments. Ok. Um That, what, what could that indicate if their, if their treatment's not happening? What could that indicate if they've got, you know, recurrent dyspepsia that's not being treated with? Um, PPIs. What could that be? There's a specific condition I'm looking for. Um, and if you know it brilliant, but it's quite rare to be honest. Um, any, anyone you guys didn't know? Yeah, it could be barretts. It could be achalasia. Yeah. You guys saw the differences there. It could be those, anything else? It could be Zollinger? Yeah, that's it. Yeah, it's been well done. So, Zollinger Ellison syndrome. Does anyone know what that is? It's such the ones, like little really niche, pass med ones. Um, but that comes up like, you know, it comes as a question quite often and it could be Zollinger. Um, do you know what it is? Yasmin? Do you wanna explain a little bit about what it is? Yeah. Brilliant. So, it's a gastro secreting tumor. So, essentially in your stomach or your sort of pancreas, you get these little mini tumors that develop where they secrete, there's a gastro and obviously, you know, gastro is really important for stomach acid production. So if you're getting loads of that being secreted, um, naturally you're gonna have resistant sort of treatment to, um, Dyspepsia. Ok. So, yeah, so there are red flags that want to rule out brilliant. So, next slide. So in terms of investigations, um, what investigations are? So, Ph monitoring. Ok. Um, so ph monitoring is really important, especially you've got load of stomach acid coming back up. It could just, you know, be a bit more acidic down there. So Ph Monitoring is brilliant. Um Any other investigations that you guys can think of in terms of go, what else could be, what else could we do? O GD? Yeah, brilliant. So, yeah, gastroscopy. Um Brilliant O GD. That's pretty much what I was looking for. Um So this is given for sort of like two so sorry, uh red flag people. Ok. So most of the time you can do PHP H monitoring, but for sort of people with red flags like weight loss, obviously, the refractory treatment we're gonna give an O GD, ok? Cause that can obviously rule out anything malignant, um, like an ulcer or like a tumor, stuff like that. Ok. Now there is a classification that we can do. It's called a Los Angeles classification. I've never come across that, which is really interesting. So at least that's something I've learned today. Um But again, that's that classification that could be used for, go to sort of see how severe their, um, esophagitis symptoms are. Ok. Um, so, yeah, that's a good thing to bear in mind. And in terms of risk factors, obviously these are so o but like it's go is so common. Yeah, I've had God, I'm not gonna lie. I've had God as a kid. So it comes up, it's very common in the population. So, um, you wanna make sure you know your lifestyle treatments? Ok. So in terms of weight loss, if they're obese, you know, in their history, make sure you sort of ascertain what is your diet and exercise like um because they're not something you can come back on to later being like, ok, you mentioned your diet is a bit, you know, a bit, um a bit fatty. We can sort of help you reduce that. Um So yeah, lifestyle is really important. Smoking cessation is very important as well. Um And yeah, diet. Ok. So it's really a um in terms of drugs. Um So it's just PPIs. Ok. So uh two week trial, can you give me some PPI examples? I've already said a few. Um But you know, it's kind of like your bread and butter medication you should remember PPI off the top of your head. Um Yeah, brilliant. Yeah, you guys know your stuff. You guys are really smart. So, omeprazole on up are brilliant. Ok? Um And they do have a lot of um, side effects. So, again, this is something that could give you sort of like a drug counseling station. So you're taking omeprazole, you're taking PPI these are some side effects. What are the common side effects on PPI so common? And Noncommon, give me some side effects that you guys know any side effects. Yeah. Infections. Ok. Yeah. Yeah. Good, good, good. Yeah, I mean, just generally like, um, some of gi symptoms it can cause nausea, dizziness, vomiting, all that kind of stuff. Um One thing that I um I come across quite a lot is that PPI called osteoporosis. Um That's a bit of a, a bit of one to remember because they love asking that on post med. So osteoporosis is there as well. Um Yeah, brilliant. So in terms of side effects, you guys know stuff. Um Yeah, so yeah, next slide if that's OK. Oh I surgery as well, that was just there on the side. Um So if obviously you get refractory treatment, you can do fund application. Um What fund application is where they basically get the stomach, the top of the stomach. So the fundus heart and basically tie it around the lower esophageal sphincter and that just prevents any acid from going back up into the stomach. Ok. Back up the esophagus. Sorry. Um Yeah, brilliant. So next slide. Um so next one is Barrett's so Barrett esophagus. Um So essentially this is chronic gout. Ok. So if you get that repetitive sort of low esophageal injury. So that repetitive sort of acid going back into the, um, esophagus over time that can cause, um, Barrett's ok. Um, so Barrett's is, it's not as, it is asymptomatic a little bit but, you know, they have those gout symptoms. Um, but with a bit more sort of like, um, sort of symptoms that point something above malignant, I guess, something like about it. So, can anyone tell me what the typical histo like histology of the um esopha esophagus is because with Barrett's, what they like to ask is how the histology changes. So it's going on time with the normal histology of the esophagus. Let's throw back to year two, year one stuff. But you guys are in the chat. Yeah. Brilliant. So it's stratified squamous to column alium. Yeah, brilliant. So essentially, first of all, it's um your esophagus naturally stratified squamous and then over time with the acid, it basically goes to columnar. Um a way to remember that helps is that your intestine um is basically columnar epithelium and Barrett's, you know, it just kind of like your intestine like they got a moving look to your esophagus. So it goes from stratified to columnar. Um Yeah, and they also like to ask um sort of like what type of histology is going on. So it's called metaplasia. So they'll give you like um options, dysplasia, metaplasia, and neoplasia ever. And you know, the one that you need to pick is metaplasia of the esophagus? Ok. Brilliant. Um And so with Barrett's, what's, what's concerning about Barret's, what can Barrett's develop into over time? Not his answers been, but I know, sorry. But what can Barrett's go into over time? That's not treated any ideas? Cancer. Yeah. Brilliant. So, cancer, so different types of cancer in your suffer there. So you can get squamous cell carcinoma, you can get adenocarcinoma. So they're the main top two. But in terms of Barrett's what that predisposes mainly to is oa which is adenocarcinoma. Ok. So adenocarcinoma. So, um that's really important to monitor in Barrett's patients. Ok. Um Yeah, in terms of you sm kids, you know, the sort of way it goes is metaplasia, dysplasia, neoplasia. So that being the cancer right at the end. Ok. And Barretts is so common in your, you know, your typical old what? Fight man smoker. Ok. Um So, yeah, so that's Barrett's any questions about that. So far, we've only got one more side to do em, Barrett's then we're done. But any questions so far on Barretts? No. So in terms of your um diagnosing it, it's very easy, you can do endoscopy. Um So we can basically put a camera down, them, get a little bit of a biopsy, see what's going on in terms of the cells. Um And then we can use different criteria sora criteria which we can sort of look at the extent. Um of the endoscopy. Yeah, judge you can the whole side like it, it is fine. Um, and then there's Seattle Protocol which looks at histological stuff as well. Again, they're very little, very ne things I've personally never come across those criteria. Um, but, you know, it's good to learn, I guess. Um, in terms of treatment, just PPIs. Ok. So Barrett's chronic go PPIs and lifestyle again, use this, um, lifestyle stuff if you wanna get distinction in your sy station. So just basically being like, you know, lose weight, um sort out your diet, stop smoking. Another one is that tend to like people when they have food, for example, like a fat meal, they go lie down afterwards and that just causes acid reflux. So basically being like, you know, like after you've had food, you know, go for a walk and just like chill, don't, don't jump straight into bed and go sleep or lie down. Um So little things like those really important for lifestyle. Um And then, yeah, so again, once you've done that endoscopy and sort of look at the histology of the esophagus, depending on what it is with this metaplasia, that's not dysplasia yet. So what you wanna do is basically, um, do a biopsy every 3 to 5 years and just do a bit of surveillance going on there, ok? Just to make sure they don't progress into that um adenocarcinoma and if there's dysplasia, so we've got, obviously we've got um something more malignant. What you can do is something called mucosal resection. So it's taking out or you can do radiofrequency ablation, which is um yeah, which is your typical answer for that. Um So yeah, in terms of go and barretts, I would say very osteal, very common. So know that inside and out and obviously know how you can counsel the patient in terms of the medications and the symptoms. But yeah, that's me done. I'm pretty sure, um, George and Anna. So yeah, if you guys have any questions, just put them in the chart and I'll be able to answer them for you. Thank you very much. Right. So, um, next bit is very, very, very common. So we have ulcer disease. Can someone tell me what types of peptic sis? You can find what are the two most common types and which is worse? Actually, let's start with the types, uh, gastroduodenal. Excellent. And how can you differentiate between the two? Just symptom wise worse or better on eating? Yes. So, which is worse? So, yes, gastric worse on eating. Duodenal is better on eating. Ok. So worse at rest better with eating good. Um, so again, this is Zach stuff. Um, so it's an umbrella term for gastric ulcers. Um, more common in older people. We said they're worse when you're eating. Um, dud ulcer, male, um, middle aged and a bit better when, um, you're resting. So when you're not eating um, risk factors. What risk factors do we know for practical ulcers? There are quite a few here. Um, and some really important ones. We'll go through the lifestyle changes in a second. Nsaids. Absolutely. That's one, got quite a few more. So if we let's break it down into. Yeah, sr, so there's some medications, there's some lifestyle things and there's some other things as well. Um, h pylori. Excellent. That's the other thing I was looking for. Um, anything else? No, some more medications. Aspirin. Hm. Ish. You're right. Cos mechanism wise it could cause that, but it's not the most common one. we said sri S yes, steroids. Absolutely. Um, so I think that's all. So we said nsaids, steroids, SSRI s, there we go. Thank you. Thank you, Nain. So, these, yes. So lifestyle wise. Absolutely. So, weight loss, diet, exercise, smoking, um, cessation. All right. So H pylori, we're gonna go through that in a second. That's really important. Um, drugs. So we said nsaids, steroids, alcohol, bisphosphonates as well. Um, so it's probably a bit early at this point, but one of the classic instructions of bisphosphonate, um, administration is you wanna take it and remain upright for 30 minutes while you're having it and have it with a full glass of water because it can cause not so much ulcers, but it can cause esophageal inflammation. Ok. Um, we said, Sri S and then we said, so other things we have malignancies and we have Zollinger Lin syndrome, Ellison syndrome, which has already been mentioned. We've got a slide on that as well. It's a bit complex, but we'll at least make a small introduction on it. Cool. Um So as I said, H pylori is very common. So it's an interesting association where almost all duodenal ulcers and many, many gastric ulcers are associated with H pylori. But in the vast majority of people with H pylori, you're gonna be asymptomatic. So only 15% of people with H pylori will actually go on to develop ulcers. Ok? But if you have an ulcer, it's very likely you have H pylori as well. So it's really important to screen for that and we'll go through that in a second uh medication he said, and other conditions as well. So, inflammatory conditions, Crohn's stress can worsen that you're gonna get your reflux um malignancies, et cetera. Any questions so far, it's all looking, all right, good, relatively straightforward session. So, symptoms wise, you're gonna get epigastric pain, pain, not pain, pain, um dyspepsia. Um So that's just difficulties with your um digestion. So you're gonna get abdominal distention, gonna get bloating, you're gonna get reflux as well. Um As far as signs, you're gonna get some epigastric tenderness. If it's really bad, you can present with bleeding. So that would be an upper gi bleed. So that can be hematemesis, which is what's hematemesis and what is Melena uh you should know this by now, uh, hemes, vomiting blood. Absolutely. And then Melena is blood in stool. Excellent. Um, so those are classic signs of an acute upper gi bleed and they can obviously present in hemo Dominic shock if it's really bad. Ok, now, if it's really, really, really bad, um, they can present as a perforation which Anna will kindly talk to in a bit, but that basically means you also get so bad, big nice little hole opens up. Um Everything goes everywhere. You get a big gastric infection, you get peritonitis, you get guarding um severe abdo pain. And again, it's very likely these patients will present in some form of shock. Ok. Um It's not that common, but it does happen, right? So, as far as H pylori, this is all the microbiology stuff, gram negative spiral shaped flagellated microaerophilic bacterium, right? Cool. Um As I report 95% of people with um ulcers, ulcers will have H pylori, but only 50% of people with H pylori will actually go on to develop ulcers. Um It colonizes the gastric antrum, which hopefully you'll remember is the top of the stomach. And the reason for that is that it's the least acidic place. Um interesting pathophysiology. You can have a look at that in your own time, but overall, um it tries to find the area with at least acid, it binds there. Um And then it secretes gastrin as well that can increase the acidity of the stomach. Overall, that's why we want to keep PPI S. Um, and, but overall mostly is asymptomatic. Um, most of the ulcers it causes are duodenal. Um, but obviously it can cause gastro asma, um, associated with ulcers, mild lymphoma as well. A bit niche. Um, but it's a good little M CT thing, um, associated with gastric cancer, um, atrophic gastritis as well. Um, so quite a few things. Um, uh, I wanted to ask you that. Uh, right. We'll just go back and pretend you didn't see that. How do we diagnose peptic peptic ulcers? There's an Antrim bottom of the stomach, I'm pretty sure or not. But let me have a look. Uh, you're absolutely right. Yes. Sorry. Antrim. Correct. Bottom of the stomach. Not the top to that. Um. Right. How do we diagnose H pylori? No. What's the easiest way to diagnose H pylori? Urea breath test? Excellent, good stool cultures as well. Not the most common thing and not the easiest thing. So, overall we'll try and stick to the, to excuse me. Um, well, well, dear to the breath test. Ok. You can do antigen tests. You can do stool tests, but by far the gold standard for H pylori is your ear breath test, cos it's non invasive. It's an easier way of getting a sample and it's much more accurate. Um, you can do a urease test as well. It's, that's done an endoscopy, um, just as far as the way the breath test works is you normally ask the patient to breathe into a specific bag. OK? And what that does is it measures the CO2 levels that gets a baseline. Then you ask them to drink this little lemon flavored syrup, um which is high in urea. Then a few minutes after that, you ask them to do the same thing in the bag. And because H pylori secretes urea that will break down the urea and that increases CO2. So if you see a difference in the CO2 from the first bag and the second bag, that's a positive H pylori test. Ok. So it's relatively straightforward but very accurate. Ok. Um Now, as I said, you can do endoscopy as well. You probably that's definitely not gonna be your first line of investigation for H pylori. But if you have other symptoms that are suggestive of a need for an OGT, so more severe ulcers or gastric cancer, suspicion, things like that, then you might just do that um there and then, um you can do a biopsy at that point really important before any of these investigations to stop PPI S. So you need to stop those two weeks before you do the tests. Um And if they're on antibiotics, you stop those four weeks before the test. Um Very simple reason, you need to avoid any false negatives because if they are on PPI S, if they are on antibiotics. It's very easy to actually hide the urea test, for example. Ok. Um, so this, I've, I've not come across this in a osk, but I think it could be quite os. All right. Um, so keep an eye on that. Um As far as the management, it's the eradication therapy, which is well known as triple therapy. Um, so it's seven days of PAK or PMC. So PAC is a PPI amoxicillin, Clarithromycin. If there are penicillin allergic, then we go for PPI metroNIDAZOLE and Clarithromycin. Ok. Absolutely. Stop alcohol if that does not work. Um Then we go for a slightly different regimen. Um It's always gonna be a PPI PP amox metroNIDAZOLE. Um And if they are penicillin allergic again, then we'll go with PPI metroNIDAZOLE, Levofloxacin, Tetracyclines and Bismuth. Don't worry too much about this. This is very well. I would definitely try and remember the first couple of combinations for the seven days though. All right, not the 2nd 91. So don't worry too much about that. Um, relatively effective. Um, 60 to 80% of people will respond to the first line. Um But still there's like 20 30% that might not. So that's why you want to go down the second line. Um Any questions so far? Let me just have some water cause I've been drinking a bit. Ok. Ah That's better. Right. Cool. Um So nsaids, we said a very big risk factor probably wondering why you still use them at this point. That's a valid question. Good pain relief. Now, mechanism of action wise, I don't know what you guys remember, but overall they cause cox one and cox two inhibition. Um Prostaglandin normally in my stomach decreases hydrochloric acid secretion. So it decreases the acidity and increases bicarb. So overall will make it much less acidic nsaids inhibit prostaglandins as you will hopefully remember from the pathways and you'll see very quickly in a second. Um So you'll get increased acid and less bicarbonate. So it'll be much more acidic and that is obviously a much better environment for ulcers to slowly develop. Ok. Tommy lining is not having a great time. Um I'm probably wondering. OK. Does that you stop using nsaids? Why do you use them? Obviously, if there are risk factors in older people, we start um nsaids plus a api if they're quite young then and it's a short course, then we probably will just give you the Ibuprofen for 7, 14 days. That's OK. Um But if it goes for longer than that, then we definitely want to be starting a PPI as well. All right. So we said PPI S omeprazole, lansoprazole, those are the biggest ones. Um Rheumatological conditions, you can also use some slightly more selective ones. So, Celex Aib, I've never even heard of this before. Don't worry too much. But um there are some that can be a bit more selective and cause slightly less damage um from a gastric perspective, but don't worry too much about that. This is the pathway arsonic acid pathway. Hopefully, you remember it slightly, but these are all the different mechanisms that can cause gastric ulceration. Um I think you can have a look at this in your own time if you are interested. But overall cox one cox two inhibition will increase hydrochloric acid secretion and decrease the bicarb secretion in the stomach. Any questions so far? Cool now, uh slightly more niche. Um but Zollinger Ellison syndrome can be sorry, I'm just putting an N in there. Zollinger Ellison syndrome can be another cause of peptic sis, it is a hyper secreting gastrin tumor. Ok. So it's a gastrinoma. Gastrin increases acid secretion. So you have way too much acid, you'll have multiple ulcers, mainly gastric again. Um um It's about the question. You're like, well, hang on a minute. How am I gonna differentiate between? So and Greeson and just any normal day to day gastric ulcer. Um And the main thing in that is that firstly, the symptoms are gonna be much more intense cos you have multiple ulcers. So higher likelihood of having an upper gi bleed, overall bleed, epigastric pain, but also they are very much associated with different syndromes. So you might have heard this before, but there's men. So it's multiple endocrine neoplasia. It's type one and type two. Um We're not gonna go into this too much. It's a bit more complex. Um But just remember especially in an M TQ environment, um you need to try and make that link between Sonogra Elison and men. OK. Now, it's mainly associated with men type one. So that's parathyroid, parathyroid, hyperplasia, pituitary tumors, pancreatic islet cell tumors. I would recommend you try and go this over on your own time. I think it's, if you can try and remember the three tracks, roughly, I think again, it can get you some good niche points in some MC Qs. You won't say it often. It is a niche, but it can be useful just to, to just remember. OK. Um Any questions? Uh Not many questions so far, which is fine. I think its a bit simpler than the previous session I did, which is getting loads of questions. Uh I can't see any questions. Cool. All right. No gastric cancer. Nice little fun, Sunday afternoon. So, um 90% of gastric cancers are adenocarcinomas. And if you wanna have a look, you can use the long criteria to see how they are staged and diagnosed, et cetera. They are very, very, very complex criteria. So we have not included them in the strides in the slides. Um Intestinal type is the most common type of adenocarcinoma. There is a diffuse type signet cell. Um Now risk factors, smoking infection. So H Pylori Epstein Barr virus, high meat intake salt, slightly less evidence around that, but still risk factors. Um There is also a genetic component to it. So you can have hereditary diffuse gastric carcinoma. Um, that's an automa dominant, um, inheritance pattern. Don't worry too much. Quite neat bars, cascades. Uh, that is a complex pathophysiology behind gastric cancer. Again, a bit too complex for these slides. If you're very interested in gastric cancer, please feel free to go ahead and have a look at them. Um, but overall you can have the normal mucosa, which ends up being dysplastic gastric morphology. Um, now, anatomically, um, it is more common to find it in the distal part of the stomach as I was correctly, um, corrected Antrim is the bottom of the stomach and not stop. And that is more common in h pylori infections. Ok. Now, can someone tell me what signs and symptoms are we expecting in gastric cancer? Quite a few of you. Hopefully, let's start with signs, nausea, vomiting. Yes. Symptoms. Absolutely anemia. Absolutely. Yeah. What's the most common type of anemia that we find in? Cancer? Um, alarms oon arms weight loss. Yes. Absolutely. Dyspepsia loss of appetite, biha node. Excellent. Where is weho node? 1010. Remember? Anorexia. Yes. Pisinnia. Um iron deficiency anemia is the most common one. Sister Mary Joseph, I well done. We'll have a look at that. Alarms. Neuronic. That's very cool. Um, supracollicular. Yes. Alice, which one left or right or work has left? Absolutely. Birk has node left, tla node. Cool. All right. So, symptoms constitutional. We've kind of mentioned them. So weight loss, um, shortness of breath, tiredness, things like that. Um, dysphasia that's not been mentioned actually. Um So that's um, can be difficulty swallowing. Um Also just difficulty digesting as well. So you get bloating, um, get reflux, so quite classic nonspecific symptoms as well of ulcers of reflux, things like that, indigestion. Um, dyspepsia, I've just told you about nausea and vomiting, um, haematomas, Melina, um, and a big thing to keep in mind with nausea and vomiting. If we are talking about very progressed, um, gastric cancer, we could have a bit more of an obstructive picture. Uh where very much you truly cannot get food down. That's a very advanced stage. But um something to consider. Ok. Um As far as signs, unfortunately, with gastric cancer, when you do start getting the signs, it's probably a bit too late to have a good outcome. Um So pala cachexia. Um so it's looking a bit malnourished lymph adenopathy. So we talked about Berkow node, um can obviously have Mets. Um So bony Mets can do Hepatomegaly splenomegaly. Well done for knowing this sister married Joseph nodule. That's periumbilical Mets. Um Succession Splash. Has everyone heard of Succession Splash before. Does one know what it is? It is something I don't truly think exists, but it has been in textbooks. So I don't know what it is. Well, it's basically some guys sitting over a patient with a stethoscope over their tummy and they rock the patient back and forth and they can hear some sort of splashing noise which can be suggestive of loads of fluid in their tummy. Um, could be suggestive of gastric cancer. I would not even learn this. It is very niche and I don't think it really exists, to be honest. Um, anyway, kind, I've not youtubed it yet. It might be fun. So I'd recommend maybe, you know. Ok, so we, we said they get these signs and symptoms, symptoms. What are we actually gonna do now? Um, what would people do? How are you gonna manage these patients or investigate them? Let's say you're in GP, what are you gonna do? You've just seen a patient and you've got quite a few symptoms, dyspepsia, weight loss, um, nausea. Two week, wait. Absolutely. Um, and what are they gonna do? So two weeks go by? Amazingly, they have been seen after two weeks. What are they actually gonna do? And who are you? Two week waiting to? Which specialty are you gonna do that to? And for what? Or O GD to gi Perfect. Ok. So it's probably gonna be a gastroenterology service. Sometimes it could be general surgery depending on the area, but gastro and then will do an endoscopy, put down a camera, have a look at what's going on. Ok. So refer. Absolutely. Um, when, so we said two week, wait, if they have enough symptoms and you have, you're worried enough. Um, but a good question is ok, but they're quite nonspecific symptoms. When should I truly be worried about? Two week? Wait and why should I just do a routine referral? We'll talk about that in a second. But we said they'll do the gastroscopy to have a look into the stomach and take biopsy of tissues as well and turn off for histology, et cetera and see if there are any malignant symptoms. Um, if there is high suspicion of malignancy, um, they'll get a clinic appointment, they'll get a CT scan as well. That's gonna be a full body ct check. Firstly, for the primary side of the cancer and then check for any METS. Ok. Um And as you said, it's a cancer that presents quite late. So with symptoms presenting, there is a high likelihood of having metastatic disease already. Ok. So it's really important to find out other Mets. Where are the Mets? Ok. Um, so we said two week wait. So the criteria are these three? Ok. So if there is an upper abdominal mass or dysphagia. Ok. Now, there are two types of dysphagia, there's a dysphasia and that is difficulty in expression. There's dysphagia which is difficulty eating, difficulty swallowing. Ok. Or in someone about 55 years old with weight loss and one of the following upper abdominal pain reflux or dyspepsia. Ok. Um, now, gastric cancer is probably not the most common cancer that you're gonna get in exams. I can't remember it. And again, if you think about it with two week waits for someone that's above 55 with any sort of change in bowel habits. Um, that is a, an automatic two week wait referral for colon cancer. So again, you can, there is a bit of overlap between the criteria for gastric cancer and colorectal cancer. Um, so that can be a slightly difficult point to differentiate with, um, but just try and remember it makes sense anatomically if it's a bit more upper symptoms. So, epigastric pain reflux, then that's pushing more bit towards the gastric side. But again, even then you can probably argue that esophageal cancer slowly comes into that picture as well. Um But if you think about it, investigation wise, esophageal cancer, gastric cancer, you're always gonna do an O GD. So it doesn't really make a big difference and you're gonna be referring, referring to the same service. Ok. But overall relatively nonspecific signs where you can truly point out and be like, yes, I'm confident enough that this is gastric cancer be a node is quite specific though. So if you've seen that you can probably make a relatively safe assumption that it is gastric cancer. Yeah. All right. So, diagnosis, we have mentioned it already, gastroscopy, take biopsy as well, send it off for histology. We'll do a CT scan, we'll do a pet scan as well. Um And with that, you can do staging of the cancer. Um What's E US. Does someone know it is done during endoscopy? It's endoscopic something. Hopefully us. Ring a few bells. Mhm. Ultrasound. Absolutely. Ok. So you can find the lesion, use an ultrasound and that way you can assess the staging and the spread a bit better. Ok. Um Herceptin two testing that is useful um for treatment because you can have Herceptin two blockers and I can just um help decide whether I need chemo radio et cetera or just use medical antibodies. That's oncology stuff. Um Treatment wise if they are fit enough for surgery, you can do a surgical resection of the stomach, whichever bit is affected all of it, whatever. Um And then obviously plus minus chemo and radiotherapy. Ok. Um Now slightly more new surgical stuff if it is operable and it's tumor one node zero. So what is that mass tier size of the tumor node? Is, has it metastasized or not? You can do take part of the stomach out. So, subtotal gastrectomy and mucosal resection anything more than that, you just take the whole stomach out. Ok. Um inoperable if there's distant spread of the cancer. So you have distant mets, then you use systemic chemo, as I said before, if it's set to positive, then you can potentially use other agents. Um is not a great cancer to have um average life expectancy is 20% of five years. Ok. So as we said, signs and symptoms are normally quite a late sign of disease. Ok. Happy stuff, right. Um And that is me done. Sorry for the coughing and choking. Um Anna. Do you want to share your slides? Yeah. Share one sec. Any questions so far? Can you see my screen? Perfect. Ok. Um Yeah, so I'm gonna be talking about, about gastric perforation and also just perforation in general in any kind of cavity or any um area of the gi system. So basically gastric perforation is when there is a hole anywhere in the gi tract or perforation in general, it's just a hole anywhere in the gi tract from the mouth to the anus. Um It, any delay in surgery, it's really serious. So any delay in surgery can, um uh or resuscitation can lead to sepsis, it can lead to shock and it can eventually lead to death. So it's really, really important to know, especially for exams and ACY. Um So anyone that comes to the ed with an acute abdomen, which just means like acute abdominal pain, no matter where it is, has a perforated gi tract until proven of their life. So again, it's really important for us to know. Um So does anyone know any causes of gastric or general perforation in general in the gi tract? And there's a lot so feel free to throw some out and actually some have been spoken about already today. Yep. So peptic ulcer disease is a big one. definitely want to know as well, stabbing. Yeah. So, perfect. Trauma. Cancers. Yeah. Bowel obstruction. Yeah. Can you be specific in terms of causes of bowel obstruction, small and large bowel obstruction, for example, like what's the most common cause of small bowel obstruction in like the developed world? Stuff like that? Adhesions? Perfect. So, thinking of like patients who have had past surgical, especially in the gi tract, um, or like for women, if they've had a hysterectomy in the past, that can increase your risk of having adhesions as well. So just things to think about, I'll just run through these. So there's quite a few peptic ulcer disease, diverticulitis. Um And it's more, that's more common in higher income countries, uh malignancy. So, colorectal cancer or gastric cancer procedures. Um So that would be iatrogenic trauma. Someone said stabbing um appendicitis me diverticulitis. Um that would be more common kind of in your younger population. Um Mesenteric ischemia, bowel, obstructions, adhesions, which you guys must have talked about last week. Um and then inflammatory bowel disease. So Crohn's and then lastly toxic megacolon and behaves syndrome and behave syndrome is like one of those like past me things that you, I've never seen someone in real life with Bo Syndrome, but it's just kind of um a rip in your esophagus due to excessive vomiting or rup. So I think there's a triad for that and I would just look at that, but you don't need to know too much about Bo syndrome. Ok. So does anyone know any signs or symptoms of a gastric perforation or perforation in general, let's just say perfect. So someone said distention. Yeah. Guarding rigidity. So that would be a sign. Yeah, but perfect hematosis. Yeah. Rebound tenderness. How is the patient gonna look in general? Like cause we've spoken about how emergent this is. How would they look when you look at them without even talking to them without even touching them yet? In terms of examination, how would they look? Someone said like crap. Yeah, they're not gonna look good. Basically, they're gonna look, I think Zack you the use the word Murray bound. I'm not sure what that means, but they're gonna look like not good. Um Yeah. Um, I haven't seen someone that's had a gastric perforation so I can't say that I've changed yet, but yeah. Um, they're gonna look unbelievably unwell. They're gonna be shocky as people have said, the, these are all signs that they're gonna have so rebound tenderness, they're gonna have diffuse abdominal pain, but the main thing is the pain, they're gonna complain about a lot of pain as well. So it's really important again that we don't rule out, um, gastric perforation until you've done investigations, what we're gonna talk about in a second. Um, and then it's just important to know that diffuse pain is way worse in terms of, um, your clinical suspicion for perforation compared to localized pain. So, if you remember the parietal and the visceral peritoneum, diffuse pain would indicate irritation to the visceral peritoneum and that's obviously worse cause it's closer to your abdominal organs. Um, so that's just important to know as well and they're gonna be shocky. So they might be septic, they might have a low BP and a high heart rate. But again, it's really important that the pain is addressed first. So in terms of investigations and diagnosis, um, you're gonna wanna do a um full blood count, you're looking for your CRP. So, inflammatory markers, they would have a high white cell as well on lactate and lactate just indicates that there's decreased um blood flow to certain areas. So they're using anaerobic um metabolism. So yeah. Uh does anyone know which two scans would be done in terms of if a patient is presenting with a query, uh gastric perforation or perforation in general? What two exams do you wanna uh order quite urgently to investigate? So someone said chest X ray, that's good. Um Yeah, erect, that's perfect. I actually got caught out erect, chest X ray. So you want them to be erected when you're doing it instead of kind of lying. So you wanna be able to see specific signs. Um Does anyone know the other investigation that you would wanna do as well? The very well abdominal X ray as well? Perfect. So those are the two exams that you're gonna be doing and or sorry, investigations that you're gonna be doing and does anyone know I kinda gave it away, but does anyone know you would see specifically on an erect chest X ray? And then what you could see on an abdominal x-ray as well? Free under the free air under the diagram. Very good diaphragm. I can't speak today. So uh yeah, pneumoperitoneum. Um And does anyone know a specific sign that you might be able to see? Oh, someone's already said it. Everyone's a ahead of me today. Everyone's doing so well. So regular sign. Um and regular sign. If you just search up a picture on the internet, once you see it, once you'll never forget it, it basically, it, you can see both side. So if you think of a normal abdominal x-ray, you usually can't see the lines which would indicate kind of both sides of the duodenum or the ileum or basically any of the small or large bowel if you have air or some type of matter within or yeah, if you have some type of thing in your abdominal cavity, you're gonna get both lines of the intestines, you're gonna be able to be seen on abdominal X. Ok. And that indicates that there could be air or some type of perforation that's causing you to see both of those, both of those lines. And that's not to be confused with another sign which would be called uh or another kind of triad, which would be called Rick's triad. And does anyone know what Rick's triad would indicate or any of the three things that are in Rick's Triad? Ok. No worries. So, ri triad indicates gall gallstone ileus. So, basically, if you think about the anatomy of the gi tract, if you have a gallstone from your gallbladder or your, uh, kind of biliary tree, and it goes down all the way into the small bowel. So it's gone past kind of the common bile duct and it's gone all the way into your small bowel and it obstructs an area of your bowel that's called a gall gallstone ileus. And there's three different things that you would see on act or any investigation in regulars triad. So, the first one would be, um, a gallstone and the actual small bowel. And then you would also get, um, air in the biliary tree. And the last one is, um, signs or symptoms of a small bowel obstruction. So that's Ri's triad. So, just to recap because I used to get these two confused. Regular sign is a sign of gastric or perforation in the abdominal cavity. Whereas Ri's triad is specifically for gallstone ileus. So, if you have a gallstone that's causing the obstruction in the small bowel, hopefully, that makes sense. Ok. Um, and the last thing is like, literally you don't have time to do, like, oh, let's sit and think about what investigations we're gonna do, someone's presenting with with what you think is a gastric or um gi tract perforation. What's the gold standard? What's kind of the investigation that you wanna just do um to kind of prove that's what they have. Does anyone know? Yeah, perfect. So you would wanna do a CT scan and you're gonna do a CT abdomen. Um and hopefully, or I guess not, hopefully you would be able to find out if they do or do not have that and then you can kind of rule that um, diagnosis of exclusion off and you can think about other causes of acute abdomen. Ok. So in terms of treatment, there's a few different things. And for me, I found it kind of useful to think about why we would do these things. So does anyone know in terms of, um, treatments or like what, what's the management of someone that has a perforation? What kind of things are you gonna tell them to do? What kind of things are you gonna do as well as the? Yes. So perfect. Someone said surgery before all of that. What is like the most important kind of things to do? So, obviously, the kind of end goal is we wanna do surgery, we wanna treat that will cause whether that be peptic ulcer disease, whether that be trauma, whatever. Yeah, someone's asked me quickly before we move on. Ok. So perfect. I'll come back to this in two seconds. Someone's just asked me to explain the investigations after a chest X ray and abdominal x-ray. So the what you would wanna do in terms of to um investigate if someone had a perforated, perforated viscus in their abdomen, you wanna do in the right chest X ray and what you would see under that is air under the um diagram diaphragm. Oh my goodness. And then an abdominal X ray and there you would see regular sign which is where you have air or something else on both sides of the um small bowel. And that's gonna give you a distinct line. I suggest like searching a picture up because I think like it came up in ay a few times or last year, it came up. So just so you know, um what that look looks like. So those are the two things, two signs that you would see, but usually in an acute abdomen, if you think someone has a perforated viscus of their abdomen, you're not gonna have enough time to do all of that. So the gold standard. So if it said on a past my question or on like an M CQ, um what is the gold standard investigation? It would be CT scan and that's when you're gonna see whether or not they have a perforated viscus. Hopefully, that makes sense. Now. So would you see WRS and pneumoperitoneum um in, in a right chest X ray, you're more gonna see the kind of chest and then a bit of under the diaphragm. So you wouldn't necessarily see a regular sign in the right chest X ray. You would see the pneumoperitoneum in a right chest x-, right? And the regular sign in abdominal X ray. Hopefully that makes sense as well. Ok, perfect. So moving on someone's already answered this question. So I'm just gonna go through what kind of uh management would be for a perforated viscus. So you're keep them know by mouth. Obviously, we would get senior involved. We're not gonna be able to deal with this by ourselves as F ones. Um, you would keep them know by mouth, put a broad spectrum antibiotics. And can anyone think why you would put, um, a broad spectrum or give them a broad spectrum antibiotic? So, we kind of already talked about this. That's OK. So perforated. Yeah, perfect. Someone said it. So all the flora, it can basically cause sepsis. If you think about what's in your small bowel in your large bowel in kind of any area past your stomach, even in your stomach, it's not good to the, there's a reason that it's kept in kind of the abdo in the gi tract because it doesn't, it shouldn't be anywhere else basically. So they're, they're gonna get overwhelming sepsis. If you don't treat them fast, you wanna give them a broad spectrum antibiotics. You also wanna start sepsis six as well. Um If they're showing systemic signs of sepsis, um, you also wanna give them a nasogastric tube um it's considered, I remember reading as well that nasogastric tube can be a cause of a perforation. So just to keep that in mind, you might give them a nasogastric tube, but you also wanna think about the benefits versus the risks and then IV fluid resuscitation. That's also again because of sepsis, et cetera, et cetera. Um, and pain relief. That's important. I always forget to put that um sometimes on like acies and stuff, but you also wanna treat the patients symptoms as well. Um, and then in terms of specific treatments, as someone's already said, you want to, it depends on the cause, but most likely you're gonna do some type of surgery. So midline up laparotomies, I know, II can't say that word. A gram, a gram patch. Yeah, I think that's how you say it is for, um, peptic ulcer disease. Basically, if you think about the omentum, the thing that covers kind of your small bowel and your large bowel, you're gonna plug a part of your peptic ulcer with the omentum. Um, so that's specifically for peptic ulcer disease. Um, and you bowel resections, et cetera, et cetera. Um, perfect. And so that was all gi tract perforation. And then the last thing we're gonna be talking about today is pancreatic cancer. So, yeah, it's one of the most deadly cancers. It's usually not found. I think I remember learning last year. It's not found until quite late. And so unfortunately, it has a really, really poor prognosis cause it's asymptomatic until kind of the last stages. Um, most likely it's gonna be an adenocarcinoma. So, and, and most likely the most common co, um, location is at the head of the pancreas. If you remember what the pancreas looks like, it's right near the bile duct, which is important because we'll talk about that in a second. Um, again, it usually presents in old age. Um, Does anyone know specific risk factors for pancreatic cancer? Alcohol? Yeah. Uh it's more specifically about alcohol. Um Can you think of a cause or kind of uh I don't wanna give it away but a disease that if you are a chronic alcohol um abuser you take intake too much alcohol can put you at risk for which could therefore put you at risk for uh pancreatic cancer. Yeah, chronic pancreatitis. Perfect. Ok. Can anyone think of any other risk factors for um pancreatic cancer things that are kind of risk factors for any condition? To be completely honest? Smoking? Yeah, perfect. That's the one that I wish I was hoping you guys would all say. So, smoking age um drinking chronic alcohol abuse, which can lead to chronic pancreatitis and then also hereditary things. So as we spoke about before, um uh multiple endocrine neoplasias, um H and PCC, which is related to a lot of cancers in the gi tract. So like also colorectal cancer as well. BRCA two. and pu pu genes, cyst syndrome. Oh, my goodness. Um, but yeah, in terms of signs, signs and symptoms, what you wanna remember about chronic pancreat or sorry about pancreatic cancer is, it's a patient. They're older than 40 they present with jaundice that maybe they didn't even notice one of their family members noticed and they have a palpable gallbladder or palpable mass in their abdomen. So they, it's painless jaundice um, in an old patient and they have an palpable um abdominal mass. And if you take painless jaundice and a palpable um abdominal mass, what is that called when those two part together? Does anyone know? Yeah, Ks Ks Law. Ok, perfect. So in terms of other symptoms that um people that have pancreatic cancer would get, usually it's asymptomatic, as I said before and it doesn't present with symptoms until final stages. They may get epigastric pain and it may radiate to the back. And that's just if you remember referred pain, um the pancreas refers back to the back as well. Um, they'll have weight loss, anorexia. Think of your constitutional symptoms of cancer. They're gonna be um complaining of weight loss, they might have nonspecific symptoms. Um Yeah, and then they also might have Hepatomegaly and that's just because of the backup in terms of the biliary tree. Um, and they might, might also have malignant ascites and then uncommon symptoms would be your loss of exocrine function of the pancreas. So, if you remember the exocrine function of the pancreas is to release enzymes for digestion. So they'll have um decreased fat, um absorption or fat malabsorption. Sorry. So all of the vitamins that are required fat is required to absorb them is ad ek so they're gonna have deficiency in all of those vitamins. They're also gonna have fatty stools. So that's steatorrhea because they're not able to digest their fat properly because they don't have the proper enzymes. And then they also have a loss of endocrine function of the pancreas. So they'll have insulin, um hyperglycemia due to insulin really resistance. Oh my goodness. Ok. Um And then as I said before, Crusoe's law is when you have a right upper quadrant mass associated with painless jaundice and you don't wanna be thinking of gallstone. You, you wanna be thinking of pancreatic cancer, especially in a patient older than 40. Um perfect. So in terms of two week, wait, and this is kind of again, something you just have to memorize unfortunately, and or it intuitively makes sense as well in a patient that's presenting with um pa new onset jaundice, um especially if it's painless above the age of 40. You wanna refer them for an investigation in terms of pancreatic cancer. And then again, um if you wanna refer them urgently for act abdomen, um and pelvis if they're over 60 with weight loss and then any of the following symptoms. So, diarrhea, back pain, abdominal pain, nausea, vomiting constipation and a new onset diabetes. Ok? And the new onset diabetes, I just wanna go over that again is because they lose their endocrine function of the pancreas. So perfect. And that's again, just something that's really important to know because they love to throw questions where you, you got this whole nice vignette. And that's what's the management of this patient and what's the next, what's the next best step for this patient? And usually it will be a two week wait, if they're presenting with some type of thing that's making you think of pancreatic cancer. OK. I think this is the last slide or one of the last slides. Um So for TS sorry, so for investigations, you wanna be thinking of like a full blood count using these LFT S specifically and you're gonna see an obstructive picture. Does anyone know in terms of uh the four kind of tests that are on your LFT S? What would indicate an obstructive picture in comparison to maybe other causes of deranged LFT S? Perfect. So high bilirubin, high alp and high GGT and kind of a question not directly related to pancreatic cancer. But if you have a high alp by itself, what would, what would that, what would you be thinking then instead of pancreatic cancer? So an isolated high perfect bone, someone said bone already. So you're thinking of Paget's disease, something to do with typically your bone so quickly to go over LF TSI know that you guys must have got teachings elsewhere, but you have four kind of things are in your five, but four things are in your LFT S. So Ast and A LT and then Ap and T, and the way I remember is Ast and alt are related to the liver and then AP and GGT are related to the biliary tree and the pancreas. So if you have a raise in your A LP and your T you wanna be thinking about kind of an obstructive jaundice pitch or something to do with your gallbladder or your pancreas? Whereas if you have a raise in a LT by or a LP by itself without t you wanna be thinking about bone and usually the vignette or the um stem of the question gives it away as to what the cause is. Um perfect. So ALP is raised, we talked about that CT and that's the kind of diagnostic investigation slash staging investigation for pancreatic cancer. And you would see a double duct sign. And does anyone know what can anyone explain what the double duct sign would be or kind of how that is caused? That's ok. So to quickly go over the double duct sign. So if you think about where the pancreas sits in terms of your duodenum, so you have your pancreas, your head of your pancreas here and then your small bowel kind of running alongside it and then the two ducts that go in to the du duodenum, one is from the pancreas. So you have the pancreatic duct and then you also have the common bile duct and they come together and then they go into the duodenum um to secrete all of the different enzymes and uh um bile um if you have something that's obstructing the head of the pancreas and as we spoke about before, the most common co the most common site of pancreatic cancer is at the head. It's gonna obstruct that area and that's gonna cause backflow of bile back into the biliary tree. Um So you get backflow into the pancreatic duct and then also into the common bile duct and that's what causes the double duct sign. Um And if you, if you um search up a picture, you'll be able to see a perfect kind of picture of that. Um Someone's asked when you say high ap what issues are there with bone. So specifically, if you have a raise in a high ap, you have what's called, it's usually what's called Paget's disease or Paget's disease. Um I would search on past my, just a quick summary, but basically, it, it's an increase in kind of sclerosis. So you have high bone bone turnover um and you get sclerosis of bone. Um and it's usually in an older patient, they're gonna have fractures and stuff like that. You don't need to know too much about it like this year, but I would say just Paget's disease if you say high A PP, Paget's disease always or some type of bone disease. Ok. Back to this. So, MRI as well, you can do um to investigate pancreatic cancer, but you're kind of staging once you need to stage it um pancreatic cancer. So you're gonna do that through biopsy and you can do that either percutaneously or endoscopically. Um You can also think about doing kind of an M RCP or an E RCP as well. Um And that's gonna show dilated pancreatic ducts because of what we spoke about earlier. Um And does anyone know the cancer marker that you would get kind of in your serum? Um If they have pancreatic cancer? Yeah, perfect ca 19 9. And the way that I me and my flatmate like to remember it is that like the nine kinda looks like a pancreas. So there's a few different funny ways to remember the different cancer uh markers, but that's how we remember that one. So 19 ca 19 9 is like uh cancer marker, the serum marker for pancreatic cancer. OK. In terms of treatment, I think this is the last slide. Now, I always say that um it's basically it's terminal. So you wanna be thinking about making them comfortable, the patient's comfortable. They usually again, don't present until late. So there's not much else we can help or really do for the patient. Um You wanna give pain control. Um think about nutrition, um, and also a mental health support as well, especially for the family involved and stuff like that. And in terms of symptomatic relief, you can think about stenting. So, stenting the, uh, bile ducts as well to, um, kind of decrease kind of the symptoms that the patient might, um, experience. Um, you can also give surgery. Does anyone know the specific type of surgery that you would give in pancreatic cancer to remove the pa or remove the um, cancer? I think if anyone loves Grey's anatomy. Yeah. Whiffle. Um, they spoke about it on Grey's anatomy. It's called the whipple procedure. Um, and you're basically going to be taking out a lot of the kind of gi tract related to the pancreas. So you're gonna take out kind of the head of the pancreas, the fundus of the stomach, a few other place. Uh uh a few other things, sorry that I can't remember. But, um, it's not very suitable in most patients. So most likely it's gonna be kind of palliative care that you're thinking about. Um, and then it's just important to remember that in a patient that's have a whipple resection. One of the most common complications or kind of um effects is called Dumping syndrome. And that's just because if you think about if you're removing a lot of the pancreas, a lot of the stomach and a lot of the uh duodenum, you're gonna be left with a really short gi tract. And so patients that have dumping syndrome, they just have a rapid kind of influx of food going through their gi tract too fast and it's not being absorbed properly. And so they get symptoms kind of of nausea, vomiting, abdominal pain, after eating stuff like that. But I wouldn't know too much about that. I just think just know kind of the two complications related to the whipple's procedure. Peptic ulcer disease and dumping syndrome. Ok. And that's all for today. Ok. 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