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All right, guys. So just going to start and hopefully people that join in later. So welcome to the ace and Medical Siris. That's again. So today we're going to cover a general surgery on it just to be about myself. So I'm my name's Abdullah, one of the 50 and medics part if on coincidentally, I'm actually on general surgery at the moment as well. I've been on general surgery for the past five weeks, so I've seen a lot of patients. We'll be able to tell you about it. Okay, so let's begin. So this syriza's part. So this Lexus both love of the lectures that we've already done. Some turmoil, infections, disease and chronology in hematology on If you just like our Facebook age, it's the cure rate. Is there She haven't already signed up. Okay, so today we're just going to covering a few conditions, like might commonly come up in the progress tests. All the tests we doing clannish university on the left, on the ones that we're gonna actually cover today on the right, we don't have enough time to cover those but anonymous, kindly written and summer, she's full of these conditions. So door ever, and you're not getting inside to those conditions. Okay, so this is a slide from the gastro Electra. If you attended on, I'm not gonna go through it now because safe already has. But it's just good to have it on the same slide because it's quite important in general surgery. But really, the the idea behind this is when thinking about where the pain's originating from, you really just have to think about that and not me. So I just get the raisin point. So up here in the right, but for for example, it's most likely going to be out of biliary down here. It's gonna be a UTI sets things to do with the blood because that's just way out of tragically. And it is okay, so just gonna begin with an SBA. So, Sylvia, a 64 year old woman presents to any without Donald. Extension on Greenville is 40. Okay, on examination, tinkling bowel sounds of heads on abdominal X ray is taken to concern. The diagnosis is what is the most likely just I don't give you a few minutes down, so I started a minute marks of insurances. Okay. Good participation getting about 10 more seconds. Okay, let's get so most of you have gone for be so well done. That is the correct answer. So let's go through three options. So this is so if you know the sign it. But we're gonna get that straight away. So this is called Coffee Bean. Sign on. It's just literally President's like the coffee. Um, another way you can tell it's sigmoid A Z well is because it's coming from the left iliac fossa, and it's going up that way. So the signal it would be done here if it was a secret of all of this is more likely originated from here, and it will go that way. Involve your list is just twisting the ball. For those who don't know, small bowel obstruction is unlikely, and I'll show you what it looks like later on. Also large. Take me. This is large, but it's small. It's it's described as a volvulus and sooner members. Colitis is something that happens in another condition, which which is covered in customers month. But we won't do that today, so bowel obstruction. So this is quite a few topping that comes up in exams in. You need to know it, Clay. Lot of detail as well, if we ask these, especially as well, so just a quick definition. So it's a surgical emergency and involves the obstruction of food fluid on sometimes, Gus. Now it's really important to ask about if persons, if the patients passing gas because they differentiates between a partial obstruction on a complete obstruction. Okay, so that's quite an important thing to always consider in the history. Okay, on, obviously, when something that struck did because it. But because it's back pressure on subsequent dilation, off the ball sew something that you saw on the previous life as well. Another thing that's important on despite central to the management as well, is the hypovolemia that comes with obstruction on. This is because the GI I produces a lot of fluid, produces a lot of and bile and enzymes, and all this is has a lot of fluid, but it's actually absorbed later on in the GI tract. Obviously, if there's an obstruction, then you can't absorb it later. I'm on, so it builds up and actually it least eventual hypovolemia. So that's quite central to the management, because we give them leverage when it's okay on you need to know the three key causes of obstruction. Probably any sort of any general surgeon will cuisine about these. On the three are occasions hernias on malignancy that he continues being all that most more likely in small bar on malignancy, being the most common in the large bowel. Okay, now there's other causes, like Volvulus, like What we just talked about are strictures which could happen and Crone's diverticular disease, usually in older patients on Interception, which is more repeated at records. And that's when the bottle telescopes into itself. Okay, so the way it was dances presents with Central up to a pain, nauseous and vomiting as well. Constipation again very important to us if the person window no distention tinkling bowel sounds absent if it's complete obstruction, sometimes they like to say scanty bowel sounds. Well, watch out for that and exams investigations to the key ones. That one. I just looked at, uh, up to x ray. It's quite important because then we can French, eh? As well. What type of bowel obstruction it is, and the way we can do that just by looking at the diameter is using 369. Well, so the upper limit of the small band is three centimeters. The larger six cecum is nine. So if anything is above this, we know that that's abnormal diameter. Okay. And another thing that's important is to get a chest X ray, specifically an erect one on. That's to check for under the diaphragm. Because if there's end of the diaphragm and then most likely an obstruction has led to a perforation and so there has gone up into the diaphragm, that's quite serious, cause it means they need to go into surgery straight away, all right, and see to abduct city. And it's sometimes used as well. It's more definitive on. But obviously, if the diagnosis is obvious, they're missing always necessary. Okay, So I'm just gonna ask ask you what you think of these slight of these X rays and grace. So can anyone in the comments tell me what this is? You could private messes. You should try. Yeah, yeah, yeah. It's a small dollar stretching. So Well, then, um, so the reason this is small ball, um, is actually quite simple When you have it. Small bowel. You want to look at the ball and you want to see you want to look for, ah, white line that runs from either end of the bar. Okay, so a radio opaque line on these lines are called it out through the port of NT's. On these are just formed is just because of the how the mucosal fills formed in the small bowel. Okay, it's moving on to the next X ray. So could you. Don't tell me what this is kind of process of elimination here. Yeah, perfect. So, yeah, so it's large. It's large bowel obstruction. So Well, then on day again, the way we tell that's large bowel. Usually most likely, it's usually peripheral, although this is kind of like twisting forwards and there. But usually it's peripheral on but much more, much larger in diameter on what we look for his house dress. So it's these things, so it's the white lines that don't quite cross all the way across from you. The end of the ball. Okay, so it's kind of just partially going in. And that's just how the muscles are formed in the large bomb. Okay, Can't even tell me what this is showing So just the black our What's the point in two. Does that mean Okay, you repair it will turn more so yes. So this is quite a classic and just x ray on the, uh it's just restoring. So from a probable perforation on best pass and of the diaphragm. Okay, So this is that Rex just That's right. All right. So can anyone tell me what this? Okay, so it just says on this life. So this is what intussusception, uh, it's like so, as you can see, it's telescoping off the ball on that. Like, is that this is more a pediatric cause of obstruction on after pain. Why? I really want to know. So what is what's this cycle? So this is called the ultrasound of this on become a pin test? Quite a lot. So it is useful to know what this is. Cool. Yes. Well done. S Oh, yeah, it's called Target sign or someone has already correctly said and during that side as well, so that can and publicly exams. If someone has doing, it's not entirely a sign that it's most likely going to succession. Okay, So a bit more about the management So he put me on my head of something called Dripping Suck, which basically means that you want to keep the mail by mouth with the IV fluids and also energy, too. So that's the subparts. So you want to allow free drainage so normally to give them internal feeding that way. But what we're doing is actually just allowing any food contents to the stream out of the barn. Okay, if if this doesn't work, which is, which is most, which is the case in most complete obstructions, then they'll probably be after the port out of going to have surgery on right away, even in partial obstruction. If this doesn't work, then especially they'll have to go to surgery is well on the specifics of the surgery, usually related to the underlying cause. So at easier it is. Your license is when they have adhesions, so it's quite important as well. And histories we always ask about Prosser jiggle history on this is important because it this past surgical history is likely scarring on, but they're storing the seven called adhesions that form on these can wrap around the board. The ball and the national was quite sudden balance direction. So that's probably one of the most important closes. And I'll see her knee repair as well. And stenting a swell, Um, especially in pilot of care if surgery is not, uh, is no viable. Okay, so I just wanted to know about Pirated. Really is. Is this something that confuse a lot of people? And so it's a nice bonus. A diamond, really. It's all just curious on it's when the bowels, when there's an obstruction in the bowel, but due to lack of peristalsis in Paris starts. It's for those who don't know it's just the muscle movements, and that's what makes the food to go through the ball on. This usually happens in the small bottle, and it happens to patients who are actually is usually POSTOP and have electrolyte imbalances on day after surgery is basically when the bowels healing. Sometimes it doesn't function it well, and so this is a very common after surgery. So if someone has a bowel obstruction following a recent surgery than abdominal surgery to be specific on, this is the most likely cause. Okay, on again, management is the same dripping suck, but they also encourage verbalization because this stimulates the peristalsis in the bottom. Okay, on Also, total parenteral nutrition might be needed. So dust is when they feed them and a lot of nutrients they need through the through the veins because it can. It can stay. It could stay like this, supply a while. Usually, however, they don't need peripheral veins and to use kind of central lines just because of the risk of infection troubles related to something that also called pseudo pseudo obstruction. But this usually affects the large bowel, and it's something called and it's a type of obstruction, which is called a functional. This obstruction. And this is when there's an obstruction. There's no actual thing obstructing it. Um, so that's that. That's another thing to happen, to wrap your head around. Okay, but just the key thing Aliases, usually small bowel pseudo obstruction is large. Okay, so moving on. So only a 47 year old man presents to his GP with a lump in his right groin that disappears when he lies down. He is diagnosed with an inguinal hernia. Which of the following statements about inguinal hernia this falls? Yeah. So give you a minute. So? So This is a tricky one, I have to admit, quite swollen since. Okay, for, you know, seconds, Lord. Okay, we'll end up all that. They have a look at the results. So most of you have gone for D, But it's also quite spending maybe insidious. Well, so well, then, to those who didn't d because that is correct. Okay, so Oh, I'm sorry. It's so yes. So I got mixed up with this all the time as well. Um, remember, this is a negative question. So it's acid which ones? False. So if you look at that and ask me, I'm gonna talk about that in a bit, but yes. So it's superior medial to the people. Typical. It is associated with pain or activity. A lot of the time they do. If they have quite a laborer's jobs and or go to the gym, it usually gets worse after that on and also it and usually after he is repaired, even if it is isn't a magic. And the general consensus is if you're physically fit, they want to do the surgery on you because it can eventually lead to complications. If you felt that they prefer to do the surgery on you on may occur in influence. Influence as well. Stronger nation is actually read on another hernia called femoral. Hernia is much more likely to strongly. Okay. Ah, All right. So I'm just going to give you a brief summary of what he is. Also, a hernia is a weak points in the cavity wall on these weak points, then allowed the in in a lot off the bowel or anything in the abdomen to protruding up. Okay, so the presentation it usually presents is a soft lump. It can be reduced a ball. And what we mean by reducing is that we can push it back in. So if you get this, we can push it back in where normally is on is able to go back in, okay. Usually protruding on coughing or standing or straining on. Quite a classic description of it is an aging pulling on dragging sensations. So if you see kind of a drugging sensation in a question stamina example, then it's a lot of the time It is, uh, and these are some different times of hernias that we were gonna go through intellectual. Okay, So it's important to know the complications of hernias. So, as I said, it can be reduced below and reducible. It means that this bit of bowel you push back in. No problem on if you just go out and then as it pleases, when when we can't push it in anymore and it stays in this position and then it's called incarcerated or irreducible. Okay, now this isn't an emergency. It's only an emergency when it when it goes on too strong relation. And this is when it's so tight than that actually causes ischemia to the ball because it's pressing on the capillaries and the older blood supply as well. On this is a surgical emergency because, as you can imagine, it can eventually between necrotic and they can die pretty quickly. Okay, but incarceration all CS a dangerous situation because I think easily going to strangle it. Okay. And also it can cause obstruction. If it's as tires to restrict blood, supply it almost like you restrict the food going through as well. So this to be hand is you need to know about in detail uh, inguinal hernia, of which we have direct and indirect and also federal. So this is a topic that's quite confusing on a lot of people don't understand. So I'm going to try and explain in the simplest way possible. So everything really resolves around this inguinal canal, which is contained in the inguinal ligament. Okay, on it's important to know where this England human is because it determines whether terms whether her knees are gonna pop out from Okay, so the England ligament it stretches from the anterior superior iliac spines. Or the ace is it's just the, uh, protruding bone come to the size of you and also the pubic tubercle in place of this to people treat because that in the middle of the pubic symphysis Okay, Yeah. So the blood alcohol you could just think of as a tube the top of the tube or the opening is called the deep or internal ring on the on. The bottom one is called assume official, right. Okay. And that's just because this one's deeper in terms of intensity issue. Okay, uh, in terms of the location off the deep inguinal a ring, this is important because sometimes a nasty location of different areas. It's right right in the middle of the inguinal ligament. So it's the midpoint, and it's slightly superior to that's a slightly above the midpoint of the inguinal ligament. Okay, the superficial ring is superior, so above a natural to the period. Dutiful. Okay, so just that. So it's usually just the bottom half of a mental thing. But in males, this allows the passage of the spermatic cord, the perineum into the scrotum. And in females, it passes a lot of passage of the round pigment from the uterus all the way to the Lady and Majora and in both sexes that it carries a nerve called the tingling the ilioinguinal that well. So there's 22 types of England on any answer. Indirect on day before I put any text on the slides, you could just remember it by an indirect hernia is when the pain just goes through the natural route. Let's see, it's not so natural because of this shouldn't be a weakening there, but it goes through the Depression normally, and it can go out the superficial right eso there isn't any abnormal, abnormal passengers. A direct hernia is when it doesn't go through the differing and actually makes its own way into the Canal on the way I remember that is just kind of directly invades into the inguinal. Now it's kind of dislike already goes through the proven room, Askew can say so there's some key buzz words that you want to know that I could come up in exams. The indirect hernias is due to something called the process. Is vaginal honest failure for that to close to close on What that is is so if you just quickly go into the sliding glass plants when when the testicles are are descending, for example. So it's It's not like this in three months and see, but you can see that it's bored and buy something called the processes marginalis on by a lot of the abdominal muscles. When the testicle eventually descends at this, this to like, structure disintegrates usually. But when it doesn't, then it can lead to the inguinal heaviest. I'm just gonna explain in a bit on the extent to which this degrades determines how much the the bottle is going to treat it in. Okay, but really just need to know press this button ons is indirect. Okay? Onda abdominal desk passed through that deep ring and now here in direct. It passes. No, not through the deeper in but media to the deeper never, never to the left side. Okay, on there's actually a chemical test that you can do to tell the difference between an indirect and the diarrhea. Tonia on the way you can do this is you just reduce the hernia. Impress on the Depression, either midpoint of the inguinal ligament on. Do you ask them to call? It protrudes that it's a diet Ernie? A. If not, then it's indirect Now. Also, this is not very reliable. They come from up in exam, so it's useful to know to know the chemical test. Okay, this is just a visualize it a bit better. So again, it's just that, you know, I just wanted to know it's a tube like structure with a deep Bring the opening on the end superficial. A direct one is not going to go through the deeper in. Like we said, it's gonna penetrate right into the, uh, inguinal canal. It's gonna go directly into the cup. Okay, on usually the put the area that this penetrates into the canal is called the Hassleback Triangle, and this is just the area where usually the direct hernia protrudes out of and usually by the lump is it was quite useful to know Onda it's board. And so this has a bacterial is just formed off the rectus abdominus. So just your six pack inferior epigastric vessels, which is just vessels that that form near the inguinal canal on the inguinal ligament. That's what he said. Okay. And there's a way that you can remember this and it's called a rip. So are being the rectus abdominus I being inferior epigastric and vessels and pee being Poupart's ligament, which isn't really helpful. But that's another word for a granola. Okay, well, you need to know is processes regimen off indirect through hassle, but has a, like a triangle four and direct. Okay, so I just put this in to remind me I'm gonna show quite an explicit, explicit photo of a scrotal hernia. Well, so it's quite interesting to see what? What an indirect Then you can do. I can look like Okay, so if you're squeamish, uh, look away now. So this quiet, massive scrotal hernia. Okay on. I just wanted to show this because I wanted to us So what do you what's most likely? What's this? Most likely to be a direct or indirect hernia? So you want to put in the truck? What you think this is? This is going to be a director in direct. Oh, that's great. Yeah, so in direct. So that's very good. So the reason that's indirect is because, as I said, indirect, it's using the path that's already there. It's going through the deeper in, and it's going on the superficial. So there's not much resistance. A direct, as I said, directly invasive to the Inguinal Canal. So it's probably gone through a muscle, and it's quite a lot of resistance. Okay, so it's very unlikely to go away down into the superficial ring and then go out of the scrotum. That's well, okay, it can still do that, but it's less like All right, so moving on. So the second type of hernia need to know it's called a ventral hernia. Okay. And again, this is centered around the inguinal ligament. Uh, but we're focusing more on the vessels underneath the inguinal ligament. Okay, so we're looking at the nerve. The federal, the family lives from a lottery and formal vein on also something called the federal Federal Canal. Okay, so the artery and vein or contained within a she's on meat. Veal to the vein is something called the federal femoral Canal, and this is just a space usually just allow the vein to expand for venous return. It also can contain some teaches you under under lymph node to call that in fluid of Cloquet. But that's not too important when you really need to know is it is. This space is quite tight. It's bordered immediately by something called a liquid a ligament on, because this is just a tight, narrow space when there is bowel going through this canal. If you become strangulated quite quite, quite commonly okay, and when the strangulation there's result destruction. Um, it's usually a surgical emergency. Okay, there's a way to remember the order of this was just navy with the why being the up the abdominal creases in the groin creases. So, as I said the herniation to the canal, there's a ring called the femoral ring that separates the peritoneum from the canal. And, as I said, very high risk of strangulation. So really all you need to know is femoral hernia strong condition? Okay, that's the most important thing on F F femoral F four females as well, much more common in females. It could still happen in males, but much more common in three months. So I've made this table just highlight the key differences you need to know. So as I said, direct hustled a triangle on in terms of the location in in terms of the epigastric artery, it's medial and inferior to the arteries here for indirect patoot through the inguinal ring on passes lateral to the inferior epigastric artery formal hernia inferior to the inguinal ligament. As we said this underneath. And it's natural to the Purex you with that as well cause you to cough in direct processes. Vaginalis failing too close, direct weakness in the transverse fracture in the area of the hassle factor. And, um, okay. And, as I said, highest risk of strangulation trouble. Hernia. They can all occur in adults in direct can occur in infants. So that was one of the questions that was. One of the options is in the previous question. If you remember, and as I said, f f femoral effort feels hernia that family and is way more common treatments. Okay, the rest of usually, man. Okay, so these are The other thing is you need to know about which aren't so important, but they're quite easy to learn. So Incisional hernia is really what it says. So it, since it is just a hernia at the previous incision, usually just the previous can't they have made in surgery. The bigger it is, the more likely a hernia on bills. A hernia is just a hernia in the umbilicus, the belly button, and it's much more common in the units. There's different types. We're not going to go into that. That's more pediatrics. Every gas streak is just hernia in the Epigastric area. So it's this area here. If you look at the groups that I showed him beginning of the lecture and spit jelly in here, and you know, I'm not sure it's saying that right, but this is just this's just on the border off the lateral rector's on do. It's technically between the rectus abdominus on something called the Linear, since the reader semillon Onerous, which is the site of the fascia called the Speed Jerry in Fastness that That's why I really always know is this's lateral to the rectus abdominus you things back a cane. So there's other hand. Is that each nodes a bit more difficult to understand, but the son called an off to rate a hernia. Just be aware of these off the other ones I just mentioned more important, but operator hernias just herniation herniated through the operator foreman on. But again, this is calm and in multi Paris women. So what, multiple literally reads is over. And that's just given birth to off Children. Okay, so if you get in the question stand, someone who's multiple wrists and they're complaining of some pain specifically extending from the inner thigh to the knee when they hit is internal irritated. And it's most likely this hernia on this pain. It's called How shit Romberg sign A swell Okay, and it's just due to compression of the alternator nerve that runs through the alteration for me High entertain. You know, it's something that's a bit more common that you probably heard off, and there's actually quite a few types, so there's type 123 and four on. Just visualize that they're better. I've got a diaper on. So if you have a look here, this is what it looks like normally, with the black line signifying the gastroesophageal junction. So in type one sliding and entertain A A. This is when they're gastric off. The salvageable junction is actually going into the mediastinum, and a bit of the stomach goes along with it as well. In time, too, the junction stays at the diaphragm were supposed to be but another part of stomach. Actually, Patoot protrudes into the mediastinum, and usually this is the funders. As you can see, Type three is a combination of the first two times, so sliding and rolling on Type four is just when there's such a large opening that, actually other other parts of the abdomen compatriot through. So, usually just some small bowel, as you can see in this picture, and finally just out of interest in some calls, Diastase is break time, which is when there's widening off the linea Alba, and you can see that sometimes in body builders, actually that that six pack there's like a gap between them. But obviously it's more common in progenitor in a beast. Patients and also a pregnancy as well. It can, however, occurred in progenitor Leah's well. But be aware this is technically not a hernia. They can't quite a quite obviously in a patient, so management, so they management of tennis. Like I said, um, if they're associated with a few symptoms that can be measured conservative, they can be managed conservatively, especially when the patient has had it for a lot of years on. Don't mind signing. They don't mind the appearance of it, Um, if it's recent on. But if they're on, if it is unsightly and if they're fit, then most likely they'll they'll go in for surgery to prevent any complications. The reason they did all the patients is usually they're not fit for surgery on if it's been there for quite a few years, it's very unlikely to strongly if they've been okay for a few years on something called a hernia. Trust can also be used on us for patients who are not fit for surgery as well on in terms of the actual specifics of the surgery. There's something called a surgical mesh repair, and this is kind of the leading, so nearly all surgeries use a mesh, so it's just a just put a mesh. And when they closed the defect on it just promotes scarring tissue, and it kind of closes. The weakness on this is Do anything that you need to know about this is that you could get chronic pain with it because also, you have a foreign material, and it can irritate to you the fashion around, so moving on. So the head of a 45 year old woman with a background of biliary colic is complaining of severe epigastric pain. A serum, um, Elise is found to be 1200. Which of the following features are not associate it with the likely diagnosis. So just this is a bit harder to your bit more time. It's been over a split between see any? All right, so we'll stop that. So the charge of you have gone for a unfortunately steers correct. So well done for those Quincy. Okay, so is it ever gets a bit of a class one, but so let's just go through it. So hypercalcemia is actually seen in pancreatitis on is actually a marker of prognosis, so it's a marker of severity. So if someone has hyper consume. It's actually a bad sign on this used in scoring systems, which we'll talk about in a bit. Carlin signs and Cullen on Great in a sign that both occur in pancreatitis and they're just a type of content is a periumbilical bleed just means that, um because it kind of bruising around the belly button. Great. And a sign is when this kind of hemorrhages on the flanks on the science of the tummy and you can see that dermatitis as well a scheming retinopathy isn't even a rare thing that you can see. I thought I don't know how to pronounce that. That apparently that can't come in. Just a well, very niche thing I thought I put in hypoglycemia is actually the trick one you actually see hyper my senior. Because if you think about the pancreas is responsible for producing insulin, so I'll see if you're not producing, not the you're gonna get high blood sugars. Okay, so let's just go through it. So this is a very common condition on day. I've been in surgery for the past five weeks on, but nearly half the patients come in with a few privatizers, so It's very common, so it's very likely they'll put it in the exam. So there's acute on this chronic. So 22 types accused also you rapid onset. But the key thing to remember is normally function returns. Eventually, it can take a while. Some patients, for example, will need insulin after and, you know, usually forever in chronic. It's a bit longer term. The pain on it can actually cause permanent deterioration. Or both explained under interpret function. Uh, explain all that is in a bit, and it doesn't possibility for the office. A physiology only need to know. It's It's just the watery eyes extra and the pancreas using enzymes. So it is a type of the change it later on. But this eventually needs to necrosis okay on the key causes that you need to know. Garson's on alcohol post. The recipe is also a common thing that woman exams, but the key ones you need to know are gallstones and okay. However, there is a lot of courses on they can remember that could be remembered by an acronym called I Get Smashed. Probably heard of it before. It just covers all the front claws, is off pancreatitis. Okay, so gallstones, ethanol, trauma, mumps, steroids, scorpions think it's the one that everyone remembers, but it's quite unlikely to come up with questions. Time hyperlipidemia as well. Ercp Like I said in certain drugs as well. So sodium valve or a which is used in like epileptics. You can get someone to you as epilepsy, and there is a condition in a question stand, for example, and they can develop 100 twice so into the presentation it presents with severe epigastric pain. And sometimes this radiates to the back vomiting as well as a woman on a fever, but usually a low grade fever as well. Tachycardia a swell and rare features like I mentioned off Colin Sign, which is the periumbilical discoloration. Great in a Sinus, different discoloration. And I said, Right now, even more even more error. But it can actually cause permanent blindness, usually temporary but permanent as well. On the key investigations that you really need to do or serum. Um, Elise, And so I'm like peace. Okay, I will explain the difference between the two. So, um, malaise is usually is usually used, usually more readily available, and it's actually raising nearly 75% of patients. But it's not enough for amylase just to be raised. It has to be more than three times the upper limit, according to Nice, anyway, because there are a lot of a lot of other conditions that can actually cause a raised. Our money's okay, So that's why, in the questions then I said 1200 when the upper level was about 300. Okay, so I need to be considerably raised on. So, as you can see here, so these older conditions like, calls it a swell. It's very important to mention that families, and, like, peas, they don't chloropicrin it to severity. Okay, no matter how high they are, just chorea, it's correlates. Actual practice is happening, like peas can also be used. It's more sensitive on this. Usually use for patients that present after 24 hours because it has a longer half life. Usually, diagnosis can be made just from the pain on from the amylase are like these. But ultrasound is usually used as well to identify the course because, like I said, I got a gallstone is the most likely called so really will help visualize that So there's, um, scoring system that you breathe you need to know about. So this ransom, Blasco. But the easiest 1 to 10, I think, is Glasko because you can remember with a new monitor called pancreas. Okay, and this has most of them are elements of the other sport assistance as well. You can see the oxygen Palestinian, so oxygen is usually the dose of the hypoglycemia. Hypo hypotheses high because he was also seen so uh, raised urea, certain enzymes as well. The albumin on as I said. So sugar. So, um, hypoglycemia as well, on the way, they grade it here. If it's one. If it's zero when it's mild, two is moderate and three or more severe. Yeah, so it's a management. It's very important to fluid to give the money fluids aggressive. Fluid resuscitation is very important because the two thirds space loss and they can lose about 3 to 6 liters of fluid. So it's very important to resuscitate him. Um, Onda, even though they're not rich in the mid meal by mouth? Uh, a. Sometimes they are, and sometimes they give him parenting on nutrition instant, especially if it's lasting for quite a while, but they're not in routinely made by mouth. And also analgesia is quite important as well as well as antiemetics and usually your periods any because that's how severe opinions on specific treatment later on depends on national course. So Goldstone's they probably need yeah, City River still stiff, and it's very important to you only give antibiotics if there's evidence of infection, it's not routinely given, and that can come up in exams. A swell as an option in a in an entity. Yeah, and it's just going to notice the key complications so you can get in a crisis. Inflict infection up abscesses you get. Pseudocyst is well, which tend to bleed a lot on off the current chronic pancreatitis, which will briefly touch on now. So in this one, alcohol is by far the most common cause maybe in 90% go again. It has epigastric pain, but it's a chronic, and it results in los of exocrine and endocrine function, So going to what that means is so the pancreas is responsible for producing enzymes. Such a Liapis anomalies on D on Gwen, these aren't when these aren't secrete. When these answer pretty it into the right track. People struggle to absorb and break down food food so specifically. So if you're not producing like please, you know, going to be you're going to be able to break down the lipids on a lot of the time they get deficient in fact, soluble vitamins. So everything a d e. Okay, lots of endocrine function just usually just usually just referring to theater cells being affected, which produce insulin and then eventually lead to diabetes. A very common presentation of acute hepatitis is a sudden worsening off. Sorry, chronic princesses this Wessling off existing type two diabetes or a new onset try to like reasons. Okay, on you can get damages and strictures to the doc sistemas. Well, um, on, like just said, pseudo cyst announces it was part of pregnancy. Those investigations it's slightly different, and it usually involves a CT or an abdomen. X ray on. This is to look for calcifications on imaging on these are quite these are kind of kind of a telltale sign of chronic hepatitis. There's something called a fecal. The last days, a swell, uh, which you could measure. And that's another sign of penetrators. Really, The things financially and right in this presentation of kind of the buzz words, they're gonna come in SPS on exam. So it's important to know others on the management is quite straightforward. So the pain you have the allergies here, you want to replace the enzymes, usually in the form of crayon on ball. So give them vitamin supplementation. Either you want to make that you wanna encourage him to abstain from alcohol. Want to keep causes of it on surgery. And stenting can sometimes be used as well. Okay, let me be on to the next question. So current is a 46 year old female who has been diagnosed with a sending cholangitis. Your consultant tells you that rarely these patients can present with a collection of symptoms called Raynaud's Penta. Which of the following statements about renals Penta true. Okay, if you have time to read this this quite hard, sir, do you know longer slave for seconds. Yeah. All right. So it seems to be quite split, But do you seem to have one with a n. C being quite close? Okay, so So the is actually corrects the world's own the majority of people. So this was quite harsh of me. And but unfortunately, in example, might give you is really long Windows questions, so I'll just quickly go through. So you really need to know what radio spent on is on. Renter's Pintid is just shot. Let's try it, plus shock and confusion. Okay? And shark, let's try and his fever, right. Upper quadrant Pain on drawn This. Okay, so if you have a look here, we have service. Try and but we you know, when you have low BP tachycardia which both together is the shock. So this is ruled out be we have fever, right upper quadrant pain But then we have shock and couple of couple of psychosis know important shock is part of Raynaud's better, but we don't have joined us. We don't have confusion. So not not be for see, we have fever. You have raised liver enzymes, right quadrant pain. Now this this kind So this isn't kind of correct. It is, um because actually it's not correct because we don't get a raise Liver enzymes. It's more importantly we get the respiratory. Reuben's. That's incorrect. Now this is the one that has all of them on. I've kind of disguise. The drawn this with Rays bilirubin a lot. People don't know that. It's actually the Rays. Bilirubin is the most important thing, and it'll just joined us. So it's jaundice, right? Common pain, fever and shocking profusion is all. And this one is wrong because I put confusion ultimate with multiple mental status, which is the same on. But there's no fever here is one. Okay, so he's a great, so we'll be able to go through acute call in giant us. Um, so in terms of the pathophysiology, where you need to know, for example is the most common cause is ico I That's followed by Klebsiella and enter about. This is all on the most common predisposing factor is gall stones. So usually someone with a past medical history of biliary colic on it also commonly affairs after the recipe on using presents. As I said, it starts. Try it on day fever, being the most common thing God for that, occasionally with hypertension or confusion as well, making it rain and spent on okay, it is investigation. What we really want to do first is ultrasound because we can look for a biologic dilation and also stones in the bile duct itself. Uh, usually with this race inflammatory markers as well. So COPD is used used in terms of management. The key thing that you want to do is give IV antibiotics and IV fluids on. Also, you'll be given analgesia and antiemetics. You don't have the new one by mouth, but another important example in a swell is Ercp is now only done, usually 24 to 48 hours after to release obstruction. And that's because you want to treat the infection first, and then you can remove the obstruction on the Goldstone's. Okay, so moving onto another question. So after a 58 year old man presents with vomiting and fever, all liver function tests are normal. One palpations or is right upper quadrant. You realize he suddenly stops inspiring. What is the most likely diagnosis? Okay, good engagement. Get about 10 more seconds. So well, the guys. So the overwhelming majority are saying a Okay, So, yes, it is a cute cause. It's status. So just to quickly talk, so is love terms here that sound a lot like each other. So I just wanted to clarify all the differences between these kind of complicated tens. Easy to remember. So the three key ones you want to know it's Billary Clinic, which is just the intermitted pain that you get because of the gold stones in the bile ducts. Cholecystitis. It's when it's inflammation off the gold miner, so the right is being information, the closest being the gold plan. It's closest items it is here against the cholangitis. So, like we sent information. But but others now the other ones are being more confusing. Is called Stasis. Chronic Stasis. You want to just look at the last letter so stay sisters means still stationary. So that's when the when there's a blockage of flow to the bile cholelith eyes just khalidiya qualifies and putting the two ones that people get mixed up with on down. They both, um, for tickles stones. That's what you need to know on the way to tell the difference between the two years because it has Kalydeco doke. Oh, duct sounds kind of similar. So it's Zaza's in the bile duct on Just My Children on Cholelithiasis doesn't have the dough Cobalts. It's just call stones. That president remember? All right, so but and I imagine it's personal goal, but cholecystectomy and cholecystostomy so just remember ectomy means and removal of anything because Colaces there. So it's removal of the gold bladder. Ostomy just means a hole. In this case, it just means a drain in the gold butter, and this could be used in a lot of situations. Not just noticed this. Okay, I just wanted to quickly go through biliary click. It's quite it's quite a simple topic, So because of the positive physiology, it just happens when there's a lot of cholesterol. Lower bowel assaults on this biliary states is on. It's just is usually usually happens after meals, and you get this intermittent pain on. This is because, especially after fatty meals to be to be specific. And this is because fatty meals encourage the release of something called College College Sister Kind or C CK, which actually causes the contraction of the gold bladder. On This contraction causes pain because you, because if there's a stone in the duct specifically the cystic duct, which is the one just in between the gold bladder and the common bile duct, and it's going to cause pain on it does this intermittently So that's why it's colicky s. So that's basically the pathophysiology on that it presents with the pain and also nausea. Vomiting on the Q. Thing to remember is, well, is the risk factors so the patients usually fact fair female and 40 so very PC. That's probably the easiest way to remember it onto the diagnostic criteria you needs usually needed ultrasound. Top of the Goldstone's and LFTs as well continue a cholestatic picture. Cholestatic. Well, I mean by the obstructive picture is just indicative of an obstruction, and that's usually what they'll peace. Prize. If you see a a piece rised more than a L T. Then always just think obstructions raised LP rays bilirubin on Do usually ultrasound can't see anything you move onto ML CT on ercp is the invasive one. So that's one that you used to take out the take out the Goldstone's ballsy convince you alive visualize as well. MRSA is just magnetic residence. So this is imaging. Remember? You know, the difference between the two and management usually usually just tell the patient to avoid fatty foods. Obviously on do you want Oh, you want to opt for an elective arthroscopic so I'll call Cystectomy if if they're symptomatic and that just means they'll get the get removal off. They're off their goal butter. But it's not urgent case, so usually it spoke to on a waiting list. Okay, where we want to keep calling cystitis. So, as I said, it's information off the golden on developed secondary to Goldstone's vast majority of patients. And it's just good to be aware that there's something called a calculus cholecystitis. It was just just close. This place is that occurs without gallstones being present when there is when it's president is called calculus cholecystitis. So just in case you come across that you don't get confused. Onda Lot of the time it's seen in hospitalized patients. Um so So if you if you just ignore the gallstone causing color societies and we focus on a day like this, call cystitis is so This is a bit weird, because why would Why would why would that be? Information if there's no obstruction, well, usually happens in people who were hospitalized for a long time on because they're not eating, for example, the goal. But it doesn't have to really spiell. There's no fatty food for it to contract anyway, so there's actually lot of spaces. So when something stationary, when when a puddle of water, for example, of station is always infested with Wardak period than running water, for example. So it's the same same analogy here on also a combination of infection and hyperperfusion contributor. Okay, just just to know that immunosuppressive patients, if you call cystitis again, develops Second reason is something called cryptosporidium on, uh, like to make the virus is well, so into the presentation. Right? Covering pain is almost always seen. That may really it to the right shoulder. This time you get fever, nausea, vomiting, system it systemic upset So tachycardia to cook here and you get something called Murphy's sign. So this is something that was in the question that you just answered on. This is when they on deep palpations, so usually ask him to breathe out. You press you could press quite hard in the right upper quadrant on you. Tell them, Teo, you tell them to take a deep breath in, and if you think about the mechanics of it, maybe take a deep breath in your diet. Front flattens when it flattens your abdominal contents kind of protruding out on the gold bladder will go into your finger, and that's when they'll probably probably screaming pain and not stop inspiring because they don't. They don't want that. Okay, Ondra member. That was important thing. The reason I said, All liver function tests are normal because you very you never get jaundice with a few cause a slight. It's usually don't get jaundice, and that's because you're not stretching any of the bile ducts. Everything's within the year using the gold out of yourself. Now, to be more confusing, there is actually a condition that you can get raised drawn this with a few because it's not just on. This is called Mariza Center, okay, and it's basically when the Goldstone is just about the cystic duct and it gets inflamed. It gets so inflamed that distends that distends this area, it can actually cause obstruction to the to the biologics and next to the old letters with this, like the common bile duct. And this is the only situation that where the cuticles it's nice that you got joined us, okay, but this is quite red. It doesn't investigation ultrasounds. First line M A C P can be used if you quantitating ultrasound. Some called collis into scintigraphy or high discomfort also be used as well. Uh, but like I said, no. If they don't present with jaundice, then it's most likely if you have the slightest times on. Do you usually get raisins from three markets and Leukocytosis, which is two sprays to my blood cells on the management. Anything to give his IV antibiotics off the anti emetics and, uh, analgesia as well. But nice. It's important to be aware that Nice now recommended early labs will be causes that to mean so within one week of diagnosis. And previously surgery was delayed until the information subsided. But now nice recommends within a week. Okay, so next question. So, Mary, um, is a 67 year old female presents with jaundice anorex here and weight loss on examination, she has a palpable Goldwater. What is the most likely diagnosis? 10 more seconds because the rush for time all right, so it's actually clinic close call between C and D. But the right answer is actually see so well done. But right, the so that should be clear about with It's the Body because this is a classic presentation off a sort of cancer on. But it's actually called curvaceous sign, which is when there's jaundice with a palpable goal bladder. It's almost unlikely to be gallstones, and it's one I think to be a cancer now the only reason I dive. The only reason that I've chosen pancreatic cancer, as the answer is because it's more likely than plunger of carcinoma. But they both can present with this patient undergoes can present with convulsive Simon's All. So this is quickly go over the target of cancer. So although this I should be quite a classic presentation, they can actually present in quite a non specific way. It Is it the pump because of the microbiology. 80% for about, uh, you know, the Newman's on usually at the head of the pancreas, is well, and they usually present with pain that strong on this so pale stools, dark urine protests on again obstructive pictures stories. A L P. On these symptoms resulted from a rays from a destructive and kind of pathology. It's more. I'm going to go through, um, LFTs as much in this section because it was done in the August through one. This is important to know this curve eyes is low. As I said, the pain is instructive. Jaundice in the probable gall bladder unlikely to be gall stones. Okay, on. Like I said, very sometimes is very non specific, this kind of constant presents. So anorexia, weight lost, unpaid as well. Even though Covisint Sinus painless, constructive dryness, you get a loss of estrogen function as well. So something called Stiolto area. So this is when you're not using like a Z, so you can break down the lipids so the liver's go and think your stool You kind of kind of floats up floats up in the toilet bowl, so that's kind. Of course, the artery is just very a lot of difference in it on lots of endocrine function as well. So I said, Maybe just present and also back pain. There's another sign you need to know that the government exams culture is a sign on. This is just my great tree thrombophlebitis, my greatly meaning that it goes, travels. It goes to different places, and so from before, biters could happen in different places, and it's common in other countries. It can happen other cancers, but it's well college students. Okay, uh, and there are specific referral guidelines which could easily be tested on exams. So the key want to know is, if you're over 40 on, have jaundice, then you want to send them for an urgent suspected cancer referral, which is a usually a two week wait. If they're on this also, and if they're over 60 with weight loss on any of these symptoms down below, then they referred, usually directly to a CT abdomen on. This is one. This is the only case. This is the only time of cancer where a GP can actually refer you straight for a CT. Okay, Onda away just to remember me to remember these kind of symptoms and because it's quite a lot is just Is that just basically all the symptoms usually asking a g I history. So starting, starting from the top to the bottom, you've got nausea and vomiting from the top. Then you can go to up, then go down to the up to a pain and you get constipation or diarrhea. Um, and then once a diabetes is because of the actual pancreas on back pain is just something extra to remember because it's never days. But that's something you can use to remember. It's one of the investigations. Usually CT is used for acid investigation of choice on The thing you just need to know is that you'll get a double duct sign. Okay, so if you see that in the question stem is very likely to do this on. Also, see, a 19 9 is just a tumor marker that's raised in this type of cancer, but it's also raised, raised in color to cost and cross the numbers will, in terms of the management it's usually just involves surgery on Didn't call the Whipple's recession is clear. It's quite a big surgery, and that's why I know a lot of people actually suitable for surgery is only 20% of our because it's quite extensive. Century on the key things you just need to know about it is it's a pancreaticoduodenectomy involved removal of the pancreas, stomach, duodenum, gold, bladder, politics, even lymph nodes as well. On this key side effects is just dumping syndrome, which is when the food just troubles too fast through your GI system, because a lot of the bottle has been taken out and you guys sit in symptoms without Okay, So Ali is a sex 61 year old one. Sorry presents to put his GP with weight loss and change of all of it. But the full blood come is taken, given the likely diagnosis is what would be the best course of action. Yeah. Oh, all right. Five more seconds. So well done to those who got a nice correct. So what we're seeing here is just a microcytic anemia. Um, when that happened. So this is the day missus here is bowel cancer. So I kind of miss lady of it is a very concerned on. It says it in terms of their symptoms is presenting. It's an urgency, weak referral for cancer. And I'll tell you why in a bit, um so just quickly go through about concepts was the fourth month most present prevalent cancer in the UK behind breast, prostate gland and Keirrison actors. Just a family history and two conditions F A, P and T H and H and P. C. C is well, also notice lynch syndrome on that should usually that's kind of like a traces that you just need to just recognizing exams because they come up a lot every day is also a risk factor smoking and least in his well and also alcohol so usually presents with change in bowel habit, unexplained were lost, rectal bleeding up the pain. I'm deficiency anemia and a mass on examination. So these are all important to know because they formed the referral criteria I'm gonna talk about in a minute. So the followed referred in, referred urgently within two weeks. So if the patients over 40 years with unexplained weight loss on the other pain that's for thinning, each preferred in two weeks if there were 50 with unexplained rectal bleeding, if they're over 60 on with iron deficiency anemia or change in bowel habit, they also need to preferred within two weeks. There's also a frontier fall on those who should be considered a nerd and referral. But this is more high yields, and the way I remember this is and it's kind of a, um um, what's the weight loss loss? Having four letters after pain pain, having four letters. So Cross wants to the 40 bracket okay in here and the bleeding is five letters or consequence to the over 50 bracket, and here it's six words. Response to the 60 bracket, if that's too hard to learn and you don't have specifics. Of the six words that change is six letters are consequences to 60 and bracket because the only change of worried about is change in bowel habit. On this one's a bit farfetched, but I am. If you go back to chemistry, the two irons are F E two plus and three plus times and together they're six. That's a bit farfetched, but hopefully it's weird enough that you remember, Yeah, uh, and it is a screening, but then it just office it every two years to Almen and women age 60 to 74 in England. It's the same in Wales as well. Wells are trying to get it down to um 52 74 like Scotland is and, uh, but it's supposed to be rolled out this year, but it's important to remember, even if you're over 74 you can still request a screen when, when patients are eligible. That sent something called an F i t. Through the post a few kilometers, a chemical test this used to be called a fecal occult blood test. So ever be on basically, these testers detect blood in the stool. The previous one that ever be could detect all types of blood. So different animals. If you had a steak, it would be positive. This is just more specific to humans. So that's why we've just twist it on to the F I t. Okay, This is the criteria for people who don't meet the two week way referral criteria. And usually they're sent an F i T. Because it's not. They're not as worried a Z other, because the other was the other kind of group of people. The criteria is of it's similar in terms of the actual actually something going to go through this, but it's just a bit less severe in terms of the symptoms. Uh, if this if this if it is positive, then the central colonoscopy. Uh, they used to be also a one off from, and flexible Sigmoidoscopy offered the age 55 but this was actually abundant this year, mostly because of Cove it. But it does show good results, and then my introduces, so it's worth to keep an eye on that it is a small cancer. The investigation is just as I said, gold standard is colonoscopy. You consider other things like sigmoidoscopy. A CT is usually used to stage it on the tumor marker. In about answer is C E A. Okay, on the management just involves a combination off most cancers. So what most consistent bowels? The surgery, chemotherapy and read it, Uh, I'm going to slide in just so you know, we'll add up the way. It's the way about cancer stage. So usually that's where they do a CT, just a stage it and they use. And they use just tnm staging so looking. And it's just all dependent on how much I'm just going to leave that one. It depends how much it invades into the bowel wall, starting from the Lumen on going out with. And it is important to remember that the t one corresponds to the sub mucosa. So nothing because a and then you just go down there. So two is when it goes to the muscle. T three is when you go serosa t four was when it goes out words. Okay. Do you remember it that way? And and an Emam say, for that same father, most cancers as long on in terms of the specifics of the bowel cancer surgeries, you just need to be aware. So only the sliding is, well, I'm not going to go through it. He does need to be aware of the key differences off different types of surgery they might give you. So the special house high interest section What this what? This remove any distant to know what they removed if you want to know, is difference between the low anterior resection and abdominal paraneal recession, because it's quite similar, as you can see. But you can see here there's an anal stump left, which means they can eventually join it back together. Here, they actually remove that anise. So, so so the anus a swell, and they have a permanent colostomy for life. Okay, so be aware. Off the small a dose stump. If it's present, make sure you remember myself last question. So it'll Evans, 20 year old year old, a 20 year old male, presents today any with gradual onset Central of Pain, which has now moved to his right iliac fossa, he describes the pain is a seven out of 10 but denies any episodes of vomiting. He has a temperature of 37.9 on has raised inflammatory markers. Which of the following investigations is needed to complete the likely diagnosis. So, yeah, okay, it's between. See, any seems okay, All right, we'll send it there. So it seems to be actually almost put it between see any any winning slightly on. But it's actually easier world into those super easy. This is quite a hard one, but you need to think, What else would any of the other investigations give you on? It's just important to know. So this is appendicitis on. You can actually almost always be diagnosed clinically. Now. Usually CT is done for a surgical planning, but it says of the diagnosis, You actually don't need any investigations that imaging. Okay, ultrasound. You won't see much. You might see some inflammation, but you want. It's very likely actually see the actual appendix so quickly. Just the pathophysiology, because this has been covered industrial. But it's this inflammation of the tendon, uh, usually presents with central abdomen. Pain eventually goes to the right with your fossa on. You got something called Rosing sign as well, which is pain in the right there for so many press on the left iliac fossa. And that's because you're just pushing the abdominal contents from the left side to the right so that pending it's comes to it's to the surface and irritates of the heart of the parent in you on it was the best interest of management. You just need to know that it's a pen deck to me. Usually prophylactic IV antibiotics are used, especially if there's a preparation on the leader. Lavage was cleaning. If it doesn't perforate on last flight, so all you need to know, really keeping it's not appendicitis is. And so they said. It starts from here, then gradually go to the Rite Aid for sir. And usually the pain is most prevalent in something called the McBurney's point. Okay, on a slow is interesting to say that McBurney's point actually represents the base off the appendix, and that's clinically important to. That's what surgeons care about, even though the headaches can be put in different positions. You don't need to do the specifics up of this, but just know that if it's pelvic, you'll probably get more pelvic symptoms. You can go a way down to the groin if it's retrospectively actually a very mild symptoms. So the centers depend on the location. But McBurney's point is the teething to remember here on. That's it. Thank you for listening to me. Just want to say that. Yeah. So just want to say that case sources I use is in Syria, too. Finals plus plus minutes and get genetics. Teach mastectomy as well. And really, Peter, for the images on, um, that's it. Um another, another member of ice Tea team has kindly written summary sheets and all the conditions we covered today on also the ones that we didn't manage to have, like diabetic medicines and hemorrhoids. So that will be included in there in the slides on. But you could get if you show up if you back form. Um, yes, of the few that forms in the chart. If you want to fill that in, Thank you very much. Thanks a lot. And we just put the feet about formula link again. You have any questions? I'm happy to answer any. So there's a question about the to clean bowel sounds and why we get out so tingling. Well, sons, that just happens because of the gastric fluids just kind of seeping through the partial obstruction that you get on. You won't get those sounds if it's a complete obstruction, but it's just the sounds. It's just quite basically describes tinkling down sciences choir characteristic thing to say. But remember, you could also be called scanty balls around since one. The is just how does the possible obstruction Thanks. Everyone wants to go coming on. Thank you dot All that was Onexton session. We'll see you all like the next one, which is Thursday for infectious diseases, Same time, same way, like right? Oh!