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Hello, everyone. And welcome to the weekly surgical Siris by mindedly Thank you very much for joining us. And today we're going to talk about appendicitis, which is quite a common topic and one of the most common surgical emergencies. So if he if you do well on a surgical ward, you're most likely are going to come across a big would have been the scientist, and so without further ado and I'm going to start the session. But just wanted Teo remind everyone that you can just close your questions in the chart at any time. I'm going to try to make the session a bit interactive. So I'm going to ask you questions as we go along. Um, on, if you have any questions at any time, we can also contact us at their mindedly on email, which we're going to you both later. And if he want to have access to you today session, they're recording and other materials you'd have to fill in their feedback form, which we're going to post later on. And so let's just move on to their sessions. So the key point it's mild like ti pattern today is like everyone to understand what? The presentation of acute appendicitis. This we're going to focus on key parts of the history and examination, then regard so occupied key surgical investigations on going to practice application of those skills during a case. So my name is Sarah. Action off Scot. I'm an academic F y to doctor and I currently working Mary's during vascular surgery and my interest about from vascular surgery group plastics and teaching and research. So the case for today you have to bear in mind that you're going to be the surgical F way one on take and you're going to be clocking clocking a patient. So the patient that um, comes through the door and you have to assess her name is Rose. She's a 21 year old female. She has no past medical history. She presents with nausea and vomiting, which started this morning. She's unable to eat. Um, on the first introduction notice was that generalized Abdominal pain, which started two days ago, um, and now has moved to write Elliot's closer. She also complains of some diarrhea on. She feels hot and sweaty and say, I would like you to be think about it, potential differentials. So what are seven? Um, some possible with allergies here, you can put your answers in there in the question box. If you can just think about what could be that from the appendicitis, which is the topic of this conversation. And if you could think about what other diseases or what other problems crazy might have. And I'm going to try and look up the channel box. Correct And lab today through this way parties now? Yeah, that's very good. That topic Pregnancy of our incidence of our interruption. Yeah, that's a very good Yeah. Okay, Chris, I okay. That is very good, because it actually that everyone was thinking about it. Not only Castro in the spinal causes Well, it's about kind of college. It'll pathologies. And also, somebody said testicular torsion interception like school. Very good. And so when you when you have a patient, he he comes for the door of abdominal pain and you have to think about all the possible differentials because that's going to tol pew. Decide what investigations you're going to do on how you're going to monitor the patient. So the way we're going to approach this case, um, we usually use the pneumonic stumble when we're taking the history. Um, so we have to know what the signs and symptoms are. We need to know if the patient has any allergies with medications they're taking. We need to know what the relevant past medical history is. We want to know because they might need a surgery. When was the last time they had anything to eat, but also for females? We want to know when The last when? The last minute, Mr Period. Waas, um we to examine the patient s. So we're going to do the 80 examination for Rosie on going to do the investigations, which I'm going to go for in a second. But those aren't consists off bedside blood cell radiology. I'm so moving. Teo, our differentials, um, you have identified them very correctly, So there is one way of looking at them is to group them into an atomical six times or body systems. And so the dust a designer causes, as you rightly said, could be the inflammation bowel disease, meckel's diverticulum, um, gastroenteritis. And it could be the stick it a torsion. If we're thinking about urological causes that we did, um itis, or UTI, and some gynecological pathologies could include ovarian cyst, rupture a topic or pelvic inflammatory disease. So this is why it is very important, as we're going to touch on in a second that for a while females we have to do a pregnancy test on day and Advair course could be mesenteric adenitis, and that's usually seen in Children. And usually it's preceded by so afraid. And and you did. The treatment is conservative, so it's quite a important, important differential. Acute appendicitis, um, as we're going to talk about it in more detail and DKA is quite important. Thank to bury mind, because appendicitis is most common in people in second defends the head of life. Um, sometimes first to defer decade of life, depending on on the source and again president very similar to DKA. So this is why it's very important, as I'm going to attach on a second that we do the blood glucose level for the patients who come in complaining of abdominal pain and vomiting. So, meeting on so acute appendicitis, um, festival we, we're not really sure will develop the appendix cysts. Um, it might have some, um, some functions are related to the immune system. But reading through the literature it's really difficult. Identify with the rule of appendix is and it's attached to seek in on day. Um, usually, what happens in acute appendicitis is, I guess, obstructed. Um, in younger patients. Usually it's due to lymphoma hyperplasia, usually after a viral disease, and in older patients it can be blocked by, um, by her. It's still called a fecal on very rarely malignancy. So tremor off affecting cecum already appendix. So the pathophysiology, um once their appendix gets obstructed, the mucous secretion and normal secretions that usually happen in the appendix continue. The pressure increases because there's lots of secretions and the out that is obstructed. Um, at the same time, the bacteria, um, over Gross and that then results in a Dina ischemia and the crosis. So it's quite a bought entity. Treat those stations in that time they manner, Um, because when they present to the simple appendicitis, taken quite easily progress to to complicate your preference. Appendicitis. So debating appendicitis, Um, I think majority of you would have heard about the migrate three pain, so I just wanted to explain a little bit off was the reasoning behind it and and why they're paying start in the center of the abdomen and then moves. So the appendix is the right from the mid gut in the embryo. On the mid good is, um, there are visceral a friend pain fibers which are associated with structures right from the mid goods, which will which will localize the pain to a T 10 dermato. Um, So when the visceral party, um, gets irritated, those five is will cause this generalized pain around the Enbrel like it's around there, the belly button. But as the inflammation progresses, um, the outer layer, the Paris or peritoneum of the appendix will get irritated as though. And that activates somatic nerve fibers, which are much better a discriminating where the structure is inflamed and it's causing. The pain is located at, as opposed to the visceral Afrin too painful pay fibers, so this then causes the migration of the pain from the center of the abdomen. Teo, the right iliac fossa. And there is also a change of the nature of the pain. So from the sort of a dull pain, it becomes sharp and localized in the right index also, that's that's classically happens within 12 to 24 hours, and the patients usually describe this central domino pain, which then makes the right iliac fossa, changes the nature from Delta shirt, and then it's associated with nausea and vomiting. So when the pain localizes t right iliac fossa, it migrates to the point, which is called the mug Burn explained. So there's just there's a little diagram for you to show where the McBurney's point is located. So it's to fend off the way from the umbilicus to the anterior superior iliac side, the patients who presents with appendicitis when we examined them. There are some specific signs that we can elicit, which will help the diagnosis so that the main signs that we are looking for um are in a straight in here. So still, a sign is characteristic for director seek up and decided Tous. So it's the appendix in that retrospective, so behind the cecum position, which, by the way, is the most common location of the appendix and so disciplined it's behind the cecum is irritating the adjacent sauce major muscle. So when we're stretching, um, stretching, discuss major muscle by extending the leg um, this will cause the patient a great deal of pain moving on, um, at the bottom, the operator sign again. We can elicit, um, pain and discomfort in a patient who has up and decided by rotating it. Flex 30 um, internally. And that again will cause irritation on the surrounding structures because you're stretching the muscles on. There's a lot of inflammation and of Dema on, but that causes irritation of the certain extractors the rope saying sign, um, that elicited when we press or women part bait the left iliac four, sir, that causes increased increased pressure in the entirety of the gut on and the will elicit. Is there pain in the right iliac fossa? So even though the appendix as, um hopefully everybody knows most of the time it's in the right hand side, palpating of the left side will cause the pain on the right. Um, because of this increased but pressure in the in the gut caused by the port Asian and lastly, that much bread and sign is the pain that localized to the right iliac fossa. So the classical point where the pain and appendicitis is felt so going back to our patient. Um, we're going to do the 80 assessment, but the patient comes for the door. She's complaining off all the signs and symptoms that we have, um, mentioned so far. Um, and we're going to do the 80 assessment on hurry. So the other way she's maintaining by itself, she is breathing a little bit fast. Risperdal latest 20 free here. Oxygen saturations are 97% circulation, and so her heart rate is 115. So it is raised and the BP is 90/65. Um, her GCS is 15 or 15, her pupils are normal, and we do notice that she does have a little great fever on dear is quite quite a great deal of thing. And, um, Peritus, um in the right iliac fossa and what she described just eight out of 10 and the sauce and drop seeing signs, the ones that we've mentioned just now are positive. So this is the breakdown off the 80 assessment and abdominal examination and Raisi. But I just want to highlight and hear that in male patients, it's really important. Always exam next. There no genitalia because, as you rightly said in the comments, the abdominal pain and the patient feeling unwell in males could be caused by a testicular torsion or epididymitis, and it's really important, and it's very important to spotted. Assume it's possible. Is those patients with the secret ocean we need surgeon intervention. So with the patient who presents with abdominal pain and vomiting, there some red flags that we need Teo for and it's very important to you. Just put them because those trigger the immediate escalation. And so when you're clocking the patient, um, when you're examined examining them and they have involvement regarding the ridge, it's on, and it's really difficult for doing to me because it caused them a lot of thing. You should suspect that the patients, if you were suspecting appendicitis, you should suspect that he could have perforated. Or it's not just a straightforward, simple appendicitis, and there is a combination of the entire abdomen and irritation to the peritoneum. That's not a good sign. If the patient is in a lot of thing and look very unwell, you should escalate this as soon as possible as well. And if the patient is hemodynamically unstable and we should escalate it as soon as possible. It's a we've raising. Um, she is thought he called it on her BP is it's too low for us to be to be content with. So in this case, we will have to escalate either senior as soon as possible and act on anything that we find in the 80 assessment. So most likely we're going to start with giving her some IV fluid. Pollicis. I'm going to ask that just seeing you, but, um, assuming every waiting for a senior on we know I have to order some investigations. Let's think about what investigation would be relevant in here. So if you could think about some bedside investigations, some bloods, they'll be relevant. And some radiological tests that could be relevant in this scenario. And if you could please put them in the in the chat section. Okay, so we've got the abdomen X ray ultrasound. Okay. He's a GI back, because yet those were very good. Yeah. Yep. That's very good to be too hasty, G. Okay, I'll give you one more minutes. Do you think about anything else that's relevant in here? Right. Well, I hope that all this knowledge is coming from our previous sessions because he guys, um, you guys got it, and it's it's quite spot on. I'm just going to try Teo through dose investigation systematically. So going from bet side, leaving ti bloods and then radiology and try to justify why we're doing each of them. All right, so the bets investigations as majority Yes, some people have mentioned in the anus is been doing the CT, as we do for every patient who comes for the door, especially foreign well, patients, um, and also raises tachycardia. So we have to do the EKG. We're going to do a cover test because most likely and most like she's going to get admitted. So that's one of the reasons. Also, I haven't because you know that credit has seven. Um, no, the very classical presentation. So we're just going to do it, Teo, because we're going to keep it on their list of our differentials. We're going to do a urine dip, urine pregnancy test and blood glucose. My the urine dip. Um, it's important because it's going Teo, help us relates some of the pathologies. So if we're thinking about it, give me stones as our differential. The patient is likely to have some blood on their urine. Death if we're thinking about you, die that night trades and week, so it's going to be raised, Um, but in the patients with appendicitis, the leukocytes can still be slightly raised, especially if the appendix is lying on the top of the bladder. That's going porton to you to keep in mind. So if they're leukocytes are just slightly raised, we shouldn't jump to the computer thing that CTR You can still be appendicitis. The urine pregnancy test. Very important, um, in females because that's going to change our management altogether. If we think that it's the ectopic pregnancy causing the symptoms or is it regular pregnancy because of the symptoms? And also, um, we need to know that because if we're thinking by giving the vision, any medication, especially antibiotics, if we're thinking about doing any scans, were really doing it. You know, divisions pregnant, um, and about because quite bottomed because of tea things. So the patient could be high burglar. I seen it. So then I have loved that glucose is because of the vomiting on because of the fact that they were unable to eat for a prolonged period of time of appendicitis or they couldn't have high blood goes so they can be hyperglycemia because they might be suffering from DKA again. That's important. Tested do because they'll guide our management. It will help us to to rule it and other important differentials moving onto bloods. So, um, I think if you have attended previous having us and you might begin to sport the theme So if we're the surgical patients, um, the blood orders are pretty much the same every time we did in a patient who presents with and abdominal pain, um, or any other and sagittal general surgical presentation. Um, so we will need to do a full blood kind of investigations because we're suspecting that the white cells are going to be raised. Um, we're going to do use anything because the patient is vomiting. Ondas Nauseous is not eating and maybe dehydrated, so that can effect the electrolytes and kidney function we're going to do. That little function test is a baseline on you also, because we're going to give the best, um, antibiotics and back in haven't their liver functions. It's an important test you to do. Is a baseline, and we're going to do this therapy again. It's raised that could suggest, um, inflammation or infection going to do magnesium and a bone profile. Because again the patient has big nauseous has been vomiting is not eating. So we need to know, Um, what the magnesium, the bone profile it's And it's important for Baseline. We're going to do, um, malaise, because the patient with abdominal pain, um, and the pain would just quite significant. And we have tombo about pancreatitis. So, um, relations could be in a jumped in trying to do like the pancreatitis because sometimes again, the pain in my decided maybe put it localized and says important destituted and also be raised if there is a perforation of any and of any organ in the abdomen, and because we are thinking that the patient, my need, the surgery, we have to do some important preoperative, let's as, uh so two of those would be grouped and say for clotting. So this and this set of bloods I think you're going to to get quite familiar with, and that's going to be recurring during the sessions that we're going to do because this is a routine set that we do for essentially all surgical patients that come to the hospital. And so roses results. And her urine dip shows one class of Leukocytes, As I said before Doc and Re Coast, that could be seen in appendicitis. So it's important to be aware of that. Her beat a hasty GI test is negative, so she is not pregnant. Have that glucose is normal. Her hemoglobin's normal white cells are quite significantly raised at 16.6, as the CRP at 70.2. Her family's is 67 which is we've been a normal limit, and these knees and LFTs are normal. So again we should just have symptoms which are suggestive of been decided up and decide is her white cells and CRP a raced, which again seen in appendicitis. And she has a fever on and and the urine that shows one possibility. Besides, which again can be used as an adjunctive to diagnose up and decide. So even with the radiology and sound wave, you said that we should do an abdominal X ray. Some of you said we should do an ultrasound, and some of you did mention CT, so up in his eye test is usually a clinical diagnosis. So in our patient, um, because, as we did say, the Bloods are The bloods are suggestive of appendicitis, and her symptoms are quite typical for appendicitis. And one could argue that she does not need on any radiological investigations t, um, to diagnose up in deciders. Um, but in females and the ultrasound is quite a n'importe know first line investigation because it helps us rule lights and other but allergic in particular gynecological pathology. And it does have a benefit off, not involving ionizing radiation, um, which is really helpful in females and in Children I haven't. So it's ah, within hours. It's quite a good test, but the issues are that it is operated dependent, and on the weekends and out of hours, it's a very difficult E to do the ultrasound. So if the patient presents in ours were fairly uncertain, I love it up and decide is or whether it's some of the pathology, we could use ultrasound as as the first line management. And but, as I said, it could be just based on their clinical reasoning. The CT is another test. Every two years for appendicitis on, But they're picture on, um, my right, your left public and the stream a CT and showing an up and decide if so, it shows. And large appendix. It's not in here by letting me on with sticking rules and quite significant amount of a Dema around it. And the issue of the CT is that it does involve ionizing radiation, and so it might not be the best choice and females, and it might not be the best choice and and Children. So depending on the senator on down on the hospital, they work out. Um, sometimes it is used quite commonly, but because of because of it involving ionizing radiation and those being able to diagnose up and decided to space of clinical symptoms, Um, it's not necessary in diagnosis. So if you're a Z, we decided to go for the ultrasound, and it's you could see it's order again, the light hand side for me, Um, and then we'll just I just know Sinus suggestive of gynecological pathology. But the A pendant exists non compressible, and it does have a diameter eight millimeters. So anything above 60 minutes this is suggestive off inflammation on, decided to just the wounds are thickened, which again is a, um, signing off appendicitis. There is some free fluid in right, like force it. And as I did say, with appendicitis, we do have this obstruction and then increased pressure. But all the secretions are, um, continue to be to be secreted. And so some of this fluid a little seepage on begin. That's another sign off inflammation in the appendix, but on the ultrasound and there are no signs off appendiceal perforation. Abscess is so some of the complications that we have the suspect, especially if it's a delayed presentation, which is quite common in Children because the symptoms are quite non specific and Children and pregnant ladies and early people I said they are, um they aren't risk of developing complications before we realized it was appendicitis. Um, so the complication that you can see in here is the gangrenous appendix on DSM. Other complications include up in appendiceal abscesses, perforation and mean sepsis. Right? So, just to summarize this section and the key assassin point when we are examining a patient abdominal pain, who are well is we have to, um, we have to be able tol is it? What type of paying the patient is suffering from because enough and decide is it's an aside, Didn't say you do have this classical pain off that sounds in the center, and that moves the right hand side and my nose always be the case. But it's also always important, too, as the patient about the timeline of the pain. So how do pain has changed from when, when it started, what type of pain they're feeding associated symptoms over important and in appendicitis. It's mostly nausea, vomiting and other erections and not being able to eat. We then really want Teo the examination on In appendicitis, we always have to do the abdominal examination. Um, we have to do external genitalia examination, especially in the males. And if the patient isn't well, we always have to do are 80 assessment and and then there are some specific sign that we can address it as I mentioned before. So some of those are Doctor A to sign the star sign rock seeing signs and my burning sign. And then we may want to doing some bloods, bedside investigations and imaging, and that should help us make her diagnosis, right? So for patients with, um, that we're suspecting appendicitis in and we're all patients in with abdominal pain, he complain of vomiting. They're unable to eat, and especially in this case, where the BP is slightly, though, on the heart rate is race. We're going to start with intravenous fluids, so we're going to give both doses of fluid if the patient requires food resuscitation. And so if they're unstable hemodynamically. Um, or if you're stable but vomiting, unable to eat, we're going to. And to give them a maintenance IV fluids, we're going to give them antiemetics because it's really important what a patient who's in a lot of pain to give him comfortable. So go to try to stop them from from vomiting from being nauseous. We're going to give him a good analogy XeA using the W hydro ladder, which we have talked about. It's during the first session and we're going to give him some antibiotics. And if we're quite confident based on the blood, especially race white cells and a CRP that there is inflammation and infection process going on, I we're going to keep the patient to mail by life because they might need a surgery on and for the patient to be able to go to surgery, they have to know what to eat anything for it, least six hours and not drink anything for two hours. So it's quite important. Especially the patient may need a surgery city, but, as you'd find in up and decided is, the patients are not very hungry, so they might not want to eat on anyway. So the management options and we have started, we've and with all of those. So we have given the patients and fluids we have given them some an urge easier of genetics that that made a patient feel bit better. We have started to have the biotics on. Do you have started them based on the local guidelines? Because that was different from the hospital hospital and then at options are either conservative management. So we're not operating for a surgical management. So for appendicitis, um, laparoscopic appendicectomy is currently gold standard treatment. Um, so it's a keyhole. Surgery with were very low mortality in with mobility rate. Um, it's a very common surgery. There are bunch 50,000, um, are still pick up under secretaries in the UK on every year on Ben Recent cook cream, not assistance friend. That's, um, liver. Start becoming the sector Me shouldn't fact remained gold standard because antibiotics, even if given for a simple up and decided up in the slightest on antibiotics alone, have a failure rate off 30% of one year. So if we went to treat all the patients with simple and decides is just live fluids after six in antibiotics, for to pretend of them would need up in and would need, um, Appendicectomy within one year anyway, So it's quite an important thing to wonder patient about it. And when we're trying to decide between antibiotics on your antibiotics and lumbar scopic up in the sector, me in a simple appendicitis I know if we're doing the patient, who's, um, civilian? Well, hemodynamically unstable on. They have complicated, um, appendicitis. So if they have a gangrenous appendix or before the Bendix, they need the surgery straight away. All right. So give them a preoperative antibiotics that we're going to, um, we're going to do surgery straight away, and some complications of the surgery is that it's a the morbidity rates are very low and the patients will I get are sober, too bleeding on the surgical site infection. So the nonsurgical management, um, can be attempted in some cases. And so there's some off in some instances on. So, for example, in a patient who is hemodynamically stable, um, for the patient who presents overnight, we're not worried about them and they can wait there so you can be delayed by 12. Let's I talked to 24 hours and we are going to be use the severity of their systemic inflammatory response and as, ah, a guy tee time when we should operate on the patient, um, inpatient to presented appendix masses. So appendix mass is, and a result off the omentum in a small bowel was sticking to you. The appendix. And if they're stable, we might give them until biotics and delay the surgery by 6 to 8 weeks. And in Children with interpreting your obsessive, they might need a drainage before the prick take his drainage before we consider, um, was it a surgery? So in Rose's case, you can message in there in the truck books. Do you think we should or per eight on her straight away? Or should we go for a non surgical management skin? Just an answer today. So as I did say she presents, I didn't actually say the time of the day. She presents urine today, but she is hypertensive, and her BP start, you know, because a low grade fever, she complains of nausea and vomiting, right? I feel like there are lots of lots of budding said, Is there ever want to operate? All right, they have one in on Saturday. All right, all right. So we've, um Yeah, majority, the vast majority of you. All right. So for Rosie because she presents, We've, um, with him more than an uncle Instability. We are going to Teo stable as a fist. So we're going to give her IV fluid bonuses and then go to give a maintance fluids. And we are going to progress to surgery straight away because she is hemodynamically stable. Um, were fairly confident that she just had appendicitis. We did the ultrasound, which confirmed it is appendicitis. And and because of the human dynamical info bitty, we're going to progress the subject. Rectum. All right, So the treatment that we gave up, just Teo just recap. It's going to involve IV fluids with resuscitation fluid. So bruises or 500 mL. So, for example, surgeon chlorides followed by maintenance through it. We're going to give her antibiotics going to give her some good on urge. Easier to keep a comfortable. We're going to start antibiotics before the surgery, and we're going to treat her with same day laparoscopic up in the sector. Me right, and we can see Hying Appendix looks in your life on their site. So you have to seek him in an appendix. And that's then view from behind, right? So before we before we move on, Teo the questions that you might have. I don't wanna just a few questions myself, so we're going to have three or four questions and then we'll go to meet one t Um, a short time, and I was there any questions you might have? So the first question is, um, in patients he have shoulder take pain following peritoneal preparation, and where do you think which structure has been irritated? And you could just answer with a letter in the chart books. So the patient's complaining off shoulder pain and where do you think the part in your preparation and has gone to and irritated in Oregon and say is a diaphragm is a vagus nerve, your PSA or intercostal muscles? Typical guys is smashing it. Yes, and the answer, um, dancers and be a because of the referred pain. Um, so the phrenic nerve originates from C free to see five on it, then troubles dying and innovated I from. So if there is a personal perforation, which irritates the diaphragm that was referred paying two, usually shoulder tip Union, actually, or both sides that's quite golden. If that's another sign that we can use Teo, decide if it's simple or complicated appendicitis. If the patient's complaining of shoulder pain, they're most likely is a perforation that's irritating the diaphragm. Where is the mother bear in this point? So you have four ounces and again just pose deed. The answer. In a chance. No. Yeah, from time acidic right, Say the Mark Band is Point is, in fact, located too fat of the way because between the umbilicus in the aces, and it's important, know where it is because this is where the pain and appendicitis localized right? Nothing wrong, too thin. Next question. And which of the following describes a sauce line. I think that would be my last question. And then we can make going to your question. Do you think? Okay, I'll give you one minute. Fantastic. All right, so the answer there's be but his the sauce sign, Um, it's elicited when we extend the right hip because that was stretched a sauce, major muscle. And if there is, and information on bloods of infection, um, in the appendix, which is very close to this last major that were a little pain when we extend the hip. Really? So just a summer ice Will, we spoke about today, Um, distracted is one of the most common, um, surgical emergency. So if you're working on the surgical would most likely you're going to see many, many patients? We've been selected coming for a little. The presentation, um, one of the most common symptoms are described is in their face. Tried. So that's not even warmer saying low grade fever and right across a baby. But we do know that the pain classically starts in there like this, and then it's right across. We always have to remember to do pregnancy test in females or tried bearing age. We always have to examine examine genitalia in males because we're worried about the stick it ocean and epididymitis, um up in decides remains mostly clinical diagnosis, but there are some other ones that we can use. So there are some blood tests that can help us make a diagnosis we can use ultrasound on. But in some cases, you can use a CT. Um, the management. So as a junior doctor, when you're accepting the suspecting in the slightest is very important to remember that we need to stabilize the patient. Uh, based on our 80 assessment, we have to give the maintenance fluids and keep them nearby my life. We have to give them antiemetics and another Jeezy to keep him comfortable. All of those things I'd like very simple, um, simple things to do, but it does make a lot of difference for a patient. Um, when they're coming in with the with severe pain and their civilian will make and make their symptoms of it better, it does improve their their experience on but just improved their their wellbeing. So it's really important to remember about that and this is something that you use a junior doctor on our more than capable of doing. And on day, as a rule of thumb with the patients and stable, they need your surgery. And in some cases that we talked about the surgeon could be blade, right? So I just wanted to you remind everyone that's those free surgical webinars are, um, are held weekly. Um, so please join us for for decisions in the future. Please visit to mind the belief website. Um, so it's mind a bleep that called forward slash surgery and to access and articles on all the sessions and all the other articles. Um, so for dissection and the article is going to be uploaded very shortly, and you can just use it to to recap everything there spoke about it, um, and and you can use is a cheat sheet when you are actually seeing patients on the surgical take and to know what's what to do and how to assess the patient. I on if you, um if you'd like to join us next week, they're session is going to be on surgical causes of john desk. Um, this session is recorded. Let me just move myself up and this session is recorded. But if you want to actually recording the written content and if you want to to learn more from us, we like your tea filling the feedback form. Um, just this kind of rescue arcades on that's going to give you access to all the recorder material. More importantly, it's going to give us loads of tips on war we can do to improve decisions to make sure that, um, that you get old information. Do you need to be to be a better doctor, feel more confident? Um, And if you do feel it in the feedback, you're going to get a certificate on for attendance. Just use it for your portfolio is. And so I'm just going to if you, for the next couple of minutes post any questions that you might have in the chart books, I'm going to answer them in a second. If you don't feel like asking questions, not you can always, um, just contact us at, um webinar. Ease at minded people come. So what I need you to do, You know, if you have any questions, post them in their track books and please. The's Scandic, your courage to find the feedback phone. So leave the feet but form, um, through this gun just to make sure everyone has access to it. And then I'll give you a couple of minutes, and then we may go on TV and I drink any questions you might have. Well, I like the length of the feedback for me. Give me one second. Yeah, Yeah, just keep the questions coming, and I'm going to go through them in just a second. Hello, Start. I didn't drink for the feedback for you. All right, then we just posted. Give me just one second. Okay? Apologies. All right. So here's the link for the feedback. Please. Please fit in because it's really reported for us, right? Okay. So please bring the people from ongoing free the questions. Um, the first of this can happen. Actually be done with pregnant woman. I think it's a very, very good question on very, um, technically difficult. So it can be done in the pregnant woman, but it's not done. Laproscopically. It has to be done via an open incision, and the care has to be taken into note. Bridged. Uh, the wind barrier. Um, but actually, reading for you for a literature, the up in the air scientist in general in pregnancy is that these be less common than in the general population. And the risk is Lois in the feds, um, trimester, Um, but if we are doing appendicectomy on the pregnant lady, it just have to be buying open incision. All right, So the next question is, when is the best time to give you antibiotic for appendicitis? And so somebody has suggested 30 minutes versus surgery in our or once a diagnosis has been established. So and I think the simple Santa is once diagnosis has been established because there might be some delay. Um, we're going to surgery because of loads of lots of reasons, including just ordering the fetus lot and etcetera. Or the patient might have had some water and that we have to wait for longer setting. The easy thing to do as a junior doctor is to start antibiotics as soon as you have consulted, you're finding super senior, Um, and you do you think it's up in deciders on the patient's blood? Suggests that it's appendicitis and there is an infection going on and then starting down to biotics as soon as the diagnosis has been established is that is a good starting point for you. Can we proceed with up in dissected me in appendical abscess. So it depends on the patient's state. And so if the patient is, um, is very unwell and then it doesn't mess if they do have an abscess or not, we have to proceed straight to surgery, and the patient is stable. Um, sometimes we can try Thio and try to manage with antibiotics. Face that, actually, the up says, might be the court, maybe the results off appendix appendiceal preparation. So in that case, we have to. We have to do a straight away. So if it's a capsule because my preparation, we do the surgery straight away. And if it's an appendix Mass, then we can delay the surgery. Um, and yet the patient is stable with the with the abscess, and it's not caused by perforation. Then we can try conservative management as well. Do you guys have any other questions? Because it's it's a If you have any questions at any point, you can always contact us. Um, should give you one more minute. Please make sure you fit into feedback form, and And if there are no other questions and all right, so it was okay to give paying relief. If we're considering the patients suffering from Is AP appendicitis in this question, I think it's always always a good idea to give patient. Been really? For the patients in pain. We have to We have to make them feel more comfortable. Um, what symptomatic would you give to the station? Well, that's depends on the Usually depends on the trust that you work at. Um, when you do you a surgical job, everyone, uh, kind of have stair their favorites antiemetics. So some of the anti emetics there and you can give is cyclizine or ondansetron going, um, metoclopramide. So all of those are good first line options. Um, and depending on how high the patient is feet and you can give them on, really? Or IV, um, with morphing, um, alerty. So the last question is, and should we avoid morphine and we should use that w hydro ladder to manage the pain so we wouldn't start with, um, with more thing. I don't think that based on any literature, there is a one single best pain medications up and decide this, and but we should use it every hotel bladder, so it tries to find out easy like paracetamol and then try to move on. Move up the ladder if if it's not working. And I said we would not start with was more frustrated because that's that's a the top of your of your bladder and they have loads of adoptions before. I hope that answers all the questions. The half at the moment. Um, the antibiotics, um, we follow tribes guidelines, um, for antibiotic. So when it's not working in the hospital, every trust has their own trust guidelines. So, for example, in the trusted I used to work out, we would give patients come Oxy. But that's not a heart of us. Rule on dot will depend on the trust that you're working out. So it's always very important when you start working somewhere. Teo to look on the Internet or they're always usually absolutely can use um, which have trials guidelines on it on. But it will have specific orders for a specific disease, like a micro guide or Rx guidelines. But that's again will differ from trust addressed. All right, um, thank you very much, guys. For for your time, I heard that was useful. And how does it make you feel a bit more comfortable when he have to deal with with a patient? He has appendicitis yourself. Um, and if you if you can, if you do work in a hospital, it's really cool to go and see the surgery because that helps you helps you understand the disease a bit better and then helps you to anticipate with a complication, the patient's my house. And, oh, no, not able to feel the feedback from Let me replaced. It's really important. And all right, so the key walker didn't work. There is a there is a link again. So I'm going to leave you to it. And the link is going to be available when I stopped there. Stop the session. So have everyone has a lovely evening and we'll see you next week for the section on John desk