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Hello. Hello. Sorry guys. We're having, um, problems with the mind. Um, so I'm, we've got an echo so I'm just trying to sort that out one minute minute. I don't know. I sounds bye. Not my mind on my side. That's fine. Shingles. So, so. No, no, that's am. Yeah. To sleep. Ok. I know. No. Hello? Oh, ok. Right. Sorry about that. Everyone. Um, I think this is sorted now. If you could all just let me know if you can see my screen. Um, and if you can hear me, um, without any echoes, if you just say something in the chat. Yeah. Ok. You can hear. Brilliant. So, my name's Tim, I'm one of the F two doctors in Swindon. Um, I've got Scott here as well. Oh, you can see as well. Brilliant. Yeah. So my name's Tim. This is Scott over here. Um, and yeah, we're two of the F two s in Swindon. Um, and we're just with some of the other F two S, they're just doing some, uh, teaching on surgical, surgical issues, surgical topics, et cetera. So, um, I am doing covering general surgery today. Um, and these are the topics that I was going to cover. Um, so a pancreatitis, acute pancreatitis, appendicitis, bowel obstructions, um, ileus and bilary pathology. Um, I don't really know what level of people we have here, whether we've got sort of med students or maybe F ones and F twos. But all of these are fairly, fairly important to know about, sort of, regardless of whether you're sitting exams or if you're working on the wards. Um, and I just sort of chose a handful of things that I like to sort of possibly talk about rather than rather than other things. So just to start, we are going for pancreatitis. So, pancreat pancreatitis is inflammation of the pancreas. Um it can be acute or chronic, but generally surgical um departments take the acute pancreatitis and that's where you have a rapid onset of symptoms. Um and the it can be self limiting, but um a few of the cases can be quite severe, requiring sort of it or HT U admission. Um So it's quite important to try and recognize it early and, and start the appropriate treatment. Um and distance as they're chronic is just long term inflammation. Um quite often these patients have quite poorer prognosis and are sort of spend months in hospital at a time um and come in and out with, with chronic pancreatitis. So what the, the main causes, the three main causes are gallstones, um alcohol and post E RCP, which is a procedure that we can use to retrieve stents from the, from the bile duct. Um, the other causes that they're important to know about for exams, et cetera are listed on the right. And I don't know if you guys have seen this pneumonic, I get smashed. But it's quite useful when, when you're revising to think about the, the, the less common causes such as, you know, scorpion stings that II don't think you'd ever see that in, in real life or hypocalcemia is an important one to, to, to recognize as well. Um, but they, they're all listed there and I can send the, send the slides to you after to. Um, so you can, you sort of have a look but you can just Google, I get smashed pancreatitis and that will, that will come up. We see a lot of patients I'm currently doing gastro at the minute. A lot of patients who are, who are big drinkers. Um, I don't know if you can hear me. All right, I'm just here for Metal Support. It looks as if your presentation is stuck on the first slide. Oh, brilliant. Sorry, I couldn't hear you. Um, I've just heard you though. Let me see if I can refresh it. Can you, what side are you on now? It was switching slides just now. But I think what's happened is you've shared the kind of powerpoint but not the presentation itself. So you can do two ways. You can either share your screen or what you can do is you can convert it to PDF form and then have it up nicely. So you see the chart as well. Let me, I'll just share my whole screen. That might be easier. Um No worries. You won't be able to see the chat, but I'll stay in the talk just in case you have any issues. Oh, brilliant. Thank you so much. No worries. Um Let's see now if hopefully, can you all see that without changing? So at the moment, we're seeing your presenter mode. Oh, if and let me try again. No worries. Mm Scott. Have you got any ideas? Naus, let me start that. I think I would have start the presentation and then try and share it maybe powerpoint slides show that should work. Right. Right. Hopefully it is working. Yeah. Yeah, you can see that now you can't see presenter mode. Yeah. Um And you can see it moving. Is that right? Yes, that's brilliant. Thank you so much for, for letting me know. No worries. Cheers. Um So these are the sides that I possibly missed. So this is just the the pneumonic that I was talking about and the the commonest causes of pancreatitis. Um So when thinking about pancreatitis, there's sort of clinical features that, that you'd expect to see and investigations which are important to, to order as well. Um So generally pancreatitis presents with severe epigastric pain which can often radiate into the back. So from front, the front of the chest, into the back. Um and these patients often present with sort of extreme the extreme end of of nausea and vomiting. Um and they have some abdominal tenderness when you examine them in the epigastric region, most likely. Um and they can often be systemically unwell. So with fever and tachycardia, um it the the vomiting is quite important to remember in these patients cos they can be be really dehydrated. Um So the investigations on the right hand side of the screen, these are quite important to get i in any acute abdomen. But in pancreatitis, we have a scoring system that can be used called the Glasgow Emory score. Um and these um investigations for below count using these LFT S calcium er and an ABG for the oxygen saturations is is quite important to get um in in pancreatitis. Um also amylase and lipase. So, um I believe lipase is more sensitive and specific for pancreatitis. Um but I've not seen it be used in, in practice in, in Swindon, we just use amylase. Um The amylase needs to be in increased sort of 33 times the upper limit which here in Swindon is 100. So for it to be significant. So for a pancreatitis here in Swindon, you'd need to have an amylase of over 300 before we were starting to think about uh without any imaging, could this be pancreatitis? Um obviously CRP you know, is is good, that's good, good marker of infection and inflammation. So always get that and then imaging, you know, we can use ultrasound or the the best really is a ct of the abdomen because we can assess for complications as well, um which we can, we can touch on the complications later on. So I just mentioned the Glasgow Emory score. So this is the the the score here. Again, there's a another pneumonic pancreas there that you can use if you want to, I don't really think you need to remember, remember this, but you get a point for each of the following. Um and it helps grade the severity, severity of the pancreatitis that you can see in the top, right? So if you get more than one, basically it's moderate. Um and then three is severe and this just helps sort of indicate which patients might, might need that extra support or might need to go to it or HD U setting. Ok. Um So the management of pancreatitis, um they obviously need to be admitted to hospital for acute pancreatitis. Um And if the patient's systemically unwell, you need to be, you know, seeing them in their AD ABCD E approach um for any, any unwell patient um pancreatitis. So the one of the general principles is to give them IV fluids as, as fast as you can. Um So you need to be tailoring it to, to get over naught 0.5 mils per kilo per hour of urine output. But I think there's, there's some sort of fluid regimes for pancreatitis that are, you know, gi give a liter over, over an hour, then over two hours, then over four hours or six hours. It's something like that. Um, and however, I think, I think it, we are moving away from that a bit because I think we're finding that a lot of these patients are becoming quite overloaded um, in the 1st 24 hours. So I think it, it'll probably if take some reading of sort of low trust guidelines or, or what's recommended now, but generally they need some IV fluids because of the, because of the vomiting. Um, it's good to put these patients nil by mouth as well, um, or how, how sort of relieve their symptoms of nausea, vomiting, pain, et cetera, um, adequate analgesia is, is obviously required. Um, and then treatment of the underlying cause. So if they're, if they're a big drinker, they need to, they need to be abstinent from alcohol. Um If they have gallstones, you may need a cholecystectomy or an E RCP. Um And if there's any evidence of infection or abscesses or anything like that, then they, they'll need some fairly broad spectrum antibiotics. Um and that again will be tailored to trust guidelines, um what's used wherever you're working. So, um and most patients improve in, in, you know, within a week, but but sometimes patients don't improve with, with acute pancreatitis and they, they can sort of take a turn for the worse and either not improve or, or, or die. Um So, complications of pancreatitis. So, um you can get necrosis of the pancreas, um or an infection in, in a necrotic area. You can also get abscesses that form that might need sort of surgical, surgical intervention or drainage. I think also we there can be like um interventional radiology can drain, can drain the pancreas. Um If it has, has any abscesses, you can also get collections of fluid around the pancreas and pseudocysts which are like um small cysts that, that develop e every now and then every four weeks or so a a after the after the acute episode. Um and obviously a, a big complication is chronic pancreatitis where these patients may, you know, keep on getting pancreatitis and the, the exo and endocrine function of the pancreas reduces over time. Um Unfortunately, they also don't have very good prognosis. Um So that was a really quick sort of overview of pancreatitis. I've tried to squeeze in as many sort of pathologies as I can. Um And I know we started a bit late, so I am I'm quite mindful of how much time we have left. So um we can do questions or anything towards the end and we've also got some questions at the end for sort of like exam style questions for you guys to go through. Um but for now I'm just gonna crack on so brilliant. Um So it doesn't seem to be working again the powerpoint. So just bear with me, we'll try and get to the next slide. Um What's going on in here? OK. B oh There we go. OK. So appendicitis. So, so as pancreatitis was inflammation of the pancreas, appendicitis is inflammation of the appendix. Um generally we see it in patients that are, you know, between 10 and 30. Um and it's a bit less common in younger Children and, and and older adults. But I mean, ii saw quite a few younger kids when I was doing my general surgery rotation that had pancreatitis. So I'm not quite sure how accurate this 10 to 30 years, years really is. Um So the appendix is a, a small tube arising from the caecum of the bowel. Um We don't actually know the function of the appendix um or why it's there. Um But pathogens can get trapped with within the appendix. Um and that can cause inflammation and infection. Um and that may eventually lead to rupture. Um And obviously, when the bowel ruptures, um feces and and other bacteria can get into the abdominal cavity and, and cause peritonitis. Um So what are the symptoms of, of appendicitis? So you have uh abdominal pain that starts centrally and moves to the right iliac fossa, which is sort of on the right lower side of the abdomen. Um You can get nausea and vomiting again, you can get a fever, um, and also loss of appetite that would obviously come with, with nausea and vomiting. Um So signs, this is something that you'd probably, you might sort of get an examine questions, um, just to try and recognize the signs. But so you get tenderness over mcburney's point, I'll show you a slide after this with, with these, um, you can get Rosings sign, the so sign and the obturator sign. Um And you can also get guarding of the, of the abdomen, which is where when you, when you palpate the abdomen, when you press on it, um the muscle beneath sort of contract and, and try and protect what's, what's inside, that's how I think about it. Um And then obviously, peritonitis, if, if there's a rupture of, of the bowel and the, and the peritoneum has become inflamed and infected, then you get rebound tenderness, um and sort of tenderness to percussion. So just even, you know, tapping on the abdomen causing intense pain. Um I think I remember from when I was on surgery, uh something that some of the registrars got their Children to do was to see if they could stand up and jump on the spot to see if they, whether they would have um appendicitis. Um That's a good test apparently. Um Just trying to get to the next slide again. It's taking a moment. Ok. So these are the signs that I was talking about. So, on the, on this image here, we have Robson's sign which is, er, tenderness on the opposite side, um, to where we are. Um, uh, it's opposite to mcburney's point, which is two thirds distance from the, from the be the belly button to the right, anterior superior iliac spine. Um So it's basically when you press on the left side, it causes pain on the right side. Um And obviously you have pain over mcburney's Point, which is here, which is described here. Um And you get the sewer sign and the obturator sign. So if, if someone's l laying down with their, and you move their leg this way, it causes pain in the right iliac fossa. And if someone's lying on their back with their knee flexed, er, with a hip flex in their knee flat, extended flex flex, then um you'll get the pain as well um in the right out fossa. So they're just sort of specific signs to look out for and, and exam questions or obviously, if you see any patients that you think might have appendicitis, so, investigations, so it's generally a clinical diagnosis. Um, a lot of patients go to the theater without having any imaging, um especially the, uh I, I've seen it more in adults, I think. Um So it's generally the signs and symptoms that make you think of it with high inflammatory markers indicating inflect infection, inflammation um imaging that can be used to, to support is ultrasound and ct ultrasound is better for Children, you know, it's lowering their, their exposure. Um and also for, for pregnant women, it's, it's better as well. But things that are important to exclude in appendicitis are uti pregnancy and renal colic cos these can all sort of mimic quite closely the, the um signs and symptoms of appendicitis. So it especially as well. Pre pregnancy needs to be ruled out in any sort of acute abdomen, um, in a, in a female of, of reproductive reproductive age that really needs to be ruled out as a one of the first investigations, really just a urine pregnancy test. Um, so the management, so you can do a diagnostic laparoscopy. So that's just sort of going in and having a look, um, without any imaging prior sometimes. Um And if, if the appendix is inflamed or if it's ruptured, you can, you can remove it at that point or obviously, uh, an appendicectomy laparoscopic is better than open. Um I think now most of them are la laparoscopic. Um, and obviously patients prior to surgery will need IV antibiotics and IV fluids. Um, and they'll probably need IV antibiotics and IV fluids after surgery in Swindon, we use a lot of, um, IV Coamoxiclav on general surgery. So that's probably what, what these patients would get if they weren't penicil penicillin allergic and they were in Swindon. That's what, what they would be getting. Mhm. Yeah. But micro guide will, will have all the sort of trust guidelines on it. Um, ok. So just take a breather for a moment and we'll move on to the next, the next topic. Um, yeah. So the next topic is bowel obstruction. Um, so I thought it would be good to go over sort of large bowel obstruction, small bowel obstruction. Um, and then Ileus as well cos there are three things that would be good to be able to sort of differentiate one again on the wards or when you're larking people on surgery or also for exams as well. It's like quite common for, for the surgical questions to try and get you to differentiate these three presentations. Cos they can all, they can sort of mimic one another. So large bowel obstruction is a surgical emergency. It's something that if you see you need to sort of, you need to escalate to asemia as soon as you can really. Um, so it presents with abdominal pain, patient will also be a bit bit bloated. Um, they'll have nausea and vomiting as well and they'll have absolute constipation. So that means that they're not passing, um, they're not passing any stool and they're also not passing any wind. Um, the, the main causes of, of large bowel obstruction are sort of a tumor that is, is compressing the bowel and stopping it from having that nice flow flow of feces through the through the bowel strictures as well. So you get strictures from, um, that's where sort of scar tissue can form and, and cause sorry structures is where you get sort of narrowing of the bowel, um, volvulus, which is where the bowel can sort of entirely rotate on itself and sort of trap itself off hernias. Um, and adhesions and adhesions are sort of scarring after surgery. So, maybe a woman's had a, uh, a lady's had a Cesarean section. Um, and the, the, the process of, of that procedure, the way that her body is healed has caused loads of little scars to form in the abdomen and that can pull and nick the bowel in different sort of a different ways that it shouldn't be moving and can cause cause um, obstructions. They, they just sort of develop over time, I believe. Um, just trying to get to the next side again. Uh That was weird. So, er, the investigations in a large, large bile obstruction. So you want an abdominal x-ray always first. Um, I know a lot of people, a lot of, sort of people don't do this, but if you call a surgical sho and say, I think I've got a bile obstruction, they'll, they'll tell you to get an ab abdominal X ray first, um, rather than a act. Um, and you can get the CT, uh, the CT will probably be needed after cos, it helps you establish the cause of the obstruction so it might be possibly that a patient doesn't know that they have a, a bowel cancer and then they, they get obstructed and that's how they find out. Um, and it's important to rule out sort of those, those causes of it. Um, the general treatment, er, is analgesia, er, fluids. Again, anti sickness is a big thing. You, you know, we want to be giving an IV and making sure that patients have a good, good dose for that. Um, so that they're, they're not being sick anymore. And then, uh, we can try a drip and suck as well, which is where we put an NG tube down or a ris tube, um, which we can use to aspirate and pull out any, um, food or fluid that that's stuck in the stomach or, or er, the start of the, the small bowel. Um, and then we can, um, give them a, a drip which is just IV fluids. Um, and some of these patients may require surgical intervention and that can be laparoscopic or open. Um, and I II, if there's suspicion of things like intestinal ischemia or closed loop bowel obstruction, then the surgical intervention is, is, is definitely indicated in these patients. Um, another important thing to mention is sa sigmoid volvulus, which we'll cover later on. Actually, um, that I've got a slide on that and then just to mention palliative care so often with malignant bowel obstructions, which is where patients will have, have cancer. Um, and that's what's causing their, their bowel to obstruct a, uh, a bowel cancer, then I, if you just, if we're not going to remove that cancer because it's, it's too large or it's spread elsewhere or it's, uh, inoperable, then if we, there, there's nothing that we can really do essentially and we just need to treat them palliatively. Um, we need to sort of make sure that they're comfortable and, and we've helped with their symptoms as much as we can. Um, and it's quite important that sometimes you have to recognize that sometimes that might be needed. Um, but obviously that's a very select few, few patients. So this is a abdominal X ray for a large bowel obstruction. You can see that, er, these htra, which are these lines that, that go across the bowel or sorry, that only go about half way across the bowel or less. And that's how we know it's that this is large bowel that's all dilated. Um, and the cut off for large bowel is seven centimeters. So if it, I think if it's, if it's seven centimeters or above it for the large bowel, then I think it, it's a sign of obstruction. Um, and we can just measure this on the, the radiology sort of software that you have at, at the, um, hospital. We can just drag and drop and, and measure how large the bowel is, is largest point. Um, but the and generally it's around the outside of the abdomen. Um, whereas a small bowel generally is more centrally and won't have these lines here. These hatra won't have these. So now we've talked about small bowel obstruction. Let's move over to, er, large bowel, sorry, we'll move to small bowel. So, obviously, this is where we have a mechanical obstruction of the small bowel. Um, and patients tend to percent very similar to large bowel obstruction. So, you know, will have distention. Um, it can start as like a colicky pain and then it will change to continuous. Um, and they often have bilious vomiting. So the, the products that the, the go out produces bile, often the obstruction is, you know, just after where that enters the gut, um, somewhere in the small bowel and that the thing that the patient will be vomiting will be bile. Um, and they will also have failure to pass stool or, or wind. Um, they'll also quite often, um, have a history, a, uh, uh extensive surgical history. Um, and they'll have high pitched bowel sounds on, on examination. Um And, and the rectum will obviously be empty as well. If we were to do a apr examination, then they'd have no stool in the rectum. The causes are fairly similar to a adults. Um So we have adhesions again, which is the most common cause of small bowel obstructions. So they're those, um, scars that form post surgery, hernias, malignancy, foreign body was interesting. I saw this come up. I wasn't quite sure what they were getting out of that. I don't know what foreign bodies people might be swallowing to obstruct their bowel. But, um, yeah, something to consider, I guess. But you, you would see this on a most likely see this on an X ray, I presume, um, and then Children, these are the causes that you get in Children, um, o often intersection comes upon exam questions. So something to just take note of. So the investigations again is, you know, we want the usual bloods as we were with any anything. Um And we want an abdominal X ray and on the abdominal X ray, you'll see the, you can never say a valvular con invents. Um And that is the appearance of the small bowel that makes it look like coins stacked on top of one another in a, in a circle. So I'll show you, I will show you a photo of that in a minute or a, a film of that. Um And also you won't see any air in the rectum o on a plain film as well. And again, as with large bowel obstruction, we want act, we wanna see the cause we wanna see exactly where it's obstructing. We wanna see if it's partial or complete, you know, is, is it that liquids getting through? But solids isn't and, and things like that. Ok? And there's also when, when bowel obstructs. There's a transition point of, of what, where the obstruction is. And w it's quite good to know, know where that is as well. Um, it's also good to know that we have gastrograph and studies which is a radio opaque dye that we get patients to, to swallow and then we do abdominal films after they've swallowed it. And it helps us see. Also, it helps us assess, um, how, how the obstruction is affecting their, their digestion and how, how they can move liquids thr through their, through their gut. So the management again is uh analgesia fluids, antiemetics and sort of the principles of, of small bow obstruction and then obviously drip and suck again. So that is a large bore ng tube that we can aspirate fluid through. Um And then the, the drip part of that is, is the IV fluids because these patients won't really be eating anything. Um If all of this fails, then we will go for surgery and we can, you know, we can try and get rid of the adhesions, but in surgery, but obviously, if you're, if you're trying to get rid of scar tissue, you're probably gonna create more scar tissue. So I think a lot of the time this, this doesn't help that often. Um And we have uh bowel resection, tumor resection and, and sort of fixing hernias can, can try and help with that. Ok. So this is the abdominal film for a small bowel obstruction and here we can see those. Um, yeah. Um, which I think of it, it just looks like loads of coins stacked on top of one another. And you can see it's more central than the, um, than the large bowel obstruction. You know, the large bowel obstruction was sort of around the outside like this. Um, whereas this one is, is more central and that, that again, quite often. Finals. Um, I remember when I was revising, we always have every now and then you'd get an Abdo x-ray popped up and it would say what's the most likely diagnosis, you know, small bowel, large bowel and then a few other things. Um So a volvulus is an important, um, sort of cause of bowel obstruction. So you can have them in the sigmoid colon or the cecum, the sigmoid colon is generally what you see in older patients. And the, the sigmoid colon is the last part of the, the colon, um, before the rectum. Um And we often ii won't go through these causes here, but generally older patients, you get, you get a, a sigmoid involved with us younger patients and or all ages it says here, but I think I always learned it as younger patients. That would be the, the cecum. Ok. Um And then on the sigmoid vulval list, you get a coffee bean sign on the abdominal film, um, which I can show you in a minute as well. Um, and these are treated with a rigid sigmoidoscopy, er, with a rectal tube in, in insertion. So that is essentially a tube that goes, goes into the back passage. And II believe you put some air into it and it helps, um, helps untwist the bowel. Ok. Um, and then loads of sort of poo comes flying out of a tube. Um, I've seen it a few times. It's quite, it's not, not very nice. Uh And then the sequel Valvula, so you need to manage operatively. Um It says how often a right hemicolectomy is needed. Um So just, just trying to explain the Volva a bit more. It's where the, the colon sort of twists around itself con uh compromises the blood flow, um and causes a closed loop obstruction. So it means that nothing can get through. Um And it can lead to ischemia of the bowel and um perforation if not, it's not sorted soon. So this is what the abdominal film looks like. So there's a massive coffee bean on this one. Unfortunately, it won't look like like that um in real life, but you can see on this one here, this is all bowel, this this area here. Um And you can see it kind of looks like a coffee bean. Oh, you can't see the mouse fine. Um So yeah, anyway, the, the film on the left, you can kind of see the bowel is all, um is large and it kind of looks like a coffee bean. It, if you just take my word for it, maybe you need to google some of these yourself, you know, type in sigmoid, volvulus, abdominal X ray. Um and you'll be able to maybe spot it. Um but it's more just to make you aware of it and then in your own time when you're advising, you can go and have a look at it if you'd like. Um So another, sorry, the sides are a bit busy as well. Um So this is for postoperative ileus, which is quite important for surgical jobs as a junior, um, to be able to recognize. So this is where, um, you have a slowing or complete stop of the, the motility of the guts and it's quite common post operatively. Um And again, it can mimic an obstruction and it can make you think is this an obstruction or is it just an ileus? Um, so the risk factors for this is, you know, being of increased age, having electrolyte derangements, um, use of anticholinergic medications, use of opiates. Um And the main thing to, to, to mention is the, you know, the handling of bowel during surgery. So if you take the bowel out of the abdominal cavity and you're, you're touching it, you're disrupting it and it doesn't like that. So when it goes back in, can sort of, can take a while for it to sort of wake back up and, and, you know, resume normal peristalsis. Um, and what will happen is you'll get patients to have the failure to pass wind or feces postoperatively, they'll feel bloated and distended. They might have some nausea and vomiting as well. Um, and they will also be, be distended. Um, so again, it, it mimics, um, it really does mimic a bowel obstruction. So it's, it's quite good to take a, you know, detailed history of these patients and really try and figure out what, what might be causing their, their lack of, uh, you know, being able to pass, wind, their bloating, their pain, their nausea and vomiting. Um, and these patients again have an NG tube put down or a Ryles tube, um, to so, and we put that on free drainage initially. So we'll make them know by mouth so they can't eat anymore. We'll, uh, put a tube down down the nose, um, into their stomach and we'll drain out any sort of fluid or, or food contents that, that isn't moving anywhere and making them feel bloated and rubbish. Um, and then we'll also give them IV fluids to, you know, just maintain their, their normal fluid balance and then slowly over a few days, what we'll do is we, we will, you know, give, start giving them clear fluids to drink first. So we'll give them water, maybe black coffee if they're tolerating that maybe in a couple of days we'll go for some soft foods. So like soup jelly and ice cream. Um, and then once they're to tolerating that we might move on to a light diet, you know. So just, you know, eat, eat how they would like to eat, you know, but nothing too heavy. Um, and then hopefully within maybe a week these patients might be back to, back to their normal diet and their, the bowel has sort of woken up again because we've been kind to it by only giving it fluids and then only giving it only giving it soft foods et cetera. Um, if these patients though, uh, you know, s say if we try and put them onto soup, jelly and ice cream diet and they can't tolerate that and we have to put them back to clear fluids. Then for prolonged, you know, cases of no being ill by mouth or only having fluids, we're gonna have to start thinking about, uh, TPM, which is why we give nutrition through the vein. Um, and that, that, you know, that, that allows us to give, uh, nutritiously dense f uh, fluids to patients, um, to replace their, their oral intake of, of, of food, we are almost there. So, II think this is the last sort of, um, pathology that I have to go, which is biliary pathology. Um, again, I appreciate this has been quite, it's been quite a, um, quite a run through of everything, but I just want to try and cover as quite a few things, um, that then you can go and have a look at for yourselves. Um, and also, you know, just try and highlight the key things that are on the ward or, or in exams you might get asked about. Um, so bilary pathology. So, bilary colic, um, that is where that's pain. So the act bilary colic is, is pain caused by the obstruction of the cystic ducts, um, which I will have some photos of in a minute. Um, and that's usually due to stones. Ok. Um, so the risk factors for stones that, that I remember learning were fat female, 40 fertile, which aren't quite, I don't know how, you know, politically correct it is to call someone on fat. But, um, that's just, this is just saying that, you know, obese patients are at high risk, females are at high risk, um, fertile patients. So, you know, females, uh, who, who are fertile. Well, we have a higher risk and patients in their forties as well. So quite often you will see on the surgical take, you know, a, a slightly larger lady that comes in, in, in her forties and something that you need to think about is, you know, something that should be at the top is she's got abdominal pain in the right upper quadrant should be bit of colic or cholecystitis, something like that. Um, so this the, the symptoms of bilary colic are intense pain in the right upper quadrant and it's colicky. So that means that it's, it feels like the pain's contracting it. You know, it comes in waves and it's often triggered by a fatty meal because after a fatty meal, the gallbladder contracts, um, and when the gallbladder contracts with a stone blocking it or stones in it, it's painful. Um, and these patients will of often be nauseous and, and vomit, the definitive management of bilary colic. So, just the presence of stones in their, in their gallbladder, um, is, er, an elective laparoscopic cholecystectomy. So, we, ideally we don't want to be operating on patients that have obstruct, obstructing stones and, and things like that or that have infections. So it's best to do it electively. Um, I think it's usually if they've had a, a few episodes of it, of it or of cholecystitis, then we'll, we'll think about taking it out. Um, some, it's important to know some patients may pass their stones. I think they may just, they may just pass down into the, into the cystic duct and into the gut and they, they might not realize. But, um, I think for a lot of patients they become an issue. So, important complication of bilary colic is cholecystitis. So, this, so bilary colic may lead to acute cholecystitis, which is inflammation of the gallbladder. Why does it get inflamed? So it gets inflamed because a stone which you can see in the image, II don't think you can all see my mouse. I should have used my pointer. I have a pet pointer. Here, here you go. I should have used it a bit earlier. So a stone from here will get large in the cystic duct. Um, um, when the gallbladder contracts it, it can't get anything out and essentially it will lead to stasis in here and then it'll become inflamed. So this will be full of, of, um, of like bile that can't, can't leave and the gallbladder will become inflamed. And you get a sort of a severe right upper quadrant pain that, that is not colicky in nature, it's more constant. Um, and you get the nausea, vomiting and obviously, if, if there's inflammation, there's likely to be infection. So there may be some fever as well. These patients will have a sign called Murphy's sign. Um, and that's where you sort where when you press you, you ask a patient to take a deep breath in and you use the sort of side of your hand and, and place it under their, under their rib cage on the, on the right, on their right side of their abdomen, they will take a deep breath in and when they breathe out as the, the gallbladder moves down again, it will catch on the pa on your hand. Um, and it will cause cause the pain to happen and that's called Murphy's sign. Um It's quite, quite a good sign for cholecystitis. Really. These patients will have a elevated white cell count. C RP and their liver enzymes might, may be off as well. Um But something else to think about with um with stones and the, the, the bilary tree is ascending cholangitis. So this is where uh a bacterial infection moves up the bilary tree towards the gallbladder. Um And that's due to the obstruction, often, often down here in the bile duct. Um Another cause of it though is sorry, I think my images cut off the this writing here but is um is like uh structures which is narrowing and the narrowing can be caused by tumors. Um either pancreatic um or I can't think of the word. Now. Cholangio, I can't think of the word cholangiocarcinoma, cholangiocarcinoma. That's it. Um can can cause it. So that, that that's an important cause or you can have benign strictures. So just, just benign narrowings that just need to be, that need to be dilated. Um So you get obstruction of the bile ducts, stasis of the bile and then bacterial infection that that's, that tracks upwards towards the gallbladder. So these patients will have a triad of symptoms which is fever, right, upper quadrant pain and jaundice. Um and the jaundice is because there is an obstruction. So the bile can't leave, um can't leave into the gut. Um And then you can get Raynaud's Pentad, which is in severe cases, you have these three from the triad, but you also have hypotension and confusion. And that is just indicating, you know, that there's bilary sepsis present severe bilary sepsis that needs to be, needs to be dealt with. Um, these patients will have an, the high infection markers as would, um, CT cystitis, but they'll have an obstructive picture of on their, er, LFT S. So that means the AP will be very high and the bilirubin will be very high. And when we see that with infection and right up causing pain, we need to be thinking about ascending cholangitis, um especially if you have fever, you know, keep your eye out for this triad and this uh this triad and this pentad, um and everything should be fine really. Um especially again, exam questions. II, remember quite a few, few coming up. We're, we're all, we're almost there. I think we have one more slide after this and then we've got some questions just to go through quickly. Um If you guys like so investigations that we want. So we want an ultrasound, that's quite often the first line investigation. Um And an abdominal ultrasound is quite good at looking at the bilary tree and the, the bile ducts. Um, we can also get act as well. Um, some patients will get a CTA their PAP that might tell us, tell us about that. But, but obviously, we can only see gallstones if they're calcified on the CT. Um, we can get an M RCP which is like an MRI of the bilary tree. Um, and that allows us to have a high detailed picture of the bilary tree. Um, if the, if we suspect there's stones there. Um, and then another sort of half investigation, half management is E RCP, which is endoscopic retrograde cholangiopancreatography. It is a bit of a mouthful, but, um, basically, it allows us to go in down so down my mouth into the stomach through the apolo vata, which is where the bile duct drains or is it the cystic duct? I can't remember where it drains into the gut. Um, and we head up there and we can, you know, use, use a camera and um, tools to relieve obstructions or place stents or also, uh, yeah, I think we can break up stones, remove stones and, and things like that. Um So I've kind of covered the management there, half covered the management for some of it. So, a cholecystectomy. Uh, so a hot laparoscopic cholecystectomy is, you know, when we have surgery, it's arranged within 72 hours of the onset of symptoms. This is reserved for, you know, the, the very unwell patients who are septic, um, who are not, not improving with antibiotics. Um, and often sort of hypotensive tachycardic have a fever that just doesn't improve. These patients will, might get a, um, an emergency cholecystectomy. You can also have an interval cholecystectomy where, you know, we don't do the heart operation, but we, we know it needs to come out fairly soon. And what we do is we'll let the patients get a bit better. Um, and then, and then remove the, the gallbladder. So, obviously this is, this is for, um, this management here is mainly for the, er, bilary colic. Well, not even biliary colic, it's for cholecystitis, the inflammation of the gallbladder. Um, wouldn't be too useful if we had, if we were doing missing a patient with cholangitis, it wouldn't be too useful. Um And then obviously the laparoscopic elective cholecystectomy, that's what we want to be doing. We don't want to be doing, you know, emergency surgery in, in patients like that. You want to do something that's planned, the patient's had a really good thorough work up. Um, and it can be removed, you know, as a, as a planned procedure. Um I'm not gonna cover this bit at the bottom, I think in the interest of time, I've made a, I actually use Chat GPT to make you stable. So I did check it over as well. Um But this is something, you know, a good revision tool for you guys or, or ii sometimes refer to to something like this and, you know, it's just good to remind yourself of, of the key differences in these, in these patients. You know, there you've got three conditions summarized in, in a tiny bit of info. So if you can remember some of that, then, uh, when you're seeing patients and when you're doing exam questions, it, it becomes a bit easier. Um So I've got a mentor here. If you wanna, if you wanna join, feel free to join. Um I've got, you know, five exam questions, exam style questions for you. Um I'm just gonna start the start it up on my phone um in May. Mhm Talk. Oh Come on to make um and log, book, log in. Brilliant. Thank you. I forgot that we're talking through the phone so that everyone's probably hearing taping. Um fine. All right. I think I've got a, I've just got a Scott next to me who can sort of test it with me. Um We on step. I see. Oh yeah, we've got a few people in which is good. Um Again, yeah, thanks to everyone who came. Um tell you if you think it's been useful, then please feel free to tell some of your friends about it. Um Every week it'll be one of us different. So if you don't like me, then next week it will be some different anyway. Um, urology on Thursday this Thursday. Yeah. Yeah. So we've got urology this Thursday. Um and I think we'll be doing some others as well in the future. We've got that um poster that we can send out. Yeah. Um we've already sent out as well. Um But thanks again for everyone who came, sorry, it's been a bit of a rush. We had a bit of a nightmare with the it and everything. So um ok. So question one. So a 46 year old woman presents to the emergency department with sudden onset abdominal pain, vomiting for the past five days. Um She feels nauseated and cannot tolerate any food and only minimal liquid. She denies diarrhea and has not had a bowel movement for four days. Uh Past medical history includes chronic lower back pain and she takes regular cocodamol. The last time she was in the hospital was for ac section 10 years ago. Examination findings. So she, she appears clammy and dehydrated. Her abdomen is descended and tender throughout bowel. Sounds are inaudible. So I'll start augmenting now. So what do you think the most underlying cause is? And I think you'll have 45 seconds. Um similar to an exam question. I think I, no, it should be on the screen. Yes. So yeah, just take your time. Um I think everyone's answered fine. So we'll, we'll go, we'll skip on to the answer. So the uncertainness I think I'm on the answer. Yeah, is adhesions. So I've just tried to, you know, I'm gonna try and work through it really quickly um and try and say why it might not be other things. So she has abdominal pain and vomiting. Um She's not had a movement in four days. So already we need to be thinking, is there an obstruction in this lady? Be that small bowel or large bowel? Um obviously she has, she takes the regular cocodamol. But, um, you know, there, there's other pointers towards what might be causing this like her c section that she had 10 years ago. Important cause of adhesions is, is, you know, previous bowel surgery. Um, examination wise, she's dehydrated and she's tender. Her bowel sounds are inaudible. So we need to be thinking obstruction, small or large bowel. Um, and adhesions are the main cause of, of a small bowel obstruction. So this in this patient would, you know, the most likely cause is adhesions. Um Gallstone ileus doesn't seem it, it's unlikely to, to be caused by that. I think in, in this, in this case. Um And also the opioids, I think there's just, there's two of, you know, she wouldn't be that distended. She wouldn't be that tender. Um And she wouldn't have inaudible B to Bowel. Sounds next question. So, question two, Scott, I'm just trying to figure out how we, there you go. Question two should be up. Um Oh, I hate this thing. 22 guys. Question two, a 77 year old man. Um I'll, I'll actually let you guys read it. I think it doesn't help to have someone read it for you. So, uh I'll wait about 10 seconds and then I'll start the questions, start the answers. I will also show you the X ray as well. So that's the X ray and we'll start. There you go. I think you can start answering now. It's got a manager. He Chy three Pleura. There you go. Sorry. What, so what do we think of that, that X ray. Yes. So we've got all the answers there. Um I'm just gonna skip through, so I've actually written sequel Volvulus, but it is a Sigmoid Volvulus. You are all right. It's not a sequel Volvulus. Um That must have been a, an error when I was doing it cos it's, it's come up on ment meter that er it is definitely a sigmoid Volvulus. I think that was me late night last night, you know, struggling, struggling for a few minutes. Um I have got actually on my presenter mode as well. The correct answer is sigmoid ULV. Um You know, the patient has in er intense abdominal pain and constipation, uh which are two, you know, called no signs of acute bowel obstruction. Um In this case, it's due to volvulus, we can see that there's a large dilated loop of bowel. Um Sorry, I'll go back to the image quickly, largely dilated loop of bowel. Um Here. OK. That kind of resembles a coffee bean in this case, but I'm not, not quite sure. Question three. Hopefully this is working again. So question three we have here. So I'll let you read, read that for me. Bye. OK. Oh, I think I may have skipped it. I'm sorry, I don't know what happened. Who's cake cakes doing well. C cakes doing pretty well. He's cake. There you go. Sorry, I just one of you didn't get the chance to answer. I think I accidentally skipped it. But you want this patient ill by mouth. You know, we're thinking, thinking this patient, you know, they, they have an obstruction or they have an ili something's going on where the bowel's not working properly. Um That's again, you know, not passing wind, not passing stool, recent bowel operation, vomiting. We need to put an NG tube in, um, and give them some fluids. The NG tube again will allow us to aspirate out any fluid that's in the bowel or any, um, any sort of stomach contents or food, et cetera that's in there. Ok. Um Next question. So we're getting a bit more, less reading now. So which of these is not a sign of acute appendicitis? It's a bit of a, you know, if, if this was the first time you've heard of these, it's a bit harsh but I, you guys have probably all heard of them before. A Yeah, so we got three out of three on that. Everyone got that one right. Um Yeah, we've got Murphy's sign. This is a sign of cholecystitis. So these are the signs for appendicitis, you know, mcburney tender over Burning's point, mcburney's Point wing sign. So sign sign, they're the ones you remember for appendicitis. Ok. Uh Last question here we are. It's a bit more of a read one I'm sorry, sorry, in advance. So I'll give you a minute and then I'll just start, start the quiz. OK? I have put the reference ranges next to the um next to the lab results as well. Just so. So you can see, I've also started the timer as well. There we go. So we've got two of you going for a um ascending chol, ascending cholangitis and one for pancreatitis. So again, you've just gotta look for the, look for the clues um in the, in the question. So ascending cholangitis is characterized by the, the triad that we mentioned earlier, which is right, upper quadrant pain, um fever, which is here 38.9 and jaundice. So how do we know this patient will be jaundiced? Their bilirubin is 80. So I think you start to see jaundice after sort of 40 and you tend to start seeing jaundice even though it's, you know, for above the normal range, you might only see it in the sclera, the eyes of that at 40. Anyway, so they've got the triad. So we've gotta be thinking about cholangitis. Um If it was cholecystitis, you know, you, you wouldn't get the jaundice in this patient. Um And pancreatitis doesn't usually cause jaundice. Um And amylase, we would probably expect to be much higher than 300 if they had pancreatitis. OK. Um So I think that's everything. Thank you guys so much for everyone that came and took part in the questions and bear with us at the start as well. We had the, the technical difficulties. Um, uh, what we can do is we, I think there's some feedback at the end of this, I'll pass my phone over to Scott. He can figure out how to stem that out. I think it probably sends it out. We'd really appreciate it if, um, if we could get, if we could get some responses on that. Um, and yeah, the, I think the next, the next one is on Thursday with, is it with Emily? Oh, it's with Scott on Thursday, Thursday evening urology, um, on urology. So again, I, if tell your friends about that, um, and we can, you know, I think it's gonna be, there's done some more the week after as well, so it's gonna be a few weeks of these. Um, hopefully it might just help you some basic, you know, some things that you need to know for exams or things you need to know for the wards when you're at F one F two. but yeah, thank you so much for coming. Hopefully we're over the teething issues now. Yeah, hopefully my, my session was, I got the one where we had the issues at the start with, er, technology and things like that. Um, I'll just check if there's any questions. I don't think so. Um, any questions, feel free to email them over to Scott Scotts later at nhs.net. Um, but yeah and yeah, please come to the next one. Thank you. Bye. I don't know how you stop this thing, man.