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so I think we'll start now. So thank you for coming. Everyone, Um, if you don't already know, this is part of many, many lectures that we're doing a sit today. We're going to cover general general surgery. Uh, and I've got, uh, swizzle and F two in Queen Elizabeth Birmingham. Who's going to be teaching this session today? If you have any questions rather talk, please use the Q and a function of feedback form. I'll upload after an hour, even if we do run over a bit, Uh, and I'll try to get back to you as soon as possible and with the Q with the questions. So keep them coming. Uh, swizzle, if you're ready, uh, we can start. Uh, I'll also be dealing with the pause as well. So we're trying to keep it as interacting as possible. So when you're ready for that yet, All right. So I think I'm sorry. Can you hear me? Yeah. All right. So, um, so, let's see, today's topic is, uh, it's June, so we're going to go with and Okay, just a minute, I think, Uh, okay, I'm just Sorry about that. All right. So the first, um Yeah. Okay, so these are the topics that we're going to cover. It's basically just general acute emergencies. All right, so all right. So first, basically, abdomen is just a general anatomy. Abdomen is basically divided into four quadrants, so you have your right upper left upper right lower and the left lower, and then against divide into nine different regions. So basically, you have two vertical lines and the horizontal lines. Your two vertical lines basically pass to your midclavicular, and your first, the top most horizontal line passes through your tip of your ninth intercostal drip, and the lower horizontal line passes through your trans trabecular plane. So it's divided into right and left, hip or contract. Uh, then you have the epigastric, the top, most midline. Then you have your right and left number, then the umbilical region. Uh, and the lower most is the right and the left leg and the hip, uh, gastric region. So depending on what uh, structures are found in these places, you have different, uh, different conditions that can arise. So the next slide is so most of these conditions is not so. Even though, uh, some some conditions are present throughout the that can be the right hypochondriac or the left hypochondria, for example, the pancreatitis. It is not very specific, but it can help us narrow down or come to a differential diagnosis, depending on where the patient complaints, the pain is Okay. Uh, so let's start with the first question. Uh, so the question is, Gina know it's who is a 34 year old woman she presents to any with abdominal distention and green bilious vomiting on examination, thinking about bowel sounds. Heard. An abdominal X ray is taken to confirm the diagnosis. So So if you could just type in or I think we have an S B as well. So if you could just, uh, no down what your answers are. So have you got any answers? Yep. Yep. So I'll send the pool there. Can you see that? Uh, no. Sorry. Think I need to? Okay, that's fine. I'll do it so we can see that. Most be. I'll let you know next time. Okay. All right. Okay. That's great. Uh, yeah. So? Well, that's right. That's the That's the correct answer. It's the one that you can see here is characteristic of Sigma and volvulus. That's a coffee bean sign. Uh, so before we go forward with Sigma Volume, as I can explain that to you, let's just talk about bowel obstruction first. So bowel obstruction is a surgical emergency, basically physical obstruction to either food or fluid or gases. And because of which, uh, there's dilatation of the proximal part, and because of the dilatation, there's there's lots of fluid and the third space loss as it is that it can affect the CVS as well. Uh, the most common causes for bowel obstruction is usually adhesions, so usually post operatively. You have hernias, which can which can get strangulated or incarcerated later on. Malignancy is usually in the large bowel, so that is usually your sickle cell carcinomas, and the other cause is like you, said Walgreens. You can have strictures. Diverticular disease is etcetera, so usually the patient presents with abdominal pain. Uh, they can have nausea, vomiting, Uh, if it is usually proximal approximate so it can be various vomiting as well. There can be constipation, usually lower down in your GI track. There can be there's abdominal distention, and you can have, uh, tingling bowel sounds in case of early conditions. So investigation. Usually the first line would be an abdominal X ray. So, as you can see, for example, involves, you can have the coffee bean sign. Or sometimes you can have the air fluid levels as well. Uh, so the normal basically to identify there's an obstruction or no, you need to know what is a normal diameter of the bowel. Uh, for small bowel, it's usually three centimeters large. About it is six centimeters and cecum. It is nine centimeters, so above this is then you. Then you can confirm that it is an obstruction. You do you need to do a chest X rays, basically sometimes along with obstruction that can be perforation. And just to rule out, uh, you know, air under die from or any pneumoperitoneum. Then it's better to have a chest X rays while and finally you can do a CT abdomen, which is more definitive. Uh, so this is basically two different pictures of identifying whether whether it's a small bowel or large bowel, uh, small bowel obstruction, or you can see the first picture here, you can say something known as the valves confident in. So this is basically long mucosal fold, which is along the length. Okay, uh, basically vertical along the length of the whole, uh, the small bowel where, as in large bowel, you have the horse striations, so these are usually halfway across the bowel. So basically, this is one of the characteristics features you can you can use to identify whether it's a small bowel obstruction or a large bowel obstruction. Uh, so here, uh, I was talking previously about, uh, hair under the diaphragm. Uh, so this is air under the diaphragm, which helps to identify if there's a perforation in the bowel. And normally you can see the gastric bubble on the left side on the left side as well, so it can. Sometimes you can get confused if it's actually the gastric bubble or the area under the diaphragm. But if it's on the right hand side, then it's. It's confirmed that there is some cooperation somewhere, Uh, so management for these obstructions will be first. You need to, uh, resuscitate the patient so you'll have to pass. IV cannula is, you know, do an A B C D approach, and then I'll keep the IV fluids going to have to tell the patient not to eat anything overly, because you need to identify whether obstruction is or if there's a perforation, uh, the patient's vomiting. Or you can just pass an N G two for decompression as well. And, uh, sometimes usually if it is, uh, a perforated. If it's a big perforation, then probably the patient will be for surgery. And if the patient is stable as unstable as well, then we'll be shifted for surgery. Otherwise, sometimes, usually we go for a more conservative approach and see how the patient is doing and accordingly, decide if the patient needs a surgery or no, uh, you're coming to volvulus, uh, volvulus, basically the twisting of the intestines along it's knee centric attachment. So the volvulus is a closed bowel obstruction, Um, and it's usually one dose twisting. Uh, the blood supply can get compromised because of which it can undergo ischemic changes and then finally, perforation. So the most common site for the volvulus is the sigmoid colon, followed by. You have the stomach, the cecum, which are usually the rare ones, but then sigmoid colon is the most common. Uh, you have the long medicine specifically the long the century that are attached to the sigmoid colon and because of which it twists on it by itself. The features the signs and symptoms again is a similar one. But here constipation is more pronounced than vomiting because it's usually lower down in the GI system and, uh, and usually the abdomen is distended. You'll have a tympanic, uh, to focus, and it's usually a surgical emergency, uh, so similar to, um, similar to how we manage a bowel obstruction volvulus. Also, we we need to manage a similar way. But however volvulus we can, we can decompress it by a sigmoidoscope or buy inserts of latest tube. And the indication these are the indications for surgery. So if the patient, if it's a chemical, there's a perforation, or if the decompression was not successful then and if the bowel is necrosis, then those are the definitive signs for a surgery. Uh, there's another form of bowel obstruction is the intussusception. Now These this interception is most commonly seen in Children, and it's basically the telescoping, uh is basically one part of the bowel goes into another so basically telescoping of the bowel because of which there is a blockage of food fluid. And because the telescoping you have the blood supply is cut off and because of with similar ischemia, perforation and same thing happens. So it's very common in Children and one of the characteristics features or the clinical features. What happens, intussusception is you have this red current and jelly stools. Uh, the reason for this red current jelly students is because the ischemic part of uh of the bowel is then is then what comes out by the back passage? Uh, again, a child will be very, uh, very irritable the vomiting. They'll be a lump in the abdomen. The standard abdominal decreased appetite decrease. Eating will be very irritable, and the diarrhea will be present as well. So the first, usually once, Uh, as you can see here, the characteristic feature on an ultrasound is usually the target sign. That's basically the first. The other one is the bowel and the one the, uh into the small bowel that has gone into it. Um, then you can attend the reduction so reduction can be done with either a contrast enema, so that can be the liquid or a. It's not a surgical procedure it's a radiological procedure. And yes, you can attempt that. If not, then probably, uh, there's ischemic changes, then probably go for a surgery that would be the best definitive A treatment option. Okay, moving forward with a bowel obstruction so you have a paralytic alias. Now this paralytic alias is also another type of bowel obstruction that is most commonly seen in post op patients because of which the, uh, the bowel is usually silent. So there's a lack of peristalsis in the bowels, the most common the poster. Or if there's an electrolyte imbalance like potassium and sodium, uh, infection. Yes, in case of peritonitis, that is usually if there's, uh, some infection of the peritoneal, uh, peritoneum. Then there can be a parrot paralytic a list as well. Uh, so the management is usually conservative management and, um so usually you can give patients a parental nutrition just till they're about regain some function and that that's about it. So Okay, so the next question is Ali Hussein, who is a 47 year old man, presents with the GP with lump in his groin. Uh, that disappears when he lies down, so he is diagnosed with an inguinal hernia. Which of the following statements about inguinal hernia is sports? So if you could just answer that and let Yeah, we'll give it, like, 30 seconds to let people answer. Yeah, mhm. That time. A few more seconds. All right. So I can see the most popular answer is D uh, the occasion. Is it B or D? The Okay. All right. So the answer is, uh, see strangulation. So let's see why. It's okay. Uh, so before we discuss about the question answer, Let's just talk about hernias in general. Uh, hernia is basically an outpouching from the normal. Uh, it usually has, uh, just basically protrusion from the abdomen. Uh, it can be reducible. It can be irreducible. Uh, usually in some patients, it just reduces by itself on lying down. It protrudes out on exertion. For example, coughing. It can rise because there is a rise in intra abdominal pressure patients. Sometimes it can be a symptomatic, but patients usually complain of some. Some like pulling, dragging sensation. So you have different abdominal hernias? Uh, it's just a picture. And then we'll just discuss about each of them. Uh, so the most. Let's talk about the complications. The abdominal hernia is basically the complications are you have three, so you have either. It can get obstructed, either it can get strangulated or incarcerated, so an obstruction is similar to bowel obstruction because of the neck of the neck of the hernia is very small. So the bowel gets into the, you know, into the sac, and then it gets obstructed, called bowel obstruction. That can be because it can cause vomiting, nausea, et cetera. Strangulation is because of the blood supply is affected. So in this case is it's irreducible. And then it goes. Ischemic changes, and it's an emergency, so it causes quite significant pain. And bowel obstruction can be present with it as well. Sorry, uh, the third one is incarceration. So in these patients, it's it's an A reducible hernia and can either go to either obstruction or strangulation. Uh, talking about the hernia is the most common type of hernia that we can see in adults is the inguinal hernia or the femoral hernia. And inguinal is again divided into direct and indirect. Um, so about the inguinal hernia. So inguinal hernia is basically, um so talking anatomy or discussing anatomy. So you have the inguinal canal, which is usually like a tube like canal, which is, uh, just above the inguinal ligament. And the inguinal ligament is, um, just to, uh, just, you know, uh, surgical anatomy. It runs from the anterior superior elect spine to your pubic tubercle. Uh, just above that, you have. So basically, you have the deep inguinal ring and the superficial. I'm wondering. And between those two is your inguinal canal, which lies above the inguinal ligament. I hope you understand that. Uh, so now, to identify with what's the position of this deep inguinal drink and to identify the position of the superficial and wondering so deep inguinal ring is basically just above the midpoint of the inguinal ligament. Okay. And the superficial and vaginal ring is so you just need to locate the pubic. Typical. So it is superior and lateral to the pubic. Typical. Now there are different contents. So in males, it's different. Females is different. So in males you have the spermatic cord, along with the ilioinguinal love and in females. It's a round ligament with the ilioinguinal nerve, so I just hope that it's clear. So basically, this diagram is very descriptive and tells you what the position of the inguinal ligament that deep and superficial and the sorry. The inguinal canal, the rings and the inguinal ligament. Uh, so yeah, So how do you know if it's a direct or indirect inguinal hernia? Uh, indirect is more common in Children. So the reason why is because it is thought, uh, because of the failure of the closure of the processes vagina list. So this is basically helps in the center of the testes in Children into the scrotum. Uh, here, the abdominal canal passes through the from the deep, like enters to the deep ring, and then the superficial ring and into the scrotum. This is an indirect hernia. Where is your direct hernia is because of the weakness of your posterior abdominal wall. Because of which the hernia enters from the posterior from the posterior and one from the posterior abdominal wall and not through the deep ring. And, uh, basically, this is one of the This is the characteristic teachers. Um, so there there are a couple of tests you can do. Uh, one is, uh you can try to reduce the hernia, and you can press the so you need to identify where the deep ring is. So that is basically just above the midpoint of your inguinal ligament, and you need to press on it. So basically, when you try to reduce it, and then if you just tell the patient cough if the patient copy while the patient coughs and you can feel it at the tip of your I mean the tip of your finger. When, when When the patient is coughing, it's a direct hernia. If you're not feeling anything, Uh, then it's, uh, indirect hernia. Yeah, So if you if you can see a protrusion on coughing, then it's a direct hernia. That means it does not pass through the deepening, and it's just from the posterior wall. And if it is not, that means it's an indirect hernia. Uh, yeah, This is basically the processes vagina list, basically, which helps in, uh, which helps. And, you know, um guides the testicles down into the scrotum, and this is the the most common cause for indirect hernia in Children. Okay, so this is just a little bit of anatomy. So you have something called the Hassleback strangle, which is again helps you helps in identifying, uh, the inguinal, the different inguinal hernia, the direct and indirect. So it's more of on table, Like when you when you're doing the surgery, you can see it. Uh, the the demarcations of this triangle. Basically, you have directors, so you have the lateral border of the directors, and then you have the inguinal ligament, and you have the inferior eccentric. Uh, so the anything medial to the inferior mesenteric is your indirect hernia lateral to it is your, um your sorry? Yeah. The media to it is a direct hernia and lateral to it is the indirect hernia. That is because just the position of your deep inguinal doing that basically helps you to identify if it is a direct or an indirect. Um, the other most common is the femoral hernia. Now, this femoral hernia is very common in females. Uh, this is, uh this hernia usually comes. Uh, it protrudes out to the femoral canal. Now, the femoral canal is basically is part of the femoral triangle that you have in your groin. So you have you have three components to it. So you have the media most is your femoral canal, which usually contains, uh, some lymph nodes and fat. Latter, you have the pain in the artery, and the most lateral is your nerve. So the three components of, um, the nerve is usually outside the femoral triangle. You have the femoral canal, the rain and the artery in the femoral triangle. Okay, so the fabric, and that's the point here. So this this is just basically a different to differentiate between the three. Uh, so you have indirect, more common in Children, Direct, more an adult. And femoral hernia is more in males. The point where it originates. Indirect hernia is basically from it travels from the deep inguinal to the superficial. Direct is along any any any point along the posterior abdominal wall. And the femoral is from the family by the femoral canal. Uh, most common indirect hernia enters into the scrotum. Direct hernia usually have a bowl, so really, uh, descend into the scrotum and the femoral hernia is never into the scrotum. Um, so just, uh, some additional differentiating points. So strangulation risk for, uh, direct hernia? Uh, direct and indirect hernia is on the lower side, whereas for femoral, hernia is on the higher side one is because of. It's very narrow, the neck. So it's very so even if they contact, you know, protruding out, it is very high risk of strangulation. Okay, the other ones that have already gone through. Okay, so these are the different other hernias that you need to know because they can ask you questions about So you have the incisional hernia. Usually POSTOP patients, Uh, POSTOP patients, old patients. Usually a few years after, uh, or even a few months after the surgery can develop an incisional hernia. Uh, umbilical hernia is to the umbilicus, so it can be seen in especially new needs after delivery and usually reduces by itself, but sometimes even seen in older individuals as well. You have your epigastric hernia. You're struggling hernia. Speak. A little hernia is not very commonly seen, but it's usually the hernia that arises from the lateral wall. The lateral aspect, I mean, from the lateral side of the rectus abdominus. And it's just Yeah, and the lien a semi semi Luminaries. Yeah, I think. Okay. So, uh, the different other types of hernia that we can see is opportunity. Hernia is by an operator. The opportunity for men more common in the multi Paris women. Uh, you have a certain sign. Call us the Romberg sign of the house, Uh, Romberg sign. And it's usually the pain that shoots along the inner time when the hip is usually internally rotated. This is because it compresses on the operator nerve. And the operator now usually supplies the middle part of the Thai because of which you have, uh, you have the pain shooting along the medial aspect of the thigh. Uh, hiatus hernia is, uh, you cannot visit the seat. So it's basically rolling of the stomach, uh, to the diaphragmatic opening. So either you can slide up where it slides up with the gastroesophageal junction. Or it can roll where the gastroesophageal junction is usually under the diaphragm. But a part of the stomach then rolls along. It just creeps up along the side of the east of figures. You can have sometimes a combination of both the sliding and the ruling. Uh, yeah. So these are the few other extra. Um, there is something Well, as diet medication of directors or the dust the dust. This is our directory, which is not basically a hernia person, but it is more like because of the weakness of the abdomen, especially in older age or following a surgery. Um, it's basically you can just see bulges. This is just because of the weakness and the widening of the Linea Alba. It's not a hernia. It can be mistaken for me, but it's not a hernia. Uh, so how will you manage a hernia? Is that if it's it's symptomatic, then you can probably conserve, uh, have a conservative management. If it's, uh, an emergency, then obviously you have to operate the patient. Um, so first, you need to see the patient medically fit, even if there is symptomatic. Uh, sometimes, if the patient is might have several co morbidities so might not be for surgery. Might not be an appropriate candidate for surgery, so you'll have to do a probably give a trust. So hernia truss. It's basically just to keep the content inside. Um, otherwise, if if surgery is an option, then you can do a mess. Mess repair. So bilaterally, it's usually, uh, it's usually that we do a laparoscopic repair, but if it's unilateral, you can just do an open repair. Okay, so the next question is, um So Gemma, who is a 45 year old woman with a background of biliary colic, is complaining of severe epigastric pain. Her males is found to be about 1200. Which one of the following is not associated with the likely diagnosis. Okay, so give you, like, 30 seconds a few more seconds. All right, so is the most popular answer. So it's hypoglecemia. Okay, so so do you know what I mean? You've already shown side. But then so the most common cause for one of the differential for a severe epigastric pain is pancreatitis. Basically, you need to ask about the background history as well. But pancreatitis is, uh, to rule out alcoholism or about the conditions underlying risk factors for pancreatitis. So pancreatitis can be acute or chronic. Acute is usually where the function basically because of some infectious conditions or either, uh, the function of the pancreas just returned back to normal. But in chronic pancreatitis, because of some underlying probably gallstones or the patient is, you know, chronically drinking alcohol. Then over a long period of time, the pancreas, because of acute flare ups, can destroy I mean, undergoes just direction. And Dettori ation As a result, the exact crime. That means, um, the endocrine function your insulin, your glucagon and your legs are in the different enzymes Trips in, uh, like, based on all the enzymes Dettori it in activity. And this is usually the cause. Uh, the pathophysiology is basically, uh, the authorization of the pancreatic enzymes. And there's a necrosis. Most common cause is gallstones and alcohol. So gallstones can is one of the most common causes of acute pancreatitis, uh, alcohol over a long period of time after two pancreatitis flare up can cause chronic pancreatitis as well. And now, in patients usually who undergo ercp, that is, uh, endoscopic procedure to retrieve stones can also developed pancreatitis. Postprocedure. It's one of the common complications. Uh, So what are the causes of acute pancreatitis? Um, so these are the It's just easier to, uh, no, the pneumonic I get smashed. Uh, so most common is unknown. It's idiopathic. It can be. Sometimes you don't really know what What is the, uh, cause driving the pancreatitis. So then it's just idiopathic. You have gall stones. Alcohol. Like previously said, trauma, steroids, moms usually in Children or two. Immune, um, hyperlipidemia ercp and certain drugs as well. Uh, So now what are the signs and symptoms of acute pancreatitis? So you have patients who have severe pain, uh, severe pain. The reason why you have severe pain radiating to the back is because your pancreas is a retro peritoneum, Logan. So you have back pain as well. Uh, but then if the patient complains of pain radiating to the back, that's one of the pancreatitis or any pancreatic condition should be at the top of the difference. Your diagnosis list? Uh, you have vomiting, Uh, low grade fever. Tachycardia. These are the few symptoms vomiting? Not as much, but then patients usually have nausea as well. Um, there are certain signs which are not characteristically or not seen very often in patients with patriot like this. So this is the colon sign of the great honor. Sign the colon. The colon sign is basically a periumbilical discoloration. And your great aunt assign is a flank. Uh, discoloration. Uh, So the retinopathy, which you said it is not very common, is also a rare feature. Okay. And it is It can cause temporary or permanent blindness as well. Um, yeah. So the investigations that you do is when a patient comes with, uh, symptoms that you're suspecting, the patient is pancreatitis. You send for all the blood, all the blood tests, your routine blood tests send for a serum animals as well serum families. If it is more than three times the upper limit, then it is. It is not definitive, but it is. You can say, Okay, it can be pancreatitis, but the most sensitive one is your life is, but it's like is it may take time to, uh, may take time, you know, to show it in the blood. So but the more definitive one is like this, but a male is also helps in diagnosis as well. So there are different scoring systems that we use to, uh, determine how severe the pancreatitis is. So this is basically on pancreas. You can, uh, just know it, but then it's always available, so you don't have to basically learn this whole thing, but in practical, you can just use it to like to identify. Okay, is this mild, moderate or severe form of pancreatitis because you need the other different values to be done as well to identify. There are other scoring systems as well. You have the ransom scoring and the A party scoring, too, as well. Uh, so the management here is that there's not so basically in pancreatitis, an acute inflammatory condition. There's no surgery. Uh, it's more of conservative. So in pancreatitis it causes basically systemic because of the inflammatory reactions or because of the rise in different inflammatory markers. Um, it can affect the cardiovascular system, affects the vessels and because with the third space loss and because of because of that, you need to you need to rehydrate the patient. You need to get the patient more fluids if the patient so sometimes the patient can be n B m as well. But then, uh, that usually depends on if the patient can tolerate eating and drinking. Then that's fine. The patient. Now I can eat and drink. Uh, if the patient is very severe, that sometimes the patient might not eat anything because it'll be complaining of the nausea or vomiting. Then you can just give them, uh, parental nutrition or UH, IV fluids or some other source of nutrition as well. Uh, energy's the pancreatitis is the pain is very severe, so you need to, um, you need to my anticipation with a lot of energy here, probably step of the energies as well. And yeah, so you need to. You need to first know if the patient has Goldstone's, uh, do an ultrasound or an NMR CP to identify the patient's Goldstone's. If the patient is gallstone, well, that's your That's the reason why the patient having pancreatitis other than that, probably then you might have to do more investigation is to identify why the patient is pancreatitis and antibiotics are not recommended, so you need to probably give it only in if there's disrespecting an infection. Um, so complications are very common in pancreatitis. You can get also with recurrent pancreatitis. You can get necrosis. It can get infected as well. Uh, what we see in the long term is that patients who have long term or chronic pancreatitis develop cirrhosis. So Pseudocyst is basically, uh, it's a collection of fluid behind the pancreas, and it's very well contained, and it usually develops about four weeks or later, and so this basically the Pseudocyst then causes compression effects on the stomach and then causes other symptoms. Or acute pancreatitis can go into chronic pancreatitis as well. So the most common causes of pancreatitis is the most common cause of pancreatitis is alcohol. Um, so usually the patient has severe. I mean, has chronic constant dull in the epigastrium may complain of back pain as well, so there's lots of endocrine function. There's, uh, there's lots of exuberant function, so because there's loss of endocrine function, your insulin is not manufactured enough because of which these are. Your sugars tend to rise, you have hypoglycemia, and you're prone to diabetes. Lots of endocrine function. Uh, the normal ones that, uh, sorry. Uh, yeah, the normal ones is that there's lack of the pancreatic enzymes. Usually the life is because of which there is the fat. The fatty food is not, uh, not digested, and usually they have problems with the digestion they might present with the diarrhea as well. So that's when you give them additional supplements or additional enzymes to help them with such such symptoms. Um, because of this chronic or, you know, regular. Because of this repeated inflammatory process, uh, the biliary system or the duct system is affected and because of which it develops strictures and it does obstruction. And it affects can affect a billion a tree as well. And over a long period of time, the pseudocyst and abscess formation as well. Usually a pseudocyst is sterile, but sometimes it can get infected. And it can affect the patient called sepsis or a fistula into the, uh into the stomach. So the investigation is basically, uh, not usually we don't do an album next day, but CT is the one that is more sensitive and helps in identifying the patient has chronic pancreatitis. Acute pancreatitis flare up because on the CT, we'll have you just see like stranding fat stranding. That's basically like fluid around the pancreas. So that basically helps in identifying if the patient has a chronic or acute pancreas. You can do certain tests to identify the exocrine of the endocrine function of the pancreas, but doesn't routinely done uh, what is the, uh, what the management is you need to see. This patient will have chronic pain, so probably you need to manage the chronic pain you need to replace the enzymes. So Creon is one of the most preferred, uh, replacement. It's usually to the enzymes that are there are usually grown in, uh, I think the postseason gut. So sometimes, yeah, that is, that's from the it's derived. And you need to educate. Or you need to tell the patient to, you know, to reduce alcohol intake. Because if if they continue to do that or reduce smoking because they continue to do that, then that can be the cause of acute flare ups later on. Um okay, so moving on to the next question, we have, uh we have Karen, who's 46 year old female, and she has been diagnosed with, uh, sending cholangitis. Uh, your consultant tells you that really, these patients can present with collection of symptoms call as the renewals entered. So can you tell me which of these is right? So I'll start the pole in a second, just let you read the options, and we'll give you, like, a minute for this is a bit longer. All right, so we'll say like 40 seconds. 15 seconds. Mhm. All right, 10 more seconds. If you don't know. Just guess. All right. So it's kind of split between a and Di di just about winning. Okay? So are we done with the poor? Okay, so, uh, dances. All right, So you have the you have tried, and then you have the painter, so, uh, Okay. All right. Um, so acute cholangitis is basically your infection of the biliary tree. Most common organisms that is found in the laboratory is the equal, followed by your klebsiella, and they enter cocaine. Most common cause of cholangitis is a gall stones because it obstruct and then bile gets accumulated. Uh, you know, and then there's the seeding of, uh, the bacteria and that causes the cholangitis and most commonly seen after a procedure, which is the ercp procedure. So the tribe is basically you have the right up. According thing, you have fever and you have joined this joint. This is why? Because if there's a gallstone, it can obstruct. And then there's, you know, there's this blockage of the biliary tree, and then you get jaundice. What makes it a paint out is you have when it takes. So you have hypertension and confusion. So these are the other two factors that are there, which causes it painted. Uh, investigation. Forget cholangitis is you do an ultrasound first an ultrasound. Why? To identify There's a biliary, dilatation or know and to see if there are stones in the biliary tree following which you can do an MRI. C p M R C E p is preferred compared to a city because it will help you identify if there is a medication that will help. You see there's a stone in the biliary system and in this usually have rising the inflammatory markers. So CRP is going to rise. And if there's an infection, there is an infection here, so you have a rising WBC count as well. The management for this patient is, um, before we used to give the patient N B M. Now you can ask the patient to eat and drink unless he's for the procedure, but the patient can eat. Uh, the patient is stable enough can feed himself, you know, has no nausea, vomiting. He can eat and drink. Uh, you give IV fluids and you start the patient on broad spectrum antibiotics. Uh, and just see how the patient response, uh, you do you need to do an ercp as well. So if there's a stone, so you need to retrieve the stone. Sometimes the stones can be small and can usually, uh, it just passes by itself. But if there's a huge stone, then you need to, uh, manage the ercp. Uh, so here I've written that you need to treat the infection first. Yes, you need to treat the infection before you do an ercp. But if the patient is very unwell and the patient you know, if the cholangitis is not settling, then probably you need to do an ercp as soon as possible. Uh, okay. So the next question is, um, James Smith, who's a 58 year old man, uh, presents with vomiting and fever, his liver function, testifying on palpation in the right upper quadrant. You realize that he stopped? Uh, he stops taking a breath. Uh, so what is your most likely diagnosis? All right, 30 seconds. All right. So the most popular answer is a okay. Yeah. I think this is one of the most characteristic sign is called the morphine sign, which is most commonly seen an acute cholecystitis. Uh, this couple of, uh, just, you know, here and there to identify the different terminologies associated with the biliary system. So you have a biliary colic. This is usually when the gall stone passes with the biliary tree and you have very severe acute pain that develops, Um, so and then you have the colecystitis. So colecystitis is basically the the gall bladder. So if there's inflammation of the gallbladder, it's colecystitis. Cholangitis is basically the biliary tree. So the belly, the bile ducts if there's an event you have cholangitis called Stasis is, um so the biopsy, because of some blockage somewhere down the line gets blocked and get this get stagnant in in the biliary system. So that is called Stasis. Uh, you have cholelithiasis. Cholelithiasis is lettuce is is basically stones. So cholelithiasis is gall stones, stones in the gallbladder. You have Kalydeco lithiasis. So Kalydeco is basically you have in the biliary tree. So you have stones in the bile duct or in the biliary system and not in the girls in the gallbladder. So that is the lithiasis. Uh, if there's a stone blocking the cystic duct over a long period of time, it can, uh, it can become an empire murmur. Now, this empire, Ms sometimes can be sterile. It can, or sometimes it can get infected as well. So if there's usually an older patient, uh, if there's some sort of infection there, it can grow certain bugs in there and get infected. Um, now there are two procedures that you can do. One is cholecystectomy is where you would remove the whole gallbladder so that the surgical removal, which can be open of a laparoscope and the other one is cholecystostomy is where you insert a drain into the gallbladder. So this is usually most commonly done for, like severely ill patients. Or, you know, patients are very septic or even, um, if the patients cannot undergo cholecystectomy and you just put a college sister's tummy, do you wait for the, you know, the bile to drain out and for the infection to settle. That's it. It's basically more of a symptomatic treatment. Uh, biliary colic is the pathophysiology, basically is. You have a blockage of the biliary system, Uh, and then so once. Basically, what happens is that if there's a blockage and you have eaten something, so there's fat content in entering the gas. The GI system, which causes release of certain enzymes, which is the CCK of the cholecystokinin and this basically is a stimulant for the gallbladder to contract because of which you have this pain after eating in patients with gallstones. Okay, Uh, the most common symptoms you have, you have this quality pain that comes in waves, mostly in the right upper quadrant. Why? Because the position of the gallbladder is in the right upper quadrant, followed by meals, especially fatty meals. That's the reason why we tell patients to goal is to reduce the fat diet or to reduce the fat in the right and nausea. Vomiting, most commonly nausea. Uh, so this is a way you can basically find, I mean, God and also the most commonly seen, uh, in fact, female of a fat female or a fair female or, uh, mostly about the age of 40. But we have seen that even in younger age group less than 40 as well, it's common. Uh, so investigation. What we'll do is you're an ultrasound scan first, so ultrasound scan again to check for any stones or be the retaliation, and you check along with the LFTs and then you use this to to see if the patient requires mrcb. You know, if you find that this on on an ultrasound that the patient has a stone. Then probably you'll go later. For an ercp to basically remove, remove the stone in the biliary system. And if the patient has gallstones, then you'll probably wait for the infection to settle down and then have a cholecystectomy probably later than once. The infection is fine and on discharge. Always given advice of fat free diet. If the patient following episode of biliary colic or gallstones go to school. Uh, so acute cholecystitis is inflammation of the gallbladder. Uh, so basically, here is again, uh, secondary to the gall stones. Uh, it can be calculus or calculus. Uh, Acalculous is, uh, you don't see any gallstones, But then sometimes these can have been very sludge as well, so which can trigger the colecystitis. And this is basically because of gall bladder status, or hyperperfusion or infection, as well as one of the causes of acalculous cholecystitis. Okay, so presentation similar to what we saw in biliary colic. We have the right upper quadrant pain paying on inspiration. So that's the mouthpiece. And that's very commonly seen on examination. Uh, nausea, vomiting, uh, usually pain after eating, uh, and usually and there's there's no jaundice because it's the gall bladder that's involved. Not the bile ducts, not the biliary tree. Just the gallbladder. So you won't have jaundice in these patients. Um, so the investigation will be, uh, ultrasound again. You do an M R c e p If the if you want, Sometimes the stones can be in the gallbladder, or it can be in the biliary system as well. So along with cholecystitis, patients can have cholangitis as well. So it's important to do MMR CP. Just to identify the patient has, uh, you know, stones, the gallbladder. Just to rule that out, uh, liver function test. If if if the stones are just in the gallbladder, that would be normal, it can be a little bit on the higher side, just above normal. But then I think it should be. It's usually normal, um, with So there's something called Barrett's syndrome. Now there is a syndrome is basically I mean, it just sounds like a huge name, but it's it's a very simple term. It's just so there's this, So I don't know if you guys have heard of the Hartmann's pouch. It is basically a small pouch, which is, uh, near the cystic duct and just a pouching, which is that sometimes the stone can form in the in the Hartmann's patch, or and then it compresses on the biliary system or the bile duct, and it causes it causes, uh, it causes symptoms similar to the cholangitis. Call cystitis. So this is called basically Marissa syndrome. When it compresses along the bile duct and because of which you have affecting the back flow is affected. You have signs of obstructive jaundice and expectancy compression, and then you have inflammation causing cholangitis. Cholecystitis management is, uh you treat the patient, uh, conservatively. Start the patient on IV antibiotics, IV fluids. Patient can eat and drink as he or she can tolerate, and you can. So sometimes, if the patient has recurrent episodes of acute cholecystitis, you can. When the patient is so, there's certain window period during which you can operate the patient. And if the patient has passed, I think probably, I think two or three days I'm not quite sure at the moment. But if the patient presents to you in those within those days of actually developing the symptoms, you can actually uh you can actually, uh, you know, do a surgery. So that's called a hot cholecystectomy. Uh, if not, if you have passed the window period, then, uh, that's basically it's quite very all the adhesions develop, so it's quite difficult to, uh, do a surgical operation. It's It will do more harm than good. Uh, so for then, you just wait for the, uh, for the infection to settle down, and then you can do it even in one week's time. This is according to the nice skyline as well. But then, uh, sometimes, usually you do it now. Nowadays, they usually the once the the hot face has. Basically the hot face is the inflammatory phase has settled down. You can do it after four or six weeks time and then, you know, it's a much, uh, it's less, Uh uh, it's just a better. There's no adhesions, and it's just, uh, just help you in the surgery. That's it otherwise than that, because if you if you're doing it in the post of window period, it's a small risk of complications. Um, so the next question is, um, we have mega seeing who is a 67 year old female who presents with jaundice, anorexia, weight loss on examination. She has a palpable gallbladder. So what do you think is the most common diagnosis here? 30 seconds again? Okay. Mhm. All right, A few more seconds. Okay, So the most popular answer is the but it's deep. Yeah. Okay. All right. Uh, we'll look at just want to know why. Why do you guys think it's deep? So this based on the question that it's just it's one of the most common presentation in someone. I mean, it's one of the most common diagnosis in a person who presents similar symptoms. The answer is pancreatic cancer under study. Why? So I think you guys must have heard the cold versus law. And this is what, uh, you know, this is one of the most common cause is the most common. Uh, you can see terminology associated with pancreatic cancer. Now, pancreatic pancreatic cancer, uh, is usually a very patient. Usually presents very late. It usually develops, but then the patients, the symptoms that were very late and sometimes it can be even inoperable at times, Uh, most of these tumors arise from the head of the pancreas, so it can either arise from the ambulance or from the duct. The most common are from the duct, so you have the adenocarcinoma. The classic picture in the pancreatic cancer is that the patient first will have weight loss. Second, we'll have decreased appetite. Third will appear jaundice. Why? Because you have so there's a blockage of the biliary system because the so basically, you know that the common bile duct and the pancreatic duct joined together to empty into the duodenum. If there's a if there's a tumor in the pancreatic, you know, in the pancreas and the head of the pancreas. It will also cause compression on the biliary system because of which this is not obstructed from form of jaundice. And because of that, you have. So there's all spaces of vial it gets extravasated gets deposited in the skin on the sclera, and you can have the yellow jaundice appearance on the yellow discoloration of a person. The coziest law is that the patient has first, it's painless obstructive jaundice and also has a palpable gallbladder. Now you do not see a palpable gallbladder in patients who have gallstones because it's just the gall stones are all in the pouch, but then, in a patient with pancreatic cancer, some patients will have. You can actually feel the gallbladder in these patients. Um, so patients usually have very nonspecific symptoms. But if a patient presents the painless jaundice, when you, you know, see it in the hospital about 90% of the time it's pancreatic cancer. Sometimes it can be an adenoma, but 90 90% of the time, more than 90% of the time, it is pancreatic cancer. Uh, so you have lots of the functions so similar, like having pancreatitis. You have lots of the endocrine and the endocrine function, So endocrine is basically again. Now, the insulin is not there, so the patients will be diabetic. You have the loss of exocrine function, so your fats are not, you know, digested properly. So you have the patient will have very white, greasy stools, uh, complain of very dark urine. So this is one thing. The reason why they have pales stools is because the bile is not basically does not enter your gut. It all gets, you know, it's all states, there's all spaces, gets absorbed in the urine, and so it gets absorbed in the blood and then passes out in the urine because of which of the ball bile salts you have dark urine In patients with pancreatic cancer, almost 100% or 99% of the patients will have pales stools and dark urine. Uh, you just have to ask them. They look greasy, pale white, clay colored stools that you see in this patient. Sometimes patients can also present back pain, which is which is also one of the, But you have to rule out the other causes of back pain. And then it'll be like, Okay, then probably pancreatic cancer. Be like usually the low most in the differential diagnosis if the patient doesn't have other other symptoms. Um, so true. So sign is migrated. Trump of phlebitis is also it's very common, and it's most commonly seen in pancreatic cancer than the other cancers. Uh, so in a patient who has painless joined this, you have this two week referral criteria, according to them. So if the patient has it's more than 40 and has joined this visible jaundice, painless jaundice, no pain, you know, usually in pancreatitis. Sometimes you might have joined us as well, but over 40 and joined this. You need to refer the patient as soon as possible to a higher center Will Probably which will help Canadian diagnosed with pancreatic cancer. But the patient is more than 60 has weight loss, and there are a couple of additional symptoms below. So you need to have some some of the symptoms and then probably refer this patient or secondary bankrupted cancer for this patient to the higher center for investigations. Um, so basically on the CT, Yeah, so this is kind of Okay, so in pancreatic cancer, what you can most commonly see is a double duct sign. The double duct sign is basically one is so you can see here in this picture is you have the bigger ones, the pancreatic duct, and the smaller one is your, uh probably the, uh the Levitra. The biliary. Yeah, the bile duct. So the reason why it's a double duct sign is because you're so the entry of the CBD and the pancreatic duct into the modem is blocked because of which is dilatation. That space is dilatation of the bile or the pancreatic juice is, and you can see as a double duct sign on CT on transverse section. Uh, the tumor marker for pancreatic cancer is C in 99. Uh, so this is it is common. So it is it. I wouldn't say it is specific. It is. Uh um, So it's not very specific for pancreatic cancer because you can also see cholangiocarcinoma, but it helps in aiding. You're in with the diagnosis because the symptoms your investigations, you're certain CT and altogether clubbed up with just the 99 will help you, uh, in diagnosing pancreatic cancer. And plus, you need to do a biopsy as well. It was exciting. Uh, so the treatment for pancreatic cancer is it's surgery. And that again depends on how how the patient is doing how advanced the patient is if it's involving certain vessels here and there. But then the main surgery that's done is the Whipple's procedure. So where the pancreas, along with that part of the duodenum, is removed, So it's a pancreatic code duodenotomy. Um, now, a couple of days, they keep, uh, yeah, So this is so the side effect of this type of procedure Is that so? In the earlier ones used to remove the pylorus as well. So because of which there was something called dumping syndrome. So basically, whatever you're eating gets then directly empty and you know, enters into your gut, your ileum, you're judging them. So because of which you have certain early and late dumping, it's it's just a little bit too much. But then just to if you guys want to go and read about it, it's quite interesting to know, but yeah, so But then now they do something called the Pylorus Preserving translated duodenotomy. And because of which the dumping syndrome is very less common. Uh, if the patient is not surgically not a candidate for surgery, you'll probably do a stenting Do an ercp that is an endoscopy procedure. Pass a stent to board the ducks and you, you know, you wait for the just basically, just create a partially for the village for the bile duct, and the pancreatic juice is to enter your gut. Okay, So next question is, um, is she to call who's a 61 year old man? Male, uh, presents to the GP with weight loss and change in the bowel habit. Uh, a full blood count was taken so this is in the full blood count. Uh, so based on this, what do you think, Um, is the best course of action. So it's a It's a female, by the way. Sorry for the diaper area. All right, We'll do it. 20 seconds. All right, 10 more seconds. Okay. So the most popular answer is a okay. All right. So it Okay, so the best course of answer? Yep. All right. So let's go forward. So, based on I think you guys got the answer, right? So it's basically it's bowel cancer. Now, the bowel cancer is very common, and it's very one of the most common conditions following, you know, proceeding. It's basically the breast cancer prostate lung, and then the bowel cancer Most common is in the genetics you have is the FDP or the H and P C C, which is the head. It's very non polyposis colon rectal cancer. So these two have a genetic component. Uh, so most common is so genetics do play a huge role in bowel cancer. It can be, uh, in patients who have non genetic components basically critical. The diet, basically the lifestyle that causes the bowel cancer and There can be some components of genetics as well an increased age presentations, so that depends on the location of the of the cancer. So if it's the, uh, if it's the ascending colon that's involved, the patient usually have has anemia or and deficiency anemia like you saw in the question if the patient, if the patient, if it's on the left side. So basically the descending colon, the sigmoid colon, uh, patient usually can have bleeding, you know, bleeding PR or even obstructive conditions. Uh, there can be unexplained weight loss as well. Do you have change in the bowel habits? A patient might have constipation. Two days might have diarrhea the next couple of days, or alternating constipation and diarrhea. Uh, abdominal mass is not very common, so that on the left side is not very common. But on the right, you can have an abdominal mass. And on rectal examination, that is, you basically see if there's a rectal mass or even a segment mass as well. Uh, so the referral criteria, basically so that you need to have two weeks referral criteria. So if the patient so basically depends on the age, so if the patient is more than 40 has weight loss and abdominal pain. You need to refer. If the patient is more than 50 then he needs to have unexplained rectal bleeding. If the patient has more than 60 then you need to have either iron deficiency anemia or that there's a change that change in bowel. Then that's a two week referral. Uh, that's a two week referral criteria. So if if, for example, if you find the patient has a rectal mass on your examination, if there's some alteration of the patient, is less than 50 and has either and has the the abdominal pain change in the bowel habits and deficiency anemia. After ruling out all the other causes of anemia and weight loss, you need to again for the patient urgently. Uh, the Indian HS. We have, uh, the very efficient screening process so usually women and usually individuals. Between 60 to 74 years in England and Scotland, it is 50 to 74 years. Again, uh, they undergo the small keep testing, which is the fecal immunochemical testing. And this basically helps to identify any, uh, any blood cells. Uh, it's basically quite if any, any uh, blood in the stool samples. And based on that again, you need to refer the patient, uh, for the two week, uh, two weeks, different party. If the patient if the food testing is positive, you need to send the patient a colonoscopy. And, uh so this is the whole thing. Uh, So how again for bowel cancer again, you like how we saw in pancreatic cancer is you need to assess the patient's fit if the patient has other comorbidities. If the patient is fine that way, then the patient can go for surgery because there's no medicines that, you know it's the cancer, so that needs to be taken out. So first you need to investigate. You can do a colonoscopy, receive microscopy. Uh, you can do a colonoscopy and probably take a biopsy sample and to see what type of cancer it is. Uh, C E a is a tumor marker, which is very specific for the bowel. Uh, not not very specific, but then it is very commonly tested in bowel cancers. Uh, having a high see, it does not necessarily mean your bowel cancer, but if the patient has bowel cancer previously was operated on bowel cancer. Um, and his see the CIA has reduced. And now, if you see, like, after a couple of months, if you see that the C is rising again, you need to suspect the patient might have a recurrence. So you just that it's just basically helps in, uh, just monitoring the patient. Okay, Uh, so the management is surgical dissection, you know, chemo or radiotherapy or palliative care, depending on how the patient is, Uh, the staging of colorectal cancer basically is according to the depth of the bowel, the bowel wall, it it goes through, and then involvement of the lymph node. And if there's a distant math as well. So this is basically how it is. Uh, you don't have to know the whole, uh, you know, t one t two. That's not quite required. Um, okay. Okay. So the different surgeries that we see here is that you have, um so, depending on the type, depending on this part of the bowel is dissected. So you have low anterior resection is where you have you take the sigmoid colon along with the rectum. Uh, and the anus as well. You have high anterior resection of that. The illnesses spread sigma like signal. Colectomy like the names is always the signal is removed. You have the left hemicolectomy where the left part of the of the intestine removed right is you have the cecum with the right hemicolectomy. Uh, abdominoperineal resection is that when you take the whole part of the whole stigma and direct, um, anus and basically you close your close, the ending the anal opening, and then you have a You have a storm outside three abdominal wall. Uh, total proctocolectomy like the name suggests whole part of your large intestines removed subtotal that you spray the sigmoid colon. So it's a different, uh, surgery is depending on where the tumor is. You do certain surgeries, and even depending on how far has gone through along the bowel wall as well. Uh, here, this is just another diagram is to show what is, uh, you know, the different colectomies that are done. Okay, So the next question is, um, So Chris Martin, who's 20 year old male, she he presents to the any with the gradual onset of central abdominal pain. Uh, it has now moved the right iliac fossa. Uh, he describes the pain is seven and 10, but there's no episodes of vomiting. He has a temperature of 37.9 and has raised inflammatory markers. So which of these investigations do you need? Do you think you need to do to confirm the diagnosis? All right, 10 more seconds. Okay. So it's a bit split between B and A B and E, but I think he is just about winning. Okay. Okay. All right. So, yeah, he is the right answer because this is very, um you can say in a in a young, in the young face in a young person who's complaining of the right abdominal pain with the standard this low grade fever a little bit on the high side, the pain score with these inflammatory markers that does. You know, acute appendicitis should be on the top of the differential list. The cause for acute appendicitis is basically again. It's a it's a hollow organ. But it's, you know, damage is very small. It can get obstructed with either some worms or, you know, I got worms or fecal it as well because of maybe some inflammation. There's lymphoid hyperplasia because of which it gets obstructed. Uh, there's fluid accumulation, uh, the seeding of bacteria, and then this causes inflammatory process. If the patient, for example, if sometimes in certain severe conditions, it can cause ischemia and perforation as well. Uh, acute appendicitis. The patient first can come with periumbilical pain and which then, you know, localized to the right elect force. Uh, it was the pain can worsen on coughing. Uh, usually the Children usually will have, Uh, yes. For this patient is usually, uh, appendicectomy. You can do either either independent appendicectomy. It's usually once the cemetery process has settled down. And then once the information is settled down and then you after about six weeks time, you can try to do the appendicectomy and, uh, try to give the patient antibiotics recessive to the patient. That's important, uh, investigation wise. So the first line will be have to examine your history taking check the blood check for any inflammatory. Uh, also in females. You need to do a pregnancy test because, uh, acute appendicitis can and some So appendicitis me. Uh, appendicitis. Most common is the McBurney's point where you have tenderness on palpation there. Uh, so the position of the appendix also is very important. So sometimes it can be really, really post ileal. It can be pelvic. So the most common is the real deal. Uh, is one of the most common, and you can have post surgical as well. Uh, so the other positions of your appendix, uh so just a couple of few extra slides on different, uh, conditions that just you can have knowledge about is cholangiocarcinoma. So cholangiocarcinoma like first we saw is that in pancreatic cancer it's basically affecting the pancreatic ducts in cholangiocarcinoma. It's affecting the biliary ducts. Okay, so it's very common so it can be in the hilum. That is where the bile then divides bifurcates into the right and left and then into smaller branch is so high. Like that's a highly cholangiocarcinoma. But the most patients are susceptible to these highly cholangiocarcinoma, uh, your patients with primary biliary, uh, sclerosing cholangitis. So it's usually so. These patients who have PSC have ulcerative colitis as well. So cholangiocarcinoma indirectly can be seen in patients with all theoretical and cholangitis they can present with similar complaints. Uh, symptoms basically again, pales stools, Dark urine. Uh, so because why again? Because of you have obstruction disability, That is, uh there's no vial into the duodenum, so you have basically bile. It's absorbed all the bile salts absorbed into the into the blood and then passed into the urine. You have weight loss again? Uh, right. Upper quadrant pain, palpable bladder again. The, uh, coziest law. Uh, so the first thing that you need to do is probably biopsy. Uh, do the biopsy, identify the cholangiocarcinoma. You might have to do a standing as well. Basically, you need to, uh, you need because there's a blockage of the biliary tree, so you need to pass in stents. So the blockage is relieved and the belly drops down. So these patients usually come with very high, be a little bit of 100. 200 sometimes can go very high as well. Uh, the treatments of investigations is against CT MRI. You can do a histology. Um uh, C N 99 is also raised in this patient. Uh, so for staging you, you need to use certain different, um, different investigations to help to stage the patient. Uh, so in surgical point of view, what you're going to do is basically depending on the of the liver involvement. You remove that part of the liver so either right hepatectomy or a left hepatectomy. If the patient is really active, then probably you insert a stent. And that's how probably usually, yeah, that's how you normally, uh, relieve the patient of relieve all the obstruction, Do standing, do a biopsy and later the patient is still fit for surgery. You wait for the bilirubin to drop down, and then you do a surgery later on. Uh, so the other extra thing is a diverticular disease. Uh oh. Diverticular. So a diverticulum is basically an outpouching. It's in the bowel wall, so this can be either genetic again or it can be because of there's a like sometimes in constipated patient, because they keep on straining. Uh, there is a certain defect in the bowel wall because of which there is a mucosal outpouching. You can see it on the CT scanned. Okay, it's very sometimes it can be. It is is normal and normal as some patients who have chronic constitution. Uh, now, if the patient has multiple diverticular, it's fine. But if the patient has diverticul, OSIs basically has many outpouchings along the bowel wall, then it's a condition. These can get blocked. Okay, the openings can get blocked and it can call diverticulitis all that. So the patient usually has pain in the right iliac fossa. So the patient has a pain in the right leg. Worse than think of diverticular disease or diverticulitis again. Similar symptoms to acute appendicitis, fever, diarrhea, nausea, vomiting that can be pain. There can be bleeding as well. If this is chemo involved because of the obstruction, the management would be similar to conservative management. At first, recess it to the patient in severe conditions So you can do a CT basically to help you to, uh, to come narrow, narrow down to a diagnosis of diverticulitis. Uh, you start the patient of antibiotics, uh, get the patient to drink or early if you can eat or drink, and then it'll slowly step up the diet, depending on how severe the condition is and pain management. Sometimes the the the diabetes can also perforate and cause and also cause severe sepsis and can just go into full blown the multi organ dysfunction. But that is, you know, the care of the rare cases. But then the first thing is, if you identify the patient with diverticulitis, it's important just to conservatively manage. And then depending on how the severity, how the how the progression of the patient progresses or you see the progression, then you do the necessary, uh, hemorrhoids is, uh, hemorrhoids are very commonly seen, So you have the internal hemorrhoids and the external hemorrhoids. So I believe in anatomy you might have studied the different positions of the hemorrhoids. You have the 35 and seven. So the normal position of the hemorrhoids. Uh, so it's it's 37, 11, Um, and then you have So basically, these are the swellings of the anal cushions and the vascular cushions. So you have internal hemorrhoids and you have external hemorrhoids, the internal hemorrhoids. External hemorrhoids are the one that you can usually see and most likely undergo strangulation. And because of which you have very severe pain. Uh, the patient usually presents with, uh, he or she will be like a blood on my pan on my, uh, you know, toilet plan. Uh, we'll have the are bleeding. Sometimes patients can present with mass producing, uh, protruding down on the back passage as well. Uh, So it's It's a very visually diagnostic, um, diagnostic condition. So basically, uh, if you see a mass mass protrusion, it most likely is hemorrhoids. Uh, sometimes it's reducible. So, depending on the depending on that, it's graded into 1 to 4. Uh, so the management is usually if the patient is fine if you know there's no other. Uh, if there's no pain, so usually you can just give a topical treatment, like just for conservative management, you can try and doing for usually for the, uh, for the external hemorrhoids. You can do the band ligation, or you inject a certain material into the injections sclerotherapy orange red calculation. So this basically helps in reducing the size of the hemorrhoids. Surgical wise, you can do, uh, you can do a ligation, the femoral artery ligation. Or you can just totally remote the hemorrhoids called Humira hemorrhoidectomy. Uh, so this patient needs to be advised on, uh, the food. So basically, the most common cause of hemorrhoids can be constipation, so you need to advise patients on fluid intake. You know they need to have a lot of roughage in their food. Uh, so the increase fiber content in their food and to use laxatives. When? When? As it's not required. Now, Um, probably, I think almost feel almost towards the near of this. Uh, so you have something known as acute medicine Trick ischemia. So many sensory is the part of the basically, uh, it's a pass, a pattern and that attached to the bowel wall and through which the bowel receives its blood supply. Uh, in certain conditions, because of some reason, they can be either some clots somewhere or because of some trauma it can undergo. The blood supply to the bowel is affected because of it's because of the mason tree. Uh, patients usually present with central abdominal pain. Uh, there's weight loss. It can be missing. Check. Ischemia can be acute or chronic, but acute is usually patient presents with severe acute abdominal pain. Weight loss is not very commonly seen in acute conditions, and there can be a bruit as well. That can be honest validation. Uh, in a pure Ms centric ischemia, you need to do a contrast CT. So you basically see that one part of the bowel might not be very enhanced on See, on CT? Uh, it just appeared all compared to the rest of the bowel, which is non ischemic and on see on chronic Ms Centric ischemia, you need to just do a angiography and see which part of the, uh, the blood vessel is blocked because of which, you know, the certain bowel is not receiving enough blood supply. Uh, if it's if it's an acute, you need to do a surgery, because you you will have to remove. Or I mean, you need to do a laboratory to identify what part of the Ms Center is involved and do surgery based on that if there's a massive necrosis. So basically it's important that you just remove the bowel because it's already undergoing necrotic changes. Uh, in chronic. Basically, uh, the bowel might not. It is viable, but then you need to They might have intermittent dull pain you need to monitor. You need to modify the modifiable factors. Uh, you need to probably start the patient on statins on anti platelets, aspirin, clopidogrel, and might also require stenting if the if the bowel is salvageable. All right. So I think we have come to the end of it. Thank you. I I hope you have at least understood some point from the general surgery. Uh huh. All right. Thank you. Everyone for coming. Does anyone have any questions you want to ask before they leave? We'll be here for the next few minutes. If anyone. If anyone wants to ask anything Otherwise, thank you very much for attending. All right. Thank you. I think we'll end it there. Any other questions? Just stand on Facebook chat. Okay. Oh, the face. Yeah. Yeah. I'll put the feedback. Think Sorry. There you go. All right. Mhm. Okay. So do you want to stop sharing now? I think we'll just end it there. All right. All right. Thank you very much, everyone.