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Okay, I'm going to start the webinar. No tennis. Can you just give it a couple of minutes? Then we'll stop the wood. Just let me know because I can't see the number of people. So just when you're ready short. So for those joining, just remember to use the Q and A function when you're asking anything, avoid using the chart until unless I say so. Uh huh. And the feedback from we'll try and post after an hour. Um, if it overruns, but hopefully we'll try and do everything right now. All right, we'll give it one moment and say members are increasing that much. And, yes, the slides and the recordings will be sent out. So you'll have to fill out the feedback for, uh, you should get the slides through middle. And also the this recording as well. So it's been recorded. You started the recording already? Yeah. All right. So let's begin. So hello and welcome to another lecture by run by the Acid Medical Series. My name is Abdullah. I'm one of the F ones in Birmingham. Me and another colleague of mine, Mohammed will be running this session today on gastroenterology and as I said, if you perform will be posted after roughly an hour where you'll get access to the slides and the recordings. Uh, throughout this lecture, we're going to have some SBS as well, so we want some interaction. Okay, remember to use the Q and A function if you have any questions. All right, so let's begin. So this is just, uh, just to show you where we're up to in a series, we still have quite a few lectures going on. Make sure to make sure to subscribe to a Facebook page. And instagram page is just, you know, when these are happening anyway, So let's go to a learning outcomes. So there's actually quite a lot of topics were going to cover today. Some of them we just made some cheat sheets instead because we don't have time to cover in detail. But all the information that you will need, uh, is going to be on the is going to be on the carpet and presentation. Okay, so let's start with an S p. A. So Mohamed is a 45 year old carpenter who was brought in by his wife and claims that he has difficulty swallowing food, swallowing food and drinking, and keeps coughing at mealtimes. He complains of heartburn. There is no history of weight loss or hemoptysis. So let me just start the pole. Uh, so yeah, so we'll give it about 30 seconds. Um, all right. And we'll stop the so most of you have said a which I understand why, and this is kind of a trick question, because a lot of the options here are actually would actually be useful. But according to nice guidelines, the answer is actually, uh, see manometry, which is when a small plastic tube is passed through the mouth into the esophagus. And, uh, muscle pressure is basically measured along that tube. And then we can kind of formally diagnose, um before we diagnosed something like Accolate, for example, Uh, other diagnoses that cause problems with swallowing a barium swallow would still help. And so an endoscopy. But it's just because of nice guidelines. This is like the first line investigation. Okay, so yeah, chalasia. So it's just everything on the screen first. So Accolate. So this is dysphasia of both liquids and solids, and that's why that was specified in the question and and it typically varies in symptoms, so everyone obviously is going to present differently. But the key thing here is is both liquids and solids, and it's basically caused by the loss of, uh, ganglion is at the bottom gangs of the bottom of the esophagus that control muscle contraction. So I'm just going to quickly skip the next slide so you can see in these X rays. So let me just get the laser pointer. You can see that it's basically a loss of Gangsters here which allow parastatals to occur, and it just causes a continuous contraction of the lower esophageal sphincter. So basically everything gets trapped up here. This this is called birds beak. And just because of the appearance of this part here, and this can also happen to a corkscrew appearance where you can still get the you still get the lower esophageal sphincter contraction. But because there's other peristaltic motion parasitic contractions and the rest of the esophagus kind of get these indentations here. Okay, so going back to the previous slide. So the key investigation to do is manometry again. You can do a swallow and a chest X ray like we've just seen and the first line management is just balloon dilation. There's other options as well. Uh, like a hell a cardiomyopathy me. So when you see a big way like this, just split it up into three parts. So auto means a whole myo means muscle, and cardio is just a specific part of the stomach that's being operated on. And then there's other options, like injecting botulinum toxin in a bit. That's that's contracting and also drug therapy as well, so moving on. So there's quite a few courses of dysphasia and one of them being the esophageal cancer. And all of these have a typical presentation and usually a specific past medical history that they'll give you the question in the exam so you can tell the difference. So it won't be very complicated, and that should be quite obvious. So with cancer, you always get kind of weight loss, anorexia and, uh, and some B symptoms, sometimes as well. A salvage itis, usually a history of heartburn and also painful swallowing as well. But you won't get any systemic problems like with cancer candidiasis you. It's a fungus, so you want any risk factors to do with that so anyone who's immune suppressed, such as someone with HIV or someone using a stone in there and if they have asthma, frequent from jail pouch. The key thing you want to know about this is that it's in the midline of the neck. Googles on PAL patient and it can cause halitosis. You always see a question about someone with bad breath halitosis, and usually that's from J pouch. In the context of this phase, um, and my senior gravis, you can get that you can get this laser in that as well. And obviously we'll be associated with the other symptoms of myasthenia gravis, such as the eye symptoms. So the extraocular muscle weakness and the cirrhosis. This is just a quick recap about the different pathology that can happen in different parts of the abdomen and where it usually kind of presents. And usually it's It's all really based on the anatomy, so hypogastric you'll get kind of the UTI s. That's where the bladder is in the right upper quadrant. That's where all the kind of biliary issues and the liver problems will be. I'm not going to run through all of this, but it's important to note that sometimes pain can be referred in certain conditions. That's why you can get appendicitis in the right area, Foster and the hypogastrium as well, also in the umbilical region. And that's to do with just kind of, um, how far progressed appendicitis has progressed, for example, and if it's irritated, the peritoneum or not. So it's just good to be aware of this table because it will give you a good idea of kind of the differentials in your mind when someone's presenting with some of the pain. So another SBA. So a 50 year old gentleman who, uh, presents with epigastric pain radiating to the back. It is usually improved by eating but comes back to three hours following a meal. He also complains of nausea. On examination, he has epigastric attendance. So what's the most likely diagnosis? So just a couple, um, poster. You could. I'll give you 10 more seconds, all right, and we'll end the pole there. So the majority of you got it right this time. So it's a delayed dinner also. So based on these kind of symptoms, we are suspecting, and also with the epigastric pain and association with eating as well. The key thing to differentiate between denial and gastric is with the you know it improves after eating. Gastric doesn't Okay, um, so let's move on. So dyspepsia so dyspepsia. It's just a non specific term just for indigestion, and it covers all the gods symptoms. So heartburn, acid regurgitation, bloating and all the other stuff that come with that. And there's quite a few causes as well. Um, there's quite a strict kind of nice guidelines on who to refer and how to manage patients with dyspepsia, and it's and it's quite long winded. But this diagram is kind of made to kind of make it a bit more straightforward, unfortunately, still have to memorize a lot of things, but basically someone with dyspepsia and any of the following over 55 vomiting and any of these alarm symptoms. So these are red flags. They usually get referred for an urgent two weeks endoscopy. Otherwise, you manage it as normal. Good. So with PPI. Yes, as will cover the next slide, and if no improvement, then you test for H. Pylori and treat treat accordingly as well, which will cover in a bit as well. So with good usually use PPI s like omeprazole and lansoprazole, and it also matters if it's, uh if the if the esophagitis, which usually occurs with the court, is endoscopically proven or not proven. And really, the only difference is between these kind of two pathways is the is the strength of PPI you give and the duration you give as well. But also it's it's related to lifestyle changes as well. So some people find heartburn less likely to happen if they don't have certain certain foods like spicy foods. And also, there's actually a fancy surgery as well called Listen, fund application as well. But we don't need to go into detail about that, but that's how it's done. It's just the the top part of the stomach is wrapped around. The lower part of that stuff is just just to prevent any regurgitation. We're going to Barrett's esophagus. So Barrett's esophagus can happen in those who have a past medical history, a longstanding past medical history of good, um, and and that's defined as the metaplasia of the lower esophageal mucosa, Um metaplasia being the change of one cell type to another cell type, and that cell type and in the esophagus, that part of the esophagus. It's squamous epithelium, and it's replaced by Columbia epithelium. And if you think about why, that is, is because Columbia epithelium is found in places where the mucus is needed to be secreted. So if there's a lot of acid where there shouldn't be, it's more advantageous to kind of change the pill, um, epithelium, so you can provide some protection. But unfortunately, when that happens, there's an increased risk of adenocarcinoma. And and that's why you kind of we start to surveil it. We start to kind of monitor it using an endoscopy and biopsies. And once we notice there's dysplasia, so that's when there's abnormal development of cells. Then we revert to mucosal resection or radiofrequency ablation. So that's what we're monitoring for when we kind of have a look at my nose esophagus. Okay, and obviously we don't have those PPDs as well, and that's what that's what it looks like a bit. So that's the abnormal. That's the abnormal part that has changed. So another SBA so O. G. D. Is performed, and the bleeding peptic ulcer is visualized. What is the most appropriate next step in management. So let me open up the pool again. I haven't been, you know. Mhm. Yeah, Give it 10 more seconds. I mean, there's no point in putting. I'm clueless. You can have a go at six. Yeah. Okay. All right. So let's stop it there. So well done. Majority got it right as well. So adrenaline and cultural ization. So I'd rather just to stop the bleeding because it causes vasoconstriction cauterization just to remove a normal part. Um all right. So peptic ulcer disease. So it's important to note that a large so 95% of duty and ulcers are caused by HPV Laurie, 75% of gastric, also caused by HPV. So the huge majority of the ulcers are actually caused by a micro organism called H. Pylori. And then the remaining percent is caused by other things like NSAID. So, like ibuprofen, SSRI is like citalopram, and then an even smaller percentage are caused by a rare syndrome called so lingered Ellison syndrome. And that's when there's excess level of gastro is being produced, causing more acid to be produced and more corrosion. Okay. And that's usually managed again with PPI. PPI is until the ulcers healed and but the specific protocol for H. Pylori that we're going to cover in a bit and the way to remember it is 321. So it's three medications that you take twice a day and for a week. And those three medications are a PPI and then two antibiotics. Uh, that depends if your penicillin allergic or not. If your penicillin allergic, you'll have metronidazole, clarithromycin and the PPI. If you're not, then you'll have amoxicillin and then clarithromycin or metro medicine. And that's the only difference, really, and the way we usually test for it is the urea breath test. There's other tests as well, but usually it's the urea breath test that we can look. We can also look at it in in the stool. We can see if there's antigens in the stool as well. Uh, there's also a urine test as well. Um, we've briefly talked about something. Alison syndrome. Gastroparesis is, um, is can come secondary to diabetes. So remember diabetes can cause neuropathy in the legs and in the hands and the fingertips. It can also affect the nerves of the GI tract, and when the affect the nerves of the GI Tract, then there's not as much. Paracelsus. There's not as much. It's not as easy to move for food to move through the GI tract, so it can just You can just feel very, very full. Even if you're eating a small amount, you don't you don't get that hungry. Maybe you get a bit of weight loss because you're not digesting as properly. You're not eating as much, so they're kind of like presentation of custom process perforation of the esophagus That can happen, obviously due to trauma. Swell. Swell, uh, swallowing foreign body. We can also something you can get something called behalf syndrome, which is when severe vomiting cause a perforation and that will have its own presentation, usually quite sudden answer. Quite severe bleeds, shortness of breath and vomiting as well. And usually you can actually do a chest X ray. For that, you can see something called subcutaneous emphysema as well, which is when there's a rare releasing into the mediastinum. So another SBA. So Hussein, a 25 year old male, went to a GP after four months or struggling with having to go to the bathroom to open his bowels 4 to 54 to five times a day. He says that it has been worse around his exam period because he hasn't attended any assets Lectures. He feels blurted and worse after eating. He's generally quite fit and had previously tried dietary changes. Fbc es are CRP field calprotectin anti t TG is they're all within range, all normal. So everything is normal, really in his blood. So what is the most appropriate treatment option at this stage, given his likely diagnosis girl, Right. 10 more seconds. Right. So majority of you got it right as well. So loperamide, um so if you just think about it, this person is going to the bathroom a lot. So he has diarrhea, so we definitely wouldn't give him lactulose okay, because that's more of a laxative. Um, I know it can be used that can be used for diarrhea in certain cases, but usually lactulose as well is definitely not used in this suspected diagnosis of IBSD, which I'll tell you what the diagnosis is. So in I bs, we try to avoid the lactulose, actually, because it can make the bloating even worse. Usually we try to use linaclotide. I'm sorry for the type of that. It's not enough to write you an appetite. So that's the laxative we use if they have constipation. If they have diarrhea, then we'll use the Paramount. Okay, so I bs. So it's a functional bowel disorder. So what that means is, is that it's basically once we've ruled out all the sinister, insidious causes, um, of the patient's symptoms. Then we can start to think about this once. Everything is negative, Um, and it's usually characterized by bloating, diarrhea or constipation, and it's usually worse after eating, and it's improved by opening your bowels. So let's go into another SBA. So TIA with Lulu is a 27 year old woman who's investigated for bloody diarrhea. This started around six weeks ago. She is currently passing 3 to 4 stool motions, loose stool motions a day which normally contains a small amount of blood. Other than feeling lethargic, she remains systemically well, with no fever or significant outdoor pain. A colonoscopy is performed, which shows inflammatory changes in the ascending transverse and descending colon consistent with you see bloods show the following. So what is the most appropriate course of action? So I'll let you just have a look at that. You have been longer than this. All right, five more seconds. Okay. Um all right. So this is this is quite split among you guys. So the correct answer is actually be oral and rectal. I mean, that's obviously so this is a bit I mean, um, because your a and B can be kind of right, but no, we wouldn't actually give all prednisolone in this presentation, and we'll go through that in a second. Uh, just before actually, let's do one more SBA. So those are, uh is a 30 year old woman who was admitted to hospital with Abdul pain and diarrhea. She has no past medical history other than depression, for which she takes citalopram. She smokes 20 cigarettes a day, drinks 20 units of alcohol per week. Uh, really. A colonoscopy shows features consistent with Chron's disease, and she is treated successfully with glucocorticoid Claudio Cork glucocorticoids therapy, one of the most important intervention to reduce the chance of further episodes. Okay, so we'll just do another one because it's in the same topic. This should be a bit quicker. Well, all right, 10 more seconds. Uh, huh? All right, All right. So the majority got this right. So, um, stop smoking. That's the key thing. Remember, it's you see, that smoking is protective against Kroger's is the opposite, so I b d So you see any Crohn's? So both of them roughly affect 0.20 point 15% of the population, and they both have a by model distribution, which means that they both peek in certain age groups younger and older as well. You see, is associated with the gene HLA b 27 which means it's associated with inflammatory conditions. Those conditions, I mean things like ankylosing spondylitis, reactive arthritis for all the stuff you kind of do in rheumatology. Um, and usually there's a 10 to 20% family history as well with the UC, Um, and again, as I said, is linked to smoking. And it's also found in people in white with white European descent, particularly Ashkenazi Jews as well. And you do have an increased risk for developing developing it right after appendicectomy as well. And this is a nice diagram from Pass Med that I found, which shows kind of the overlap, but also the key features of each one. So usually you'll get bloody diarrhea in you see, but it doesn't mean you can't get insurance. Uh, and it tells you it also shows that PSC's the primary sclerosing cholangitis. More happens more with you, see as well, and it also tells you about the information patterns. So Crohn's you get inflammation of all layers so sometimes referred to as transmural. Inflammation, you see, is only the surface layers, only the mucosal. We'll go through that in a bit. So these are the key differences you need to know for the for your exam. So with you see, it only affects the large bar. Okay, you can get something called back wash ileitis, and that's when the ileocecal valve valve isn't as competent as it should be, so isn't as close as it should be. Otherwise, it's largely only basing the colon. Okay, Crohn's can happen from mouth to the anus so it can affect the colon as well. That can affect anything in between the whole GI tract, As I said, Crohn's transmural. So if you have a quick look at the picture here, so transmural so affects all these layers, you see only affects the mucosal layer here, um, with regards to the microscopic change. So when we say microscopic change, I mean, if we put an endoscopy, if you put a colonoscopy, If we did an endoscopy and we just had a look at it with a camera, we'll see something called pseudo polyps with UC Crohn's. We see skip lesions on something called a cobblestone appearance. So I have a few pictures of those here. So there you see kind of deep ulceration cobblestone. So this is what this is what I would look like in ulcerative colitis. You can see that it's continuous and you get something called pseudo polyps as well Microscopic change. So this will come up. These are kind of buzz words you have to just learn because they'll come up in an exam. So you get crypt abscess is in, you see, and you scored that sells. But the key differentiator, really here is the granuloma. So you get them in Crohn's and you don't get it in. You see investigations. So we've already had a look at some investigations the endoscopy and colonoscopy with usually a biopsy, and to have a look at the microscope and look at the images that we can tell. We can tell from that we can also tell through just blood Just threw blood testing. So looking at the CRP, looking at something called a fecal calprotectin, Um, and also other imaging modalities as well. And there's something called the true love and with score that can give you an idea of how severe the diseases. So it grades the disease. Uh, and as you can see it, just the severity depends on the presence of any one of these features. So really, the presence of pyrexia tachycardia and anemia. If that is present, it automatically goes to the severe spectrum. Uh, otherwise, it's largely based on the number of stools, amount of blood as well, and also the SMR IBD. So these are some X rays, um, of what you'll see in terms of different IBD images. So if you look at you see, we can see that this is a section of the colon and we're getting a loss of how strong. So how strong or the natural? Um uh, the natural, uh, the natural kind of things that you see in the colon and it's the differentiated between small bowel and large bowel. So how straight you'll see a small kind of indentation, and then it will go like that. It'll go. It'll go like a small semicircle. Let's see here it's quite smooth, and you can see it again. Here is lots of house do in the colon. That's kind of like a key indicators. Review seen as well in Kroger's because it's transmural. You can get fistulas. You can get something called You can get these strictures, which are quite common and they're called can't or strictures. If you ever see that exam, uh, and you can get you can get something called Can. You can get something called Rosenthal or Ulcers as well, which I don't think you can see here. There's also another buzz word to look out for for Crohn's. Um, and remember history can invade the local structures as well, so it may affect the bowel initially, but it can invade into surrounding structures as well. Okay, you see management so it can be split into inducing and managing the flare up, so it's kind of more severe cases as well. So, um, people, if you want to induce permission, the key thing to remember really here is because it's quite along with the medication. The key thing is that you use aminosalicylate so things like mesalamine topical or oral. So when you say topical in your urine rectum, uh, you mean you mean rectal? And that's it's largely based on the, uh, the actual location of the of the of the kind of information that we found as well. The the key thing here is that you do something like mesalazine in. You see either topical or oral, and and if it's severe, then you jump straight to cortical steroids, usually IV, and then sometimes it will be combined with cyclosporin as well. When you're managing a flare up again, the key thing you use here is this a one C. You don't have to worry yourself too much about this specific. So the question I gave you earlier was quite mean. Uh, the key thing you want to know really here is for you see, usually use things like muscles in this first line, and then you and then for remission. You can use other things like, uh, Azathioprine and met a cafeteria with Crohn's. Uh, you don't go to. I mean, it's a it's a straight away. You start with a little cortisone was like prednisone. So that's why that's why we started with the muscle spasm, that question and we didn't do prednisone them. Add on therapies as well, so you can use You can use methotrexate as well, and that's you can use metal capturing, uh, the therapy as well. But another key difference with maintaining remission is that methotrexate is only used in chromes, whereas in you see you'd use as A as a therapy is a fire PrandiMet a culture uniforms Sochi differentiators you see or in snow is aminosalicylate. That's the main management here. You start steroids, and you can use methotrexate. Otherwise, uh, you know, sell seats are not usually used. And the set of indications for the use of Democrats and also the smoking is a big one and aminosalicylate it's only used. So if you've had previous surgery, for example. But that's the that's the the key ones you don't have to get to. You don't have to get two specific with the drugs so moving on. So almost a 26 year old woman who is known to have type one diabetes presents with a three month history of diarrhea, fatigue and weight loss. She has tried excluding gluten gluten pollutant from her diet for the past four weeks and feels much better. She requests to be tested so that a diagnosis of celiac disease is confirmed. So what is the most appropriate step? Right? So I think this is quite clear cut, so we'll stop it here, so yes, so the large majority. So, yes, I remember that if you go off gluten, then that inflammation, those kind of key markers are going to go, so you can't really kind of diagnose it. So unfortunately, you're gonna have to tell the patient to start eating, please. And again So you can actually formally diagnosed it. Another question. So Roxanna, a 42 year old woman presents with fatigue, abdominal distention and weight loss, which comes on over the last two months, she has had fevers, night sweats and some diarrhea over the same period. She has no past medical history. On examination, she has bilateral inguinal lymphadenopathy. A blood test reveals a raised anti T TG What is the most likely diagnosis? So so this one's a bit more split. This is a very common exam question as well. All right, 10 more seconds. We'll stop it there. Okay, Um so, unfortunately, the majority, we actually got wrong, so it's actually be enter of the associated T T cell lymphoma. So basically, what I'm trying to suggest in this question is someone who has celiac. So they have raised TTG antibodies, who also has some sort of weight loss and, uh, and basically signs of cancer. And really the only sign of malignancy the only kind of malignancy associated with celiac disease is be okay. Multi lymphoma is the one associated with H. Pylori infection. So if they had kind of like the other symptoms to do with that, then you suspect that TB usually would be a bit more obvious. And it would be like in a foreign country, probably rest symptoms. Sicroidosis will usually make it a bit more obvious. In the exam will be like raised a PSA levels and, uh, and other blood tests as well and kind of kind of key key, like lymphocyte lymphadenopathy as well, um, and really kind of lymphadenopathy because of the time frame and also that raised anti t tg. You're not really thinking about that. That much. So be is the right answer. And usually it's something you just have to remember something associated with a lot of business. Okay, so now I'm just gonna hand over to my colleague Mohammed, who go through the remaining slides. Uh, so the next one is just We're just going to talk to her celiac disease. Okay, so I'll stop sharing my screen. He's going to start sharing his Yes. Yeah. Thank you. All right, just give me a second. Just showing my screen. Okay? All right. Um, Abdullah, can you see the screen? Yeah. Okay. Perfect. All right. So my name is Mohammed. I'm one of the few doctors as well work in the same trust as a bill. Uh, just a disclaimer before. And if you judge judge me for wearing scrubs on a Sunday and then get dressed up just to teach, I came back and work, so don't judge me too harshly. All right? So I'll be doing the second half of the presentation. So moving on from Abdullah's MCQ about celiac disease just to give a brief overview regarding celiac disease, so celiac involves information of the mucosa of the upper bowel, upper and small bowel. Um, it's an autoimmune condition caused by sensitivity to the protein gluten. And gluten is a protein, which is contained in things such as wheat, barley and rye. It's thought to affect about 1% of the UK population, and repeated exposure to gluten leads to visit atrophy, which is you'll come across that an MCT questions for celiac disease soon as you see the little atrophy, think celiac disease and that virus atrophy. That in turn, causes malabsorption, so investigations include anti e M. A and anti T TG I G antibodies, and those are the most sensitive tests. But when testing for this, also make sure to test for serum total IgE because if they have a deficiency in total IgE a, then you can't really rely on this anti T TG test. The gold standard, however, is a small bowel biopsy for via endoscopy and Abdullah mentioned in his previous MCQ paper in his previous MCQ question before testing for any of this, make sure they reintroduced gluten into their diet. So other conditions which is associated with celiac disease, involved dermatitis, dermatitis, herpetiformis, which is a skin condition as well as other autoimmune conditions such as Type one diabetes and autoimmune hepatitis. So some of the symptoms for celiac disease involves abdominal pain, bloating and cramping. You can also get anemia, iron deficiency at iron deficiency anemia, and if there's family deficiency, you will get macrocytic anemia. What that means is, if you look at the MCV and the MCV will be large, larger than normal. We mentioned about weight loss. Abdullah mentioned weight loss in his MCT pain in his MCQ question. In terms of what you see on blood tests, you can get on an F B C for blood count. You can see anemia and depending whether the iron deficient or UM or the B 12 deficient, it'll be microcytic or microcytic anemia. Um, and you can also get a little calcium high phosphate and the albumin. But the main things to look for an MCT papers will tend to be the FTC and getting micro microcytic anemia. So the management, the only real management for celiac disease, is basically avoiding gluten, and that's the thing that causes a problem. But that's quite difficult. As you can imagine. A lot of things contain gluten. Um, another thing you can do is just give them supplements because they will be deficient in quite a few things with the gluten free diet such as calcium and vitamin D supplements. And also, um, some people, not all people, but some people will see the disease. They tend to have a degree of functional hypersplenism, which means reduced function of the spleen. Essentially, for that reason, sometimes they're given they offer the pneumococcal vaccine. Um, and they offered boosters every every five years. And then they also offered influenza vaccine's, depending on the individual basis of the patient. So our first MCQ let me start the pole. Uh, okay, I'll give you some time to answer this question. Let me read out. The question is all A is a 30 year old male who has rushed any by his cousin following an episode of Hematemesis. He is John Doe. He has a BP of 90/60 and a heart rate of 140 BPM. His cousin admits that I have been drinking seven beers a day for the past 10 years. What is the most appropriate next step? Give you some time to answer mhm. All right. I think most people have answered, so we'll just share the results. So Yeah, most of you. Well, the vast majority you've got to write. Um, the answer is a to re approach. So for those of you chose a or D, you're kind of on the right, right tracks. But this patient is acutely unwell. So the first thing you want to do is a to be, um, this happens in real life and in your skin as well. So a TUI Airways breathing, circulation, disability and exposure. That's the first thing you do with any acutely unrolled patient. This patient's got a BP of 90/60 and heart rate of 140 BPM. So this patient is hemodynamically unstable. Even if you think this patient is having an upper GI bleed and you want to calculate the Glasgow Blackford school, the first thing you need to do is stabilize this patient. That's do you know, if you don't know about the Glasgow or black fir instance, what's happened? Can you still see my screen? It's in the power point, So if you just want to protect the slides again. Sure. Yeah, we can see it now. Okay, Um I'm just going to re launch the pool for this. This next question and for those of you don't know about Glasgow Blackford scoring, we'll talk about it later in the presentation. So you're initially suspected, um, allergy wise tier Miley Royster. But your senior told you that in fact, he's found gastric varices on endoscopy, which you ordered. What is the most appropriate definitive management for this patient? Right? About 50% of you answered, So I will stop it there, and I'll just share the responses. So most of you have choose E? Yep. But the correct answer is actually d sclerotherapy. So, firstly, let's talk about a n c T o p. Preston and board spectrum antibiotics. So, in the management of variceal bleeding, you give to the depression and also prophylactic antibiotics before endoscopy. But that's not the definitive management. If there is gastric varices definitive management, it's actually sclerotherapy. So that's injecting any albuterol to see you in a choir late. I don't know if I'm pronouncing it right, but that's the definitive management. And for those of you, choose E is only done so tips transjugular intrahepatic portosystemic shunt is only done if the the above measures don't work. So your first line definitive management would be sclerotherapy. Um, it's only if that fails, then you would try a tips procedure. But I understand why many of you would have chose tips, probably because the questions about definitive in there but the most appropriate definitive management is sclerotherapy first, and only if that fails, would you go for a tips procedure, which is the last resort. So let's talk about Upper GI Bleeds. So firstly causes upper GI bleeds include ulcers, malignancy, soft radio viruses and in the soft radio viruses. It tends to result from severe vomiting, and they tend to be alcoholics and people with various soft tissue viruses have large volumes of blood loss by vomiting. And then you also had bought harvest syndrome, which I think Abdullah mentioned earlier. It's when there's a spontaneous rupture of the esophagus, which occurs after repeated episodes of vomiting, so symptoms of clinical signs of upper gi bleeds include hematoma. Missus, which is vomiting of blood. They also can complain of coffee ground vomiting, which is because the blood is digested in the vomit, and it looks like it looks essentially coffee ground. Molina um that is like tar like black, greasy, offensive digested blood in the stores. A few days ago, I saw Melena on the ward, and it's the only time in clinical practice that I've ever gagged. It smells really, really bad, and it literally looks like tar. So if it's one question you tend to ask by gastroenterologist. So when you say, um, Melena is is the patient on ferrous sulfate tablets? Because if you take ferrous sulfate, which is basically iron replacement tablets, your stools tend to be black. But with Molina, it's more tar like and runny. And that's how you can differentiate between the proper Molina and just patient on ferrous sulfate. But, yeah, it smells really, really bad. It can also be human dynamically stable, human dynamically in stable. So if they are losing blood, they may have a low BP, and they may be tachycardic to try to compensate for this blood loss. And they can also have epigastric pain as well, which would indicate ulcers, possibly John Johnson as well, indicating some kind of liver disease. So moving onto scoring systems for GI bleeds. There is two scoring system to use. Glasgow Blatchford and Rocko scoring. So the way I remember it and differentiating between the two Glasgow Blatchford score, Blatchford has a B so be before endoscopy. So Glasgow Blatchford is done before endoscopy and rock. All is done after, I guess maybe after ends in an hour so you can remember after the locals go so Glasgow Blatchford score. Um, that basically, you do the scoring for the patient and that determines how high risk of a patient is a upper GI bleed. If the score is zero, they can be considered for early discharge. But if it's any higher, then they probably requires urgent endoscopy. Um, and the things you look for in Glasgow battles going is a drop in hemoglobin. If there's a horizon urea. The reason why they look for a rise in your area is when the blood gets broken down the GI tract. It releases urea BP, low BP, heart heart rate, if their, if their if their systolic. If the if the heart rate is above 100 on admission, they score one on the Glasgow Blackford score Molina and syncope. You don't really. You don't need to know how to calculate the Glasgow Blackford score. Just know that it exists. And just think about rising. You're dropping hemoglobin. Those are the kind of things you look for in Glasgow, back from school. And the Rachael score is what you do after endoscopy to see if to determine the risk of re bleed and overall mortality after endoscopy. The management of the upper GI bleed, as we mentioned earlier in that test in that MCQ paper, Um, a to re approach is very important. Um, so a B C D e immediate resuscitation. Um, the blood. So the blood you'd send off is fbc to, you know, check for the urea for the low blood count. Um, you'd also want to send off a group and save a cross match. For those of you who don't know the difference between a group and save and what cross match is group and say, if you just take a blood sample, send it to the lab just so they can see what kind of blood type the patient is. Um, whereas a cross match, if you send in the lab, um, not only did they try and determine what blood type the patient is. They also save some units of blood for the patient, for immediate transfusion. Um, going through this, um, a B A B a t e d. Approach two large bore cannula is very important for them to transfer to transfuse blood immediately if required. Um, endoscopy, as you mentioned before to stop any anticoagulants, uh, and said so if they're on apixaban, for example, I have a If they if they have a f and they're on apixaban or some other type of anticoagulant, the first thing you want to do is stop it and see if you can reverse it at all. For example, if they're on warfarin, you can give prothrombin complex vitamin K um, and then the management here. I won't go into too much detail because I think we're running out of time. Okay, But saw for your virus is so you have to only person. You get bored spectrum antibiotics prior to endoscopy, and then you do virus your band ligation. And if all that fails, then you can do the tips procedure for gastric biopsies again. Totally. Person Broad spectrum antibiotics. Definitive management is chemotherapy. And if that fails, tips procedure. Okay, Got another MCQ paper. Keep on saying paper Question Sweet orange for so Brenda, a 49 year old woman presents with a five day history of right upper quadrant pain, jaundice, hailstorms in dark urine and the temperature of 38.1 Celsius. The following lft results were obtained. What is the most likely diagnosis? Yeah, I'll just wait for 50% to answer. And then sorry if you didn't get a chance to answer just we're running out of time. Um, so that's in the pool and the show. The results. So most of you actually got it right. The answer is cholangitis and we'll go through Why? That is so for just explaining cholangitis Ascending colon. The itis is a bacterial infection typically caused by E. Coli, um, in the military. And the most common predisposing factor is gall stones. In this question, the patient had right upper quadrant pain, jaundice and fever, and that is typically known as Charlotte's Triad. So, in an MCQ paper MCQ question, if there's those three symptoms right upper quadrant pain, jaundice and fever just think cholangitis even the clinical practice it doesn't happen that frequently probably happens in about 20 to 50% of patients with cholangitis just in an M. C. Q. Question. They'll make it really obvious. So Charlotte's tried, uh, right upper quadrant pain, fever and jaundice. If they also on top of that, if they have hypertension and confusion, that's something called Raynaud's pentasa. But, yeah, that's the answer to that. So call a static markers. So called Stasis basically is when there's a stagnation or a marked reduction in bars, secretion or flow. And the typical, uh, market which are raised in that kind of condition is L. P G, T um, and Billy Rubin. So LP's therapy is raised. But there's a low specify specificity because it's also raised in pregnancy and in bone growth that has Paget's disease and breast cancer. GGT is more highly specific. Um, it's seen in call Stasis and also raised an alcohol use. If a patient comes in and they have a history of alcohol, use the GGT, but most likely be high. And then Billy Rubin could also be raised, and some of the causes of, um, conjugated Hyperbilirubin Abia. Let's see here because we're finishing four minutes so I'll try and rush through. These apologize from rushing through them if you fill out the feedback on in the end, which hopefully someone will post, Um, soon you get all the slides, Um, and also the MCT you questions that you didn't manage to fit in in this session. So John Doe's you can split it into three different types of John just prehepatic hepatic and post hepatic. In Prehepatic, you tend to get normal urine normal stores. In hepatic, you get dark urine and normal stores and then post hepatic, which tends to be obstructive, such as Goldstone's. You get dark urine and power stores and this table here. It's really important to memorize, because in in progress tests, they will probably give you some LFTs and give you some symptoms. Whether the patient has darker and pale stores and ask you to determine what kind of jaundice it is, whether it's obstructive or, um, prehepatic, Um, so I won't be able, unfortunately, to go through this table, but just in your own time. Once you get the slides, just make sure you memorize this table, which is really important. Um, on the liver, I'm just explaining some of the liver markers, um, in some of the markers, which are raised when the liver is damaged. So an A S T um, that is raised when there is liver damage. But again, it's not as specific as others because it's also present in the muscle cells. Lt is typically raised in liver disease, and it's usually more highly raised, an ASD apart from when there's alcoholic liver disease, where the ST to lt ratio can be 2 to 1 or 321 are women is also used as a marker to determine how much damage is done to the liver, as well as prothrombin time, which is probably the most accurate or the most specific marker to determine the synthetic function of the liver. And PT stands for a prothrombin time, which is basically the time it takes for the blood to clot, so liver cirrhosis finish in two minutes. Okay, uh, liver cirrhosis, Um, just quickly going through it. Um, just know about the child Pugh scoring system for a liver cirrhosis, um, you get a maximum 15 points and causes Felicity causes here. Management includes ultrasound and AFP every six months to check for hepatocellular carcinoma. Patients with liver cirrhosis are higher risk of developing a hepatocellular carcinoma. Also consider endoscopy every three years having a high protein and low sodium diet. Um, and also doing well. Now it's going every six months to see whether they require a liver transplant. Hepatitis um so hepatitis basically describes information in the liver. So the different cause of hepatitis can be alcoholic, nonalcoholic fatty, liver disease, viral autoimmune or drug induced. And they typically present with abdominal pain fatigue itching because of the high bilirubin, um, nausea, vomiting and, yeah, quickly going through viral hepatitis. Um, it's important. Just memorize the the key differences in the stable for your progress test. So the key differences is for fecal oil. Hepatitis A and hepatitis C E. R. Both transmitted fecal orally. Hepatitis B is only one, which is DS DNA type of virus, and it's also important to know which ones you can get vaccinations for and which ones you can't again. Just memorize this table. I'm sorry I don't have enough time to go through all of it. Um, let's do this. MCV Q. Question. Uh, let me read it. For those of you, Um what would you read? A six year old male garage with alcoholic liver cirrhosis is seen in the pathology outpatient clinic is visibly jaundice. And since his last follow up appointment is developed, worsening societies which of the following blood test when compared to his previous will best represent changes in his liver function? I think it's eight o'clock. So if either Daniel Abdullah can post a feedback link for those of you for those of the participants, so you need to leave early, right? Okay. And the pool there and you guys are learning a lot. Yeah, you got it right. So most of you got it right. It's prothrombin time I mentioned earlier. Prothrombin time is the most accurate marker of synthetic function of the liver. So when there is any hepatic cellular injury, just try and look at the clotting time, both on one time. Um, okay. Another MCQ question. Let's share the whole. So Abbas is a 20 year old male medical student. He's unsure if he has had his happy vaccination or not. In any case, he required to have psychological testing. Um, please interpret the following results. You know, for those of your medical well most of your medical students. Make sure you got your happy vaccination done. It's important. All right, Um, wait till 50% of you've answered, and then I'll share the results. Okay, I share the results. So about 43% of you choose E, which is the correct answer. So it's basically a table you just have to memorize. But HBs a G is a surface antigen for the hepatitis B, and if that's positive, you're basically you basically have an active infection going on. Um, an anti H B. C is the core antigen of the hepatitis B. Um, and if you have that, it's most likely a chronic infection. But the thing which differentiates between acute and chronic is this I g m I gm is negative. If this is positive, then I would understand if you could put if you put Dee, um, an acute infection. But because I GM is negative, it is a chronic infection. So this is just a table you have to memorize. I'm sure it's everywhere. If you go past that, it's probably there is the same table everywhere. Just make sure you memorize it, because when I do progress tests I remember when I did progress tests. At least one or two of these came up like every year, so it's just memorized it to be fair. Um, okay, alcoholic liver disease. Um, so we'll just talk about some types of alcoholic liver disease. Um, some of the symptoms with alcoholic liver disease include jaundice, hepatomegaly, gynecomastia and sometimes asterixis, which is a flapping chairman, which the only really get in decompensated liver disease. So alcoholic related fatty liver disease is when drinking leads up to build up a flat, which builder, which is stored in the liver. But if you stop if you stop drinking, the person's tends to reverse in about two weeks. Alcoholic hepatitis um, that's when drinking alcohol over long periods of time causes inflammation in the liver. Uh, mostly mild. Alcoholic hepatitis is reversible with permanent abstinence, and then cirrhosis is where the liver is made up of scar tissue rather than a healthy liver tissue. And this is irreversible. But still, you told the patient to stop drinking because further drinking need to do further damage, and the prognosis is really poor if they continue drinking nonalcoholic fatty liver disease. Um, so that's when you have fatty liver disease, but they're not. They don't have a history of drinking. And that form is part of the metabolic syndrome, which is a group of chronic health conditions relating to the process of storing energy. And this increases the heart of the risk of heart disease, stroke and diabetes. UM, so that is characterized by fat deposited in the liver cells. And these fat deposits can interfere with the functioning of the liver cells. Um, it doesn't initially cause a problem, but if it does progress, it can cause hepatitis and liver cirrhosis. And liver ultrasound is used to confirm the diagnosis of, um, nonalcoholic fatty liver disease. Um, and you can also do E l F blood testing as well, which can help specify how severe the alcoholic fibrosis, the liver fibrosis management includes weight loss exercise, the topic of smoking, avoiding alcohol and then referring them to a specialist, a liver fibrosis specialist. It was 8 to 6. I'm really sorry you had to question the end. I know one hour of listening to us, um, can be difficult, but this is the feedback realm, and hopefully someone's posted a link down below. There's still about, like 15, maybe 20 slides left, where we talked about PBC, PSC Wilson's disease. And there's a few other MCQ questions, But you will get all the slides for that. And we've also put noting in the slides down below, um, for when you fill out the feedback from you'll get the slides. And there's also some MCQ questions as well. Um, so, yeah, gastro is quite an intense topic, and it's quite a few topics to cover. So maybe I think we could consider if we have some free time to do another presentation on gastroenterology and do, like a gastro to version two point. Oh, because I appreciate we rushed through the end, but I hope you learned something. Um, and yeah, if you could fill out the feedback form and let us know, what could we do? Better? What was good? Um, really be appreciated. And thank you for taking out the time on a Sunday to listen to us. Um, and I'll have a look at the questions and see if I can answer any. Yeah, thank you very much. Yeah, I think if you if you asked, um, So you do get the slides in the recording. Um, if you feel like the feedback home, if you have missed out the previous, um, presentation that you wanted the feedback form for to get the slides. Just message us on either Facebook or INSTAGRAM, and we'll try and get the slides out to you. I think there was some issue with the respiratory, um, feedback form. So? So we're going to just, uh yeah, the form is fixed, but we just need to re upload it. We do have a list of people who filled in the temporary for we made, uh, sorry. We will try and get them. Upload it tonight. I have actually uploaded the side. Just so if you do access the, uh, metal page, it should be up there even if you didn't feel it pulling the feedback link. I'm sorry, Jenny. No one responded to on Facebook. I'll make sure I look out for your message and I'll apply to Jenny, but yeah, I'll go try and chase up on who is meant to be applying on the face book. Facebook messages. That's why l t greater than esteem. Nonalcoholic fatty liver disease. Um, so L t is the more specific marker out of the two when there's a liver damage. It's only when you have alcoholic, um, alcoholic liver cirrhosis. That's when the A S t is greater than the OT. And it tends to be in, like, 2 to 13 to one ratio. Um, I was just answering one of the questions I want to hear. Um, just a disclaimer. I didn't come up with these slides and one of my colleagues there for boss. Um, he came up with those slides. So many, thanks to him. Also, that QR code isn't up to date one, is it? Is it not? I thought I thought it is a beer Sent it to me. You put on Okay. Okay, that's fine. I think so. Let me let me check my phone and let me see. Just follow the link that we put on the track. Yeah. Have words with the beauty of This is wrong. Not nice, right? Yeah. No, this this coupon code is right. Thank you. Thank you, dear, for sorting out the feedback from as a big shot out to you. Yeah. Okay. Should we send it there then? Yeah, sure. Thank you, everyone. Thank you very much.