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Okay, So that further do I should start with last question. Which one? Off the, uh, which of the following ends? I was directly responsible for bilirubin formation. So if I give you a minute, uh, we just see if I can get the poles up? No. Is the pole popping up for you guys? Because I crate to the pole, but somehow allowing me to do so you strained. Okay, just one second. Okay, let me start sharing and just sort this out really quickly. Sorry about I think. I think now the pole has popped up. Let me just show my screen again and see Okay? Yeah, that would go, uh, if I just give you a minute, so I don't know why whenever, Because Because I don't have a host at the moment. So whenever I parked the pole to view the results after, like, stop sharing, pause a screen share for a second. But essentially, if I just give you another 15 2nd and I will go through the answers in a bet. Okay. So that's almost coming up to a minute. I'm gonna end up all that. All right. So most of you have gone for C, which is the correct answer. All right, so obviously, if you want to learn about the very disorders, a lot of it has to do with Billy Ruben on. We just have to Ah, professor, establish the bilirubin metabolism. All right, so, in terms off formation of bilirubin, if I get your tension on the right hand side square. So if you think about, um, visualized that has no reticuloendothelial Selves in this plane. Essentially, the red subnormal red cell span has for a, um my sex life span off 120 days on at the end of their life span, they would get broken down by the reticuloendothelial. So into him on global and on global parts will get broken down further into amino acid and those immune, I said, we'll get this. I called on, but the human part. So you have a train off reaction, tattered wise by different enzymes. That's a strong here, so that will be converted to Bill a bird and first and then an end Uncle Bill birding reductase book. Then convert that to bilirubin. And then what happens is that, um, the bilirubin. And so this is the on Contrave ated form off bilirubin that will get transferred into the liver on the liver cell essentially attached that to other molecules to make it conjugated bilirubin. So is more soluble in the blood, and then that will the essentially the bilirubin obviously exist in bile and that will get secreted into the hepatic ducts, and then the bladder will then store the bile and it it secretes in relation to food consumption. On day, once your food reaches the stomach and the duodenum, um, it will stimulate the bile contraction on. Then a conjugated while will be released from the your bladder, which contains conjugated bilirubin on, then in the garter, the got bacterial that were then convert that into your billing Noja. But your bile in urgent and circle violin and with your bile in it. And that's a lot of it will be absorbed at the terminal ileum because of the interaural hepatic circulation on the stock vial in which is what gives color to store. So that has a brown pigment, so that will make your store appearing that dark that that will get essentially excreted out of the body. So that is the whole bilirubin metabolism you got any questions? Feel free to put them in the chart, but otherwise we're just gonna move on to the next question. So case, too. Which off? The following substance can stimulate bile secretion. So I just give you another 10. Uh, sorry. One minute. And then if you could just answer that question from a Okay, So it's coming up to about half a minute on distill couple of you who hasn't answered If everyone just give it a try and we'll go through the answers in about 15 seconds. Okay, Cool. So the majority of your relatives I'm just in a shadow results? Yes. So the majority have gone for B, which is totally system's kind in. And then I have opted for C and E. So the majority of you all right, I'm just gonna go through each drop the substances, But first of all, isn't really, um uh when we ingest food and, um, in the stomach, it will be broken down. And then there will be pancreatic enzymes breaking advantage of fatty acid. And, um, you know, acid is on once it reaches that first part of the small intestine. Asshole. I lighted hair in pale red. Um, it will trigger colecystitis kind and secretion into the blood on desaturating Police System kind and then stimulate pancreas to increase the secretion off. Digestive enzymes on also causes thirst finger of oddi, which is what connects the pancreatic duct to the second part of duodenum. To relax, to allow the secretion to enter into the second part of the duodenum on also Colace Sister Kind and causes the war bladder to contract to release bile so that would cause fatty acids or for my cells on. That would mean that that would be easier for the body to absorb those fatty acids on just got a table so on orders function site of production on each of the options that we had to the question. So in terms of trips in now that is produced by the pancreas on the trips in essentially, that's an active form and when it was first produced, is produced at a time urgency. That means that inactive form often enzyme that's called trypsinogen, and essentially, that's a enzyme that breaks down corrosion. So it's protein elliptic on with the astronauts that secreted in the stomach on again is released um when it sends his, um, you know, acid and peptide presence in the stomach on that essentially causes stomach to contract to toe with motility on, Parastatal says. And also that has a power crying effect. Teo, the cells that secrete acid in the stomach as well on We've already talked about colecystitis kind, and the only thing to add is that is produced in the small intestine, usually in the 1st and 2nd part of the duodenum, on going down to secrete in again. It's produced in the small small intestine on but also together with polycystic kind and has a, um, sort of, ah, additional effects to stimulate pancreatic secretions to age with digestion on. Then GIP again that's produced in the small intestine, but that has nothing really like to do with the Gestion itself. My has a effect, Um, on, um, but the appetite by feeding back to the hypothalamus, but also that has an effect on insulin production and secretion by the pancreas. Obviously, that's important Teo transport glucose into the cells itself. So that's our second question. Done so, Case three, which is so the following conditions. Such procedures increases the wrist off osteo information except for one off them. So I put the whole again. Uh huh. There we go. So I'll give you another minute just to answer that question. Okay, We come up to a minute again for another five second. If you're not sure, just give it a go, and then we'll go through that all together in a bit. Okay, so that's a minute up. I'm gonna share the results. Yes. So we got quite varied answers for this one. And Santa spit difficult eso The correct answer is actually also typical Isis just gonna go through. So I'll go through the basics off our foster, and then we'll go through. Why be alternative colitis was the right answer. So in terms of risk factors and racially in med school, you've all been taught the fine f's. So you're listed here. Female fact, 40 found fertile. So these are your big fine risk factors, but I think we want to go a little bit beyond that. So, um uh, talk about some additional factors as well, but before we delve into that, just a brief introduction to the different types of four stones. So we may. We got three types as listed here. So cholesterol pigment on met stones on out of which cholesterol is the most common type. Of course, that and on is mainly made up off cholesterol, triglyceride and fatty acid with pigmented stones to the main composition. Then it's been a Ruben on bio acid or by outcry on. Then you get mixed owns, which is a mixture off cholesterol run pigmented stones. Um, and there are certain conditions whether that's acquired or inherited, that can increase your risk off course. The information, um, so ah, yes. So in terms off, um, sort of the conditions that can increase cell turnover. So, as we said before, because of Red Cell has a left life span off 100 20 days if your cell turnover of increases if the life span short ones, it means you are going to get more cell breakdown on more bilirubin formation in the spleen on also, um, things like chemotherapy and cancer. Because they have a more of an effect on the the structure off the cells, you would have more breakdown of the cells. Therefore, you're more predisposed to having a pigmented or mixed stones when you have conditions that increased cell turnover, Um, and in terms off conditions that increased red cell turnover. So a similar thing to cell turnover is exact. Same principle, but specific to red cell turnover would be hemolytic anemia. Whether that's a quiet or congenital acquired, it can be through. Um, yeah, I have Tradjenta, uh, drugs on congenital can be things like a G six pd on, um on satin enzyme deficiency on also sickle cell disease. Because the sounds more like Teo turn into us, it's more likely to sickle with increased oxidated stress on. That would mean they're more likely to break down on. But there will be more bilirubin circulating in the blood, contributing to the stone formation on DA also condition that causes excess off any different Austin component. So with high cholesterol and obviously that can be acquired through diet and lack of exercise. But also you can have a familial hypercholesterolemia, which predisposes you having very high levels of cholesterol. A very young age on giving century. Conditions were related to high cholesterol like stomach, heart disease and strokes on Do you listen I hand syndrome. So that's a congenital syndrome which causes high uric acid level in the blood, so that would cause you to have essentially, like, predisposed to having gout on. Also, uric acid can also be a component off some war stones, but that is quite rare, but nonetheless, it can predispose you to having Boston's on. Then, um, we talked about that enterohepatic circulation, where the bile. So the bilirubin in the gut is, uh, absorbed back into the circulation at the terminal ileum and then recycled back to form bile. So in thing in conditions that destruct, then for hepatic circulation like crone's disease because you would have a lot of, um, biles bilirubin left over in the guards. Essentially, the concentration builds up, and you're likely to form stones on do things like, especially in chromes, when you have inflammation off the terminal ileum that impairs the intrahepatic circulation even more s o as a complication of crone's, you can have, uh, increased risk that increased rest off or stone formation. So we just go back yet. So as we said, sickle cell causes more self breakdown because I read sour lifespan is shortened. Therefore, you have more Billy Rubin in the circulation, so you're more predisposed to pigmented stones. Alterative colitis, on the other hand, only effects the large bowel on gum. You don't really? Um yeah. You don't really have an increased cell turnover, and you don't really affect the enterohepatic circulation. So also, information is no really unknown risk factor for your stone formation in terms of your resection s. So that can happen in severe crimes disease, where people have terminal ileitis that's unresponsive to steroid on sometimes two biologics. So once you've receptive that you can have a build up off bio on Billy Rubin, therefore again causing pigmented stone formation and familial hypercholesterolemia. So that's a excess off the precursors off or stones in this case, our cholesterol. So you would have a lot of cholesterol stones in familial hypercholesterolemia and G six PD deficiency. So that would be a congenital form off him a little anemia again that would cause a short bread cells lifespan giving rise to a lot of pigmented stones. So that's third case done. Moving onto number 4, 45 year old woman presents to Andy was constant right upper quadrant pain, she said The pain came on 1 to 2 hours after dinner and since then the pain has been constant. In terms of past medical history. She has known Goldstone's, um, the blood results. I leave you to interpret that for yourself on gun examination. She's spiking a temperature on she is slightly tachycardia on. When you examined the abdomen, she's got a right upper quadrant pain, and it's mercy sign. Positive. So, um yes. So you think your own judgment? Um, let's just start the vote. Just wrote for whatever you think is appropriate in this case. Okay, so we're coming up to a minute. So 10 more seconds, then we'll go through that. Yes. So that's a minute. I'm going to end the pole here. Uh, I'm just gonna share the results. So pretty much most of you have gone for D on day one second. And yes, that is the correct answer. So again, we'll just go through the basics off, uh, war stones and then we'll talk through why that is the case. So, essentially in this condition, the lady has a known or or stone history on be proved probably has a strong history off biliary. Call it where, after eating her pain comes and goes. But in this case, the pain has now become constant. So it's pretty, Um, from a clinical point of view, the clinical diagnosis would be acute colecystitis and also if I just throw back. So in terms of the blood of White self, 15.7 is pretty elevated on ball. So crp off 60 eyes, Um, in conjunction with the high white cell, because there's a lot of information going on on. The thing is, if you pay attention so a, L, C and LP uppers are part of a component of liver function tests as well. It's bilirubin. So a lot easiest. An inflammatory marker off deliver. So in this space is raised. So you know the liver is going to have some inflammation on AARP e eyes A marker essentially, for, um um I guess I you can't say it's raising. Your stones are usually present in the common bile duct on bilirubin, in this case is also raised. So from the lft pictures, you conduced that there is a space is in terms of bio flow because bile is not flowing through the ducts very well. Therefore, they're they're very concentrated on their four. It will give eyes, too high bilirubin and high AARP and also cause liver inflammation. So, um, in this instance, we're worried about the presence off your stones in the common bile duct, which has shown in this picture hair on dinner sit here on de centrally. This is the condition where we call it coli Jokela thigh assist, so that usually just means the presence off Austin's in the common bile tops on. But the reason why we want to do an ultrasound or a MRC pee is because she's clearly clinically on well. But we're worried about that being a stone in the duct rather than just a full bladder itself on when there's a stone in the dark, because that obstructs the bile flow that could easily get give rise to infection. And also commonly, that's the commonly known as ascending colon. Joy it' on. I'm pretty sure you're no, you try out off ascending colon joy. It is if know, just pop a question that our answer it, but essentially because off the lft abnormalities in this case you want to investigate a little bit further. Teo, ascertain if she has stones in the common bile arcs Onda. Um, usually you can order a a ultrasound abdomen to look for that. That's pretty much what everyone gets these days. Even sometimes it's they just have acute police societies just because you want to rule out presents off or stones in the common bile duct as a complication. Onda, um so annulled tra sound. Sometimes you can see ah enlarged common bile duct so normally five millimeter and below. That's considered normal than on ultrasound. You can tell whether the diameter is increased or not, and usually if ultrasound is normal and their liver functions improves during their in patients, they you don't have to do an MRI C p. But if their liver function is persistently abnormal on, but also the ultrasound shows an enlarged common bile duct, you normally would proceed onto MRC pee just because it has higher sensitivity and specificity rates. To rule out a stone in the common bile duct. Onda, which is gonna have a look at the yet so chocolates try acid that's fever jaundiced on upper quadrant pain on. There's also something also related to ascending colon dry. It is called Reynalds pen. Todd, I'm just, uh on. That's essentially a fever drawn this and, um, right upper quadrant pain with confusion on hypertension that so that's when you're really septic. On day. Things are getting really bad because bilirubin can cause is, um, essentially bring to this to dysfunction, so that would cause the confusion. And then the massive sepsis is the infection would cause hypertension because you would have a lot of basal dilation. So that's the try out Penta off ascending colon ritis eso if we just go back to our options. So normally, anyone with acute pretty cystitis with a blood picture like this, you would admit them and set up discharging them on gum, unless you can just prove it's simple. Oh ah, cockup acute cholecystitis with isolated raised white cells and CRP without any abnormality on the liver function. Then you can discharge from home after discussion with your senior. But in someone like this, with the abnormal liver function, would definitely admit them on would definitely start. The IV antibiotics depends on the trust you're working in, but usually would be IV comb. OxiClean if they're penicillin and allergic usually would start them on ciprofloxacin and my metronidazole together. Usually that's a seven day course on because again. Like we've explained before, we're worried that there's a stone in the CBD, so we would want to get a ultrasound on Dalser Oh, to see, depending on orchestra result to see if MRCB is necessary later on on the reason why we don't just plan for your CP straight away. It's because there's a rule that you normally have to have an MRI C p before you go for an ercp because I'm asleep. It's just a memory imaging off the biliary system. You have to prove that there is a stone within the common bile duct First, before you can proceed with ercp on scope them to take the stone out because if you just go in blindly, the risk would away the benefits. And it would be a point, this procedure if you don't find any stories on scoping. So we go to Question five with nearly halfway eso the same patient with from the previous question under when MRC pee on Dem RCP shows that has dilatation in for her Pasic ducks, and the common bile duct is measured at nine millimeters s. So what's the most appropriate management management option for our patients? Let me just put the pole up again. Yes. So, again, we've got a minute on. Just choose whatever you think is the most appropriate. Okay, so we're coming up to 40 seconds. Um, so I just want a few more answers. Give you another 15 seconds or so before we revealed Answer. Okay. Cool. And the pool there. So the majority has gone for be with some seasoned these stuff. All right. Side to the correct answer is actually D in this case, um, explain why in Okay, actually, if we go back to the fourth question um, yes. So it's just some hidden details in the questions. Damn. Um, let me have a look. Wants one second yet, So here. No, we go, um, basically enforce are in the fourth question. Under past medical history and drug history, we said she's alone a f, and she takes a picks about normally for a FTO for her anti coagulation risks on because of this, um, we obviously will assume that she's admitted with pickes about, and she's been taking a picture of an as she has been instructed. So normally, that's 2.5 or 5 mg twice daily. Because of that. If we go for our your CP straight away, she would have, ah, a really high bleeding risk. So normally, people who are admitted on Doac we withhold oh, up for two days 48 hours before they can go for your CP. And if it's until platelets like clopidogrel, we normally would want to hold that for five days, but again, like different trust, have different guidelines. So this is the guideline from where I'm working. But normally it would be the gastroenterologist who are trained in the ercp who carries out this procedure. Normally, when they consent them, they would go through all of this with the patient on then the gastroenterologist who carries out the Ercp themselves would make a plan regarding stopping anti coagulation or anti platelet prior. But in this case because, um, at the moment, even though she's gone infection and it does show up in her clinical observation. But she's still maintaining her BP for her cap refill. Still two seconds, and she's still alert on eso at the moment. She's not in septic shock, and she is perfusing her organs quite well, so we don't want to rush into it because in this taste, bleeding would be on unacceptable risk if we could just wait 48 hours to lower that risk for her. Whereas it would be a different taste if this patient came in insect it shock and completely confused on DA very hypertensive. In that case, then I think we can accept a wrist off leading to Untorse to hemotologists Teo give her some blood products like a platelet or clotting factors of reverse that picks a band. But in this case, because we already treating her acute cholecystitis with antibiotics and other supportive measures waiting for 48 hours to do that you are seeking wouldn't be that bad. Far off was in the meantime, I would need to have to take blood daily for her. And that would normally include your usual sets of blood, but also liver function and clotting factors. Just to make sure that her clotting is not deranged. Because in this case, the liver is affected with bio could bio Stasis is so just a quick slide on ercp. Um, again, we're already touched on benefits and risks, so the benefit is that it has a diagnostic and therapeutic purposes and has a very high successful rate for stone removal on before the age of ERCP. Normally, the patient would have to go for a emergency code is a step to meet. Take the gallbladder out on Dad on injured. In the meantime, they would take a stone out of the CBD darks. Where's it go for a year on CP? It's less invasive than surgery on day. Don't normally taken just normally be sedated. They don't have to undergo general anesthesia on the wrist again, with any procedure. Has, um, uh, converse of risk of bleeding infection on. In this case, it's worth mentioning that Yaz Weekly is one of the causes of pancreatitis is so after your CP is done normally would keep the patient in for about a day. Also, just to monitor if they have any new abdominal pain, because that could be an indicator for pancreatitis. And again, with any procedure, you always have a wrist off failure. In this case, with failure to retrieve the stones or failure to pass the stone to a certain point of visualize the dark on a very, very rarely you can have our perforation with your CP and if you are sleepy does fail to retreat. The stones, um, patients Very unwell. What you can do is go contact interventional radiologist and do our packet anus. Reinisch. So what? That means Just insert a drains from the skin into the war bladder and drain the bio out on that would avoid any further complications while she'll buy some time for a definitive treatment. And usually that would involve surgery. Um, so just before we go to the second half, I'm just gonna post the, uh, feedback form here to do it at your own time. Uh, only takes about a minute, but otherwise I'm just gonna go straight onto case 6 70 Old man presents on well, too and e his having upper quadrant, right? Upper quadrant pain. And he also looks Ah, a little Hey also looks drawn. This so the blood results again. A shown here. He's ml cp This time shows dilated proximal common bile duct. But the rest of their has a normal diameter. Hey, underwent ercp but there was no stones found in the CBD. So what's the most likely diagnosis in this case? Uh, so minute stops now. Okay, So another half a minute. Okay, so we're coming up to a minute, so I'm gonna pull that now. Um, again, we're pretty divided on this one. So a third of you went for a than another third for C on D A bird. What? He so the correct answer. It's actually Ah, he on. Do go through what's never see syndrome. So nurses in Vermont centrally is a common bile duct, obstruction by spoons present in the whole bladder itself. So usually it happens when the stone it's so large and could see on the diagram. Here it's so large is impacting on the neck off the war bladder that's actually compressing into the CBD and causing a narrowing or complete obstruction. They're too tight. So the first types, quite simple, just presents off stone in the, uh, or your bladder or the cystic duct, then compressing the common bile duck. The other type, we just bit more complicated when the stone is compressing onto the your bladder. But it's created a lot of inflammations there on that causes some cell breakdown on. Then eventually you create a fistula between the your bladder itself on the CBD, so on the right artery on the left hand side of the diagram mystery. Type one on. Then on the right hand side show and talk to, and you can see that the wall of the your bladder, the purple is spinning out, and there's a fistula for me. Onda, in terms of clinical presentation, is very, very similar to ascending colon joy. It is on Dunstan that weather confusion lies, and that's why some a lot of you went for that option. Um, Andi, So you can totally present with Charcot is try as and the same blood picture that you would have, um, like, uh, increased a Opie's high inflammatory markers and also high bilirubin on, but also the management. So that can be your CP. If there's a fistula or if there isn't a fistula, then you can just let them go for emergency. Coolest step to me, too. Get the gold bother out, and I would relieve the pressure on the reason. I just want to say yes. So MRC pee shows Ah, dilated proximal CBD. So that usually indicates that there's something compressing on it because the rest of ah diameter is normal in means that there's no compression for the rest of the dark. So that alone itself shows there is a stone somewhere, but just not in the common bile duct itself. So that's why a calculus colecystitis not correct, because in the case of a calculus POTUS cystitis, you wouldn't necessarily have the obstructive drawn this picture. Would a liver function shown here on also the diameter off the CBD would be pretty uniform instead of having one heart dilated and another part normal. So that's why, um, memory see syndrome is the correct answer from all of the other ones. Okay, so okay, 7 40 year old female patient presents with right upper quadrant pain again on day has a history of biliary colic. Right now, the Penis constant on. Do you order the ultrasound? And it shows that there is a full bladder, and I mark, that just means a lot class accumulating in a full bladder. And right now, the your blood is very enlarged on, but it can rupture at any time. So where is the full bladder most likely to rupture from? Um okay. Just relationship in the hole. Okay, so we're coming up to a minute again. I'm just going to end the cold, it's gonna share results. So a third of you have gone for the funders, which is the correct answer. Um, so understand this question is a little bit hard again. So we're just gonna go through Rhett. Um so to answer this, you would need to know are some anatomy regarding the biliary system on the blood supply to the goal bladder. So on the diagram on the right, I've drawn the blood vessels here. Essentially the sick vessel down the bottom's the common hepatic artery that's part of the celiac trunk on bifurcate, into left and right hepatic artery on from the right hepatic artery. Have a terminal artery called a cystic artery on supplying all of a ladder on. But I'm not rich means that's the end off a branch on. But once the cystic out for our tree branches off it forms are a lot of our anastomosis and little networks around the war bladder on, in terms of the anatomy of the war bladder. So I know in one of the options is this head off the whole bladder. But the war bladder itself actually doesn't have a head, has the neck, which is literally where the heart means pouches, and then it has a body, which is the majority of the other. On the end is the funders and why. The reason why the fund it's most likely to perforate from the funders is because, obviously, that's the further It's away from the origin off assistant car tree on one's, the artery on forms, anastomoses and capillaries there, when the gold bars is very enlarged and then gorgeous, very easy to compress on those little arteries on, deprive the funders off blood supply and oxygen on. That's why when it, the tissue necrosis is that the funding start will be the first part to go with the first part to die. So that would create a point of weakness in the structure. And it will most likely for the pressure to relieve through the funders on brush in there. So we're done with what questions? Seven. So just question. A 63 year old woman with no more stones has been experiencing biliary colic. Her GPS arrange an ultrasound abdomen for her on the ultrasound has revealed that there are multiple stones on day. In addition, there is multiple rows present on the your bladder, so your blood results are a stone on what other words? Most likely the So let me just pop the pro again. Okay? So again, you've got a minute. Okay, so gonna shut the whole year. So again, very mixed results. Um, yeah. I don't think essentially, in this case, cholesterol polyps, So I don't think polyps or are your bladder polyps or cancers Put that much in medical school, but I just thought because they can't quite common is that we're just, um it's important that at least that we're aware of there. Um, so essentially, uh, it's just simple definition, just a growth into the your bladder or protruding from the mucosa on gum. And really, there is kind of no clinical presentation. It's very usually asymptomatic on, but it's usually a incidental finding on the ultrasound on dust. Talk about the classifications a little bit, so you can have ah nonneoplastic on your plastic polyps. So non know plastic obviously are your, um, polyps that basically will never really, like, turn malignant on. The most common type would be the cholesterol polyps on, because Elestrin, if you remember, is also the most common type of or stone makes sense that when, um, you have high cholesterol level, it also becomes the most common type of polyps. Essentially, when your serum cholesterol is high, it's a similar pathaphysiology to, um, author Circular sclerosis, where the macrophage is sort of comes in and sweeps up the cholesterol and then form these like foam cells and cause a, um, aggregation off these 1000. And then it caused a a polyp Teo happen on, then the next one is adenomyoma is. You don't really need to know the specific details, but essentially, it's just a proliferation off the epithelium off the war bladder. And then you can have inflammatory polyps. Theo. Only thing to mention is that these are the infirmary. Three polyps are essentially benign, but because it's due to chronic information on that itself is a risk factor. Teo Cancer Developing. So even though these are normal, ignorant and nonneoplastic, it's just important to keep in mind that, like decades down the lie, it has a potential to time malignant Onda. You can have new plastic polyps on the other arm. On that, again is different. Prided into, um, malignant, benign rather than been. I think it's better to categorize it as pre malignant because they have the potential to turn malignant, which are added members on. You just need to keep an eye on them on. But you can have your malignant polyps, which can be added know across Nomar, which I just made up off connective tissues. And it's the most common type off malignant polyps, and you can have your squamous cell carcinoma, so that's usually the epithelium. Um, uh, that has a cancerous growth rather than the connective tissues on with, um, use nous cystadenoma. So that's a lot of mucus production in the cyst on then that can essentially only spell into your abdomen on Adderall are controllers is actually like, really, really rare on. But yeah, I'm not entirely sure what type of tissue that's made off. Um, but I think I can have some Tarantino sites in there. So moving onto a penile ultimate question, 70 old man presents The GP was six months history off, right toe up, according pain off the meals. Occasionally he was experiencing nausea and vomiting, bloating and some acid reflux. You are the GP, and your range is an X ray and ultrasound X ray shows there's some radio. A pass It e s o essentially that some brightness around the whole bladder. And then the ultrasound shows a fibrotic your bladder was stones. So in this case, so haven't think about what could be happening. And what would be your frozen management plan for the patients? So the course on two now? Price of five more second. Okay, so got to stop it, Dad. Shadow results. So all of you have gone for cholecystectomy. But there's a difference in opinion on whether elective or urgent. Yeah, cause cystectomies needed. So in this case, be an elective cholecystectomy. So what we're talking about here is actually a horse playing war bladder. So the radio pacies of that ring off brightness around the war bladder is essentially calcified tissue because the patient has had a long history off the arm, biliary colic and also inflammation within the core bladder that itself causes fibrotic tissue to form on day, become calcified and show up on the X ray as this bring awful pass it e around the whole bladder. Onda again is often asymptomatic. Well, because he's had a history of chronic inflammation, he has a risk factor on off this developing into, um cholangiocarcinoma, which is the cancer off your bladder. Um, but however, in this case, um, because so, actually, I haven't given you any. Um uh, actually, I haven't given you any blood tests, but let's just assume like his blood tests are normal on his and liver function. Tests are normal on does no indication for him to undergo an emergency or urgent cholecystectomy on. So what kind actually happen is that you could root with for him to outpatient to join the elective cholecystectomy list on. But that could be done in a convenient time for the patient on for the surgeon as well, just going through the other options. Pretty conservative management with lowfat diet's not going to change his risk factor off developing cancer book or bladder because the fibrotic tissue is really that there's already some changes within the tissue. Does low fat diet smoking? Reverse that cereal, abdominal ultrasound for next few years. You can do that. But the most convenient thing is to get rid of the risk factor itself on that say, elective cholecystectomy on, um, you don't really want to do nothing just because there is a risk there on if it does happen for the patient. Um, the yeah, I would say it would be a lot more harm to him down the cholecystectomy itself. So in this case, you would choose a convenient time. I'm planning elected cholecystectomy. So they were on to our last question. Um, the GP put the previous patient on the waiting list for elective cholecystectomy, but the patient did not want to go through with the procedure on Done. Um, some of the symptoms have gone away since seeing the GP on after five years, the same patient presents again. And this time with century or floor symptom fever, lethargy, loss of appetite, weight loss. Um, Andi in that. So we're ready. Alluded to this. What's the most likely diagnosis in this case? Put the pull up one last time. Yeah, Okay. We're just going to stop the pole of that. Yes. So majority of you are right. Um, So, yes. So he is most likely to develop Karanja carcinoma. Hey, has probably developed cholangiocarcinoma, but obviously that would Haywood convert meant by doing biopsy on down staging stands to see how bad the spread. Um, off um, the cancer is on just one thing to mention. I'm sure you're ready. Come, cross is it's on examination. He's drawn this and he has a vase years sine. So that's it's essentially when you palpate the abdomen, you can feel a mass on the right upper quadrant, but the patient is not complaining off any pain on usually if you feel a mass in patients, complaining off pain on is most likely down to information and something else like or Brother Empyema, but in this case is painless. Drawn this with the right upper quadrant mask. So that's a sign described that's specific to cholangiocarcinoma on just quickly unclimbed a carcinoma you don't need to meet. You don't need to know much about this, but it is a multistage process, where on a thelium off the gold bladder, undergoing better place here, where they change into a different cell types. So in this case, it can be from epithelial. Cells are more like fibrotic tissue, a sweet seen by in the case of ports lately or bladder in the last two days on, then now has undergone displays here, where there's a disregulation off um, the South Side calls, therefore causing a growth and the math off the wall bladder on. In terms of clinical presentations, you can get some abdominal discomfort because of compression on the bow. And also you get on the floor symptoms that we've mentioned on the patient has presented with them in the questions them. And also because you have a new accumulation off bio on, uh, bio acid and bile salts. It means you have a lot of bilirubin circulating in your system. So that conceit power into the tissue and causes a lot of itchiness a lot pruritis on. Also, obviously, the bilirubin itself causes a john distance parents. Um, So what were the floor symptoms again? So I just write that How so is fever? Uh, key, my right. Yeah. So? So those other four symptoms are usually if people have got a combination of thumb. Uh, you are always worried about malignancy and cancer, so I think that is the end of March. It oral would really appreciate if you're just fill in the, um, feedback form for maybe just gonna post again, and I just stay on for another five minutes to on any questions that anyone has on you again. Just reiterate this is the last few trial off yet before Christmas, I'll send a updated, um, timetable for early January. Um, so, yeah, just be aware that there is no total tomorrow on, um on sunday yet because the cheaters that have been pulled to do extra work me thank you guys for joining honor is really close to Christmas, So yeah, takes a lot of, well, power to sit through one of these. Can I get the previous session feedback link? Ah, so is the previous session. Ah, Lowell in fractures. If you just confirm that, I'll get you the link. Right. So if none of you have any questions, then I'm going to close the chart. Just please, please just do the feedback form. And that would really help me on done. We've also, like, handle off generals in the new year ago. Well, on that include one off the ah Siris on PS PSA, which is the prescribing exams on that anyone in final years gonna take. So if you feel in the feedback so we just know how to, um, direct our future tutorials. That would be great on. Okay, I think if there isn't any more questions, I'm just gonna close the chapter now on. Just hope you'll have a lovely Christmas right season, guys. Bye.