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that you? Medical student of Imperial? Yes. It's a basically going to be going over the abdominal examination on the abdomen system in your CPA. So, Yeah, just kind of before we start some, I guess. Some housekeeping. So if you got any questions or anything like that, just feel free to pop them in the chart. So I'm going to be having a look at the chart throughout, so yeah, I just feel free to basically put the stuff in that We'll try and answer questions as we go along. If I ask questions yet I'm trying to make is interactive as possible. So you guys can done as much see one s? Oh, yes, it please just answering the child. And if you feel brave enough or you do have any questions, you can tell me if you feel brave enough, but no pressure. So, yeah, just what we're going to cover today. So first thing we're going to do is the structure off the joy station. So the kind of things that you need your expected to do the basics of the introduction and that kind of thing. What I'm going to talk about crucial vision point So this is just gonna be things that are is that are essential to basically know in order to pass your CPA. So things like planes and surface markings, all that kind of thing just say that you have all the ground like the basics covered and then with and gonna spend time on the abdominal regions. So how we can how we can divide the update system into its respective regions, and then we're gonna be linking that too abdominal pain. So talking about side character, um, radiation of pain and then how this is basically going to allow us to classify some very common pathologies of the abdominal system within a tube abdominal imaging. So at the end of CPA exam, you basically get a couple of questions. I'm one of them is always an imaging question on. I found abnormal ridging quite tricky in terms of differentiating what imaging modality is. So we're going to be covering basically how to identify what imaging reality. It is looking for common findings and complete ology ease, and then seven keep don't know pathologies and how you can relate that to the exam itself and then a couple of practice questions at the end site fasting fast. So the structure off the G I station so will cover this quite quickly so we can move on to the more important stuff after. So first thing is we need to introduce ourselves and we use the wipe and ammonic. And I'm sure you've all heard this 1000 times, but, yeah, the wiping ammonic is basically to wash your hands and she's yourself, um, position your patient correctly, explain what you're gonna be doing and expose thumb. Yeah, So that's the white ammonic. Um, we then need to your position and expose the patient, and we'll go in in a couple of minutes into more detail in each of these sections. We don't need to inspect the patient. We then to palpate the patient, the costs and also take So, um, one thing that I find really, really helpful is acronyms. So I'm sure you've all heard of pepper. Um, which is kind of order things that you do in practically all the exams apart from your neurological. And you're on this case. Um, so, yeah, just remember Pepe on another thing that's really relieving to know is that your cpk you don't have to perform everything in order all by yourself. So because of the nature of examine the fact that there's very limited time, they will tell you, they will promise you and basically tell you what they want you to do. So they might skip anti steps. They might not do any inspect them. Sorry, they might not do any palpitation, but they might ask you to auscultation couple times Or because several different regions on then ask you about service markets and stuff. So don't get too bogged up on enduring. You could do everything in order perfectly. Just make sure that you can follow and respond to commands that they're going to give you. So, yeah, in terms of the position on exposure, See? Hey, we got physical picture off the position and exposure. So in the abdominal exam, you want the patient to be supine, which is basically flap, um, makes 11 key thing is making sure you know how to move the bed. So I'm sure you've had a lot. But the most embarrassing thing is going into station on. Do not knowing how to move the bed, because that just waste time and it kind of it just makes you look about professional. So you make sure you know how to move the couch. If it is a 45 degrees Teo basically back. So does anyone know why the patient has to be flat for the abdominal exam if you put your aunt's in the job? Yeah. Relax the muscles. Exactly. Yes. So the whole point of, um, of supine positioning is to allow relaxation of the abdominal musculature. So, um yeah, because if a patient isn't supine in their muscles told tents and you go to palpate, you might feel rigidity. You might think it's pathological when, actually, it's just because you're positioned correctly. So that is why positioning is so, so crucial. So, in terms of exposure, you need to expose the patient from the safest on, um, to the pubic symphysis again. When you're talking to patients, you need to ensure that your bedside manner is really, really friendly. Make the patient feel very comfortable. So, um, the word exposed isn't really the best. So when you're interested in talking to a patient and you're kind of doing that initial wiper and you say to the patient, I need Teo expose you from blood, blah. Try to avoid the world exposed. I normally go for something like s O for this examination. I'll need to be able to see you from the waist up words, because act just kind of is a little bit more comfortable Ondas a bit more familiar and participation. I eat basically, um yeah, so in terms of inspection, So all you need to do is make it really, really obvious when you're inspecting kind of it feels a little bit awkward, but you just have to swallow your pride. I just kind of have a look at that. Really, really obvious. Basically, um, so, yeah, the things that you're looking for So you need to have a look for the shape in symmetry of the abdomen, skin abnormalities, any surgical scars and any masses from. So this is kind of things that you're looking for again in the CPA or your patients are completely healthy, so they shouldn't have any of these signs. However, just have a look just to double check because you don't really know what they're gonna 30. Um, So does anyone know any reasons why the abdomen might not be symmetrical. If you could just pop your Lantus in the chart while you're doing that. In the meantime, call question. So someone's asked, Is it more about knowing what happens in each that rather than in the order of the steps? So, yeah, you need to know kind of the basic order of the steps and that is again is just with the pep in ammonic. But and yet you don't need to know the old. However, in the exam, they won't ask you to perform it all in order. So it's more about you just knowing what step comes up to walk. And if they were to ask you to do something, you know exactly how to basically perform that? Um, yes, it does Anyone want to put in the chat? Any reasons why the abdomen might not be symmetrical? I'll give you couple of seconds to do that. Yeah. So someone said ascites hernia. So I'm hardly a definitely so something with ascites. So if you haven't heard of ascites is basically when you get a large collection of fluid in your parent new cavity, which is, um, the space between the visceral and parietal peritoneum on But if you think about it, fluid tends to kind of settle uniformly so occasionally you could have a symmetry with societies, but it tends to be kind of aggressively symmetrically distended abdomen. But we'll go on to that someone's organomegaly abdominal wall Mass. Yes. So this is really all really good, so things to look out for. So yeah, obviously need to have a look up and bellicose. So even on delicates could be addicted off on a medical hernia. A sunken umbilicus. This is typical or obesity. So it's no a pathological finding, but it's just something that you see typically and obesity. And they could ask you describe the appearance of the umbilicus or something or other. Um, and then if you just kind of have a look a the abdomen in you see in large veins on the anterior on Biblical. This indicates portal hypertension. So does anyone here know what pulled like retention is on bonus points. Why, it can cause these enlarged veins. So I'll give you a couple of seconds in the chapped to maybe half ago. Yeah, sledging That another thing. Yeah. You You're looking for swollen or distended abdomen. Um, okay. so I'll just I'll just get it through, um, the enlargement. See, basically, with portal hypertension if you've got it's essentially high pressure in your portal vein on your portal system. So if you got damage to something like the liver, blood isn't gonna be able to flow properly into the liver. Um, so it's going back up into a portal system on day to kind of relieve the pressure. You're, um yet in order to relieve the pressure you need the blood is going to try and find it. Alternative on what it does is it tries to get into the systemic venous system. And they're certain points in our body where the portal system on the systemic venous system actually joined. Um, knees are are called are sites of estimate. She's on the side. One of these sites is the umbilicus, Which is why in portal hypertension, because of this blood kind of backing up, you get these in large veins on the anterior bill. Cool. Yes. Oh, someone said increased pressure portal vein to chronic liver disease. Yes, so it's not always due to chronic liver disease, but yet, but it's definitely one of the biggest causes off off these things. And yeah, again, the symmetry is indicative of something like an abdominal mass. So here we have, um, an image off someone. So that's imagine that you are inspecting them. Can you'll put in the chat? Maybe one or two abnormalities or things that you can you can see. So give you couple of seconds to do that. Yep. So uniformly to stand abdomen. That's really good. Gracefully sense optimanu. Yeah, eso we also talked about so we talked about kind of general parents way. We also talked about the skins that can anyone actually see everything on the skin? So yeah, I appreciate that The images into lodge um, but yeah, we'll just go through it. So he findings? Yes, we've got very distended abdomen, so yes, someone said township tiza a Tia. Yeah. So really good knowledge. Um, yes. So we've got distended abdomen and even some billick ast. And then if you look really, really closely the skin, you can kind of see these red marks. So these red marks, um ah, cool. Despite levi or inject easier. Um, and they basically are a classic classic features off liver disease. So from someone is certainly could check six. So, um, I can I can kind of see where you're coming from. Um, but I wouldn't say that this patient is particularly toxic, which basically just kind of means, um very, very thin and, um, kind of signs of a little muscle wasting and that kind of thing. Yeah. So in terms of probation, so palpations, I guess it's probably the heaviest component off the up to exam. So you've got, like, our patient deep palpations never spleen kidneys and then pop patient off the abdominal aorta. So again, troubled hips palpitations they want the thing that's absolutely crucial to remember is that, um yeah, One thing that's absolutely crucial to remember is basically that you that the whole point of palpations is to identify what the patient isn't paying and to just have a general feel. So what? The most important thing is to actually have a look at? Yes, actually have a look at the patient's face while you're populating because that could be inductive or any pain. Or it can give you a lot of nonverbal keys, which is really important. So that's what the main thing to remember how patient when you performing it don't look at the patient's stomach. You can feel with your hand you feel with your hands. But you look at the patient's face to kind of see what they're in any physical discomfort. So, yeah, if you crash on to the level of the patient on news at that face, um, he can and see whether any payment all, um, yeah, always, always before you palpate ask the patient if they are in any pain. Um, and so this is just really useful because firstly shows that you're thinking about patients. Secondly, if the patient isn't any pain, you start at the opposite region. That pain. So, for example, if they have pain in the right lower quadrant, you're going to start in the upper left corner in to kind of minimize any discomfort and obviously go a little bit lighter over the painful area. Um, and yet we always palpate in an s shape, as you can see in the dark room, so you can start at any point. But the shape is just really good because it controls you. Don't forget any of the region's. So yeah, um, so now we're going to talk about like a patient, So yeah, like a patient. You're essentially using one hand, Just kind of have a German feel over the abdominal regions deep in used to hands on a feeling a lot harder, but not to the point where you're gonna put the patient, that discomfort, and then we pop it for the repalpate the liver. So just anyone know where we pull pay or in which direction on what we start for palpations off the liver. If you just pop you want to in the chart, it could be a couple of seconds to do that. Yeah, so yeah, really? It also right region? Yeah, that's really good. Um, so, yeah, we start for the liver in the right iliac cancer, and we pop a upwards and again, we always help pay on inspiration. So you ask the patient to take deep breaths I/O on when they breathe in. That's when you kind of palpate and I say, breathe out. You don't move your hunter next position. Um, we don't pop it with spleens and the spleen again. We started that right. Iliac four, sir. I mean, we've diagnosed you in course, left up to the left Cost a margin. So the reason for this is that when the liver enlarges, it enlarges and vertically downwards. But the spleen enlarges, diagnose, which is why it's important to cover the region. Dagney, form that right iliac fossa. And then we kind of do about by manual per patient kidneys. So you the technique for all of this, um, is is best covered in kind of your your CPK tutoring. So I'm sure you've also kind of signed up to the mad at schemes on that will kind of go through this with you more detail because the books of this electric more about examination findings and pathologies and abdominal pain and then, yeah, we need to help you for the abdominal aorta. So the way to find that is you find them medicus and you look one centimeter lateral 11 centimeter superior TV and bellicose on. That is where you'll find the abdominal aorta. So you just place both hands like this on your feel, the pulse really easily. It's question so that in terms of percussion, yes. So we're gonna because for the board of the liver, because explain because we're looking for signs of hepatosplenomegaly, which is basically just a fancy way of saying enlargement of the liver and spleen on. Then we also need to because the shifting dullness, which basically confirms the presence or the absence of ascites So quit date about sounds when you because it's so the normal sound is rested. Um, yes, it's normal upon palpations sorry. Upon percussion of the abdomen. Um, no sound is resident if you cannot fluid. The sound is going to become adults if you had a so if for some reason you got in your abdomen that sound Concerta too hyper resident. So you might see here hyper president sounds on percussion, and we'll go into, um, reasons why you can get air in the bowel or fluid in the ball and the other one in the lecture. We don't need to auscultate so quick thing about Scott A shins. The only listening to regions. Um, does anyone know the reason why we don't have to listen? Overall, nine regions of the abdomen it was popular. It's in the chart. Yeah, exactly. Thousands poorly localized, so there's no point listening. Overall, my region is because it's not a very sensitive test. Basically, Um, yeah. And you listen to 30 seconds. Do a quick dip. A result in a CPA. They don't actually expect you pleasant for whole body second. So process scope on the patient and then listen for bed and say, ideally, I'd like to listen for 20 seconds or longer, and then in order to actually conclude the bowel sounds absent, you've got to listen for 3 to 4 minutes before concluding the pharmacy. So you have to listen to the full amount of time before you conclude anything. So some keep pressure points. So you're here. We're not gonna go through these because you got great notes on in Sandy. Um, but these are basically lest off things that you have to know, Um, for your CPK. And it kind of covers. Um, quite a lot of the kind of questions that they can ask you. Um, so someone is asked, Does palpations disturb the bowel zones? Um, well, you're only likely palpating and deeply palpating so not really. No. I can see where coming from. Um, but you're never gonna be palpating hard enough to actually cause change in bowel sounds. Basically, um, yeah. So if we now me on. So we'll just pause for a couple of seconds on, see if anyone has any questions about the stuff that we covered so far. Someone is. How do you because of the liver and spleen. So essentially, when you're causing so yeah, that's not really fix this lecture. It's more about the allergies birth when you because in for the liver and the spleen your costing to see what they've enlarged. So you're gonna because for the upper border on the no border of the liver So you gonna start basically and I think the fourth intercostal space because down until you hear a dull sound which indicates up border and then you start saving in the variety impulsive. But you palpate upwards until you hear change from resident to adult sound where you're populating over solid liver tissue on again. The spleen is really similar. So you just because to find the borders of the organ Um, yeah, So if we now go on to, um I don't know pain so again was really, really important is that you know, the abdominal regions, so just keep sending them in the most dick on doing have to think about war Region is well, something that's quite important, remember, is when you're on is really, really obvious. But in the kind of the stress of the exam, we can easily forget it. When you're looking a patient, Obviously you're right. Is there? Left on their left is You're right. So, um, I've I've done it in a more corn Swear they told me Teo palpate because various different things. Um, my technique was correct. And then I kind of realized that the left hand side was I was doing everything that was supposed to be on the left on the right, so, Yeah, just kind of get that in gig. Think about that all the time. When you do in the afternoon is that we've got the vagina regions here. Um, Andi, we've basically you basically also need to know the names of the planes. So in the first diagram, where the abdominal region is divided into nine, um, you've got vertically is divided by the middle finger lines. And does anyone want to say the the horizontal divisions? What the name of the Plains are for that? I'll give you a couple of seconds in the chart. Um, so transpyloric Yep, on but the other one. The other one is the trans tubercular. Because going three, it is basically going across the judicial. Basically, yes. Oh, ensure that you know the nine regions. But not only that, what? Where the organs actually lie within the abdomen? Because that's really, really crucial and basically being able to instantly think of reasons why there's pain in that region. So one really good thing about the G I system is that everything's organized quite well. So if someone's got pain in the right upper quadrant or the right heart contract region, you instantly think. Okay, so the left is that the cold blood on Be contending. All the pathology is relating to the liver in the core bladder, which might cause pain. That kind of helps us too broadly. Classify, um, differentials a pain. So in terms of the structures in each region, So, yeah, you might have a contract with your liver and your bladder, your kidney and ascending colon in the right number, region appendix and Sikkim in the right iliac. You got, uh, your sigmoid colon here, your kidney and descending colon on your last number region left hypochondriac. You've got the speed and pancreas and you got the summit Judean in Pancreas Trans Trans Osco on in your epigastric region. So this is over at this diagram here is really, really useful. Want to just know? Because if someone comes with epigastric pain, I immediately think Okay, it they could they could have something like peptic ulcer disease, which is causing the stomach and the Judah Judean. Um, you could have something gas called gastritis where you get inflammation of the stomach. So by thinking off the organs, you can think of the pathology is related to the specific organs. And that's just sounds really impressive when examined, asks you what could be the cause or pain in extra gyn because you can think you can classify all the reasons based on the organ from, and it just kind of allows you to organize and collect your thoughts little better. So now, on to the types of pain. So, um, simply, we kind of have three main types or abdominal pain. Colicky pain, which indicates an obstruction. We've got panel movement on this pain is musculoskeletal. Also damage to you. Um, the muscle, the muscle muscle of the abdomen on then, of course, constant pain. So this indicates information on a really great rate. Remember, this is our remember, The cause is basically all the conditions and and in itis because I just basically means information. So if someone's got constant abdominal pain, think information, think any condition and dig in itis on them relate that to the region. So constant pain in your liver. Hepatitis, um, constant pain. Um, constant pain in You're, um you know, go about a coated start. It's basically so in terms of colicky pain, the important causes. So again, we're going to differentiate this based on the region and related to the organs. And you're right, Have a contract. Cholelith Aces in Canada with aces, which are essentially just Goldstone's colon basis is when you got your stones in your gall bladder corner. Daily basis is when you got call stones in your common bile duct. Basically, you got urinary tract calculi, which can cause pain in your left number region and your left iliac region. Um, so it is, and you'll know. So the kidneys themselves are in the left lumber region on the on the right number region. But why would it be that you can get pain in the iliac regions as well With the urinary tract to calculate your stones. Someone put their answer in the chart. Okay, So good thought so. It's not really referred. Pain stones and ureters uterine colic. You have really good guys. So, um, always remember that related your kidney is your ureters s. Oh, yeah. The stones might not just be in the kidney. There might be in the ureter. Is so always think about pain in the kind of in your flanks. Always think about the kidney. Basically, Yeah. And pain. Overall regions smaller, large bowel obstruction because he's the biggest organs that we've got in the abdomen system. And they kind of sound the entirety off the abdominal cavity. Um, called some pain so important, cause is again, like I said, Anything ending an itis. So colecystitis hepatitis cholangitis, pancreatitis, gastro Because the pancreatitis gastritis. Okay, sorry. Um, yeah. Um yeah, pen. Decide to queens disease cystitis that particular laters on, then ulcerative colitis as well. But there's one key thing about colicky pain to this one key condition which you think causes colicky pain. But it doesn't actually said, Can anyone think of that? And populace in the shop? Yeah, biliary colic. Really, really good. So yet very holic basically doesn't percent with a colicky pain, because it's not a true colic. What I mean by that is the essentially the pain in biliary colic is caused by Goldstone's in, um, in the colon bowel duct or in the biliary system, Onda. Um, yes, even though is called biliary colic. It is. It's not true obstruction or true obstructive pain, which is why it doesn't really present as as a colicky pain. And the reason that is called colic is because you go about is constantly track contracting and a colicky motion. But that doesn't necessarily reflect in the type of pain that you feel. So the way that biliary colic presents is you've got dull via up courtroom pain that is usually post prandial on reserves within six hours. So does anyone know why the pain is a lot worse? Postprandially, which means after you eat, give you couple of minutes on what particular meals might cause. Worst pain. I'll give you a couple of seconds contracts to respond yet really good. So yes, bacterials So when you've eaten a very fatty meal, you're going about it basically releases a compound, know you got better or your stomach release a compound called CCK cholecystectomy in. In on. This is a compound which causes the gallbladder to contract and release file so that you can digest and absorb all of fats. So, yeah, after we can meal, you're gonna have increased full bladder contraction, which is gonna increase the pain. So, um yeah, in terms of pain radiation. So pain does not always radiate, but when it does, it can be basically indicative of a couple of things. So yet the gall bladder out your pain radiates through to the back and the right, Your stomach Judean, Um, and pancreas is Brady is straight through to the back and knee lined going. And we've talked about why this is because your your artistas well, on then your small bowel is he controls this code on sigmoid crude on a nutritious Typically, your pain does not radiate. Um, yeah, So in general, pain tends to remain localized. Um, so if it does radiate, you can think instantly off some specific conditions which cause pain, radiation, and we're going to that in a little while. So for pain. So, yeah, this here is a diagram over the pain and refer pain is very, very complex. But simply all it is is that your brain can't localized pain. So, for example, in your gall bladder, you might feel pain in your shoulder. Um, I'm the reason for this is because if you call butter and larger is legal, but it gets damaged, it might irritate the die from, um, on the dye forms, innovated by the phrenic enough which basically comes from the brain complex switches in the shoulder. So it's kind of all very complex, but this just learning this diagram is enough. I need There's a lot of complex signs into decide to referred pain, but you don't need to go into that machine total. So now abdominal imaging. So at the end of your CPA, you have I think three questions on one of them is always on imaging. So you just need to get really good at recognizing imaging modalities. Um, yeah. So before we go on, does anyone have any more questions? CF use. I'll give you a couple of seconds. Maybe a minute or so to just kind of put the questions in the chart. Um, I'll do my best to answer them. Okay, So how many marks? Pus station in the CPK? Um, Asar a cycle, remember? I want to say 30. Um, was past Marc. Okay, so I'm no intelligible. I Yeah, I don't think I think they don't have a set past Marc. It's kind of all determined based on how everyone does, but, yeah, I'm on the best place to answer specifics about marks and that kind of thing. Any more questions about what we talked about? Okay, right. We will move on. Yes. So here we have a new drug. Relax. A So can anyone identify an abnormality, so just have a good look on. Then we will go over. Is it just kind of type in the chart, if you can see anything abnormal? Yeah. Really good. Say subject for Matic. Uh Yep. And couple cups Pneumoperitoneum. Yeah, really good. So, um yeah, we have, um person, even the way that you kind of identify it is sort of It's in this region here, Um, and you can kind of see a little bit there underneath the dye from, um, so yeah, typically occurs due to perforation off dominant organs. So when organs get perforated, which you can just imagine them is being stopped basically allows the air to get into them, um, or to get into the abdominal cavity. If it gets into the abdominal cavity, you're gonna have a hugely increased abdominal cavity pressure that's gonna push your diaphragm up because there is pushing it up, which is something that's really, really useful to see on a chest X ray. So, um, without don't know imaging and exams, you always think of abdominal X ray ct, MRI. But never underestimate the value of a chest X ray. Um, in kind of under in in basically identifying pathology. Um, because again, we always remember that the respiratory system in the gastro system are very closely linked anatomically so, Just always, um, always think off signs. Am I see, um, on a chest X ray. So you the reasons why you can get patents the name of her today, um, is because is due to trauma, it could be just a cardiogenic. So this'll might be during an ercp, which is basically so a procedure where you essentially trying to identify and recall stones joining us A strange for endoscopy, which is just when you put a camera flexible camera into the thigh system and you're trying to image it and then or perforation often inflamed organ. Um, do you just gave me and gangrene. So does anyone know why? Why Ischemia and gangrene can cools perforation if you pop your dentures in the chart, someone else's cardiomegaly. Yeah, you can't see cardiomegaly in their stock. Much means enlarged. So, yeah, um, it's Kenya and gangrene. Basically, um, you you kind of got tissue death. Yep, on do when you got issues at this susceptible to infection on the war weakens because it's not being supplied by blood and you get necrosis so you can. Then the wall is very, very weak and and is that in susceptible, very, very susceptible to rupture, which can then lead to perforation. So what? Yeah, that's really the question is, is it was asked what the abdominal indications for ordering a chest X ray. So, typically in anyone with so severe abdominal pain or grossly distended abdomen on, it's it's obviously fasting. Could do is examine the patient. I never patient comes to you with a very, very distended abdomen. Um, you You think you're probably gonna think this in their stomach somewhere in all that? Something that after system somewhere. So all the abdominal cavity g. So a chest X ray would be indicated there, Um, Or if they've got the symptoms relating to their chest or the heart, Or if you think that they've got a problem with their esophagus, we could just do a chest X ray to kind of rule out problems with the chinchilla or any of the respiratory system. So falling out stuff and also to kind of image of chest if someone is called, um any any basically pathological signs on an abdominal examination. Um, yeah. So someone has that sudden severe abdominal pain suspecting perforation. Yeah, Thank you. So now keep features off the abdominal X ray. So here we've kind of got many table of stuff. That's, I guess, really, really useful to remember when you talk about the adrenal, actually so, and it's how to differentiate between the small bowel and the large bowel so firstly can differentiate by location. So your small bowel is very central on your large bowel is purple, your mucosa fold, say, and a small bowel We've got things called valvular I convent is which are visible across the full width of the bowel. Where is in your large bowel you've got How stroke of which do you know, complete your possible? You can see that own and abdominal X ray. And then based on diameter, so has a really good thing called 369 all where your small bowel should be Less than three centimeters on X ray, your colon to be less than six. And you see him less than nine centimeters. Yeah, I just remember the 369, um, on that easily come up is a question. So they could say, You know what I am to Should the small bowel be on of Don't know. X Ray said you remember 369. So, yeah, here we have a normal abdominal X ray. Um, so in an x ray, um, Arab, his block on bone of his white so we can see um, kind of here. We, um you you see, what can you see? My car? Because I put it comes up in the tribe. You could see my cost. Uh, no, I don't think we can see you closer. Okay, that's fine. Okay. See it? No. Yes. Yeah. Okay. So, yeah. Hit. We've got, um, the section hit. You can kind of see the smoke. A girl, um, smoke while head on this. But here is the is gonna be the ascending colon. So yeah, we've got the large bowel basically framing a small bladder. Um, yeah, someone has said, but I really I content is, um yeah, And again, just on tosta. Valvular like on event is, um yes. So in this first diagram, you can kind of see your small bowel with your IV icon, um antes, And if you look really closely, they are kind of extending across the hall with off the bell. Um, and then your large bowel, um, cost, right? Hey, I'm not really traversing the entire width of the bowel. They kind of stop like this. Um, yeah. If we know revolting, see, without going to talk a little bit about obstruction and see the best imaging modality for for a suspected obstruction is an X ray, because X rays of really, really good picking up there because they're just appears black. So if something is obstructed, um, it basically means that it's gonna be filled with that. Um And so if we see black on an up abdominal X ray, we think about, um, basically a rapid being somewhere in the abdominal cavity. So, yeah, and any bowel obstruction, the key finding is dilated intestinal loops on do in order to decide about the obstruction is a large bowel or small bowel obstruction. We basically use the features that we talked about in that previous table on Dalser is another couple of things we could have a look at. So on the left here and we have a small bowel obstruction. So yeah, we've got intestine. Lips are dilated, which means that they're greater than the normal diameter of three centimeters. We've got a stepladder sign. So I mean by this is this, um, that section that basically looks exactly like a step ladder. I say exactly as much as a step as much as it can crack stepladder. Um, Andi. Yeah, we've got intestine lips, which ovary centrally located. And the large bowel is basically the opposite. So date intestine, ribs, great in six centimeters. Intestinal loops, which are peripherally located. Um, yes. And now on to your sound. So ultrasound, um, basically help some works in very, very basic terms is that it uses sound waves. So on an ultrasound, anything that reflects we some waves back or flax echoes back is going to appear, right. So a reflects echoes, So it's gonna be white bone, Really. Your facts is going to appear very, very white on liquids basically absorb sound waves. They don't reflect them. So they appear block. So, yeah, ultrasound is most useful to image the gall bladder on to detect the presence of gallstone and biliary disorders. Still, Yeah, we can see. Here. Listen up sound. It's kind of got all the key, um, key findings or key? Mm. Key organs basically able, don't it? So, um, yeah, any. Any time you see something that is black and circular on an ultrasound, Um, basically, it is filled with fluid, so it's likely to be a vein or an artery or something without So the aorta, for example, is black portal vein is also black, and the ivc is black on. Does anyone know why the core bladder is block? I'll give you a couple seconds to Well, it's the shop. Yeah, exactly. It's filled of bile. Yes, about is an acquaintance. Obviously, it's gonna be a block. So now onto goal stones. Yeah. Here. We got a little ultrasound where there is a gallstone present. Um, and again, Uncle stones are quite solid things, So sort of things are gonna reflect the sound waves back. So they're gonna pay white, so you can see a gallstone in the cold bladder and three, my types of cold stone. We've got cholesterol bile pigments on mixed stones. So now, onto an abdominal CT scan. So abdominal CT scans are really, really useful in determining. So the underlying causes off Donald pain. So if someone comes with the pain on, you just kind of want to have a general look at the abdomen, and we probably go forward abdominal CT on. We can use something called contrast to enhance the quality off a CT scan. And they're two different types of contrast which will kind of go into in a second. So just one thing that's kind of crucial to remember is that in all CT scans, you imagine that the patient is lying on their back with their feet facing towards you have come in a diagram in a second, which will show you what that exactly means. So the T shots contrast. We've got IV contrast, so it's it sounds complex, but it's really, really simple to the ankle IV contrast. You inject it into someone's veins. So anything, any vasculature, any arteries or veins they're going appear white because they've got contrast in them on their base. That indicated IV contrast is indicated most cases because you basically just one the best quality images aspartyl on. Yeah, it's used a value information and masses and lignin sees, and then the other type is all contrast, so it basically allows it. Basically, you you can't you have to swallow the contrast, so allows you to visual. I saw the Lumen of the small on the large bowel and stomach and basically any hollow organs. The contrast is gonna get into so yeah, again, it's really useful in emerging the bowel. Bloomin. So, yeah, this just here is a diagram off, um, a CT scanner. So you always remember you're looking the patient as if you're looking at their feet. So just imagine patient lying towards you. And that kind of gets you the orientation. Yeah, and this here on the right is really useful diagram. Um, in terms off, kind of showing you what organs are at war planes. So, um, you kind of have to imagine so, for example, the transumbilical plane, which is hit. Um, yeah, the chance of Bill plane, which is here. You to see the ascending colon. You'd you possibly see the transverse colon, you'd see the abdominal aorta. You see your ureters. You see, you're descending colon on a swell. Yeah. Um, yes. And now on to update a CT. See, here we have a normal abdominal CT on this. Does anyone can anyone guess what level it is that? So the thing with CT's is to kind of because it's all slices. Um, we need to imagine we need to kind of be able to have rough idea of what plane? The C T is taken out. So if you guys want to have a go in the chart at what level you think the CT is, I give you couple of seconds. Gina says I'm gonna set t 11 t 12 to 12, so yeah, this is a noncontrast ct on it. Exact lt. Um so a little bit lower, then you thinking so within the symbolism region. But, um, you can kind of tell, um it's kind of beyond the scope of this that you can kind of tell based on the vertebra itself, because each vertebra has zoo each section. So your thoracic and your number and your sake, we all have different shapes, which you kind of be a telltale sign on your optic city. So here we have a CT with contrast. So do you want to put in the chart? What type of contrast you think it is? I give you couple of seconds to be, though, so it's either going to be all IV. Yep. See, well, seeing a which is correct, Um, on how can you tell? Have you guys wanna try trying the chop? How you can tell that it's a while, then IV? Yeah, exactly. Newman's Why? So it's gonna be anything that that basically puts contrast into the Lumen is gonna be all, um, someone has put around up. Did you question people? Question and just talk in the job? Yep. So this is an abdominal CT L3 and again, just kind of a diagram. Seek more easily visualized why the structures are where they are. Okay. Yes. And I don't ct This is MRI. So, um yeah, One of the things that they always ask you is what imaging modalities this on. If it's an X ray to really, really obvious if it's an ultrasound, it's also very obvious. But CT MRI can be tricky. So this is just kind of summarizing the key differences between a CT and an MRI. So in a CT, bone is white, whereas in it, um, all right, Bonus block called on gray fat fluid is dark gray in a CT, whereas found fluid is white and number. Right. So basically it is, um it is basically the opposite. So if you learn one thea other is gonna be the opposite. Um, CT is really only good for detailed bone imaging, Whereas an l R I is better for soft tissue injury. Onda ct is performed. Basically is it isn't a lot less susceptible to artifact, which kind of, um, findings on finding some imaging due to the imaging process itself. Um, sorry if we get back so just anyone. Can anyone type in the chart? Um, two advantages off, um, or maybe one advantage of CT MRI. We'll give you a couple of seconds to go. Yes, it cost is definitely one of them. Yeah. Rapid. Yep. Is cheaper. Yeah. So your CT takes about between 15 to 20 minutes. Um, on an MRI takes a lot longer, and patients have to lie in a whole, um, kind of memory machine on after I very, very still, Which can be very tricky for patients. So a CT abdomen, buses and MRI Abdo. Um, so, yeah, we kind of go, um, dark blue pill structures on the right Sits gonna be a CT on then. Obviously, the opposite on on the sorry on the funding on the right is the opposite. So that's gonna be out of all right. So, yeah. Now, here we have an abdominal MRI is too. Don't worry too much about, um, all the tiny little structures. They basically you're going to ask you the main stuff. So the lever, the stomach, the battery, Theodore aorta, in theory, being Cavor, all that kind of thing. So just lie on kind of the great structure and make sure you really understand why I Each structure is where it is because if you do get stuck and you do, you forget your labels. It's better to be able to work it out to then make an educated guess, because it's very likely to be correct. If you know where the organs are, where they would be and wash it, they would be on an MRI or CT. So now onto keep it on low pathologies and signs. So yet the first is keep appendicitis. So this is a classic one that comes up in CPA or whenever you're doing any sort of examination. Um, yeah, it is. Basically, appendicitis is information on the appendix on how patients will present is acute. Write it for the pain so you can always think about the location. So the appendix is in the right iliac forces, so they're gonna have to keep ain't. And as we said, itis pain is gonna be constant because it's an information. Um, we Yeah, you could also complacent with a dull period medical pain that shifts to the right lower quadrant. So what I mean by this paraumbilical just means around the umbilicus which is about anybody, and then it shifts. So the reason why this is is that in early appendicitis, you kind of get irritation off your visceral party. Um um, on this pain is very poorly. Oh, closed. So it's kind of a dull paraumbilical pain on later on. You irritate that parietal peritoneum. Um, when parietal pain is surprise, party in pain is very, very well localized. Which is why you get that. But localized left. So you're really at force of pain? Um, yeah. So in terms off signs, one of the classics is anorexia, which is also called hamburger. Sign on gets a very, very sensitive sign. Because if someone is a lot of appetite on this accu, write it out for some pain, you can kind of be fairly certain that is the key. Appendicitis seem also get nausea, vomiting and constipation. But of wrecks, your is probably the best sign. So when we helped her eat, these are the signs off appendicitis. So there are quite a lot of signs of knees. Your case, it just learning and bosses off understanding a little bit of the science behind them. So the first is when your party. You might find pain in McBurney's point. So this is self is marking for the position of the appendix. Um, and yet I thought of the distance from the right anterior. Right, anterior C period. Any explain to the umbilicus? Not have, Um, my rising site on this is upon deep palpation of the left lower quadrant. You can get right lower quadrant pain. So I signed. So right, lower quadrant pain with extension of the right leg against resistance. Um, we've got diagrams of this after, and then coops or trait to sign is another side, which is right now courtroom pain with flexion and internal rotation off the right leg. And then the bag signed. So this is just rebound tenderness. Um, which essentially, when you're palpating someone on, do you let go? Um, if they experience a lot more pain, Um, you can be so sure the, um they have inflammatory pathology. Basically, you consent that cousin of that force of them. Think of appendicitis, So, yeah, we have here just diagrams off service of so, uh, on the object to sign. See you. The next pathology is a triple A. So can anyone say one key examination finding off the Triple A. Let's give you a second to put it in the chart. An expensive unless, Yeah. Yes. See, basically what a triple A is is kind of when you have a weakening off the A Donnelly oughta, um, on that big and that could be ruptured or unlocked. Good. So anything that can weaken the abdominal aorta, all the basketball convey sickly cause Triple A. So that is what Tripoli actually looks like. Does anyone know, Um, why she plays? Uh, why an abdominal? A. Why in a or two can you is, um, is more likely to occur in the abdomen rather than in the thigh or X, because obviously, you're able to runs form of oryx down your abdomen. So pop in the chart. If anyone knows why, Okay, so the reason is that basically, in the abdominal aorta, you've got a lot less in last in, so it is less capable off kind of expanding with the pressure of your pulse. So it's more susceptible to basically we can, um yes. So you can get back pain, flank paying and hypertension, because if that is kind of pooling in your where the aneurysm is you're gonna have reduced perfusion. Pressure of your guns on ruptured Triple A is a medical emergency, and it's got a really, really high mortality. So patients will present with shock and it also consciousness because of hypo perfusion to the brain. So, yeah, um, a triple eight can either be unwrapped. Little ruptured is we've said so. If it's unwrapped your age, when we pop it it it will be pulsatile and laterally expansile You may hear umbrian on oscal take a shin do to it very top of your blood. Play on If something is ruptured, you might see, um, blood blood might leak form the aneurysm and posteriorly and cause erectile parity, new hemorrhage and some classic signs of retroperitoneal hemorrhage are graze Turner and Collins sign. Okay, so, yeah, we can see Colin Sinus kind of. You got this bruising around the umbilicus and grace Tyler, you kind of got bruising on the books, so, yeah, we're not going to talk a little bit about obstruction. So we talked about how you can identify obstruction on, um, x ray, but a little bit about what's traction is. So we've small bowel obstruction. Um and most common causes are occasions after surgery on a strangulated hernia on large bowel obstructions on most common cause is correct or cancer and volvulus so just kind of the, I guess pathophysiology behind obstruction. So if you imagine your intestine as a pipe with kind of contents flying through it, um, if something gets lodged in your lodged in the limit, there's gonna be a service Stasis of the contents. They're not gonna be able to breathe past the obstruction on what that's gonna do. Approximately two. The obstruction. You're going to get a large increase in in general on intraluminal pressure, which can cause nausea, vomiting and constipation and kind of distention of the abdomen as kind of collecting that, um, Andi bowel loops distal to the obstruction, um might not receive any buffalo on become a stick ischemic, which is why you get the colicky abdominal pain. So on examination. So someone has said taking food course obstructions Um, well, not food per se, because you obviously, when you eat when you eat food, you do to, uh, But if you try and swallow something huge, then yes, it can cause an obstruction. Um, the main cause of an obstruction. What all the most common one is base Is constipation. So hard stool Basically not being able to transit through the gum. So upon inspection, you're gonna see distention, which was a lot more obvious in large bowel obstruction about the small bowel obstruction auscultation, say, and early sign is high pitched and tingling bowel sounds, um, on late sign is absent gallstones. So if you do get skinnier and necrosis off your bottle, you're not gonna be able, Teo, the muscle isn't gonna be able to contract. And you're not gonna be able to transit concept contents through the gut, which is why you get an absence of bowel sounds and vomiting. So this more bowel, you get bilis vomiting. So you you kind of be a vomiting bile, which is an early sign on your large bowel. If your large bowel is obstructed, you can you can get something called a fecal and vomiting where essentially or vomiting feces. And it's a very, very late sign off about obstruction. So, um, okay, is most. In most cases, you identify the what about before someone actually gets thickening? Vomiting? Yes. So peritonitis is another key pathology. So the signs of this, So you kind of get into fuse of Donald Pain? Of course. Entire abdomen. You get tenderness, so we're only palpate the patient will be tender on. Do you can see it on their face that you're putting them in pain even on very, very like palpations, um, the patient will basically show guarding, which is a voluntary contraction of the abdominal wall to basically avoid pain. So if you think about if something is damaged and you you are, um, basically palpating if they have, um, if you could have could contract your muscles, you can kind of prevent palpations off the inflamed or underlying pathology, which is why it's so important. Um, which my garden is so important in avoidance of pain. So another thing is rigidity. So this's involuntary contraction of the donor musculature on cars and response to underlying information and again rebound tenderness, which is another side, which is a sign that we actually saw in appendicitis in our Bloomberg sign, because it's pain with removal of pressure on probation on yeah, another sign of heart night is because because the patient isn't so much pain there just lying still cause any movement just makes it worse. They just want to lie. Still not move to kind of relief that relieve any pain that they come. So does anyone have any questions too? I'll give you a couple of minutes to ask any questions in the chart. And then after this, we kind of got five questions that you guys can have a go up and you can just popular. It's in the child. Could you please explain the distal and proximal obstruction again? Yeah, of course I go back. Teo, Slide. Where is it again? Poke. Okay. Say, Ah, um again. Yet we've imagine that your bowel is a pipe on you obstructed with stone. So anything proximal is gonna look is gonna be not gonna be able to pass the stone. It's kind of going to get blocked. So if stuff keeps because you're going to still be eating and stuff, So if you're, you know, food and a lot of the a lot of fluid is going to be able, Teo kind of is going to accumulate behind that stone. It's going accumulate stuff. Chemo eats your base. Your bowel is going to kind of get dilated, dilated as it kind of collect with whatever. Um, whatever is kind of building up behind the obstruction of the state. Um, and that's why you get a very distended abdomen, because your bowel is literally dilating. Um, Andi, if there's a lot of content in your bowel, your pressure and your Lumen is going to really, really just increase. So that's what kind of happens proximal to the obstruction on, then distorted the obstruction. So if something is completely blocking your battle, nothing can get past that stone right on. But, uh, after the stone, Um, because there's so much pressure proximal to the stone, you're going to kind of be compressing the walls of the bowel or just going to be really, really compressed. And that's gonna then compress a lot of small blood vessels in your old small blood vessels in your Lumen wall, which means that it's blood flow is gonna be obstructed distal to the obstruction on D. If that happens, um, you're not getting a blood flow. It's gonna cause tissue death, which is why you can get in a crisis, um, at a ski me out of the bowel, which is causes your colicky abdominal pain? Yes. Um, yeah, if we go back. So somebody asked about balloting. The kidneys. So yeah, about in kidneys. Um, I'll go over it very briefly. So what is your basically trying to feel for the kidneys? See, place one hand in the cost of frantic angle of the patient. One hand, Um, a teary on that flank on you, then basically, just trying to feel the kidneys, um, through fingers. And it's a really, really tricky sign, and even kind of the most experienced, experienced gastro gastroenterologist can't really feel it because it's not very sensitive. All, um, a very good sign. But it's just something that's useful to know because someone does have a pathology with kidney. Um, you might be able to feel the kidney will feel any abnormalities. Yep. So if we now, we now have a couple or off practice questions. Get the first one patient presented, prolonged right up courtroom pain, which gets worse after that in years. Patient is nauseous and has vomited twice on the scleral pay yellow. What is the most likely diagnosis? So, yeah, if you guys put your ulcer in the shop and collect, okay? so we'll go to the arts. And second. But you guys going for biliary colic? Someone's on the appetite. It's a swell. Yeah, um, someone's got obstructive jaundiceness. Well, okay. The second thing named this imaging modality. All right. All right. Yeah. Okay. Um, that name, too. Causes of high pitched bowel sounds. Destruction. Okay, wait. A couple wants this. It's all a lot of obstruction. Ileus. Yep. Um, and then four wires, That bonus point located on what is the clinical significance off this point? Okay. Give you guys and the distance with aces. And then Benicar's the absolute indication on what is the clinical significance off the point. Give you guys compliments. Couple seconds stone. So that, um yes, a clinical significance. Yeah. Location off the appendix. Usually, um, life. Um, What happened? Contrast has been used in the imaging below IV it. So now onto the answers yet since biliary colic duty obstruction off the CBD, though, for those of you who said obstructive jaundice. So, yeah, if you obstruct the CBD, you can get very colic. And if that kind of is prolonged, you can also get obstructive jaundice. So yeah, well done. Um, to it's an MRI, which I think he said, Um, three. It was dark via um, which is already signed a bowel obstruction four. So it's located a third of the distance from it, right basis on the umbilicus. Yes, and one thing. I think a lot of you said that Ghani's point indicates appendicitis. So you McBurney's point does not. It's it's a point. It's a surface. Marking for the appendix is a position where dependence usually is if you have pain. Uh, yes, I was indication of pen deciders, but McMurray But Bernie's point specifically doesn't indicate appendicitis. It is just simply a surface marking for the appendix five a ct with IV Contrast. Yeah, because he abdominal aorta and ivc are bright white. Yes, so that takes us to the end of the lecture. Does anyone have any final questions or any comments to make? I'm just gonna jump in there quickly because I know some people don't have any questions on D I. I'm going to paste a feedback form into the chart now. There are a few feedback forms here. Um, thie. First one is the feedback form for this'll lecture. The second ones in the back for me, just for the General Siris. So if there are any other lectures that you want us to schedule if you want, like a mock an extra mock paper as a session alive session. If you want a Q and a session where we get all the electrodes in an answer questions, then please just fill out these forms. And then the third feedback form is just if you have any questions that you want our lecturer to answer in the next session. So that's the upper limit. Neurological examination, upper lower limb neurological examination. So please fill out those forms. Please fill out the first one if you want the slides. 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