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Thank you and welcome professor. I've just made you cohost and whenever you're ready, I'm sure we can start with the slides if you're willing to or however you want to start. Thank you again. Thank you. Are my slides clear for everyone. Yes, this it for you. Do you mind just making it full screen? Yeah. Is it full screen right now? Perfect. Yeah. Ok. I think guess I go to the start. Um ok. As I mean, uh as I mentioned, my name is Mohammed, one of the pe a stars in Scotland. I thought to speak about the chronic abdominal pain because this is a common condition, a common uh um symptom you you will encounter when you are graduated in the outpatient clinic and also in the emergency department. So my talk will be about uh I'll start with two clinical cases. Then I'll give a definition of chronic abdominal pain. Then I'll ask you to give me some of the causes of the abdominal pain. We'll go through approach together, then we speak about one of the commonest causes, which is functional abdominal pain, um disorders. And then we'll give you take home messages, you can stop me at any time and you can comment or, or add any uh or if you have any questions, just stop me and just uh come in. So you are right now, you graduated after one or two years and right now you are in the repaired clinic or outpatient clinic and you have your first patient in the clinic today is uh summer. So she's a 10 years old girl. She was referred to you by the general practitioner as she is having three month history of abdominal pain. She described the vein as crampy, abdominal pain, generalized, no localization, no radiation. It last few hours happens like once or twice a week and she missed a few days of school because of that between the results, she is pain free. Sometimes she's having some vomiting, yellowy greenish vomiting and some diarrhea containing fresh blood. Each lasting like 2 to 3 days. There is no history of infection, infectious contacts or foreign travel though she is in Sudan. So I think she is exposed to like infectious causes of the the she was born at term. No significant past medical history. There is no family history of inflammatory bowel disease or celiac disease or peptic ulcer or malignancies. It's ok. In the referral letter from the GB, respond, her weight is 22.5 kg. On the 50th cent time the stool sent by the GB and also some bloods. The stool showed the fecal occult blood was positive in the stools. And today in the clinic, her examination was not re uh remarkable. So, abdominal examination and full systematic examination was normal, but you noted her weight dropped from two twen from 22.5 two month with the GB to 22.1 kg. How you are going to manage or approach this patient? I'm open for discussion. You can give me your opinion about this patient. What can be the cause? What further points in the history? You want to ask any parts in the examination? Any parts do you want to do any investigations? Um I would do examination uh examination, see if there's any tenderness, um see if there's any abdominal distension. Um and look at obviously things like the liver span, the spleen, the kidneys, the bowel bladder. Sorry. Yeah. Did a rectal examination. Uh not did do the direct examination but at least perianal examination. Yeah. And you need to take a consent for that. Yeah. And also the CBC cause she has um like uh a cult's blood to see if she's anemic. Yeah, I totally agree with that. Yeah. Is it only F PC you want to do or do you want to do bloods? Uh What can be the cause for the uh she's having like rectal bleeding or uh Yeah, low G I bleeding. So it could be upper G I bleeding. It could be intussusception into sinal obstruction like that. The Yeah, but if it's inception, usually it's acute abdominal pain or intermittent abdominal pain and the the patient will be more unwell cause this patient who was having like 2 to 3 months of abdominal pain. So I expect her. Yeah. So if it's inception, she should have movement history before that. But it can be something like inflammatory bowel disease, polyps, things like that. Yeah. Disease. Yeah. So yeah, in addition to the full blood count, usually, uh this is a good start. You can do also like liver function test. You can do kidney function test some inflammatory markers like CRP or A R. Sometimes some people they do plasma vi prostate, those would be helpful. And as you are doing blood already, you can do also a celiac screen. But we'll go through all of these when we go through the presentation. So let us go to the next case and I'll give chances for more people to participate. So this is our second patient. So this is fatima a nine years old girl. She was referred by the Pedia uh also to the pediatric outpatient clinic by her GP with a four months history of episodic, central abdominal pain. Usually the episode lasts a few hours and that a like affecting her about 3 to 4 times per week and usually during the day, occasionally at night, but doesn't wa hard from sleep. Um This is associated with infrequent nob forms and does not appear to be related to her diet. She is missing some days of the school also. Um, when you ask her, she liked how high school, no issue of bullying or any other stressors in the school or home just a bit between the results. She is well and she's active girl. No history of diarrhea constipation. She's growing well, no urinary symptoms and she hasn't reached me a yet. She was born at a past medical history that remarkable. And, um, she's not on any medications and she's fully immunized. There is no history of foreign travel and family. So bowel problems on general examination was not remarkable. Also, no abdominal distension or organomegaly, no pal masses, no hernia or any tenderness. And she is on the 75th percentile for her weight, which is consistent with the previously documented way. So how we are going to approach? Maybe I'll go just because of the sake of the time. Just I'll go to the definition of chronic abdominal pain. So this is usually find three or more episodes of abdominal pain over the at least three month duration and that's severe enough to affect the daily activities of the child who is over three years of age. It's difficult to say before three years. Uh, because the child is less wearable and it's very difficult to tell about that. But yeah, still Children below that age that can present especially with inception and acute abdominal pain. So, but the the issue in the vocalization. Um How common this is chronic abdominal pain in the UK the incidence is between 10 to 14% of school-age uh Children, they have chronic abdominal pain and almost 70% of those visit the doctor at least once. And of all of these 10 to 14% of Children if we have like for example, 12 million kids. So it's more than 1 million kids presented to the doctors with these chronic abdominal pains, only like five or 10% of those have underlying i identifiable or i identifiable organic cause most of them they have functional abdominal pain or you cannot find any organic or like uh serious or sister cause for this abdominal pain. So it's accounts for many attendances in primary secondary and emergency departments. That's why we need to discuss about that. So ask me right now, I'll give some chances um for participation. So what are the possible causes for chronic abdominal pain? You can raise your to and your chest. Sorry. Yeah. No, we've got CHS who's been raising his hand for, I think the entire time you can go ahead. You can answer your question. Um Recurrent tonsillitis. Mhm Yeah. Yeah. Uh Like this. Uh Sometimes, sometimes, yeah, sometimes you can have like what is called mesenteric adenitis following uh tonsilitis like for viral infection, things like that. You can have like uh mesenteric lymphadenopathy that can cause acute, more of acute abdominal pain rather than chronic. Yeah, IBD. And celiac disease. Yeah, you are. Right. Celiac disease. IBD. Celiac disease. Mhm. Yeah. You can just unmute yourself and speak. Um, I'm happy with that. Certain food allergies. Yeah. Food allergies. That's right. It could be infections like, or it could be functional. Yeah. That, that, that as well. Yeah. So, infections, is that right? Functional abdominal pain, certain digestion issues. Indigestion, P ID and ectopic pregnancy in older Children, older Children. Yeah. So, it can be gynecological causes. That's right. Lactose intolerance could cause that also. Yeah, we mentioned food allergies, also some food intolerances, lactose intolerance. That's right. Hepatitis, hepatitis and gallstones. Yeah, gallstones, Crohn's disease. Yeah, that's IP D inflammatory bowel disease. So to be honest, the list is very, very long. We can't spend like hours to speak about the list. Just I gave it like in classification big categories. So it can be gastrointestinal. And you mentioned some of the causes like IBD celiac disease, food allergies, um infections, et cetera. Um But the list is very, very long. Still as I told you cannot, one session will not be enough can be renal causes. As some of your colleagues mentioned also like UTIs like pyonephrosis renal causes also can be a cause of problems. Can be gynecological causes like opic pregnancy, ovarian cysts, et cetera can be also systemic cause like malignancy, musculoskeletal respiratory. Though I think that's more of acute ab uh abdominal pain, like pneumonia can be a cause or abdominal pain, uh liver problems and gallbladder problems, metabolic and endocrine conditions like storage diseases, adrenal insufficiencies. DK A but DK A also is acute rather than chronic and a lot of other conditions. So we can spend hours on each condition. We can, we can spend hours also to speak about. Then we have the functional, which is like as I mentioned earlier, the organic causes, they account just for about uh 5 to 10% and the functional account for the majority of those abdominal pain causes. So let us go through our approach to this, to a patient with chronic abdominal pain. So as in medicine, in general, so we go through history, physical examination and in both history and physical examination, we need to look for what is called red flag symptoms or like alarm symptoms, which alarm for which are indicators for like organic cause or sinister causes. So if you have any of these red flags, you need to act seriously and do more investigations to rule out more serious conditions. And then we'll go through some basic investigations, they say in the books, they usually don't need investigation, but most of the most of the pediatricians, I think they go for investigation also with the baby, especially with the pressure of the parents also. And here in the NHS like um they don't need to pay for it, but it depends on the circumstances. Um So just this um just a moment. Um I know, this might be a very busy slide, sorry for that. Um So this is an approach for like chronic abdominal pain. So we mentioned about the definition more than three episodes and symptoms for uh more than three month and affecting the daily activities and the child is more than three years. If the child is having chronic abdominal pain, you need to check for red flags. So if there is any red flags, you need to investigate for that. And um sorry. Uh Yeah. So if there are, if there are red flags, you go for the investigations and you refer appropriately. So for example, if gastro sign cause you refer to a gastroenterologist. If a surgical problem, you refer to the surgeon. If it's all like uh gynecological, you refer to gynecologist and et cetera. Uh if not, it flags, then sometimes some people, they do c A screen at least because the symptoms are nonspecific or you can do without the investigation and reassure the family about functional abdominal pain. So this is um an or like um um an old algorithm from uh um education and practice chairman in 2013. So right now we'll start with the history. So what questions do you want to ask? And the history for a patient with chronic abdominal pain? So I'd ask them, uh about the site, ask them to point to where the pain is. Um uh if the pain started suddenly or gradually, um if they could dis, if they're an older child maybe try to describe the pain. So, is it burning, is a, um, is a, uh, yeah, like that kind of pain if the pain stays in that one place or if it radiates to somewhere else, um, if they've noticed any nausea, vomiting, maybe diarrhea, weight loss, anything that was a fever, anything that could be associated with it. Um, if there's a certain time of the day when the pain is worse, for example, after they eat in a certain, in a certain position with exercise like that, uh, it gets better or what, what makes it better or makes it worse. So, maybe resting makes it better. Taking painkillers, makes it better and, um, it affects my daily activities so I can know how severe the pain is. Yeah, that's, that's good. Also the duration. Yeah, the duration. Yeah. Any other other, uh, thoughts? Ok. That's excellent, actually. Uh, so I, I find maybe my, my, my, my, my history just, I'll take history rea regarding the pain, like, and, and as that symptom, then I'll ask about associated symptoms. G I or no GIS and then I'll ask about the impact of the pain. Um, also I'll ask about the expectations by the patient and the family. What's they think, what is the diagnosis or what they are worried about and what they think about the treatment and investigations and things like that. So, regarding the history as you mentioned. So uh it's used for the Secrets for medicine, the secret acronym to uh for the pain analysis. So we'll ask about the side onset character radiation and alleviating aggravating factors, timing, et cetera and the severity. So yeah, as you mentioned, also, it's important to ask about the onset and the character of the child can describe the character, the onset, whether that's acute or chronic or intermittent and also any radiation frequency duration, timing between the attacks and any triggers aggravating. Or fact, I'd ask about the bowel habits also cause many times constipation have been mentioned earlier. Constipation can be a cause of chronic abdominal pain and that can be easily treatable. So it's important to ask about the bowel habits, whether there is diarrhea or constipation, the frequency, the consistency of the stools and if there is any blood in the stool, always blood in the stool is serious and it's a red one of our red flag. So we need to rule out more sister causes or there is that, that like blood in the stool. Have you heard about Bristol stool child before? No? Ok. So this is a chart you, we usually use it in the UK. In almost in every encounter. We are seeing a patient with constipation or diarrhea or abdominal pain. We ask about the consistency of the stool and we give them a chart like this to give the type of the stool. So like type one and two, they are indicating constipation and type seven is indicating diarrhea and the normal is around type 3 to 4. So you give them the chart, there are prints or cards containing the chart or even you can show them in uh your, your mobile phone and Google uh images or something like that. And they indicate which type of the stool. And this can help you to diagnose whether the child having diarrhea or constipation. Because all of them, they can have indications on our uh diagnosis I men. Um Yeah, so also 11 of the things you ask about, maybe we'll forget about that. But if you ask about pain and and itching because especially at nighttime and that can be uh an indication that the patient is having in the spinal walls. And as our colleagues mentioned earlier in a girl who is adolescent girl and who is having secondary sexual characteristics, you need to ask about menarche and the Minister cycle regularity and heaviness of the period presence of cloth and things like that and all their kids, maybe not Sudan. But yeah, outside, you need to ask also about like uh sexual history sensitively and yeah, to rule out sexually transmitted diseases. Um Then you ask about other histories. As colleague mentioned, allergies, food allergies are a common cause of abdominal pain. So you need to ask about allergy histories and any known allergies you need to have speak also briefly about dietary history and ask to take some brief dietary history. You ask about risk factors, any family history of inflammatory bowel disease, celiac disease, malignancies, peptic ulceration, any other pain syndromes like migraines? Because yeah, there is abdominal migraine as we see uh later, also, as one of the police asked, we need to know what the impact of the pain of the child. So usually even if the pain is functional, might have impact on the child or the school attendance on the sleep, on the appetite, on the part, patient and daily activities. So we need to know about that. And yeah, so we need to know the impact on the patient and the family. And if a child is adolescent like 12 years or old, also, sometimes we find it useful to use what is called heads assessment. Have you heard about that before? No? Ok. So it's, it's it's a friendly way just to check. Yeah, with yeah, to establish engagement with the an adult adolescent child and also to get some important social history parts. So it's abbreviations of these letters. So head accounts for home, you ask about the home environment. Who do they live with the relationship with like brothers, parents, the carers? And do they share the bedroom, recent changes in housing? Anything like that? And maybe so that you can ask about the animals in house, things like that because also it can be related to the abdominal pain and diarrhea and symptoms like that. Uh education. Also you ask about the school, school attendance, academic performance, friendships, bullying in the school, et cetera activities also like um out of the school sleep duration, sleep quality, what they are doing? What is their activities where, what are the interests out of the school? Drugs? Also, you know, the adolescent kids, they are at risk of, they are of risk seeking behaviors like smoking, alcohol, illicit drugs, et cetera. Sexual health. Also sensitively, you need to ask about that. Social networking, whether there are members of Facebook, social media, other social media. Do they have friend requests from people? They don't know any type of bullying, anything like that. And you ask about the safety, do they feel safe? And if not, why are they don't feel sick? Then you, yeah, you asked about the expectations by the family. So what do, what do they think the diagnosis is cause some families they k they come with certain opinions. They don't want to rule like malignancies or IBD or celiac. So you need to know what exactly what they're thinking and what is their expectations from the clinic appointment and the review. So, so to tailor your investigations of management, according to that, what level of investigations do they expect and what are the treatment options they are expecting? Uh Yeah, so you need to elicit that that will help you also in counseling them at the end. Any questions so far Yes. Uh I have a question. Yeah. Can you doctor please elaborate on how the family expectation can affect the, the the management? Exactly. Like can you give an example for that? OK. That, that, that's, that's a good question to be honest. Yeah. So um many times for example, when they are referred by the GB, for example, because the GB also sees the patient examine the patient and have his um his idea about the patient, for example, sometimes tell them, for example, he's worried about the malignancy, for example, or worried about like for example, IPD and the families that are coming with that expectation. So we need to rule out for example, malignancy and if you are not doing blood or anything like that, you, you, you're not most likely you will not be able to convince them that even if the child is well, his growth is normal. All of the examination is not remarkable coming with idea, it's difficult to convince them the opposite. So I think sometimes it's easier to do that once but that's also with, with is not without risks because sometimes you can have also incidental findings in like doing abdominal ultrasound, for example, or doing blood investigations or so it's not without risk. So we can find also and again, you'll have again, more anxiety and more worries and just the cycle will continues. Um So yeah, and sometimes, yeah, it the, the the the worry it can be very simple and just reassurance of the parents that from your examination, that's not the case. And you think just it's functional abdominal pain, for example, or something like that can be just uh the case. But we'll come to it when we speak about the functional abdominal pain again. Is it clear or? Uh yes, it is. Ok. So we come to the physical examination and maybe I'll let you speak to. Uh Yeah. So what, what do you want to do in the examination? What do you want to find exactly? I would look to see if the abdomen is distended. Um If I look at the umbilicus and look at the um flanks cause maybe there's abdominal distension like ascites or something. And then I would want to look for any surgical scars because that could be a sign of recurrence. Um And then I would want to look for in any quarter remarks, sorry. And then I would also um ask the patient if there's any pain and then I start palpating um for any superficial masses, any tenderness, any pain, sorry, tenderness and superficial masses. And then uh do look at the liver span, see if the kidneys are palpable, the spleen. Uh I think intussusception, you can sometimes feel the mass though so that could help a sausage like mass. And then I would want to do like a tape um all that stuff, renal artery. Um and then um digital rectal examination. Mhm. Yeah. And um, the urine for proteinuria. That's good urine. Yeah, that's great. Ok. Um, yeah. So maybe you are more expert on the examination but one thing, maybe you need a chapter when you are examining a child, especially when you, you come to like, um, the abdominal examination or the anorectal examination. Yeah. So you need somebody like, uh, like, um, a position in the hospital, like a nurse or another doctor or? yeah, uh uh a person works in the hospital. I know that's that that type of procedure. Um um Yeah, then most of the examination findings usually they are obtained from observations in the first place. So yeah, so during the consultation from the point, the patient arrived to the clinic room or even before they enter the clinic room, you observe the patient and you see if the patient is in pain, his behavior during the consultation, the mobility of the patient, then you do your general examination, then you come to the abdominal examination, which you mentioned perfectly and then put an examination, I'll also look for any signs of like emotional or psychological abuse, any emotional signs, things like that. So chapter will need to be present in the physical examination. As I mentioned, observations is important and you can get a lot of information just from observation alone in addition to the history. So the behavior of the child during the consultation, uh how he mobilizes when he gets to the couch, uh the perceived comfort when he's lying, when he's sitting, any signs of pain, then you go for the general examination, the growth of the child in general. So check the height and the weight of the child. You compare them with the previous weight and height. If you have the previous weight, if you have one, you block them on the central child. So you need to see how the child is growing. We check the BP, especially there is a renal problem. We look for jaundice and color. We check the nails. You look for clubbing pony signs of chronic liver disease. We check the hair. We look for s uh examine the skin for rashes or any signs of chronic diseases. Examine the oral cavity for a ulcers and other signs of the area. Um in the general examination, then you go for the abdominal examination. As you mentioned, you start by inspection and then uh you do palpation, percussion and auscultation, as you mentioned perfectly. And I not go for the details because uh I I believe all of you know the details of the abdominal examination. As you mentioned, you enquire inquire about the presence of pain. First, you look for any tenderness while you're examining, you try to distract the child. Sometimes we accept the child, there's no pain and that's can be an important sign. You examine for any masses, hepatosplenomegaly, oci hernia orifices, any scars. All of these are important then you need to do also perinatal examination. And that's important. You need to look for fissures, any fistula skin tags, uh hemorrhoids, things like that, the elect to and presence of swelling. So you need essentially to look for signs of fissures, signs of constipation, like soiling and things like that. And also looking for fistula, which is sometimes can be a sign of like inflammatory bowel disease. Also, you need, you need not to forget to do full physical systemic physical examination. So we examine for the cardiovascular system in the chest, the musculoskeletal system, we will examine for lymph nodes and general generalized lymphadenopathy also during examination. And while you are consulting, you need to look for any signs of physical abuse or any si psychosocial problems. So you look at the de of the patient, the interaction between him and the caregiver, uh any signs of withdrawal, nervousness acu and the contact, any questions so far. Ok. So right now we come from this history of physical examination, there are some red flags which alert you there is there might be like an organic acid, organic cause I need to do more physical um like more investigations. So if somebody can just uh volunteer and tell me some of them, is it um weight loss and he and Hemmes, sorry heis and weight loss. Yeah. So weight loss to that degree. Any G I bleed hematemesis Hema. Um uh Yeah. Yeah, hematuria. You get problem. Yeah. Oh. Mhm. What else? Constipation? Sorry. Absolute constipation. Absolute constipation. I, I agree with that. Especially in, yeah, that I expect that maybe an acute, uh, acute abdominal pain. You se constipation. We need to think about the obs. Yeah, my name is. Mhm. Um, like mass lymph. No, lymph. Yeah. Lymphadenopathy. Yeah. Um, like generalized or maybe the child is having, um, problem with, uh, swallowing, difficult swallowing, maybe for solid food. Uh, I can't hear you clearly. Sorry. I said um difficult swallowing, I think. Yeah. Yeah, I, I totally agree with that. Yeah, dysphagia is an important for life. Yeah, you need to, to act seriously. Yeah. Yeah. Ok. Let me just, yeah. So I think this is one of my important slides. I think if you come out just with this in um um red flags, this is important because yeah, if any patients having red flags, you need to act seriously because there will be a serious condition behind it or beyond it. So you need to act seriously to diagnose it and to uh to indicate what is the cause and that might differentiate like uh functional abdominal pain from uh from uh other causes of uh organic causes of chronic abdominal pain. So the kids, the anger, the kids, it's more serious. So if kids are less than five years, I take it seriously, maybe I'd investigate rather than not, even if no other signs, if there is involuntary weight loss, recommended weight loss or if the child is failing to try. So he's below the cent size, um or he's throbbing cents on the chart. There is G I bleeding or any bleeding. Uh uh Elsewhere like in my, as you mentioned, if there is chronic diarrhea, more than two weeks, if there is chronic vomiting, serious vomiting, though sometimes like function abdominal pain, patients can have some vomiting like mild vomiting with functional abdominal pain. If there is nocturnal diarrhea, diarrhea at night, which is waking the patient from sleep, I take it seriously might be a signs of inflammatory disease. If there is right-sided pain, I take it more serious like consistent, persistent, right, upper quadrant pain and right lower quadrant pain, unexplained fever. Any constitutional symptoms as weight loss or lymphadenopathy, any family history of inflammatory bowel disease, celiac disease, or peptic ulceration, jaundice, urinary symptoms, lower back pain also or back pains. Any abnormality in examination, dysphagia, oden, referral of the pain. Usually the functional pain is usually it is localized, does not radiate any radiation back to the shoulder or to the back or to the iliac fossa or elsewhere. It can be uh like a sign of serious pain. And if there is a history of child abuse in the past. So those are important, I'd investigate any patient coming with any of these. So what are the investigations for a patient with abdominal pain? So if the patient does not have any red flag or symptoms and his examination is totally unremarkable. What investigations we are going to do. CBC looking for signs of inflammation and if there was any bleeding or anything, you look at the hemoglobin, the inflammatory markers cause it could be an infection or inflammation. Um I might need to do B blood, you might need to do blood culture. And then um if you think there's an infection or not, um stool analysis, urine general. Yeah. Yeah, that's good. Yeah. Uh see the investigation for celiac celiac disease as well. Excellent, perfect. Yeah. So in the book like uh book wise, if there is, the patient does not have red flags and the examination is totally are remarkable. You don't need to do investigations but most of the physicians or the pediatrician, they do the practical wise they do. So I think I'll go with doing rather than not doing, but maybe if you have it in an exam or something like that actually, if the patient is well, no red flags and normal and remarkable examination you don't need to do. Uh So um yeah, the common investigations we do, as our colleagues mentioned, you do F PC inflammatory markers, either a sr or plasma viscosity. Uh you do biochemistry investigations like human heros fecrp and CX serology. Usually you do the tissue transglutaminase with IG A for some patients. It because the the the common tissue Traa antibodies we do usually is IG A antibodies and if the patient is like uh I uh like ig a deficient. Usually it's, it can be negative, false negative. So we check usually IG A with it. Um Also we need maybe to do um if the patient is having fever, uh um do you think maybe infectious cause or something like um like uh fever, you might need blood culture stool, then if there's dairy, you need to send stools. So we send it for culture sensitivity, microscopy, virology and parasites. A protectant, especially if it's chronic. And if the patient is having urinary symptoms or less than five years, you need to check the urine also to look for ut I or other urinary causes. So you do dip stick, um maybe send for cancer also. And if the patient having like gynecological symptoms, you have request also under time. Any questions so far. Ok. So yeah, so most of the patients, as I mentioned, one of the commonest causes is uh functional abdominal pain. In this case, you don't need to refer the patient reassurance, psychosocial support, patient education and uh manage pain management. That would be the the main stay. But if there are any like any signs and physical examination or red flags, you need to refer to the appropriate speciality. So G I symptoms to a gastroenterologist, if there are, for example, renal or surgical calls to the urologist or the surgeon. And if there are, for example, uh uh gynecological course is through the obstetrics and gynecology and sometimes you care for a second opinions. The problem is they are not happy about, uh they are not happy about your examination. They feel still there are issues not addressed or they are not comfortable with the diagnosis. So they might ask for a second opinion. It's fair for them to be sent for another opinion. I think we have just 15 minutes. I'm not sure whether we'll be able to cover the functional abdominal pain or shall we make it in another session? I'll, I'll leave that open for you for the participant. So because I have many slides remaining, I think because it's very important we should leave it for another time so you can do it well. Ok. Um If all are agreeing with that, I'm happy with that. Yes. Still fine. We can have it on the session. Yeah, I think, I think that's a good idea. Any questions so far about. Uh so it was uh like a general approach today for the chronic abdominal pain. So the causes are too many. But as I mentioned, like most of the patient, like 10, almost 10% or more than 10% of the kid, they have chronic abdominal pain at one point and presented uh to us either in the primary care or in the secondary care or, or to the emergency department with this abdominal pain and the basics of the medicines are the same. So take a proper history, most of the times you can get the diagnosis from the history alone and which can suggest, for example, give you some red flags. So to investigate for further conditions like inflammatory bowel disease or celiac or allergies, et cetera. And you do a proper physical examination which should be like a proper systematic examination. You concentrate on the abdomen, but you don't forget uh the general examination, the BP, the growth of the child and perianal examination. And um the rest of the systematic examination. I also look at psychosocial issues and the emotion, any signs of emotional or psychosocial problems. And if nothing in the examination, most likely uh un, no flags, most likely that causes functional abdominal pain, which are, there are several types of fun of abdominal pain. So the assurance that can be um uh can be accepted but many of the parents, according to the expectation, they expect you to do some blood investigations or some iag. So you need to address that appropriately with the parents and um maybe simple investigations like uh full blood count, some inf like infection markers or um inflammatory markers and liver function test, kidney function test and CRP might be uh in addition to a celiac screen might be acceptable. If there is diarrhea, we will investigate for the diarrhea. If there are urinary symptoms, we investigate for urinary symptoms and always check the urine for kids less than five or the young kids. Any questions so far. Mhm. And always when you have a patient who have like, uh when you send the patient home, even if the investigations are normal and everything is normal, always remember to give them safety netting advice cause symptoms might change with time. So even a patient with functional abdominal pain can develop another condition that can like uh more serious or they can have both coexisting functional abdominal pain and another condition. So, always give them a, a safe advice. What are the red flags when to come to the hospital? What are um uh what to do when the symptoms are worsening? We have to seek the help. You can give them some le le uh leaflets about uh abdominal pain and chronic abdominal pain and functional abdominal pain. So any questions? Yeah. Um Good. I would like to have this uh um is this a general question? Not, not for the a podiatrist? Is there a way we can, we can differentiate without uh maybe ultrasound or imaging uh imaging investigation. Is there a way we can differentiate between um gallbladder disease? Um ca jaundice or um tic um tumor um causing jaundice and also is caused by gallbladder. Uh He to stay away from that in um in the um investigation. So sorry, I I couldn't hear the, the the question clearly. Is it how to differentiate between like obstructive jaundice or dermatitis and things like that? Sorry. No, no, I which the information is that with from similar um information? Ok. Um sorry, sorry, sorry, sorry we could hear you. Do you mind just typing inside the chart and maybe I will tell the professor if you can just type in the chat because we can definitely not hear your microphone. Do you have any other questions that would like to ask the professor right now for the time being? Uh what's up? I I'm not a professor so I'm just a pediatric register. Oh doctor. Yes. Ok. Don't worry, don't worry about it. My bad, my bad for that. Yeah, but I'm I'm sure um if anyone else has any other question for the doctor in speaking right now, then I'm sure until we're waiting for Tara to write it in the chat. I think the lecture was quite amazing doctor. No one has any questions right now. If I can just have everyone to fill out the feedback format is very crucial for us to continue. Thank you. Thank you for that. You, the lectures in the online med school that would be very appreciated. And thank you again, Doctor for such an amazing lecture. Really appreciate it all from the comments and the feedback. Thank you very much. There's any other questions for the doctor? I think we can call it a day. May I ask you a question? Yes. Go ahead. Where are you attending, Rome? Are you from Sudan?