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Yeah, The war, we said, is give them about 30 seconds to read it and then launch it. And when we get to about 50% then if you go, you know, safe can expect. Yeah, it's faster if one person's what it does the Poles, because it can get really confusing when you pass the positive listen to or I find out. But he's doing the whole thing. Yeah, Look there. Thanks dot Okay, so the stream is finished reading it, then I'll put the pool, and I think, Yeah, good for you. And you cannot see me. Uh, let me do. Yeah. Yeah. Loaded people from, you know, you were saying that your like she was really good already. Okay. Thank you. I appreciate that. Yeah, Yeah, I had a swell on. They said they were really good. Okay, Already. Good. What's stressing about it for a few days? So glad you like, you know, because you know, people like private masters just to say, Well, don't you? So if you're gonna be better, I don't know. I'm not as common. You and I in scripts. Is moving a parent like it's a they're attending for everyone and It's seven. So worried. Yeah. Yes, we stopped. 11 on the go. I do it. Uh huh. No. Hi, guys. Welcome to a said. We're going to start soon. We'll just give it a couple of minutes. Yeah. Okay. Great. Okay. Welcome, guys. Toe asymmetric Siris. And this is our third session of our age. Part session on today. We're gonna be talking about gastroenterology so little bit about myself. So nice to meet you all. I'm safer bars. I'm a 50 a medical student at parties, and I'm currently indicating in population medicine on together with, ah group of F one doctors and finally a medical students. We've been together a really great teaching program for you guys on do. You might have already attended to of the session so far. And so the session with cardiology has been done on. But we've also had Mohammed doing Risperdal last week. I know some of you really enjoyed that. So over the next four weeks, we'll be covering these other topics that you can see here. At the end of the session, we're gonna provide a link to a medal link, and if you'd kindly fill that in and at the end of the session, you'll be able to get access to the slides. Well, all right, so I'm going to start off now. So these are learning outcomes for today, and there's quite a lot. And it looks like a lot to cover because there is. But I'm going to try and just do some of the key elements if I can. So we're going to cover all of the topics that are in the topics that are in red on. The topics in green will be left for the surgical session, which will be coming up soon. Okay, great. So let's start with an S p A. So Mohammed. There's a 45 year old carpenter and his board by his wife, who claims that he has had difficulty swallowing food, Um, and also drinking. And he keeps coughing at mealtimes. He complains of heartburn, and there's no history of weight loss or hemoptysis. So there's gonna be a pole. So if the left but the polyp for me, please. Right. And if everyone could just on send a pole, any questions that you have this put them in the queue and a function of the chart and our team would finance them. Okay, Graze. That's about about 50% of you. Wonderful. So, um, I'll show you the answer. So the answers actually see. And so for those of you that chose the other, the other ones, you're on the right line. Spirium swallow endoscopy. They are really important. But there's been a little bit of an update in a nice guideline. So this patient has dysphasia, which is difficulty swallowing on. We can't actually fairly ascertain what the problem or the causes. So what you can do is you can do something called manometer E. And that's when a small plastic tube is passed down into the esophagus to measure the muscle pressure along different points. So starting at the base of this, think they're on moving upwards. So if you chose, it will be on the right lines because they're both reasonable investigations on be also part of nice guidelines, but we'll come on to that in a moment. Wonderful. So let's talk about accolades. Yeah, So it's the failure off the sofa Jill Parastatal cyst. Under the relaxation of the lower esophageal spirit of speak to the sphincter hello s would be call it And that's due to the loss of generative loss of ganglia from our backs plexus and so typically the esophagus is further dilated above, and then we'll have a look at an image in a moment. So in an accolade, so you have some clinical features that's dysplasia, but liquids and solids, and it's typically variety off. There's a There's a big variation of severity of the symptoms, but they can include heartburn, regurgitation of food. It might lead to cough or aspiration pneumonia on in some patients, that actually might be a malignant changes. Well, so what investigations do we do? So I suffer germinoma tree on that just shows us excessive low s tone on does know, relaxation on swallowing. Then barium swallow is lots of your right pointed out, and that shows a grossly expanded esophagus on. We'll look at the bird beak appearance in a moment, and then finally a chest x ray so wide me decide him. And an increased fluid level is one. And to how do you manage it? So you manage it. First line with the pneumatic balloon dilation, a surgical intervention with hello cardiomyopathy. What cardiomyopathy me should be considered if recurrent or if it's persistent symptoms. You can also do interesting sphincteric injection of Botox or botulinum toxin if there's a high surgical risk for the patient. And lastly, there's also a drug therapies, especially calcium channel blockers and the Philippine. But thesis I'd effects actually limit the use of this medication. So here's three examples of some images. So we've got a corkscrew here. I would also go a bad beak. So a little bit about the bird be that we just talked about. You can see here that spincter out the bottom is constricted, and that gives this sort of what looks like a bird be sort of shape where your diet where dilates the esophagus. Onda corkscrew is actually where there's primary esophageal contractions, and that's interrupted by multiple tertiary or non propulsive contractions on. And that's what gives it this corkscrew appearance. So dysplasia. So there's some other courses of dystasia as well. So, firstly, esophageal cancer so dysplasia might be associated with weight loss on a wreck, CIA or vomiting during eating past history, you might also include about esophagus, a gorgeous s of smoking or alcohol use. So so then the esophagitis. So there might be a history of heartburn, a dent, aphasia, but no weight loss. And they're systemically well, that's off. Joe Candidiasis is so they might be history. In this case of HIV or other risk factors such as scoured inhaler use burned your pouch. And that's when you get a herniation between the posterior media on the thyroid for engineers and also the cracker far NGOs muscles on you. A Leo. It's not seen, but sometimes it might be a midline lump in the neck on. It'll gargle on palpations on, but these patients will also have dysplasia or regurgitation in my aspirated. And a chronic cough is, well, it's halitosis, which is bad breath. So my senior gravis, so other symptoms might include extraocular muscle weakness or Tosis. Um, especially, and with alongside the dysplasia with liquids as well as solids. So that's a really helpful overview for exams of some other causes. So once the next SBA, so those are here. There's a 25 24 year old male patient who's bought any with Harry umbilical abdominal pain radiating to the right iliac fossa. He mentioned it was worse in the ambulance when they went over the speed bumps. He's vomited once at home and is mildly pyrexia. Also, he has a temperature of 37.5 degree Celsius. On examination, there's rebound, tenderness and abdominal guarding on a rousing sign. Positive. So if you could have the polyp, I'll just give you a couple of seconds to have a look about. It's great, great constipation. Wonderful. Great. So says Thea. Wonderful. So most of you got it and I'm sure you know what it is s Oh, yes, in this case is appendicitis on. The reason that you get a radiation is because of the stretching of the appendix alumin. And the appendix is a mid got structure. So you get localized parents and Neil inflammation. Other common things which happen are under Xia Periumbilical pain and nausea on you know, that typical radiation to the right iliac fossa is a typical sign, a swell as far as being sign, although their husband and updating this where it's saying that Rosenstein is not that indicative anymore. But if you palpate the left iliac fossa, it causes pain in the right and left us that you might see the, um placement. So it's worth knowing that on them in terms of the answers. Yeah, so it's up. Injecting me is what? What you would do appendicectomy story, but you would also potentially give prophylactic antibiotics intravenously. So for those of you that chose a that's not not a bad thought about choice on this is the quick cheat sheet for a pen deciders, and you have a little later on. So just the point of that were just talking a little bit about regional abdominal pain and how because you have pain in a certain area doesn't mean that it's it's always going to be a a gastric course. So in this case, for example, we had, um, like a little pain that radiates to the right iliac fossa and see if we have a female patient. We might have been thinking about some other things, like ectopic pregnancy or a very intelligent. So that's just a summary for you off the nine questions. So the next experience a 50 year old gentleman Ahmed presents with that gastric pain radiating to the back. It's usually improved by eating, but comes back 2 to 3 hours following a meal, and he also complains of normal on examination he has epigastric tenderness. What is the most likely diagnosis? Great, Great, wonderful. Really great participation. So greater. So most of you got the right answer. So, Judy, no ulcer on. We'll go through. Why? So firstly, it was biliary. Colic would probably be in the right type of chondral. Um and they would actually describe it as a colicky pain in the questions them if it was, See, it was actually worse after eating, and in this case, it's actually improved by eating, which is our my main sort of catch point in this question. And I could be doing actually, it could be gastroesophageal reflux disease, but the question is just more likely to be in this case on DA. Lastly, if pain was severe, epigastric pain that radiates to the back, um on the patient was more unwell, as well as other signs like Collin Sign and Great Earnest Sign, which will see you in a future session. And then it would be more like to be pancreatitis. Great. So just dyspepsia so dyspepsia itself. It's a non specific term used to describe indigestion, and it covers the main symptoms of gastroesophageal reflux disease, or GERD. It from America. So some of the symptoms include heartburn, acid regards, register know or a gastric pain, bloating of a nocturnal cough and a horse voice. And some of the causes could be peptic ulcer disease, God, which we just talked about gastritis or gastric cancer. And it can also be functional. So just because of the anatomy, or and the patient will be born with, ah, functional difference. So this is a really good algorithm that I put together using nice guidelines. So if it patient has dyspepsia and over 55 you know, with a mass or one of these following would call them red flags alarm. So anemia, loss of weight and a wreck See, a a recent progressive, uh, onset of symptoms. Molina, which is Tori black stools that are foul smelling, um, or hematemesis on on Dora swallowing difficulty. Then we'll follow this. Ah, this algorithm. So if yes, any of these ones, then they need in urgency, weak and oscopy if not your manager as gastroesophageal reflux disease or peptic ulcer disease. And if there's no improvement, we test for H. Pylori, which we're going to talk about in a moment on def. that's positive. You do triple therapy, and if it's negative, you do. You give him a PPI. So I guess your stuff is your reflux disease. So the stomach acid reflux is into the esophagus, and that damages the squamous esophageal lining. You can give them a PPI, such a result, or lansoprazole, but often patients are encouraged to have lifestyle changes, so I'm to exercise. Also just do with lying down after eating in some patient they might actually choir and niece and fundoplications. So according to not, which is a procedure where you're up basically in a surgical procedure where they rub the stomach on around the esophagus on. I'll show you a picture of that in the moment. So the nice management for Endoscopically proven esophagitis is a full. There's PPI for 1 to 2 months. If that doesn't work, you give them low dose treatment for a longer time, and then, if that doesn't work in a double dose of a PPI for for a month, if it's under sculpting endoscopically negative, you give them full. There's PPI for one month. Then you try a low dose treatment on then a third line, which is not often use is an H two are a a prokinetic, and that's given for a month. But this is only for certain patients in certain groups and again, just a reminder of the red flags that into account for. So that's things. Uncle of the Nissan Fundoplications on the slides will be available for you to use after this so about esophagus. So this is actually a complication off gastroesophageal reflux disease. So the squamous cell epithelium off the lower part of the esophagus is replaced by Columbia at the billion from the stomach. On it is an increased risk of a dinner costing over by 5 to 100 times. So in terms of management, you do endoscopic surveillance with biopsies every 3 to 5 years for metaplasia, so metaplasia is usually reversible. Changes of one cell type to another after exposure to a stimulus. In this case, the gastric acid. Um, Andi, you give a high dose PPI on then, in some cases where there's dysplasia, which is precancerous changes, you do an endoscopic because of resection, or you do radio frequency ablation and some risk factors of watch out for are that 7 to 1 patients on male central obesity and smoking as well as gold, which is what we just talked about. And that's just a picture of the changes in the in the in the squamous cell Epithelium being being replaced by Columbia so that could be easily come up in the next time is a lot of pictures. So, um, energy d is performed on the patient on they visualized a bleeding peptic ulcer. So what is the most appropriate next step in the management? Um, if you could have Depo Brilliant, Great. It's between and be event Great was in the poem. So most of you chose a and some of the trees be and I can understand why, so that the is the right answer in this case. So the balance is you do you give a jenaline and they give a drilling injections of only quarter rise? Um, Andi, people who chose be so bad ligation is usually done for somebody or barest. He's so this is not a virus that this is a the peptic ulcers bleeding. So actually giving you the diagnosis on C is for gastric Barris. He's on four. So this, uh, I had to pronounce it the same stake. And I think it's since since take and Blakemore tube and is a red tube that you sometimes see on the war that's used to stop slow bleeding from the esophagus and the stomach. And that bleeding is also actually caused by viruses or, you know, by gastric varices or esophageal viruses. But it's usually slower in terms of bleeding's. That's another option on tips will talk about that in a minute. So peptic ulcer disease so H. Pylori is responsible for 95% of Judea know else is on B 75%. Gastric ulcers. Another course of peptic ulcers is a drug so and said that that's our eyes. Corticosteroids. And it's possible it's on Fedley rarer but Salinger Ellison syndrome. And that's a rare that's a rest in room caused by characteristic excessive levels of gap of gastrin and that often causes that's often from a gastrin secreted tumor. So how do we actually manage it? So usually you just give them pee pee Eisen to it's healed. Um, so, um, alprazolam lansoprazole. But for HPAI Laurie, there's a slightly different algorithms just in a really important thing to stress. Does this difference between the duodenal ulcer or gastric ulcer there. So epigastric pain relieved by eating in a duodenal ulcer on and it's postprandial you that sometimes put it as for a gastric ulcer. So H pylori so 3 to 1 algorithm or triple triple triple treatment eso It's a grand negative bacteria on do, um, it's a camp I low back to like organism s. So what you do is you do for investigations. I'll do a nap it up. A giant oscopy a urea breath test which looks at carbon 13, a stool antigen test and a rapid urease test. Um, on then management waas you'd give a proton pump inhibitor plus amoxicillin plus clothes from my Sinemet tinidazole. But they're penicillin illogic. You'd give them a proton pump inhibitor, plus metronidazole and clarithromycin. So just a quick summary of some other conditions. So Salinger Ellison syndrome we've talked about already. Gastroparesis delayed gastric emptying usually second reach a long term, poorly controlled diabetes on bill present with a lot of appetite feeling full up to eating any little bit and weight loss and pain on, then softened your perforation. Or so the cause of this could be boerhaave syndrome. which is to be a vomiting, um or, ah, trauma on the management of that is, and there's a gastric tube decompression on G feeding, antibiotics, PPI and surgery Just rushing through that. But you can always have you come out of it later. So on to the next one. So the same is a 25 year old male who went to the GP after four months of struggling with having to go to the bathroom. Too often, it's bowels 4 to 5 times a day. He says that it's been worse around his exam periods because he hasn't attempted any age lectures rookie era, and it feels bloated and worse after eating, he's generally quite fit and has previously tried dietary changes. So some of the test that we did were F B C's yes, R C E R B vehicle calprotectin anti T TG and they were all within range or negative. So what is the most appropriate treatment options to go? The whole Okay, great course again. So, yeah, most of you got it. Correct. So the answer is, deal A para mind. Okay, so we'll talk about why so in this, um, I have a lot of my body kind of concluded that this is actually I BS. It's a little bowel syndrome, So if the patients in pain, you'd give them an anti spasmodic Um, if they're constipated, you give them a lot a laxative, but you need to vote. Avoid lactulose because that can actually make it worse. But for patient with diarrhea, in this case, I could say, Look, Paramygina is the first line management, so just have a quick look at it. So it's important to know, I guess, is a functional bowel disorder. There's no underlying organic disease, but we don't use the phrase diagnosis of exclusion because it is, it is sort of. It does have parameters, so the symptoms could be diarrhea, constipation, fluctuating bowel habit, abdominal pain, bloating. It's worse after eating usually and it's improved by open bottles. So a little bit about the management. So you know, a Zeiss said, you can give the para minds or brisk a pan. Some patients actually might take a T see a or in SSRI, and in some cases CBT might be might be warranted. But, um, really important part of management is actually the conservative management, so limiting caffeine and alcohol fluid intake, regular small meals on low FODMAP diet, as well as a trial of probiotics before weeks. And that's part of the guidelines as well. Thank you. Okay, so next SBA so T we'll do is a 27 year old women who's investigated for bloody diarrhea. This started around six weeks ago. She's currently passing 3 to 4 loose motions in the day, which a loose motion is another for a term for for diarrhea, which normally contains a small amount of blood. Other than feeling lethargic, she remains systemically well, with no fevers or significant abdominal pain. A colonoscopy is performed, which shows inflammatory changes in the ascending transverse and descending colon consistent with ulcerative colitis. So her blood showed the following. So these are the blood results, and this is just a normal reference range because you look at all right. So what is the most appropriate course of action for this patient? Little bit more difficult. This question and thank you for participating. Great. Let's stop the polar. Okay, okay. So really close between B and C's. There wasn't clear cut this time on dial stand. Why? So let's let's talk about this. So the answers actually be, in this case, the oral and rectal in Minnesota. So let's so we can't really tell what the four grading is from this question, which maybe is a floor of the question. But based on the options we have here be is the answer so or allow and rectal administer. Listen, it's I'll. We'll explain why it's not open this land, but and the other options are not. Not not viable one. So we're going to next one. They get up. Sorry, night. And one more question before we talk about it's been so, uh, Horizon 30 year old women. And it's admitted to hospital with abdominal pain and diarrhea. She has no past medical history other than depression, for which he takes the teleprompter. She smokes 20 cigarettes a day and drinks 20 units of alcohol per week. Um, so she had a really a colonoscopy, which shows speech is consistent with Crohn cities, and she's treated successfully with a glucocorticoid, uh, glucocorticoid therapy. So what is the most important intervention to reduce the chance of another episode? Great. Okay. Yeah. So most of you got it right. There's a bit of competition between BNC, but, um, yeah, it's important to stop drinking alcohol, is we'll? We'll talk about the guideline in a moment, but stopping smoking is the number one sort of a recommendation and nice guidelines for a wife of being of protecting, um against remission. Great. So on the IBD. So inflammatory bowel disease. So also typical itis and current disease. Great. So they have a similar effect on the population's also supplies. A slightly more you have. Similarly, they both have. By middle distributions, family history is related to both cases. In ulcerative colitis, patients will have often have linked to HLA B 27 conditions. So there's a list of conditions that will. We'll talk about in a moment, such as I'm closing spondylitis. We are active. Arthritis is better words Writer's syndrome, which is previously what needs to call active arthritis, um, and then also enteritis. So infections that present is the cause of many reluctance on in close disease. This can sometimes company exams progress just a couple of times on that patients of white European descent, particularly Ashkenazi Jews, um, I have a higher a cup higher incidence of trains disease azelas. Since we've had you on a dissecting me. So there are risk of developing chronic of of developing currencies after the surgery, and here's just a little bit of a more detail about what it took. Like his brothers currency. So in closes is you'll get to know asthma's, which is a feel, a tenesmus feeling of being full and not being able to pass stool a fecal urgency, bloody diarrhea, abdominal pain. And that's particularly in the left lower quadrant, whereas with cruise you're going to get mouth else is there might be a bit more non specific. So weight loss and lethargy diarrhea on. They'll often have perianal disease, skin, skin tags or else is, um, so in. Patients with Crone's are not surgical isis. You'll also get, um, some changes extendedly so you'll get things like everything mono dose, um, often now that can present on people shins and limbs and pyoderma gangrenosum just examples. So it'll be more about pathology. So, um, also typical itis. The sight of that is usually in the large bowel, and it can result in backwash ileitis um, in crazies. It's mouth, too anus. So it's along the whole GI tract, and it's commonly distance. So it'll be in the proximal colon or the ileum um, infla inflammation wise. I've got some diagrams to illustrate this. So the ulcerative colitis inflammation affects the mucosa. Only where I was in chrome disease is transmural. So what I mean by that is it goes all the way down through the layers. So, um, you cosis of mucosa muscularis on the cirrhosis in currencies. On that something you might be expected to actually label in an exam as well. So make sure you able to label the layers. Um, but it's important as well, for when we talk about treatment later. And then in terms of microscopic changes, you have continuous pseudo polyps. It's continuous. So firstly, it goes in, um ah throughout the throughout the tract, in one sort of been one sort of area. So they're affected. Area will be a block of affected area off effective tissue on baby pseudo polyps. As you can see here and these ulcers, alterations, rising crows, disease, you have this really typical cobblestone appearance on bail have skip lesions, and that that makes it difficult for investigations, because when they do biopsies, not every single part of the tissue along the whole supposedly affected area will actually have changes, so they have to do multiple biopsies. Um, and patients will also have perianal history and then microscopic changes. So, um, also typical itis You have the script abscesses here concede that and reduce goblet cells. Whereas in Crone's disease, you have granuloma. Is this sort of swirly areas here, which is the lighter and stuffing something to look out for. Wonderful. Okay, so what investigations do we do? So, um, you can use routine bloods for anemia, infection, thyroid, kidney and liver functions. Um, the CRP, my indicate information and active disease really important is fecal calprotectin. So this is released in the intestines when they're inflamed, and it's usually a really useful screening test. It's 90% sensitive, and it's specific. The IBD and adults industry is important as well. So with the biopsy with the biopsy is the diagnostic on dim itching is important as well. So I've written here ultrasound, ct, an MRI, but Iraq chest X ray abdominal X ray is really important as well. In terms of grading, you can use the Drew love and with school. Um, yes, so and you can look at that urine thymus. Well, so investigations of IBD so a little bit more. So let's talk about, um uh, these two images here. So this is a barium enema for the Chron's disease One. All right. And as you can see, there's a, um there are strictures, and there's something called counter string String sign on Deacon. See? A proximal wrote approximately bowel dilation as well as what we can see it here. But supposedly Rose Thorn ulcers on distally, whereas in ulcerative colitis you'll get loss of how straight in, which are those lines that usually run across the bowel the way on a swell as thistle of long, narrow short appearance, which is called a dream pipe colon. And that's really typical. So how do we manage it? Sorry, a lot of text on this slide, so this is sort of to management's for IBD. In general, they're inducing remission and then managing a flare up. And that's for for both Crone's and collided so in colitis will have in multimodal it. You'll have if you've got prostatitis. I'm a left side of current cholitis. You'll give them an immunity to say it so something like Ms Alazine in Ah, and that would be a topical or or that there's no remission in four weeks on by topical actually mean a rectal. So it's not like you're putting on skin. It's actually a wreck. So topical actually means rectal. That aura will be taking a little medication so mild to moderate. If there's extensive disease. Based on the previous scoring system that we talked about, then you give again, you'd give a Minnesota say, but this time you give topical on the high dose or a low on do you can consider biologics like infliximab. They're like trials that have been done where patients have had positive outcomes on then acute severe colitis has to always be managed in hospital. And if there's no improvement within 72 hours, so you give steroids so it gives steroids such a second sporin um, on. But if the stories are kind of contra indicated, and if there's no improvement within 72 hours, you would then give, um, cortical steroids, plastic, aspirin, and then the last resort is surgery, so managing a flare up. So if you've got a mild to moderate flare of prostatitis, for example, Then you'd given a minister little late on get you. Follow the same algorithm and following a mild flare or a left sided extensive. You see it, then give or eliminate salicylate, but a low dose this time, and it's usually given for longer. And for a severe flare of two exacerbations in 12 months, they might give all immunosuppressive. So is it by print or contact urine? There is some evidence, actually, that probiotics may prevent relapse in patients with a mild to moderate see. So that's another, less severe method. So managing cranes is, is so we talked about this earlier in the SBA, so there's two main types of induce remission. There's a monotherapy where you can give ah like a court accord such as prednisolone, methylprednisolone, hydrocortisone and then some patients. I've given budesonide, but it's not as effective in the trials that have been done on. Then then, then you do an add on therapy. If if the mono therapy doesn't work so you can add, uh, a salad see norm, a clot up urine or methotrexate. If the patient can tolerate the previous the lab data talked about on, do you can then try things like infliximab. But Intel feeding, in addition is really important, especially for patients who might have side effects of steroids. And this is a particularly relevant for younger Children. Um, on Benmont doing flaring about managing flare ups. So firstly, you need to stop smoking on, but stops shown to have a huge effect on on the flare ups that patients might have. You can also try all the minister precedence on. Then again, aminosalicylate Um, and then 80% of patients, actually with praise disease will be required to have surgery. Eso We'll talk a little bit more about that in the coming session on general surgery in a few weeks in a week. So on to the next SP, a story that was a lot of text on that, but I've also got a little summary sheet of the end. So initial goes to 26 year old woman who is known to have Type one diabetes my lead to this, and she presents with a three month history of diarrhea, fatigue and weight. Last, she tried to excluding gluten from her diet for the past four weeks on, she feels much better, so she requests to be tested so that the diagnosis of celiac is confirmed. And what is the most appropriate next step and have the ball, please? Yeah, Great. Okay, so most of you have gone for a quite a lot of you actually gone for the other ones as well. So let's just talk through this. So, um, the reason why we ask her to reintroduce losing her diet for six weeks is because the cereal article test and the judge in your biopsy that you do for celiac my actually negative. If the patient has been following a gluten free diet, so it seems into it, it seems intuitive now that you hear it. But the patient actually needs to eat gluten for more than one meal every day for a least six weeks before you do further testing, because otherwise you'll get a false, false negative. Okay, So easy on. So so next SPS Oh, Roxanna is a 42 year old woman presenting with fatigue, abdominal distention and weight loss, which came on really suddenly over the last not ready told me story which came on over the last two months. She's had fevers, night sweats and some diarrhea of the same period. She has no PAS medical history notes on examination, she has bilateral inguinal lymphadenopathy. A blood test revealed some raised tissue transglutaminase ttg antibody. So what is the most likely diagnosis? I'm just to say the session where is scheduled until 8. 30. So I'll try and finish up earlier than that if I can, so we've got a lot to get through. Great. Okay. Okay. So it's really almost identical between Option B and E. So yeah, this is Ah, tough question. It's a question that actually seen that's come up in a in a past paper that I did, and I actually I didn't know the answer, and that's why so I'd better better going to find out. So the scenarios will get through it early. So the scenario tells us that there's a lady with celiac disease is due to her raised estrogen level. So we've got that sorted. We know what's what's happening with this patient. We know what she's got. So the diagnosis, but we know her initial diagnosis anyway. So a diagnosis of celiac disease explained to diarrhea and expensive fatigue explains the weight loss, and it explains abdominal distention, But It doesn't really explain the symptoms that we have the B symptoms. So sweating fever lymphadenopathy. So therefore, we have to have an additional diagnosis on. And, you know, one of the possible complications of celiac disease. Is this a a T l? So in terrible enteropathy. Associated T cell lymphoma on in an exam. If there's any malignancy in the context of celiac disease, you should probably prompt that as one of the differentials. So we'll go through the other answers and why they're not so reactive. Lymphadenopathy. This can occur in the context of any infection. However, a two month history is a little bit too long to explain this. Eso number two psychosis. There's no link between celiac and psychosis, and also in an exam, a sarcoid will be much more typical. So they'll say things like every few minor dose, um, lung signs and a race serum a C in tuberculosis. It could explain the presentation, but there's no risk factors that would make TV likely. So she hasn't traveled recently. Currently of origin is not mentioned here. We don't know where she's from on, but there might well should be. There's also no exposure risk factors or imaging results, so any lung imaging results on then number four number easily multi in four months. So this is a cancer that arises from the mucosal associate lymphoid tissue, and it's actually relieved. It's it's It's a response to a chronic color, but HPAI Laurie infection. There's no indications here to indicate that this diagnosis, and and also another thing, is monsters. Lymphoma generally develops more slowly and is picked up, incidentally, rather than them looking for it. So the answer was he so celiac disease will go through this quickly. So celiac is a gluten sensitive enteropathy, and it's inflammation of the mucosa of the small bowel. It improves when Glusin is withdrawn on. Relapse of inclusion is reintroduced. So what investigations do we do? Well, serologies is really helpful. So anti, um, an anti TCG other most sensitive tests. You can also dio serum Total IgE A on HLA typing for HLA DQ, two in 90% and actually HLA DQ eight as well. So small bowel biopsy is the gold standard for diagnosis. So what they do they take 4 to 6 biopsies from different parts of the duodenum on because the disease is sometimes patches Well, that's why they have to take multiple multiple, uh, multiple biopsies. So symptoms. Abdominal pain, bloating, cramping Patients will have symptoms of anemia because often iron deficient. If it's a folate deficiency than macrocytic, uh, dermatitis, a part of formers, so they'll be very pruritic little bit achy on. They might have, ah, popular vesicular lesions on. They usually occur symmetrically over the extensive surface of the arms, the legs well as the buttocks, trunk, neck and scalp weight loss wise, it's seen in severe disease and stay artery A, which is pale stools that float, Um, and that's also seen in severe disease. So so it's broken, have very fatty stools on biochemistry, so you'll see my little moderate anemia. And and if we see the folate is common deficient company Deficient deficiency and I and deficiency and B 12 on, then these ones actually can be quite indicative as well. So you'll have a low calcium, high phosphates and a low albumin, and that could easily come up in an SBA question asking staying, you know, these are the blood tests, low calcium, high phosphates and a low albumin. What what condition do you think this patient has so a little bit about some Just a little bit more detail about the micro, the micro level. So and this is Ah, normal cross section of of Torvill I showing the shallow Crips, whereas in six iliac you'll have these flat and Bill I lymphocyte infiltration and these scripts type of pleasure. So yes, so I just quickly talk about it. So really sat rough e is most commonly caused by see like this is and thean terrorist sites. They become cuboidal with an increase in the number off the flatter realize Well, so management. So as we discussed, a gluten free diet is actually the only accepted treatment of celiac disease. But endurance is really difficult, you know, like you can think we all like to be carbs and lots of the carbs we like to eat. Ah, have a lot of gluten. And then so things that are made off grains on wheat or barley wheat for sure on insurance is difficult. So the dietary changes must be, uh uh, They might actually lead to deficiency and fiber and other nutrients. And some patients can actually at risk off being overweight or obese because the eat Ah, higher intake of simple carbohydrates and saturated fats. Um, so some patients will also requires in calcium and vitamin D supplementation. But that's only if if they've got low levels on their blood tests, it's not routinely given unless they've had a blood test. And that's come up. So just just more more examples. So some endoscopic signs that that it might increase it, it might, uh, might include. So this is the, um, uh this is the healthy tissue and this is the unhealthy tissue. So you can see this absence of mucosal folds and scalloping of the folds. And here this is really evident. You can see this is evident. Loss of belies these little bumps everywhere. These of the bill I that we saw on the previous a cross section on. You can see it so smooth here in comparison. But this picture is actually not from somebody who's not got celiac, and somebody's got celiac. But it's actually from someone who's had celiac. And then they've stopped, don't have celiac disease, and then they've actually taken gluten out of their diet on Dave. Had this improvement from this original picture off celiac disease said before treatment. Upstream in so next SBA. So are you. Is a 30 year old male who's rush into any by his cousin following an episode of hematoma. Says his jaundiced has a BP of 90/60 on dairy type of on a heart rate of 140 blood beats per minute. His cousin admits the iron drinks seven busy day for the last 10 years. So what's the next most appropriate step in this case? Just give you a few more seconds. Listen, okay, yes, So I'm glad I didn't catch most of you out. So a B C D E approach that is the correct answer on just briefly talk about why. So if you chose a or D, you're on the right lines because this patient is but because this patient is acutely unwell. So this patient's hardly ever have a peanut m a cyst on because there acutely and well, we want to make sure that they're stable before we do anything else. And the first time management option for any Upper gi I bleed is first doing the ABCDE approach and making sure patient's stable. So next question you had initially suspected a Mallory Weiss tear, and we'll come on to that moment. But you're senior tells you that in fact, he's found have gastric Barris. He's on the endoscopy, which you're did so well done for doing that. And so, what is the most appropriate definitive management? So if you want to pull up, Okay, great. Okay. So obviously there's three options here which are the most popular. And maybe my question was, um, worded as well, So But we'll get through anyway. So tell a person, uh, so the answer I have actually got that I you know, that thing is the definitive one is decent sclerotherapy so tell a person is part of the treatment algorithm, and so his tips. So it sort of goes, tell a person sclerotherapy tips. But when you look at the results of what of the definitive management for patients that have, like, this patient had a gastric Barris, he's usually sclerotherapy is definitive. But yes, it's low therapy doesn't work then Then tips is also used s Oh, yeah, so well done. Because even if you chose a are you on the right lines? So I don't get a quick summary of upper GI I bleeding. So some of these causes of upper GI bleeds are soft job Aris's for heart syndrome, which we talked about earlier. The matter ey stare, um ah, last record gastric or Judean losses on malignancy. So both have syndrome is severe vomiting, and it causes a submajor rupture just for those that Mr the first time right when I talked about that. So, um, in hematemesis is that that basically means you're vomiting blood. It could be fresh bloods. It could be a variety of different manifestations of blood, but it's a general term that's used. If a patient has coffee ground vomit thing, that's when the blood is digested. And that's why it's called coffee ground. Because it's it kind of looks at Lumpy. Um, Melena is a tar like, um, black greasy offensive stool. That's from digested blood. Um, Andi Hemodynamic instability is so blood loss, you'll have a low BP tachycardia. Some patients might go into shock, but it's really important to be aware that younger patients might actually compensate so they won't actually show that a shot and quite late until it's quite late in the in the treatment. So, um, that could be, uh, that can actually result in patients dying because you haven't treated them quickly enough for shock on then epigastric pain or jaundice. So the gastric pain is usually because of ulcers on jaundice is because of ascites or it's really societies of Aristides and liver disease. So the scoring system. So you got to scoring system that we used to the first one is glass of the classic, a bunch good, and that one's used upon initial presentations. If you've got suspected, gee, I bleed. You can actually look up online calculators, but the score above zero is high risk, and these are the parameters that we use on the rock all scores. So that's post endoscopy, and that calculates a risk of a repeat of a repeated on overall mortality and percentages. And these are the parameters that we use for that management. So I used the abated management So a B C D approach take bloods too. Wide board cannula transfused the patient, do an urgent endoscopy within 24 hours and then drugs to stop any anticoagulants for any answer is and then, um so salvage your virus is we would do entirely press in prospect of antibiotics definitive would be another GD with a varicocele on ligation and then tips on, but not a nice do not recommend using a PPI. And then again for gastric varices that the dirt definitive is sclerotherapy. So now we're gonna be one to the liver. Um, which he has is an important part of July because it's related. So we're gonna talk more about the conditions that affect 11 hour. So unacceptable being so Brenda, 49 year old woman presents with a five day history of right upper quadrant pain, jaundice, pales, stools and dark urine and a temperature of 38.1 degrees Celsius. The following a lefty results were obtained. What is the most likely diagnosis? But the pull it please bit more to unblock in this question. Okay, great. So just about 50%. Okay. Great to see Yeah. So that's the answer. That I would, uh, I would say is the most likely. So, um, the reason is you can look at the results Here is well, so the results are important. So you see, the lt's raised LP is raised. GGT raised on Billy Rubin is raised, but even from the stem of the question, you can kind of a certain what it is. So, um, we have something called What would we have? Ah, collection of symptoms. Call Charcot. It's Triad Charcot's Triad, which is, um, tried of the upper right quadrant pain, um, fever and jaundice, and that occurs in about 20 to 50% of patients. The fever is the most common feature. Not seen your 90% of patients, Um, Andi if I had two other two other symptoms. So hypertension and confusion, which also common, that would become Reynalds Penta. But we won't go into too much detail, not because we'll be covering that in the surgical session in a few in a week's time. So just a little bit about the markers themselves. So LP is low, so specificity and it might represent it's deranged. Okay, let's days is pregnancy or bone growth in conditions like pudgy, it's on prostate or breast cancer. GGT is higher in specificity, and it's often seen in a Stasis meteo age and Billy Rubin breakdown of a McGlone burn from uncontradicted conjugated liver on do some causes of, ah uncomplicated hyper billion roomier are hemolysis eso from hemolytic anemia impaired hepatic uptake in drugs congested partic failure on impaired impaired conjugation and Gilbert syndrome on the causes of hyper billion Billy Ruben anemia. So difficult to say ah have participated in the injury occurred a Stasis on note that know the skin color as well, because it's clip clinically apparent. Jaundice is usually only visible when it's above 60 on. So stool color and urine color also affected her on the similar mark. So a little bit more about jaundice. So, um so I should really put a picture up to to show you what they want us to look like because it can present quite differently on people with different skin tones that's important to look up. Um, Andi. In pre apart, it causes You'll have normal urine and normal stool in the hepatic, cause they'll be dark urine and normal stool. And in post hepatic causes or obstructive causes will be dark urine on pales stools. And so, if you look at this table that I've got over here, it just tells you a bit more detail about how the blood the blood samples might be deranged special for for liver function tests so in the blood. The blood test for preop articular haven't increased in Billy Rubin, but I'll be will be normal. And the prothrombin time will be normal as well. In the particles is they'll be an increase in Billy Rubin and increase in AARP P and G T azelas S t a l t on the PT that's increased the prothrombin time. Well, actually not be correctable of vitamin K and then post about it causes a little bit increase in Billy Rubin and increased in l P and G t on There will be an increase in in the performing time, but this time it will actually be correctable with it. Okay, so it'll be more about size toxic Marcus. So ST, um so it is a matter side enzyme on. It has lower specificity, and it's also present in muscle cells. So when you get any condition up right where muscle is broken down, you can also get an increase in a ST in a lot. Er busted my enzymes. They cause an increase in acute so it increases in acute cellular in acute participate, let injury on. It's only really seen in acute injuries, so it can't really give you an insight into what the residual function of the liver is. So, for example, of somebody Hyzaar, chronic disease you can't really tell you can't really tell what the effect of off of chronic disease is based on a nail tea. In liberties in general, lt is usually higher than an STI. The exception of this is the alcoholic liver disease, where ST the ST to a little ratio is usually to toe one or 321. So in albumin, this is produced in the liver with a half with the 20 day half life on this is quite reliable for chronic liver injury. So if you see a raised albumen and you know that this patient probably has a chronic condition related to the liver and then lastly, this is prothrombotic time. So your PT on this is the time taken for the prothrombin to form a clot. Eso fact is related to vitamin K, so to 79 and 10 meq lot in Cascade and one and five us, these are synthesized in the liver, and that's why they affect the performance time on. This is really sensitive for acute and chronic measures off artists a little injury of injury. So it's a really good measurement to think about when you're trying to interpret intact but a range of tests for a patient so little bit about liver cirrhosis. So liver cirrhosis is sort of the final stage of a lot of liver disease, so we're kind of going backwards before we go, Teo were saying at the end. Actually, before we go talk about some of the conditions, but, um, the some of the scores that we can use to look at liver cirrhosis are, um, the child's Pugh score for cirrhosis, which has a maximum of 15. And I've got a little table here azelas the meld school. So in a patient that has cirrhosis, you would use a meld score every six months, and it gives you a three month mortality estimate. So it makes you know the difference between these two scores scoring systems. So this kind of grades, the cirrhosis on this one tells us along the patient really has to live or what their mortality estimate is, and then some of the causes of it. So alcoholic liver disease and nonalcoholic fatty liver disease, happy hep C autoimmune hepatitis primary. Blue cirrhosis you matter. CHROMATOSIS Wilson's disease A. One. A deficiency on a cystic fibrosis as well as drugs. So management, ultrasounds and other fetoprotein was given every six months for about just a little A carcinoma on endoscopy every three years in a patient without known viruses, Um, also, patients actually will benefit from a high protein and a low sodium diet. Make sure that a meld score is done every six months on also a consideration of a liver problem. Liver transplant. So let's go to some of the causes now. So hepatitis, so alcoholic hepatitis, non narcotic, fatty liver disease, viral hepatitis or two human hepatitis and drug induced hepatitis. So we're gonna talk about alcoholic nonalcoholic on viral in a moment. So how does it presents? Oh, domino, Pain fatigue. Pruritis is a really common one. Muscle and joint aches, nausea and vomiting. John Days Fever. So we're going back to biochemical markers because I think this is a sticking point for a lot of people, including myself. Um, is that for hepatitis? You usually see that in ST, or there'll be a sort of a a derangement and STL with proportionate less of a rise in LP on in general, the Billy Rubin will be high, so there's a really good table just talking about about viral hepatitis. So the ones you need to be worried about hepatitis A, B, C, D and E. On it's important to know which ones are infectious on the type. You don't need to necessarily know the type of virus, but I definitely know the transmission route. So, you know, uh, hepatitis a fecal oral Hepatitis B is predominately parent Terrel. Um, Hep C's Pantera will help these parental and happen is, um is figure All is well, Onda a little bit about immunization as well. So there's no immunization for hep C on you. Happy? A hefty A paired up together. So, um, the vaccine for hep B covers you for both. A lot of health care workers will be given, uh, immunizations for happy, which I'm sure a lot of you have heart. So a six year old man Raj with alcoholic liver cirrhosis, has seen in a hepatology outpatients for neck is visibly jaundice since his last follow up appointment, and he developed worsening ascites Which of the following blood tests when compared to his previous will best represent changes in his liver function. Create well done. But I'm really glad. Guys, you're all participating, which is really great. Hopefully I haven't over sp a do I know? I've got a lot of STDs in session today. I think it's helpful just to stop between your section. Okay, we'll stop. That 50 s so brilliant. So most of you have got bad the correct answer. So proform in time. So this represents the reason why this is the answer is because, as we talked about before, when I was going to the different test, this represents the synthetic function of the liver. And in this particular case, you know, he's jaundiced on he's developed worsening ascites on down. We want to actually see what the difference is between his current condition. You know, whether his liver function is actually good or not on the best way to tell that it's through a prothrombin time, right? So actually, little bit less thinking than you'd think this question. Okay, So Abbas is a 20 year old male medical student. He's unsure if he's had his happy vaccination or not because, you know, he wasn't paying attention doesn't have a red book with him. And in any case, his required have psychological testing by the med school. So please interpret the following results. Saving for the polyp. Okay. Mm. Maybe a little bit more unsure about this one. This is a case of just learning the learning, the different, the different buttons trying. Well, with some understanding, if you can. I mean, we'll stop the polar, so Yeah, So a bit of a mixed bag there, So let's just talk about it then. So the answer is actually e in this case. Okay, so maybe no weapon was thinking, but I've kind of tripped you. Actually, I wanted to make sure you guys just didn't choose the right answer just from the stem of the question. And you actually were able to interpret this. So let's have a quick look. Right? So I guess most of you chose vaccinated because he's a medical student or, you know, I think that's probably what you think, But if we actually look at the serology, so let's just look at the definitions really quickly. So HBs a G is hep B surface antigens in HB. See, a GI is hep B core antigen in anti h B c is hep B core antibody on anti HBs is the hep B surface antibody. So I would This is a really good table, and I just find it really used to learn from. So in this case, the patient had what a bus. She had an H b s G that was positive and anti h b c. That was positive. And he had an anti HBs that was negative. He also had an anti hbc i gm. That was negative. So in this case, he would have had an active HBA HPV infection. That's actually chronic in this kid. Sorry, I know is a bit of ah, a trick question, but I just wanted to make sure you guys, actually the point of the question was know about his symptoms. The point of the question was, Can you interpret a hepatitis B serology? You only need to know the serology for hepatitis B. So have a look at that in your own time. So alcoholic liver disease, we nearly there guys not want to go 20 minutes. So alcoholic liver disease, which cat is can can lead to alcoholic hepatitis and then cirrhosis. So we're going backwards? Actually, no. And so what are some of the symptoms that people have? So they'll have jaundice, but megaly spider knee by Palmer erythema gynecomastia, Which is Ah ah, proliferation of glandular tissue rather than fatty breast issue. Um, that might lift like breast tissue bruising. Do two abnormal clotting ascites and cup of Medusa, Which are these engorged duper visual epigastric Baines? Um on asterixis. So that's that liver flat if you guys have done any osteo stuff so on. But that's in decompensated liver to these on, um what? What things we need to do to look for it. So fbc So there'll be a raised a mean corpuscular volume, and the LFTs will get elevated. Lt and ST, um, on the you should be a low albumin due to the reduced synthetic function of the liver. So we talked about earlier being a good indicator of synthetic function A z well, as as well as an elevated bilirubin and cirrhosis that also be if you look at the clotting w elevated PT time do to reduce synthetic function again. So relating to the SBA that we did on the, um you need also might be deranged if there's a lot of renal syndrome, so a little bit about nonalcoholic fatty liver disease. So, um, in this case again, you get a progressions. You get non narcotic, but none nonalcoholic fatty liver disease, then nonalcoholic steatohepatitis fibrosis and then, finally, cirrhosis. So patients that affected by this often have are obese. They have a poor diet. They might have Type two diabetes, usually middle aged, um, smokers, heavy smokers. And they probably have high BP. So biochemical findings again? A little bit. It'll pull. It would call a biochemical mug it so this a little. You will be raised more than the ST on Do. Um, investigations wise, there's a liver ultrasound that can confirm diagnosis of the hepatic steatosis on another really important test is the enhanced liver fibrosis. So if you've got these reference ranges, so if it's less than 7.7, that's none to mild. If it's more of a 7.7 to 9.8, that's moderate fibrosis and 9.8 indicates severe fibrosis. You can also do something called a half of the five fibrosis score or a fiber stand. So, management what do you do? Weight loss, exercise? Stop smoking. Control the diabetes on BP as well as cholesterol. Avoid alcohol. And if patients need to be referred for, um, liver specialist and they might be treated with vitamin E and P o clock Tizer. But mostly it's the love life lifestyle factors because you can't necessarily reverse some of the effects of these of these liver of these liver conditions. So, uh, next year Jessica is a 40 year old female who presents to the GP with profuse itching. She's slightly jaundiced and has yellow deposits around her eyes. She also has a past medical history of rheumatoid arthritis. So you order a biopsy which confirms what immune inflammation in hepatic cells. So what is the most appropriate treatment option for this patient? I'll just give you 30 seconds with this one. They have competition. Wonderful. Let's stop there. Okay. Okay. Great. So, um okay, so I can somewhat This is kind of a confusing question, but let's just go through it. So we're gonna talk about the condition behind this. So the some people most people choose be, but a lot of you chose Dia's well, So you weren't you were closed. And so the reason why this is deers because it's primary biliary cirrhosis. So we'll talk about this now. So it's an autoimmune inflammation of the small bile ducts on down the obstruction of the upper lobe bile, which was not in cholestasis fibrosis, cirrhosis and liver failure. Um, so again, all those conditions we've been talking about they lead to cirrhosis and liver failure. So I got little picture here, kind of just just visualize where we're talking about in the liver so we can't be still bile ducts. Onda features of patients will have like that. They're in the stem of the question. Would be fatigue, Pro writers, July disturbance, jaundice, pales stools and the one I wanted you to pick up one was this. Once it's done a xanthoma or xanthelasma Um, which are these? So these little dots of these are these little deposits that build up, um on. But it's sort of a hallmark features of primary biliary cirrhosis. So just other signs of cirrhosis like ascites spend a mega spite of me by So investigations are probably really important for this condition, so liver function tests again. LP is the first liver enzyme to be raised, But you can also look at things like, uh, auto antibodies. So, um, a coupon drill Antibodies, then also am a, which are present present in about 35% of patients azelas other blood tests. Oh, yes, ah, I GM liver biopsies on golf. So liver biopsy is really important because although it's not the first test we do, it is a test that's quite definitive. So it tells you about the diagnosis on the staging of the disease, but it's very invasive, So you only want to be doing a biopsy on a patient for most conditions that after you've done bloods, even though that might be the best and most of finished definitive management. And here's a picture just off the spider need by that was talking about earlier. Great. So this is just a quick cheat sheet for primary blue cirrhosis, and we just look at the management. We talked about the else So, um uh, so dear deoxycholic acid. It reduces the intestinal absorption of the cholesterol so you'll remove those. There's extra Matt manifestations, like the xanthelasma on also curly star amines. So it's a bile acid sequestrian that binds to bile acid, and it prevents absorption in the gut. And it can actually really help with pruritis. So in some of these conditions, because they're conditions that affect people for probably quite a long time for the remainder of their life. I'm in some cases, a lot of it is about symptom symptom management. So that's why the answer was Was these two for long term? Yes. You can give him, you know, suppression with the steroids. But in this case, we just wanted to manage the patient immediately. And that's why you would you would give them out. Okay, so primary sclerosing cholangitis. So this is an interest. Actiq or extrahepatic Ducks be constricted and fibrotic. So here we're looking here on discourses, an obstruction of the flow to the vial out of the liver and into the intestine. The risk factors are a male age 30 to 40 alt cholitis and 70% of patients on a family history don't present with jaundice. Chronic right upper quadrant pain pruritis fatigue in about megaly. The lft is the air pee will be raised at first and then the bilirubin will be raised. And we'll also get a job to Ranged lt and ST um, diagnosis is done by Marcy Piece of migrant magnetic resonance cholangiopancreatography on you also, which is basically an MRI scan of the liver. But the liver, bile ducts and also the pancreas on then management wise liver transplant is seem to be curative in about 80% of patients have a survival rate of five years, and Ercp can be used to diarrhea to dilate and stent any strictures on. Then again, you can use a cold a star on me, which is a bile acid sequestrian that we talked about and also monitoring for future complications such as cholangiocarcinoma, cirrhosis and Barris leaves are all really important in most of these conditions associated with the liver. Just a couple more conditions were nearly done. So on SBA again. So Leyla is 43 year old female who presents the GP with profuse itching. She's slightly jaundiced, and she's been suffering with depression and a lack of concentration. So her partner notice is that sometimes she's been slurring her words, and this has just come on. So you examine her on Duodenoscope thing a bit different about the way I look and so you decide to look at it under the slit lamp is well, and you put a little bit of a blue light filter as well. But And if you wanna, based on what you can see here and based on the question, what is the most appropriate treatment option for this patient? Okay, it's very couple more seconds. I'm sure some of you know what This is great. So share the results. One forgets, and most of you have got it. So it's a Palestinian penicillin mean okay, and the condition that we're looking at is Wilson's disease. So Wilson's disease There's an excessive accumulation of copper in the body and the tissues on. It's because of the Wilson's disease protein on the chromosome 13, which is a copper binding protein, and it functions to remove excess cougher copper in the liver, and it's autosomal recessive. So you basically have two streams of symptoms that you get with this condition. So the first treatment is a copper digestion in the liver, followed by chronic hepatitis and then cirrhosis. And then the second stream that I've started separated into is copper depart. Deposition in the C. N s, which cause neurological conditions and also psychiatric conditions. Unfortunately, so this is the image that had showed you was what we call, well, a Kaiser fly sharing. So that's the deposit of copper around the iris. And sometimes we'll see this brown ring. There are some people who have naturally have brown rings, and it doesn't mean that it's a copper deposit, but it's more easily seen in patients who have light eyes. Um, so one of the features So dysarthria, dystonia, parkinsonism and depression hemolytic anemia, renal tubule acidosis is osteopenia, which is loss of bone mineral density. We investigated by doing a serum, uh, chiropractors Menand. It'll usually be low, but it's not specific enough. So you do need to do a liver biopsy forward for copper on the liver, which is the gold standard, as well as a 24 hour urine. Copper acid could be very helpful. So what we do is we do capitulation. Chelation just basically means a fancy word for removing the proper. So penicillin mean, especially being able to identify kind of like a rings. So, um, uh, hemochromotosis so hemochromatosis is a different type of story. This time it's iron, so that results in a total body I and interposition of iron, um increasing and the human hemochromatosis protein. HFE gene is located on chromosome six, and this is a lot of so more recessive, uh, condition as well. So patients will be chronically tired. They'll have joint pain. They'll get a bronze discoloration to their skin. Not that's not really the same as, um, fire sort of the thyroid ones, but so Cushing's with thyroid disease or any of those. It's slightly different color, but it might also help last erectile dysfunction amenorrhea, um, on cognitive symptoms of memory or mood disturbance you investigate with genetic testing is actually gold standard testing for this for this condition. But you can Dortch that's hemochromatosis. But in terms of actually checking the the effects of the patient or the level of disease on, do you would do serum ferritin or ah, transfer in saturation. Um, so just a little picture of a healthy liver, how it should look versus an iron overloaded liver place. Simple diagram, but it might maybe we'll remember it from that. So management wildly do venous section Savina section is when you you might've seen on placement in hematology, where a patient will come in on. They'll have their blood weekly once a week, usually removed, so they'll they'll actually bleed into a bag on bail. Do testing those on the bag and see how much iron there is, and that's just to decrease the total iron. It seems quite primitive when you think about it, but it really works that also do a pulse. Same. I haven't recently here, but there's a liver biopsy that's used for gold Standard. They'll use what's called a post. Ain't to see the extent of disease. And really interesting fact is that for men, this is you diagnosed in their forties, when they're iron level starts decreased, whereas for women it can actually present later in life because they have regular loss of of iron three menstruation. And so that's a really in the back. Put it into context. Why and how venous actually works on. Then just a quick, uh, Aces summary summary card for Alpha one antitrypsin deficiency. And this is the third surgeon it condition, which is an abnormality in the gene for a protease inhibitor. Kel Awful one antitrypsin on. We'll just talk a bit really briefly about it so last days is an enzyme which is secreted by neutrophils, and I just connective tissue is so in a 1 80 on this is mainly produced in the liver, travels around the body and office protection by inhibiting the new triple last days. Enzyme. Um so symptoms are it can eventually lead to liver cirrhosis, but it also has long manifestations earlier than liver manifestations. Management wise, you know, stop smoking symptomatic management because there's a large range of symptoms as we've talked about back and care as a result of liver damage on DNA. Nice actually do not recommend a replacement for a 1 80. Um, the diagnostic criteria is low serum alpha one antitrypsin on genetic testing. So long term wise genetic counseling on monitoring for for future complications is is probably the most we can do for this condition. Okay, it's just a SBA now coming towards the end So early lands on his gap here in for, uh, early land from his gap here in Peru, after eventful on a comfortable flight was eventful is well, um on he thought that he would have one last quick ceviche A which is a raw fish. If I need you like that. I mean, I quite like it from the street vendor before his two of our journey. He doesn't really feel so great now because halfway through the flights, he began not feeling so great on which will be the air. Hostesses are not happy about that. So his stools were watery and he has abdominal cramps and he feels very nauseated. So what is the most likely cause it'd organism of the symptoms of it. But the polyp, we'll do a bit more on this in our infectious diseases lecture, which is coming up. So this is just a really breathe, um, a really breathe intro. And I can see there's a bit of people are not totally sure the answer is that's okay because it's quite a difficult, difficult topic. It seems quite easy. Okay, so salmonella is the top choice, and that is also the answer that I've gone for. So I'll just quickly go through this really quickly. So diarrhea on the wh definition is more than three loose or watery stools per day. If it's under 14 days is acute, and if it's over 14, it's chronic. So cause of diarrhea, gastroenteritis, it might be accompanied by abdominal pain or nausea or vomiting. Diverticulitis. It's classical left, lower quadrant pain and history and fever Antibiotic therapies. So patients that are on the ward had broad spectrum antibiotics might develop. See, dear, um, uh, they might have diarrhea, but C diff is also seen with the antibiotic use Constipation overflow, Which is one of put me with the worst ones for a patient. Maybe, is, um, you know, history of alternating diarrhea and fecal incontinence. And this is quite common in the L. D. And then some courses of chronic diarrhea that we've really talked about our IBD IBSS, but like like cancer and celiac. Just a quick review of gastroenteritis and a different condition of different organisms. So the reason the answer was salmonella was because of the incubation period. So I said about halfway through the flight, so about six hours incubation. So try not to get too confused, cause it could be. This question always comes up on exams, so I'll just go through a couple of the different organisms. So E. Coli that's often in traveler's. They'll have watery stools, abdominal cramps and nausea. Jarred Isis prolonged a non bloody diarrhea, cholera, watery diarrhea on a lot of weight last you two dehydration. It's not common in travelers. She gotta months. They'll have bloody diarrhea, compiler. Back to ER now. The reason the answer wasn't combined back to is because, firstly, it was too short because it's usually 48 to 72 hours for compiler back on. But the patient would often have a flu like prodrome, so I didn't really give you a bit more. I should have, maybe giving you a bit more information about how he was feeling. I just wasn't feeling great. But if he had been a bit more fluidy and that there's more description of that, then that's something you can think about, Um, and also my mimic appendicitis. So the pain that they might have is that central pain that radiates to the right on da Mr the Sierras. So let's, uh, vomiting your ms is two types of insist. Yes, that one is the vomiting. All this in six hours, and that's typically do two rice on then. The second one is the diarrhea wellness, which is up to six hours enemy biases. So that's a gradual onset. Bloody diarrhea that last several weeks. Onda. I think that's everything. So I'm just quick, just a couple of styles left. So these are just are a said flashcards of summary statements. I've got one for good, one for you See on for growing disease. And I'm also upload one for for celiac is Bob. So thank you so much for attending today. I know it was a bit longer, but I'm glad to see a lot of you stayed on, so if you could just please follow the medal link it was already been posted in the, um it's really been posted in the chat on. But please, please follow the QR code. If you want, fill in and fill in the feedback. It really helps us. So we know how to tailor our sessions towards you. We've got a great number of sessions coming up. So urology, general surgery, infectious diseases, end of crying and hematology. So the next one is on, uh, on the Thursday which is our new only decision should be run by moment. So feel free to cut to come along to that one. If you have any questions, please put them in the queue and a and we'll stick around out to answer some of them. Um, if you want any questions, you have any questions? You want to ask me a question directly? Then feel free to do that. Um uh, put my email in the charts. I try not to bombard me on, but I hope you enjoyed it. And I hope that wasn't too long. Okay? Yeah. And so he's asking. I go back to the bacteria. Some idea. Sure. Yeah. So there you go. She had the important to remember about the bacteria. Is that the with the different organisms that cause some of them are not bacteria. Some of them have to sell. And, um, it's just to remember that there's two things to remember. The first thing to remember is what is the actual patient presenting with? That's usually the first thing you look at is the diarrhea bloody. Do they feel ill? Have vomited. So I don't I haven't put norovirus. Yeah, but that could also been another differential if they were vomiting. Um And then the second thing to look at, which I think is the hardest thing when you look at these questions is how long have they had the onus full and not always trips me out on. So this is a little thing I've given you in the top. Telling you about incubation period is really important to know. So make sure you fill in the feedback forms on, but you'll get the sides like through that as well, so you'll be able to access everything. So they've got the links been posted in the chapter. There's also a and QR code. So I go back to the prediabetic. Yes, so this lives will be available. So you have you as long as you feel in the metal metal list, then the medal survey you'll be able to access that You want me to get back to what was the pre create partic attack and passed about it? Causes of jaundice. It's regular. So I think that's probably the hardest topic. Um, I've tried to cover everything I think about that. Okay. Okay, so I haven't covered it in full detail, But you can see here and thank you, Doctor. E A. I'm glad you enjoyed it on makes you sign in the future in the feedback forms for that, you can look back in there the back of this life later. So, uh, pre about it causes. So if you think this is probably the best thing to look at on, don't think maybe I didn't explain clearly enough was whereabouts. What actually means so simply prehepatic is, um, any overproduction, um, or impaired Optic by the liver in in hepatic um, in hepatic cause, um, you get decreased congregation and interposed about it cause which is usually related to the gallbladder or the pancreas. You get decrease excretion on. Do you get an intra or extrahepatic obstruction? See, I keep the questions coming. Why is the feces different color in the tape to make sure you ask questions in the QNASL. Well, because we've got a whole list of experts who are on the panel who be happy to answer your questions. So why is it different? So it's to do with the I haven't put it in a year, actually, because it is, there's a whole like maybe I'll put it in for your for the final presentation. You can access it, but there's, ah, you have Billy Rubin, which is conjugated and unconstipated on that turns into your ability in on day, I'd have to double check on exactly what the name, maybe what Somebody in the queue and can answer it for me. And But you have, um, different substances that are come from Billy Ruben on those colors correlates the color of the stool. So especially for stay arterial, which is where you get those pales stools, is basically because you have a breakdown product on been in the case of Melena, where the stools dark and it's Tori. That's because you've got blood that's been digested on that broken down blood. It's a dark, horrible color, just from the process off off the blood being digested by the stomach acid, Um, and also in the intestine. So that's why you get a change in your stool. So stores a really good indicator, and I I didn't put a picture of it. But the Bristol's door chart is another thing. To look at it. It's a really good indicator of a person's health. In some cases, it's rudimentary, but it's it's a good way to just give a quick overview. So if the patient has a fatty stools, then you know that there's, ah, light colored stool. You know that there's something wrong with their biliary system, Um, or something wrong with the liver. That's in very simplistic towns. But hopefully that was helpful. I'll keep it open for another 5, 10 minutes. If anyone has me questions, you can put it in the, um, in the child. Great. Okay. Well, thank you very much, guys, for attending our electric today. There's nothing. No other questions then, um, so pale feces that that's, uh that's what I'm talking about. When? When you have, like, close to one steatorrhea. I think we're gonna end there. So any questions, please? Just send us. Ah. Sent us any messages on base. You feel in the feedback forms. Thank you very much for attending. Yeah.