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Hello and welcome everybody. Thank you so much for joining us for Session two in our surgical series. Uh My name is Joseph. I am the treasurer for this year. Um And today we'll be going through the lower gi core conditions and this is a pretty big topic. So I'll just get right into it. So, first, a brief overview of what we will be talking about today. So obviously, we'll have to be talking about the anatomy essential. Uh We will briefly mention some embryology. Uh I promise it's not that much, but it is important to understand a few things that is key with the anatomy, uh co conditions. Next, you can see that the list is pretty long. So we'll try and get through that as best as we can. And uh at the very end, I will direct you to read up on a few other conditions yourself that uh I didn't really have time to go over. Um And of course, some practice SBA is for you to do in your own time. Uh But firstly, uh what do we mean, what are we talking about when we say the lower gi tract? So, continuing on from last presentation. Uh We're going off of the gi bleed definition, which means we're starting at the Duodenal Gal flexure and continuing all the way through to the anus. So really that includes the parts of the small intestines of the Jin and ileum and the entire large uh large bowel before we get into the uh gi tract proper. I want to talk about the peritoneum and what exactly that is, this can be a kind of tricky concept to get your head around. Um So the easiest way for me to remember it is that when you start as a um as a developing fetus, basically. So the peritoneum kind of comes down like this. OK. And it, it, it, there's nothing in that space, but it is um a serious membrane and the membrane folds down like that kind of like an apron. And you have all these little organs sort of starting to develop behind that sack. And what happens is as you grow and continue to grow. So do these organs and they eventually they push into, they, they, they pushed into this sac here into the peritoneum and eventually they get enveloped by that sort of posterior part of the peritoneum and get completely embed by it. So that's what, that's what I mean that that becomes your visceral layer that surrounds all those organs. And then you have your parietal layer, which is, which is here that kind of surrounds it, as you can see here, the parietal layer that surrounds it, um that adheres to the walls of your abdomen. The space between those layers is called the peritoneal cavity. Technically, there's actually nothing in that cavity because the organs haven't actually uh puncture a hole in the peritoneum. They've become enveloped by it and you'll sometimes see or hear the analogy of um, a water balloon and pushing your fist into that water balloon. And what happens is then your fist kind of gets enveloped by the walls of the water balloon. But you're not actually in where the water is, um, the organs within the um, cavity, I say cavity. But there is technically, isn't anything in there but sort of within being enveloped by the peritoneum, I should say called intraperitoneal organs, uh organs that are behind it are called retroperitoneal. Um, some of those include uh the pancreas, um, parts of duodenum, et cetera. Now that the peritoneum has two main functions, it provides lubrications for organs, especially really mobile ones such as the small bowel. Uh and it also contains uh immune cells in the fluid. So it's really important for our immune response. Ok. Now, let's start talking about the gi tract itself. So the first section of the gi tract is the j which you can see here, highlighted in green. Now, judging them is all about the surface area. Um One thing that's really handy for me when I'm learning anatomy is uh form and function. So form and function go hand in hand. Things are a certain structure a certain way because they have to fulfill a certain role. So the J is where the bulk of our absorption occurs. They're taking all the really good nutrients from our food there. And to maximize the efficiency of this, they maximize the surface area of the. So we have circular folds, microvilli all there to maximize that surface area um starts at the duodenal agin flexure which is roughly at L2, uh continues on into the ileum. There isn't really any strong demarcation as to where Jin ends in ilium starts apart from histology. Histology is the main um where you can tell from where you are. Um sort of roughly speaking, it is mostly in the left, left upper quadrant of your abdomen. So if you're, you know, palpating in an abdo exam, that's where the J sits. OK. So continuing on from what I said about that surface area, you can have a look here. You can see those circular folds poking out and they're surrounded by villa and then the micro bili which surround the epithelial cells again, is to maximize that surface area. It's important to think about the layers of the jejunum. And this is the layers of pretty much all bowel, even small and large. But think M SMS start with from the lumen, the open space. It's mucosa submucosa uh muscle which has a longitudinal and a circular layer and it's finally surrounded by cirrhosa. Um So those circular folds that I mentioned that I keep mentioning in the mucosa, uh they have a name, they're called valvula convenes. Um An old name is Bowles of Kring, named after an anatomist who described them. Um And these are important because they go right around, right around the entire small bowel. Um on histology, the mucosa is lined with simple columnar epithelium as is most of the gi tract, to be honest. Um And between the v um between the single ville, there are specialized lymph cells called um crypts of lybe moving on to the ileum. Uh This is the last section of the small intestine and one of its main roles it performs is to absorb b12 vitamins and recycle the bile acids um continues on from the jun all the way to the ileocecal junction. Um and is usually separated from the cecum by an ileocecal valve. Um It makes up the remaining 3/5 of the small intestine. Um So it covers, it occupies quite a large space in your abdomen. Um Again, the layers are the same as the jejunum. But what you'll start to see on histology is the circular folds become fewer and fewer and fewer until they kind of almost completely smooth out as it enters into the caecum. Um It also has payers patches which is pretty unique to the ileum and that is the histology that differentiates your ilium from the, the lymph supply is also a lot richer. Uh Finally, uh you have mesentery which holds all of the geum and alium, all the y um It's an anchor point for the ilium to the posterior abdominal wall. Uh It also houses the nerve blood and lymph supply to those structures. Um It's designed specifically the way it is to allow movement for peristalsis. Um while it gives the J and ilium somewhere to attach to it leaves it mobile enough that that peristalsis isn't interfered with. Um continuing it on. You've got the greater and lesser omentum that we spoke about in the last presentation. Uh continuing on from the mesentery and this table just sort of highlight some of the differences between your and your ilium. Have a go at sort of filling out this table yourself with that blank and then see how well you can go. It's a good way to just sort of remember the differences. OK. Continuing on from the ileum, the ileum then goes into the large intestines here. OK. So the major function for the large intestines is actually water absorption. We actually absorb most of our water from our food through the large intestines. Um It is divided into little different segments and I'll talk about all those sections individually in a second. But um there are similarities across the entire large intestines and there are four major characteristics that I want you to remember because it helps differentiate the large intestines from the small intestines. OK. So number one is these epiploic appendages, um which I'm trying to highlight here and they're kind of hard to see. Uh And I'll be highlighting them in the Complete Anatomy app as well. These are literally bits of omentum that kind of hang off the large bowel. They're really small in this model uh in real life. Some patients absolutely covered in them. So they're much more apparent in real life. Uh The next thing that you need to remember about them is they have these things called tinea coli. Tinea coli are three longitudinal bands of muscles that run along the long axis of the large bowel. And you can see them, you can see one of them that's two, there's a third one running behind it. I'm showing you this in complete anatomy. Now, these bands run along the whole length up until the rectum. They become one muscle, they kind of form into one muscle that continues, continues on. Um But so what happens is that they run along that long axis and then they pull like pull on the large intestines and causing these bunches to appear. These bunches on the outside are called heister, these bunches here uh inside the lumen, the mucosa forms semilunar folds. So let's uh start our discussion of the individual section starting with the cecum there highlighted in green. OK. The cecum is the first part of your large intestine. Um As I mentioned earlier, the ileum ends at the ileocecal junction and feeds into the caecum and is usually separated from each other by an ileocecal valve. Now, not everybody has this, actually, it's uh uh an anatomical variation. Uh This does actually become clinically relevant, especially in obstruction. But again, talk about that later on usually lies in the right iliac fossa. It's actually very mobile though. So it's not always found there. Um What's also important is that the cecum has the appendix. The appendix is a blind tube that kind of hangs off the cecum. Um It's important for uh it has a lot of lymph tissue, first of all. Um and it's thought to sort of be a safe haven for bacteria. So if you've had some sort of illness and you have diarrhea that flushes out your entire gi tract, there's no more bacteria there. They can hide in the appendix and then repopulate your gi tract after you've gotten better. Um The location of the appendix is actually very variable. Uh Most common is retrocecal behind the cecum. About 65% of the population has their appendix in this position. Um Think of the positions like positions on a clock and going around one o'clock to etcetera, etcetera. Um don't get too caught up in that. It does become clinically relevant in appendicitis and things like that. But just for the most part, know that the appendix is not always found in the same spot. Ok. Continuing on, we now reach the colon. So the colon is divided into four parts itself and these four parts of the ascending colon, which then turns at the hepatic flexure, the liver sits up there into the transverse colon which then turns down at the splenic flexure into the descending colon, uh which then it goes into the s shaped sigmoidal colon. Now, two parts of the colon are intraperitoneal and have their own mesentery that is the transverse colon and the sigmoidal colon. Um And the insides, the mucosa of the, of the colon is lined with simple columnus. OK. So we finally end uh our tour at the rectum and the anal canal. So, as I mentioned earlier, these structures are quite different compared to the rest of the large intestine and this reflects the different function that they perform. The rectum is really a storage space for the feces that have been formed by the rest of the large bowel. And then the anal canal is obviously the communication to the outside to the exit. Um the rectum there um has stretch receptors that can sense when the rectum is, is full. Um And then the anal canal has two muscular sphincters, an internal one which is smooth muscle. So, involuntary control and an external one which is skeletal muscle, which is voluntary control. Why do we have these muscular sphincters? Well, it's of course to give us a degree of control over when we void the bowels, so we can hold contents in until it's convenient to release. Um Now, the superior part of the anal canal has, has similar histology compared to the rest of the large intestine. But below that certain line, the pic tenant line, it becomes quite different, it becomes nonkeratinized, stratified squamous epithelium. This is more similar to sort of outside skin. And that's the reason for that is because it comes from a different germinal line. You may have heard about germinal lines, but there are three main germinal lines in embryology. And um this is analogous to actually the beginning of the gi tract, which is at the mouth. The mouth also has a very different sort of histology compared to the rest of the uh gi tract. And again, this is because it comes from a different German line. OK. So now it's time to talk about the neurovascular supply to the gi tract. So, first of all, let's talk about the um blood supply. Uh you may have heard the term for gut, midgut and hind gut and this is a convenient way for us to divide the blood supply uh of the entire gi tract. Now, we are looking at the lower gi tract. So we're more interested in midgut and hind gut. Um But why do we have such a split sort of um blood supply? This goes back to our embryology. So now if you can imagine with me. Ok. So what's this big vessel here, guys say it with me? That is our abdominal aorta. Now, imagine when we were sort of embryos, when we were fetuses developing, all we had was one long blood vessel running straight through the middle. On top of that, we had one long tube kind of running over the top of that. And as you can see here, you had three branches coming off of that abdominal aorta supplying that tube. Now, that tube becomes our gi tract. And as it grows, it gets longer, it loops on itself, creating those loops there. Um but the blood supply remains the same and that's why we divide it into four gut, midgut and hind gut. Now, you can, as you can see here, the celiac trunk highlighted in green, the superior mesenteric artery and the ina mesenteric artery know what levels these come off at because that was literally one of our exam questions. Um in terms of the um S MA that comes off at L1 and the I MA comes off at L3. OK. Nerve supply, nerve supply can be a bit more complicated. Um So I'll just briefly run through it. Um There's parasympathetic and sympathetic supply to your gi tract, um parasympathetic rest and digest obviously has a large role to play. Um the large intestines all the way to the transverse colon are innervated by the vagus nerve. The very same cradle nerve number 10. And uh the pelvic splanchnic nerve then takes over from the splenic flexure onwards. The sympathetic nerve supply is mainly from the superior mesenteric plexus, which you can see here um from the cecum to the transverse colon, um the inferior mesenteric plexus and takes over from splenic flexure to the rectum and the inferior hypogastric plexus uh in the rectum. OK, guys. Uh Thanks for sticking with me. Take a little breather here. It was a lot to cover. Um I just want you guys now to take a second to try and summarize what we've just talked about in the anatomy. So start from the beginning all the way to the end. Um Think about the three main arteries that supply the gi tract, what levels they come off of what structures that they uh supply and just take a minute to digest what we've just talked about. Um And we already we'll start some of the co condition. OK? One of the biggest, most important concepts to understand about sort of uh any sort of gi um pathology is the concept of the acute abdomen. Now, even if you've never heard of this term before, you can probably guess as to what it is, it is an acute onset of pain in the abdominal area. Um There are lots of causes a lot of differentials to think about when a patient presents such a way. Um But two of the really most important more biggest emergency presentations. Perforation and peritonitis. The thing to understand about perforation and peritonitis is, yes, they are diagnosis in their own right. But they are not the end diagnosis. There's always something that's causing these things and to definitively treat it, you have to find what that cause is and address it at the root level. Um Having said that we'll just quickly go through what a perforation looks like. So, first of all, perforation is a loss of the continuity of the bowel wall. Um The causes, there are a lot and some of them are called conditions in their own, right? And we'll talk about it when we get to that. Um the contents of the bowel just start to leak into that peritoneum because of that loss, basically a hole in your gi tract. Um Obviously, this is not good if you think about it this way, this is our internal body, our entire body immune, the immune system is set up to sort of defend the internal body from the external environment. The only section of the internal body that's exposed to the outside environment is our gi tract. Now, imagine what happens if there is a suddenly a hole in that gi tract, then you've got all this outside environment, all the bacteria that's naturally in our, in our gi tract starts to leak into the peritoneum and the body does not like this. Um Not only can they go into hypervolemic shock. Sepsis is a real threat here and uh death is the end result if not managed appropriately. Uh Patients are very unwell and you're um and they, they just sort of present, the main presentation is, is pain. Um You'll do urgent blood uh CT with contrast as the imaging of choice. Um abdominal x rays, they used to be used more frequently, not as much anymore. Nice guidelines really recommend doing CT with contrast, it's better at picking up sort of perforations. Um So what happens with the perforation, bowel contents leak out, get into the peritoneum, peritoneum becomes infected again, becomes inflamed and that's peritonitis. So the signs of that are, are shock. Um These patients are really unwell and they don't want to move at all. So you'll see them, they'll lie still as a log in the bed. Um because any sort of movement will we sort of irritate the peritoneum, which covers our entire like gi tract and that will just cause shooting pain. So they'll sit still, they'll lie there and not move. Um guarding in your abdominal uh examination, you will see them actively wince and, and sort of push against any um palpation of the abdomen. And this thing called rebound tenderness. Um You may have seen it in placement if you're, if you're on surgical placement already, that's when they sort of uh rigorously percuss along the abdomen. And that rebounding movement basically pushes the abdominal wall into the peritoneum briefly and then they get, they get shocked that they're um in pain from that. Um, the pain is initially localized at first due to the omentum. You probably will have heard the nickname of the omentum, the policeman of the abdomen. So what happens is the omentum goes around roaming for any problems, basically. And if it finds anything, it sucks around it and it uh just closes it off. So that's why the pain is localized at first. Um If it gets out of there, if it, if it sort of starts to leak out from the omentum, then the pain becomes more generalized. And that's a sign that uh that things are becoming much more life threatening. Um These patients, you need to give them an antibiotics. IV. Um And as I said, you need to find the underlying cause. Ok. The next um coition to cover is intestinal ischemia. So any kind of ischemia is reduced blood perfusion to an area. The most famous example, being a myocardial infarction, its exact same sort of thought process, exact same sort of um principle except uh we are reducing perfusion to the intestines instead. And this can lead to a perforation if left undiagnosed. For long enough, there are three broad classifications, I'm going to focus on the acute mesenteric and um ischemia. Um because this is more of your sort of acute abdomen presentation. Um for whatever reason the S MA is, is the blood vessel. That's the most likely to be effective. No one knows why. Um there is often a triggering factor, triggering cause for this. So it's usually a patient who has been diagnosed with AF is post M I has like a mechanical heart valve and then later on the line, they present um to A&E and they've got acute mesenteric ischemia. Now, that presentation, what does it look like? It is the key thing to remember about the presentation here is that it's severe abdominal pain out of keeping with clinical findings. Ok. So you may get these patients fairly early and you scared them, you don't really see very much, but they're screaming at the house down there and so much pain, uh nausea and vomiting accompanies about 75% of these cases. Um So your investigations, you want to start with your bloods, one of the most important bloods to get is, is an ABG because you want to see that lactate and you want to see what sort of level of ischemia we're dealing with. Um Then those routine labs, those are the UCR PS LFT S, et cetera. Um Imaging mode of choice is the CT with IV contrast angiography. Uh don't give patients with ischemia, oral contrast, don't make them swallow anything. It's not a good time for them. Um So the CT will be able to pick up where the ST mirrors quite well. Um So there's four sort of common causes for an acute mesenteric ischemia. So there's a um thrombus in situ the embolism, there's probably a more common causes. So there's an occlusion to the S MA and there are your non occlusive causes symptoms called. No, these are things like hypovolemic shock. And uh finally, you have a venous occlusion which is very rare, very, very rare, um not commonly seen at all. Ok. Um The other kind of intestinal ischemia disease is an ischemic colitis. Uh Remember when I talked about those flexures that hepatic flexure here and the splenic flexure there. Uh Now, because of the way that the blood supply to those areas are set up, these are called watershed areas. Um The blood supply, especially in that splenic flexure is, is pretty, there's not much collateral. All right. All right. There's, there's not much back up into these areas. So if something goes wrong to the blood supply very quickly can become ischemic. Um in this case, uh non occlusive causes actually the majority of it. Um The condition can range from fairly mild to all the way to extremely severe gangrenous sort of necrotic. The tissue has died. Um sort of range in presentation uh because the splenic flexure, in fact, is probably the most commonly affected area. It um presents as lower left abdominal pain, um can be accompanied with bloody diarrhea. Uh Often these things resolve spontaneously. However, if it is severe enough has become sort of um necrotic has started to die, then you will need to take these patients to surgery just like you would with an acute mesenteric ischemia. Ok. The next lot of, um, cod conditions to talk about, uh, bowel obstruction and an s, right. So, obstructions can occur anywhere along the gi tract. Um, this can be partial or complete. Uh And there is distinctions between a mechanical cause and a functional cause and I is an example of a functional cause and we'll talk about that in a second. Um What are the causes? There are lots, uh You can see in this diagram here, it's sort of split into if it's intraluminal or inside the wall of the gi tract or if it's somewhere outside the wall. And again, we will be talking about some of the causes of the um, obstruction um later on because some of the cool conditions cause this. So I won't go into too much detail there. Um There are differences between if the small bowel is obstructed or if the large bowel is obstructed and it can, um sort of present differently and that can help you distinguish between the two. So despite all that, there's very typical presentations for a bowel obstruction. So first of all, your gi tract is designed to go, it's a one way system really in one end out the other. So if it's blocked, there's only one way for the contents to go and that's back out. So these patients will start to vomit. Um absolute constipation. What that means is that there's no um bowel movement and there's no flatulence either. It, there's just nothing because of course, the bowel has been locked. Uh The pain is usually described as colicky in nature. So, coming and going in waves. Uh and you will see abdominal distension especially in more um, more advanced cases. Um This table here talks about the differences between the large bowel and small bowel obstruction, right. So this is the big ones that you need to remember. The most common cause of a small bowel obstruction is adhesions. What are those adhesions are basically when sort of things start to stick together. And it's usually, it's kind of like scar tissue basically. And it's usually common when there has been lots of procedures, lots of surgeries done in the abdomen. These scar tissues start to form and uh the small bowel especially is, is, um uh is, is affected by that. That is your most common cause in small bowel and large bowel and obstruction is probably malignancy is the most common cause diverticular disease in vs and uh next most common causes. And again, we'll talk a little about these in more detail later on. Um Yeah, you know, bowels don't obstruct for no reason out of the blue. Um And unfortunately, large bowel obstruction is probably indicative of quite a advanced um, malignancy. So small bowel obstructions, the vomiting usually occurs earlier because it is more proximal. It's closer to sort of the mouth. If the small bowel is obstructed, it's more like the vomiting will occur quite early. Um Likewise, the absolute constipation usually occurs later because the obstruction is sort of higher up in the digestive tract. There's still all the other bowel content that is, that will still be going. You won't be happy but it will still be going. Um So because of that, you may hear what's called tingling bowel sounds. So that's when this sort of dripping, they call it dripping of um, bowel contents from the obstruction. Um, bowel sounds in a large bowel obstruction. More likely to be sort of completely absent because it's more likely to cause absolute constipation earlier. Ok. So a patient presents to you and you think they might have an obstruction. Uh, what's your first line of investigations? Well, first line is, uh, CT with contrast. Um, abdominal X ray used to be what was done first line and it is still used in certain settings. Um, I'll go through these, uh, abdominal x rays with you, um, in a second, but ct contrast is what's recommended. First line by nice. Now, uh, you'll also do all your blood tests. So full blood count in your knees, crp um, and group and save if you need to take them to theater. Um, you and these are checking for any electrolyte disturbances as well in case these patients need uh IV fluid resuscitation. So let's talk about the abdominal x rays now. Ok. So an abdominal x-ray, first of all abdominal x, the approach to not abdominal x ray should be structured just like your approach to a chest X ray is I'm not going to go through that because for one, I don't really have time to um sort of a radiologist, probably someone better to go through abdominal x rays. Um, but I'll talk briefly about what uh signs these X rays are showing and also what the 369 rule is. Ok. So, first of all, let's have a look at this one here. These are the same patients. Just one is erect and one is supine. So this patient, uh so they're standing up in this X ray, they're lying down. Um, if you can have a look here and you can see that there is this free air sort of floating up. Ok. You can see that the dark spots is air. Um And if you have a look at the Supine x-ray, uh you can see that the bowel is distended. Ok. It's, it's dilated, right? And I can tell that this is small bowel that's been dilated. Ok. Now, compare it to this one here, which is a large, um, bowel obstruction and the large bowel is distended this time. Ok. Uh It's quite dilated. You can, you can see it's quite, it's much, much wider than it should be. Um, this patient. What do you think that is just out of interest. What do you think that is, it's not a gi thing at all. It's um it's a hip replacement. This patient has had a hip replacement. So that will show up on an X ray as well. Um OK. So for standing up, right? Ok. Air floats. So it floats to the top. That's why you're seeing the air come to the top there. And the reason why there's trapped air in your, um, in the, in the gi tract is because there's an obstruction. So how do I know that this is a small bowel obstruction and this is a large bowel obstruction. Well, if you ever look really closely here, you can see that line, you can see that line, these lines, they basically go all the way around this bit of bow and compare it to here. There's, that's a good example there. It's kind of not all the way down. Uh That's, that's a good example. There, it stops, halfway stops, halfway. It kind of goes about to there. Ok. Remember when I talked about the anatomy of the ilium, having those circular folds that go all the way around, right? So the valvular convenes, they go all the way around the bow. That's how, you know that, that small bowel compared to this image here and how those lines go halfway. That's moisture. Remember halfway, hoist her go halfway, think about that. So that's how, you know, that's how you know that, uh, that's small bowel and that's large bowel. Ok. Um, the 369 rule. So abdominal dilation, you call it, you have to give it a number. You can't just eyeball it and say, oh, that looks a bit bigger. So what will happen in, in, um, in imaging is you can actually measure it across and if the small bowel is equal to or larger than three centimeters across, that's dilated. if large bowel is, um, or if, if colon is dilated to six centimeters, six centimeters or wider, that's dilated. If the cecum is dilated to nine centimeters or wider, that's dilation. So that's the 369 rule um for abdominal x rays. Ok. So much like uh the perforations and the peritonitis, um there is an underlying cause for this obstruction and to treat it, you need to manage that. Um But in the meantime, patients need to be managed sort of acutely and you actually go for conservative management first. So these patients who need IV fluids usually need to be resuscitated in some way. Um And they undergo what's called a drive and suck it. It's pretty successful. 80% success rate. It's about as pleasant as it sounds. Um, you make these patients know by mouth, put a nasogastric tube in and start sucking out whatever is causing the obstruction. Um, the IV fluids, they can be the drip part of the drip. And so, uh these patients are probably in pain. So you'll give them analgesia and if they are feeling nauseous ants is a good, uh, good idea as well. Um, these patients depending on the cause, who will go to surgery. Um, you know, for example, if the destruction is a tumor or a strangulated hernia, um, if the patient has failed to respond to a drip and suck, then they do go to a theater as well. Ok. So now we're specifically talking about an ileus. This is what's sometimes called a functional bowel obstruction. And what happens is that the, uh, bowel becomes stunned and is paralyzed. So, peristalsis stops happening. Obviously, things are not moving, it functions as, as an obstruction. Um, it's a diagnosis of exclusion. So, uh, these patients will present this pretty similarly to the mechanical obstructions that we just talked about. But, uh, if you can't find any mechanical cause of the obstruction, then you can probably diagnose nias. The other thing as well is if they've had recent abdominal surgery, the most often cause of Anias is that it is, um, surgery. Uh, the small bowel doesn't like being handled, but in a big sort of open abdominal surgery or any sort of surgery really, um, they kind of have to touch it and move it out of the way to get whatever you need to. Um, and the small bowel just doesn't like being handled. So sometimes it stops moving. Um, these patients probably have absent bowel sounds because there's nothing happening, there is no movement. Um Still the first line investigation is the same. Um, management is slightly different. It's much more supportive. Uh if they're fairly um so severe, they may need admission know by mouth N GT and to correct the electrolyte disturbances with IV fluids. Um, but we usually resolve itself in 3 to 4 days. Ok. The next cod condition we're going to cover is appendicitis. So what is appendicitis? It's an acute inflammation of the appendix. Now, as I mentioned earlier in the anatomy and appendix is, is a blind ending. And so only one way in one way out, most often you get inflammation due to obstruction of that single entrance and exit. So then the appendix starts to sort of balloon becomes red and angry inflamed doesn't like it. Um It's the most common surgical emergency actually. Um with peak incidence between the ages of 10 and 30 it's really seen as a condition in Children and adolescents having said that it it can occur at any age. And the one case I've seen is actually a 52 year old man who was taken to emergency theater for an appendicectomy. Uh There are some risk factors that very slight higher incidence in males, um, typical presentation. So you, you need to be able to think about this in your head because it it is one that's quite common in exams. So what usually happens? The story is usually this person wakes up and he's got generalized pain around the umbilical area and then eventually it will progress into a really severe pain into the right iliac fossa. Um anorexia, which is not anorexia of those who don't get those too confused. Um In this case, what we talk about in anorexia is that the patient can't stand food, they, they cannot look at food, they cannot think about it, they cannot think about the thought of eating. Um So if a patient in front of you has sort of um abdominal pain, but their appetite is a, it's a good sign that they're not, they don't have appendicitis. Um anorexia is sort of pathic of appendicitis and nausea and vomiting can um can accompany cases, not every single case has it, but um it is present in enough of them. Um The reason why the pain presents like this. So what happens the appendix becomes inflamed. This gets picked up by afferent nerves which go into the uh dermatome of T 10, it's kind of hard to see in there but T 10. And as you can see this feeding into T 10, that's your periumbilical area. So that's why it starts off as kind of generalized middle of the stomach pain. Uh as the appendix becomes more and more inflamed, it will start to press up against the peritoneum and cause that um cause a very sort of localized pain reaction from somatic nerves. Uh on examination, these patients will have tenderness at mcburney's point. Um Tell me what mcburney's point is guys, write that down. That's really good to know. Um They will also have rebab tenderness. Uh Again, as I mentioned, that's when you percuss against the abdomen. They used to what they used to do for me about tenderness is they used to push in really deep, palpate really deep and let the hand go. But uh they realize that's actually probably not a very nice way to elicit that sign. Uh These patients will be guarding as well if it's severe enough. Um Now, the one thing you need to watch out for is signs of sepsis, sepsis. So, the thing about appendicitis is if it is blocked off and it continues to grow and grow and grow, what's eventually gonna happen is it's gonna burst and then you will have a perforation. What we talk about at the beginning of these co conditions, perforations, obviously signs of sepsis. Um that needs to be managed first. An unstable patient needs to be stabilized before you do anything else. Eponymous signs, eponymous signs can be really frustrating to remember because it's all these people's names. Um But they are a very good thing to remember. So, rosing sign, if you palpate the left iliac fossa, palpate it deep enough and it causes pain in the right iliac fossa. Um That's Rosings positive. Uh What you're doing there. The idea is is that you're sort of pushing sort of the content that your abdomen across and causing the appendix to press against the um peritoneum, triggering um triggering pain. Um So, as sign, so the appendix presses up against sort of the posterior abdominal wall, presses up against peritoneum for a localized reaction. But part of that posterior abdominal wall is your soas muscle. So the so sign is if you stretch well, if you contract that muscle, so you, you involuntarily lift the patient's right leg up and the contraction of the so muscles should touch the appendix. And if that happens and that the appendix is inflamed, it will cause pain. And that's so I sign positive as well. And there's debate about whether how useful these signs are in, in diagnosing appendicitis because often you can, there's cases where these signs are negative, but when they open up the patient, the appendix is inflamed, but it's good to know it's still used. Um, someone will ask you about it. So it is good to know. Um, one of the really popular ways of diagnosing appendicitis actually is standing up on, get them to stand on their uh right leg and extend their uh left arm up and then hop on the spot again, that's trying to sort of trigger um, uh peritoneum irritation causing pain. Ok. So what investigations are you going to order for a patient with appendicitis? First of all, it's actually a clinical diagnosis. Uh, most patients, especially if they are say a young otherwise fit male that's presented with this typical story of generalized periumbilical pain, becoming more specialized, more specific, right? Iliac fossa pain. Um that's a clinical diagnosis. You can probably take them up to theater and uh and for appendicectomy. And that was again as actually one of our questions in the exam. Um in real life, things are not always as cut and dry, especially if it's a female patient. The one thing you want to do is rule out any sort of ectopic pregnancy. So pregnancy test is key. Um ed is usually very good at this. Um When patients come in, a female patient comes in with any sort of abdominal pain that will usually do a pregnancy test, urinalysis outside of that urinalysis is handy. Um Anyway, sort of, it gives you a lot of information. Uh if they have a a urine infection, that's another diff differential. Um just gives you a, it's very easy to do and it gives you a lot of information um bloods, this is the sort of routine or urgent bloods. If you like that, all most of these patients presenting will get so full blood count and in particular, looking at that white cell count. Um CRP as well, you'd expect the CRP to be raised in in acute appendicitis. Uh Grifin safe and coag screens are especially key um when they're going up to theater. Now, imaging again, because this is a clinical diagnosis you shouldn't be going for imaging straight away. Um But again, in real life, things are not always clear cut. So, um an ultrasound is a really good first line. It can be done very simply at the bedside. Um also very good at uh distinguishing from a gynecological differential ct with contrast is often used in clinical practice as well and, and uh this is how an appendicitis can present. Um MRI if you really are stuck, uh, it's pretty rare that an appendicitis goes all the way to MRI. Ok. What's your first step management with appendicis as well? Patients in front of you, they're in pain. What are you gonna do? You're gonna give them pain relief. Paracetamol is usually first line um, morphine if it's required. Uh surgical management is the gold standard. So you go, these patients will go to an emergency theater list for an appendicectomy, not an appendectomy. We're not in America. This is the UK. Um, laparoscopic is first line. You, you, you try to do it laparoscopically. Sometimes if they become complex, they'll have to be open. Um, now I was at, I had attended at a talk by, sponsored by Royal College of Surgeons and they mentioned that there's evidence for IV antibiotics to be done first before surgery. And this is um for a number of things, it helps to reduce sort of POSTOP infections. I couldn't find any of the national guidelines that recommended this step all of them said don't use antibiotics until after the surgery and then there's still, um, sort of signs of infection. So, I don't really know, just keep that in the back of mind. Um, now the, the only exception, of course to that rule is if that appendix has burst and they become septic, you need to manage that first. The manager stabilize a septic patient first before sending them off to theater. Ok. Now we're talking about Volvulus. So Volvulus is one of the more common causes um, of large bowel obstruction. And what happens in E Volvulus? It comes from the Latin word to twist and it exactly what happens. The bowel twists around its own mesentery. Remember all the way back to the anatomy that we were talking about in, it's most common in large bowels. Volvulus can happen in small bowels very rarely. Um And only two sections of the large bowel has its own mesentery, the transverse colon and the sigmoidal colon. It is much, much more common to happen in the sigmoidal column because the MSA is quite long there. So it's easy for a loop about to twist around it because of the length. Um The second area that happens is actually the cum. So the cecum kind of has its own reasoner. Um not um uh if it occurs in the s and there's usually some other stuff happening. Um But in any case, some risk factors include slow transit from the gi tract. So what we mean by that, that's constipation, things like, um and things that add to that increased age, uh poor diet. So poor dietary fiber intake, not drinking enough water, things like that. Um These patients will present usually quite quickly. Actually, they, they present quite acutely and they will have distension, which is quite strange because usually distension takes a little while to develop. So these patients very quickly, the abdomen becomes distended. They will usually have absolute constipation because that loop has closed off any sort of movement through the gi tract. Uh And then obviously, they'll be in some pain as well. Um As I said, it is a pretty rapid onset. Um Now, um investigations you usually go with uh abdominal X ray. Um and it's pretty, it's a classic exam question. So this is called the coffee bean sign supposed to look like a coffee bean. Uh If you see that in an exam question, you immediately think volvulus. Um CT with contrast again, is considered more accurate because, and from the CT contrast, there is a thing called a whirl sign. Um Basically, when you sort of look at the CT scan, um and as you move down the CT scan, it whirls around because it has looped around. Um, management management is actually conservative management. At first, you want to use a sigmoidoscope. Um usually a rigid supers cope first to decompress the twisting. So you, you insert the sigmoidoscope as, as you would, any normal sigmoidoscope and gently push it through the twisted bowel to untwist it and return it to normal. Um, and even, and usually these patients, sort of all the, all the bowel contents are rushing out because it's been stuck there for so long. It's, it's not exactly the most pleasant thing to see. Um, I can instead of fletcher's chew for 24 hours. Um, now if the volvulus, if ischemia is present with the volvulus, then these patients need to go to surgery. As I said, um uh intestinal ischemia is an emergency. Ok. Colorectal cancers are a huge, huge topic and they can be an entire talk on their own. And in fact, they are, there's a whole IUD session dedicated to colorectal cancers which will cover things in way more detail than either I have the time or the knowledge to do. So. Now, um So I'll leave it to the IUD session to cover the bulk of this. I will give you some key points because I think they are important to remember. These are the absolute bare basics. So the most common type of cancer is adenocarcinoma. And that's because the most common cell lining the gi tract is, as I said, is a simple columnar epithelium. Um The national screening is Q Fit. Um I, what I would encourage you to do is know what ages are invited to do that home screening because it is a home screening um and know what happens when they get a positive Q fit, you know, what clinic they get invited to. It's a, what kind of, what happens to red flag referrals from your GP. Um, sort of basically follow the patient's path from there because if you're in scopes and placement and consultant asks you sort of what is the management of colorectal cancer? At least you'll know that from, you know, national screening all the way to red flag clinics. Um, blood and stool is the typical um symptom that people talk about and it can be quite, if it's visible, it can be quite alarming obviously for patients to see that. So even if they don't get it picked up on screening, some of them will go to their GP saying I've seen blood in, in, in my stool. Um, surgery is curative folkloric dosis. OK. The next one we're talking about is diverticular disease. Another topic that could take up a whole talk on its own, but I'll give you some of the salient points to take home with. Um, first off, you need to be familiar with the terminology. OK. So firstly, diverticulum, it's a singular, small outpouching in the large bowel that should be out, that should be single because it is diverticulum. It's a singular multiple of those outpouchings are called diverticula as you can see. So, as you can see in this diagram here, if they're sitting there not causing any problems that's fine. Um In fact, most of us probably have some diverticulum already. Um I'm afraid to say, uh especially in our western sort of high processed diet. Um We, we tend to have these. So what causes them, what is generally happens is, uh you know, patients may be straining in particular. Um And that strain sort of puts is felt especially in the sigmoidal colon. And as we get older, the walls of our gi tract become weaker. And with that straining, these pouches start to poke out from the uh from the colon wall. So it is very common in older age, obviously. So the statistics of something like uh 50% of people at the age of 50 have diverticula. Um If they're sitting there, not causing any problems, spine, we're not going to do anything about it. But if you start to get symptoms from it, then that becomes diverticular disease and diverticulitis is a particular presentation of diverticular disease. So, diverticulitis is an acute inflammation of those little outpouchings. Um As I said, some of those risk factors, the biggest one is probably diet, low, low fiber intake is, is um probably criminal for a lot of causing a lot of these problems. Um obesity as well. Unfortunately, we're seeing a rise in diverticular disease probably due to a rise in obesity in the general population. Um It's also associated with NSAID use of smoking and family history. Uh Some of the complications we'll talk about in the next following slides. Um So how does acute diverticulitis present itself? Then if you think about it, it's acute. So it's a sudden onset, it's inflammation diverticulitis. So these patients have fever, I have abdominal pain as well. Um Usually what will happen is that pain sort of can get better if after relieving themselves in the toilet because then they've got rid of that sort of strain on their sigmoidal colon. Now, these next two symptoms, a sudden change in bowel habit and blood in the stool that can also be put into colorectal cancer. So one of the things that I really encourage you guys to do this is not restricted just to, um, surgery is start thinking about some presentations of presenting complaints, think about the presenting complaints and start connecting them with the different conditions that they could be, um, because that's what's going to happen in real life and you probably really experiencing that in the wards. Um, if a patient comes to you and they say I've got a sudden change in bowel habit, uh, and I've noticed some blood in the stools. The first thing you should be kind of worried about is, is this cancer? Now, if the patient comes to you with acute abdominal pain fever and other things that suggest more diverticulitis, then you can probably be, um, a bit more relieved. But obviously, you would still, uh, investigate any, any chance that it could be cancer. Ok. So what are our first line investigations apart from bloods um, in bloods, you expect to see a ACR P um, white cell count and lactate, um CT AP with contrast. Once again, that's your imaging of choice. Um You can use a flexible sigmoidoscopy to, to visualize these diverticulum. If you unsure. For whatever reason, note, don't ever use a rigid sigmoidoscopy in these patients because there is a risk that you accidentally perforate the bowel. Um There's a thing called henches classification. I'll leave you to read through that basically stage four more severe. Stage one, not as severe. Um These are the complications. So if there's any presence of this, then diverticular disease becomes a complex diverticular disease. And one of the big risks is perforation leading to that peritonitis uh leading to an active bleed. Um that that's emergency. You, you need to um take care of these patients very quickly. Um They can recur uh diverticular disease can follow a pattern of symptoms and then remission symptoms and remission. Uh It can be very annoying actually for patients. Um, abscesses can form, they can become filled with pus, um really not pleasant and become inflamed and that's diverticulitis there. Um They can stricture. So what that is is that uh the little out pouching somehow sort of twist on themselves and then they become like miniature ischemic ischemia. Um That's a, that's, that is a complication there. Um Any sort of a scheme you know how small is, is not good for the body and then they become, they can form a fist. So once a fistula, a fistula is an abnormal opening, communication between two structures that normally shouldn't have a, shouldn't have a communication. And the two types of fistulas that are sort of commonly caused by diverticular disease is a colovesical fistula. So that is a communication between the colon and the, and the bladder. Um And these patients then they will have, it's quite unpleasant. They can have fecal matter in their urine. So this very foul smelling, they can sort of see it, it's quite discolored. Um It's very unpleasant and obviously it puts them at risk of uti um and then colovaginal, which is a communication of fistula between the colon and the um the vagina. So then you can see um fecal matter in the vagina. Um on the examination, this is very distressing for patients as you can imagine. So, divertic disease, how do we manage it? Well, it depends um if it's an uncomplicated disease, um or if it has those complications that I mentioned. So for an uncomplicated diverticular disease, um a simple analgesia uh can actually be the most helpful thing to do uh in the acute stage. And then you want to encourage that dietary changes. So you want to make them, you want to encourage them to have more fiber, fruit and veggies. Uh you wanna increa increase their uh uh water intake as well cause that's gonna uh reduce the chance of constipation. And that's going to be the most helpful thing, you know, um to manage those diverticula. Um if it's sort of uh so uncomplicated diverticular disease, it actually can be managed in outpatients. Um They don't necessarily have to be admitted if it's acute diverticulitis though. Um they probably will be admitted. They can be treated as ambulatory patients though as well. Uh these patients because they have an active inflammation will uh go on antibiotics. Car Lola is usually antibiotics of choice. Uh This can be IV or oral uh depending on the severity of presentation. Um Again, fluid resuscitation, IV, fluids may be needed depending on what the bloods show you and uh analgesia again, cause these patients are in pain. Now, if the, if it, it becomes complex diverticular disease, then surgical management is needed. Um you know, this is usually a Hartman's procedure. So I showed you a picture in the colorectal um slide earlier uh about a big tumor sitting, sort of in that sigmoidal junction area being removed. That's, that's a Hartman's procedure. It's usually an emergency procedure and it's the removal of the sigmoid colon. OK. This is the final precondition that I'm going to be talking about and uh it's actually not really a pye cod condition. It isn't pye though. Um The reason why I included it into this talk and wanted to talk about it is because um one it's really common, especially if you're in Causeway and the with the general surgeons there, they'll be seeing this a lot. So it really is good to know about it because they'll ask you questions. First of all, number two, there was actually a question in our exam regarding the anatomy of the inguinal canal. Now, they did say to us inguinal hernias are not in the core conditions list, but they asked a question about the anatomy. So take of that, what you will um really the key to understanding hernias to me is understanding the anatomy of the canal. Ok. So the inguinal canal is, is what, what is it, it it was formed from the descent of the gonads via the Gorgona. If you can remember all the way back to that uh that lecture. Um The long short of it is is that there's a little, there's a ligament that pulls the gonads into their final resting place. Um And the channel that it goes through becomes your inguinal canal. Um The canal, I like to think of it as sort of a rectangle kind of thing because it helps me visualize what the there's, there's, there's two walls, there's a roof and there's a floor and I can visualize that best if I think about it as a rectangle. So let's talk about anterior wall, which is the aponeurosis of the external oblique muscle. Then the posterior wall, which is the uh transverse um fascia. Then you've got the roof here in the roof there. That's your internal oblique and transverse abdominis muscle and then the floor itself here, that's your inguinal ligament. This then becomes your deep ring and this becomes your superficial ring and your inguinal canal runs through that there. Um This was a source of confusion for us again. I think this was in our mock exam and I can't remember if it was in our final exam or not, but this did become a source of confusion. The mid inguinal point is not the same as the midpoint of the inguinal ligament. I remember friends and I were having this conversation. Yes, my friends and I talk about anatomy. Yes, it is as sad as it sounds but whatever. Um the midinguinal point. OK. That's, that's the middle of this canal that's between your ass, the anterior superior is your spine to the pubic synthesis. The synthesis is that sort of joint in the, between the cubicles. The midpoint of the inguinal ligament is between the ass and the pubic cubicle. Think of the ligaments or what, what is the ligament that connects bone to bone? So it is the ass to cubicle, bone to bone and the mi in one point um is a landmark for the femoral pulse. Ok. So why is the inguinal anatomy? Inguinal canal anatomy? So important. That's because there are two main types of inguinal hernias as a direct and indirect and the anatomy of the inguinal canal um matters immensely about the difference between the two. So, first of all hernias, any type of hernias is when the bowel starts to protrude through weakness in the abdominal wall. In the case for an inguinal hernia, that's when bowel starts to pass into the inguinal canal. Um, as I mentioned, two main types, direct and indirect, uh indirect is by far and away. The more commonly hernia that you're going to find roughly about 80% of patients with this. Uh it usually occurs in young males. Ok. So what happens in an indirect hernia is that it usually passes through those inguinal rings as you can see and the deep inguinal ring out into, protruding through the superficial inguinal ring. Um The definition, the hard and fast rule is that an inguinal hernia, an indirect inguinal hernia occurs lateral to the inferior epigastric vessels. You can't know that until you've opened up a patient. So I know that some people talk about, oh, if you can feel it at this side of the um, mid inguinal point, I mean, that's not exactly correct. Um That's more of like a, I guess that because of this examination, I guess that it is this, but you won't know until you actually open them up. Um, indirect hernias are sometimes called congenital hernias. The reason being so the inguinal canal to go back to the anatomy. Um Inguinal canals in males are much, much more prominent. The reason being is because the Testes have a much further descent than ovaries do ovaries remain internal, but the testes obviously becomes external. So that makes the Inguinal Canal much more prominent. What's supposed to happen is that the borders of the walls of the Inguinal Canal are supposed to close completely around the contents with no gaps in between. But sometimes that doesn't happen. Uh, sometimes that, uh, space doesn't disappear completely. Um, that creates a weakness in the, um, inguinal canal and it allows the bowels to, it, it becomes a point where the bowel can actually start to poke through. Um, by far in a way, what happens with these patients is they are usually young men, um, usually lifting something heavy and then while lifting something heavy, they just felt something poke through. Um, and then they noticed there was a lump in their, in their belly. Um, yeah, give you the example, the, one of the cases that I've seen that I was scrubbed in for, um, the patient was at a 23 year old concreter. So, manual labor job, you know, lots of heavy lifting. That's pretty typical of an indirect hernia. Direct hernia is much less common, but they're usually more seen in older patients. Um, so what happens when we get older is, uh, our abdominal wall, all the muscles start to get weaker and, uh, this makes it much more, um, likely that bowel starts to protrude through. Um So the inguinal, a direct inguinal hernia is called direct because it pushes straight through the abdominal wall and will then present as a bulge. Um Again, it's medial to the inferior epigastric vessels is what makes it a direct hernia. So that's, that's the, that's the definition. But um yeah, the reason why it's called direct is because it pushes directly through. Uh the most common area weakness is a place is, is, is a thing called Hessel Back's triangle. Hesselbach being a German surgeon and anatomist was um it was actually one of the first um surgeons to do a lot of work on inguinal hernias. And he described this area um in the uh abdominal wall that seems to be where um where the inguinal direct inguinal hernia is kept pushing through. So, the borders of that triangle is the, the medial side um is, is the rectus abdominis muscle. Uh The lateral border of that triangle is the inferior epigastric vessels and then the inferior uh border sort of the floor if you will of the uh triangle is the inguinal canal uh ligament itself. Ok. So, inguinal hernias, um they typically present as, as a lump, uh usually seen superior immediately to the pubic cubicle. So around that groin area is where you're seeing it. Um there's a cough reflex. So basically what that means is, well, first of all, you should try to reduce these lumps. You should try to reduce a hernia and if you can place your hand around it, so essentially what you're feeling is this protrusion, right? And if you can push it back in, through that hole through the hole of the uh where it was poking out, uh and ask them to cough. And if you can feel it bouncing back against your hand, that's what, that's what's called a cough reflex. Um Sometimes these hernias do enter into the scrotum. It's more common for an indirect hernia to do. So, if that's the case, you should try to feel above it. Basically, what that means is that you should um there should be a definite sort of beginning and then lump of um of bowel. Um This helps to differentiate it from, let's say a hydrocele. Um Inguinal hernias are a clinical uh diagnosis. Once again, the Royal College of Surgeons do not recommend imaging. They say that um if you can diagnose it on, on history and on your examination, deal with it there. If you're really unsure, you can use an ultrasound scan. Now, the management, as I said, you should try to reduce them and if they can stay reduced, some of these patients don't need any further uh intervention um until it occurs again, if it starts to reoccur, then that's the problem because what happens is that, that bowel, as you can see is poking out from that muscle wall, what happens if you can't push it back Well, that's called an incarcerated hernia. Uh incarcerated. It's like in jail, it's incarcerated. It can't get back out. Um The risk there is that because it is still surrounded by muscle wall, even if that muscle wall happens to be weakened, muscles still contract. And if that does contract it very easily can squeeze off that bowel and strangulate it and cut off its blood supply. That bowel then becomes ischemic. Like we talked about intestinal ischemia, the bowel loses its perfusion starts to become a chronic worst case it dies, perforates. And you've got necrotic tissue and bowel contents everywhere and that's emergency. You, uh you don't want that to happen at all. So if the, if the hernia is incarcerated or it's recurring, then these patients will usually go to theater or should go to theater. What happens is they undergo mesh repair that can be laparoscopic or open. Um Essentially they push, I won't talk too much detail into the procedure itself, but essentially they push it back. They put this mesh over the top of it and then they sew everything back up. Ok, guys, that was a very long talk, but we're finally at the end. So to sort of summarize, we talked about the anatomy where we're going from end to end. So judging them all the way to your to the anal canal, talked about the relevant embryology, especially when it comes to blood supply. Remember your celiac trunk sma and I ma and then we've gone through some of the core conditions. These are all of the core conditions that are in the tier list for gi surgery. Um, it's not exhaustive. There's so much to do in terms of it. So I encourage you to have a look, a bit of a read on your own. Uh, you notice that I haven't talked about a few things, so I left out, um, sort of anal fishes and tears. Um, this is a fairly easy one to actually get ask questions about sort of in exams. So have a quick read about, um, uh, have a quick read about how it presents. Ok. Um, I left out hemorrhoids again. This is something that, um, for some reason, exams do kind of like to ask about, especially when it comes to how do you manage them. Um, I didn't, you can read about it on your own. Um, it's not overly complicated. So I thought I'd leave that to, to you guys. Um, Stoma Stoma. Um, I know in Causeway for us they, uh, we had an education session about and it, it is very useful. Um, what I recommend is there's a textbook. It's a clinical Key called Essential Surgery. It has a section on ST it has a section on all of everything I've talked about. It has a section from, um, uh, has a section on that topic. So I really encourage you to have a look at that. Book, um, IVD, um, inflammatory bowel disease. I did not talk about, it is very relevant to gi surgery and to surgery in general. Um, but I sort of left it off here because I think it's for more to do with the gastroenterologist, the medical side of things because a lot of the management is done by the medics. The only time it comes to surgery is if they've tried everything else and it's just not working, ok? Uh, but it is very, very relevant. Um And it is something that I encourage you to, to read up on. So there's a few, few things for you to now go and have a look at yourself. Um Guys, I appreciate. This is a very long talk. Um I thank you so much for listening. Um I hope that this has been helpful. I hope, um, I've been able to sort of deliver this talk well enough that that you can sort of understand some of my ramblings and my, um ideas. Um, I'll give you some sbs at the very end for you guys to do yourself, ok? Um So this surgical series is a very new thing for us. Uh We really appreciate you guys listening and we really, really appreciate your feedback, uh, scan that QR code to fill out the feedback form. Once you do, I will send you the slides. Um These will include the S PA S at the very end that you can go through yourself. Uh If you have any questions, please don't hesitate to contact us, drop us a message on our Instagram, whatever. Um The next session will be on Wednesday, the 10th of January and it will cover the breast core conditions. Again, this will be prerecorded. Um You felt that this would just be easier access for everybody. Um We hope to hear back from you guys very, very soon and we hope to see you guys again for the next one. So again, thank you so much for listening. Hope that all was very useful for you guys. Um Drop us a link, drop, drop us a um a message if you have any questions and we'll see you on the next one.