Colorectal Cancer (Part 1), Dr Athula Withanage, Senior Lecturer General Surgery. BSS course Cardiff Medical Centre. Retired Consultant
Summary
This on-demand teaching session offers medical professionals an in-depth discussion on tumors of the gut. Participants will learn about the rarity of tumor occurrence in the small bowel, the importance of transit time, and the risks and treatments associated with small bowel tumors. They will also gain insight into genotype/phenotype variation and the role of environmental factors in carcinomas of the colon. Attendees will also be alerted to the importance of viewing the histology report for small bowel tumors and receive guidance on relevant patient screenings.
Learning objectives
Learning Objectives:
- Recognize that small bowel tumors are rare and only comprise 2% of gastrointestinal tumors.
- Describe the presentation of neuroendocrine tumors in the small bowel and their associated syndromes.
- Distinguish between benign and malignant small bowel tumors and their associated treatments.
- Demonstrate knowledge of the various diagnostic tests and examinations used to assess small bowel tumors, including plain films, US, CT, MRI, PET scans, endoscopy, chromogranin A, and 24-hour urine studies.
- Analyze the genetic and environmental contribution to large bowel tumor's, with an emphasis on the factors associated with high-risk populations.
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Still cancer. Uh We'll talk about generally about tumor's of the gut. I thought that was more important, uh, when you talk about etl or the etcetera transit time. My favorite work, right? Um Okay. So, uh small bowel, small bowel, the tumor's are very rare. And, uh, again, it's less than 2% of God, tumor's. And, uh, but there are some important, uh, neuroendocrine tumor is here. So it's less than 2%. And, uh, I always love to talk about transit time because that's the word you must be using across the table in the exam because the transit time is, uh, is very, very, very, very low in the small bowel and it's a liquid, liquid feces. The, the contact with the carcinogens. The environmental factor that we always talk about is very much less. So there are like in our, they other parts of the body guard, there is a Dean Omagh's Lipomas, not so important, but there are some syndromes, uh, that we to talk about hematoma to Hamartomas, Hamartomas and, uh, something like Betsy Egas syndrome, uh, where you get the general polyps in the, in the small bowel and you, you probably already know about it, the circumoral pigmentation which may disappear uh times of puberty. Uh And uh it is an important uh cause of jejunal polyps. And the geese tumor's gastrointestinal stromal tumor is you may not have been using that because nowadays, uh previously, it was known as Leo Myoma, you must be used to that one. But I think increasingly, I think most surgeons now use uh guest tumor's gastrointestinal uh stromal tumor's. Uh most of them are benign, but it's greater. They go according to the malignant potential, right? So, uh uh Leo Myoma, uh I also, you will use that word. They rise from uh small bowel uh from uh special sales called cordial cells. Um And uh you will get that in the uh the guest tumor's in the small bowel as well as the stomach. I don't think it's important to know the blastoma sarcoma as uh the uh we said that malignant potential uh will be decided only after the biopsy. So, uh it is uh there's a gene mutation and the uh we call it a secret expression and uh it is treated with try tyrosine kindness inhibitor, uh imatinib very difficult to find, especially uh even in Wales, we have to get the permission from the uh from the parliament because it is I must be, it must be very expensive. Uh So it may rise from the stomach, small bubble, even colorectal uh guest tumor's maybe maybe present high risk when it is over five centimeters in diameter. So other malignant humor's adenocarci know must come in Jordon. Um the Juul um and the lymphoma's so T cell lymphomas, especially uh celiac disease, the passes Joe Celiac disease, they have A and B cell non hodgkin's tumor's. Uh I think the most important one for us because it comes uh as an exam question, carcinoma of the appendix. And when you write the case history, uh I, I have found out that you don't for appendicectomy. I mean, you write the cases to for appendicectomy use don't give any importance to the looking at the histology report. It is very important, especially in the Children population to see the histology report to make sure there is nothing serious in that other than you confirm the diagnosis, you know, you didn't take out the appendix because because uh there could be some other reason uh differential diagnosis, but it is important to know there was a carcinoid, did the appendix and we'll talk about a little bit more later. Uh Of course, there are secondary tumor's invasion from other areas, stomach colon, uh bladder and of course, lymphomas, uh they can, they can bleed if it is in the stomach, stomach. And the uh the uh again why uh tumor's are less common in, in the small bowel. Although the, uh the there's a high mucosal burden the length of the small bowel because of the rapid transit time. Well, people say alkaline environment, I think the transit time is the most important one. So they cause dit bleeding. As I just said, intestinal obstruction interception is possible in the small bubble, it becomes the head of the intercept. Um and it may cause wall villous due to heaviness of the of the humor, they can perforation. And of course, you, you must when the tumor necrosis especially, uh this is the thing that we don't normally talk about when you give chemotherapy, uh that humor may dissolve away almost thin out and can perforate as well. So I wouldn't discharge any patient post chemo. After say treatment with chemotherapy for small bowel tumor's, they can get diarrhea's various syndromes. And also the carcinoid is the most important one for us. Uh because the tumor peptide uh cause goes into the circulation, especially if it cannot be coped by the by the uh if it goes past the uh the uh the till lower uh reddish blue cyanosis, flushing, diarrhea, borborygmus, me and uh wheezing asthmatic attacks types, think, okay. So when you take history for small bowel humor's, of course, you need to go through through the history carefully. Celiac uh celiacs uh past history of lymphoma aids are important and also crone's disease, also important um cross disease and uh ulcerative colitis is important in the large bowel involvement of the large bowel. So, clinical examination, normally you carry out the normal examination and the bloods need to be done full blood count. Crp esr you any lefties, uh, occasionally if there's a history of celiac disease, you need to do syriac antibodies. And of course, uh, fecal, local blood's necessary for small bowel as well as large bowel. Uh, 24 hour collection of, uh, urine is important for disseminated cars. You know, it's syndrome, but earlier on it maybe even normal. So a plain film abdominal, if the pay is an acute admission, it's a Supine films we are mostly interested in. Nowadays, we try not to do erect films because it doesn't, if it's an obstruction, you may find affluent levels. But uh I think now the recommendation is just to do a plain film because you can see the level of obstruction if it is due to a tumor. Uh barium follow through is done for a small bottle. Uh If it is a sub acute obstruction, uh barium follow is allowed uh in, in especially in the developing countries. Uh ultrasound, endoscopic ultrasound, various ultrasound can be done. CT MRI pet scan if it is disseminated into, into into notes. Uh colonoscopic e for the large bowel tumor's obviously. And of course, uh the interest copy is not available everywhere. Even in Wales, we got only one intra scope in in Cardiff, uh not beyond that. So it is not an easy thing to do where there are special people who are doing that. But cities can uh and very um follow through can still be done. So, carcino, it's are rare endocrine tumors uh thought to arise from the entro chromaffin cells. Cultured ski cells is also known as Argent Phanom A because it is colored with the stain with silver and 10% associated with multiple and uh new place here syndrome. And men, one commonly found in the appendix, uh a symptomatic until it test gone through the liver. So uh for the syndrome, it is five HD which is uh which is responsible, right. So, start as a golden yellow, which sub mucosal nodule very, really diagnosed before uh surgery. Uh mets, uh neuro endocrine cells in the base of intestinal cramps also rate to extend through the zeros uh and encircles about uh 4% from the appendix metastasized and uh 5% produced the syndrome uh flushing especially after uh flu, food, alcohol and stress. So, diarrhea, abdominal pain and wheezing occasionally, longstanding, they may get strike a spit stenosis 24 hour urinary metabolic, it fire hydrox Indal acetic acid is done. And nowadays, of course, chromogranin a can be done but it isn't, it is common to neuro endocrine tumor's and it's not specific for uh Carcinoid. The treatment using octreo tried has been, uh it's an analog of so matter statin. I think the medics will be talking about that. And so, uh why it is important to see their pandemics report histology report. Uh the uh at the end of term survey, we do some uh uh case history reports and make sure you say either I will look at the histology or if it is not available. But if it is available, uh say if you are presenting after 23 months, you must have the histology report uh appendix carcinoid, less than two centimeters. You can get away with appendicectomy over two centimeters. And especially if there's cirrhosis will bridge. And if the tumor has high mitotic index, uh it is uh it is important to re operate and do a limited right hemicolectomy all. So that is why it is important to look at the history of the report. So that's all nothing, nothing, not a lot for small bowel tumor's. Uh the reason is that but you need to know about lymphoma and also carcinoid and guest tumor's is very important, right? Do you go to uh large bubble immediately? Uh considerable geographical variation exists and that in itself tells you there are environmental factors are important. When you ask about etiology of colorectal tubers, you should be able to say something about it uh with confidence and the uh so it is a genetic predisposition. The genotype is important versus the versus the phenotype, which is the environmental factors, which is uh environmental factors are uh effective through the Lumina lumina aluminum of the uh of the co of the colon. So that is uh about cars, you know, against the transit times that we talked about. Uh common in population of high living standards, especially the upper hemisphere of the world. Uh rare in Asia uh Asia, uh South America and Africa. And that may be due to the high fiver uh diets. Um But still, uh there are some genetic variation, the South African whites, it is more common than in the South African uh blacks. So arise from uh pre existing adenomas. So that's an important sentence arising from pre existing benign adenoma as and uh why that is important? Because we, that usually they come about 10 years uh or 5 to 10 years before the carcinoma uh incidents. Why? Therefore, it must be conversion from a benign situation to a malignant situation. So that tells us you can screen these patient's. So that is why it is important. So, variation exist within the countries. I just said that. So diet and red meat, saturated fatty fat, fatty acids and high uh where their situation, high output or bile acids uh versus the protection come from the high fiber diet. And how does the protection come? It's because of the uh transit time is decreased. So, the exposure to cause an audience, the environmental factor is much less. So uh the, the, the about uh polyps, we, we talk about the size and number is important. There are various protocols that we'll talk about it later. Uh mutational activation of at least one proton co genes. So again, when we're talking about cancer or genesis, you should be able to know something about proto oncogenes and tumor suppressor genes. So, proto oncogenes versus tumor suppressor genes just know one or two. I think the uh the uh so that you can, you can uh go on talking about it. We'll, we'll, we'll talk about that in a minute. Okay. So, uh mutational inactivation of more than one tumor suppressor genes and at least one proton co genes, mutational activation. Both changes provide uh affected stem cells with a selective growth advantage. Clones d right from it will expand and expand to form a neoplasm. So that's what the genetic factor, how it, how it occurs in the colon. So the uh Kare aas the somatic proton kojin is affected in about 80% of the mutations and uh and uh especially uh if the uh polyp oh denom is more than one centimeter in size, the initiating your event in some uh acquiring the malignant phenotype, small one uh be become larger the noma as well. So it can be just a mutation of uh a larger, larger uh polyp or adenoma or smaller, the noma may become larger adenoma and eventually become new plastic because of the uh change in the proto-oncogene chaos is the one that we normally talk about. So, in activation of tumor suppressor genes, there are a few that you can remember, you know about a PC uh the polyposis syndromes uh and uh DCC deleted in colonic cancer and P 53 they are good, good genes but they become inactivated and let the tumor grow. So, uh okay. Right. So, colorectal cancer is the second commonest cancer in the UK in the and uh 20,000 new cases per year and 40,000 40% and 60% in the colon in the rectum. Uh And the uh it is why it is important because you can do it. Uh you can do a left sided uh flexible sigmoidoscopy and diagnose most of the, most of the cancers. That's why because you even even to screen that we have no time to prepare the bubble and do the colonic uh colonoscopies. But it is much easy. You don't need much preparation, just a couple of NMS and carry out a flexible sigma this copy which goes up to about splenic flexure uh and it's a shorter, shorter in Dusko. Uh So 3% of patient's uh with more than one tumor at the same time. So it is very important the surgeons as well as the diagnostician, the medical students know this. So about the fact that there are synchronous tumor's, we do ask in the exam and why do you if you find the tumor in the in the in the Sigma las copy or pr examination, why do you need to do the whole colon, do a CT scan to cover or do a barium enema in order to make sure there are no synchronous tumor's. I have seen my colleagues getting into difficulties because they want to get the patient quickly into theater. And the suddenly uh they find the uh carcinoma in the, in the, in the, in the cecum, you do a nice anterior resection and you have missed the carcinoma. Uh because if it is uh coming within six months that my um you must out miss the carcinoma. So the fact that synchronous to must are present in 3% of patient's must must be taught very seriously. And we do ask you uh uh why, why would you do if you have already diagnosed a rectal tumor or sigma it tumor, why do you have to do the whole colon and answer is it is to exclude synchronous tumor's. So if it appears after your resection, six months later, it is not a reoccurrence unless it is in the anastomosis. If it is occur in somewhere else, it is a meta Cronus tumor. So remember the two words, synchronous tumor's meta Cronus tumor's. Again, I'm not going into details about the diet. I think in every book, it is described. History of uh sporadic tumor's are about 85%. Uh but uh history of polyposis, familial adenomatous polyposis are important uh and also uh athletic colitis cross disease are important. Now, there are two methods of conversion uh or the sequence that uh whether it is due to uh due to various mutations. Uh the the sequence is known, uh, there are two types of sequence. One is, uh, I don't know my cancer sequence. It's called Wardell Stain model war gel stain model lighting. The spelling I will give you in a minute and the other one is, uh displays er, cancer sequence. So, two types of cancer sequence, how a non malignant situation become a malignant situation. So, uh the enema cancer sequenced and uh and dysplasia, cancer sequence, dysplasia, cancer sequence come from uh athletic colitis may be from Crohn's disease as well, especially in the Colon Crohns colitis. And the uh that's why longstanding early onset alterative colitis uh likelihood of uh converting it to cancer. If it has been uh 20 years, the authority colitis coming and going, then of course, there's a 10% chance of it becoming dysplastic and becoming cancer. That's why we want to do multiple biopsies after 10 years of uh of uh ulcerative colitis. Uh Right. So uh Harry, literally nonpolyposis call eyes, the uh syndromes. They are called link syndromes Lynch syndrome. One purely colorectal Lynch syndrome too, which has got uh uterine bladder breast, uh stark and various other areas involved. So, Lynch Syndrome one and Lynch Syndrome to look at those two as well because you need that because there are more younger age groups get it. And of course, the uh the sporadic als rectal cancer comes in in the seventies. And yes, as I said before, in the sixties, you get their din oma. So a benign situation. So that's why it's important to screen these. And how do you screen? There are various methods given after 60 people do fecal local blood three times. Uh in Wales that we do it after 60 up to about 63 I think they may extend that later on. So fickle local blood eggs examination if it is more than two positive out of the three, it should be done on various days of the week, not on the same day. And you ask the patient not to have red meat and also ask the pa in the, in the previous day and not to vigorously brush their teeth on the night. Uh So do it three times on three occasions and two positive, you screen the patient and do a flexible sigmoidoscopy at least. Um And that is, that is the way we uh screen the patient's. So uh the uh so as we said, the link syndrome, hair Italy nonpolyposis, uh Coli syndromes, they, they, although they, we say nonpolyposis, uh but they do have polyps, not as much, not like hundreds uh thousands in the uh family and adenomatous polyp osis. So, uh symptoms, it brought to go through the symptoms when the patient come to you read it is uh rectal bleeding and, and uh we have a thing called rectal bleeding clinics. If it is a suspicious continuous for a few weeks, the patient is bleeding, wrecked, patient should be addressed to rectal bleeding clinic and especially should see the patient within two weeks. And we talked about breast cancer in the afternoon and the uh so there are protocols in this country in the United Kingdom. Uh You have to see this patient within, within two weeks uh in the red, in the RBC clinic, we call it and uh change of bowel habits of these patient's are important. So, as I said, in the last uh lecture that when you talked about rectal bleeding, you must immediately say that whether there is mucus with it, uh mucus. Uh and also whether it is mixed, it is important because it comes from higher up if it is mixed and also uh change your bowel habit. And in the same manner, you talk about loss of weight because it may be a paraneoplastic type syndrome. The patient may generally feel fatigue and unwell. Uh of course, a past history of polyps, past history of colorectal cancer is important because as we said, Metta Chronos tumor's, they may get meta Chronos tumor's uh and the carcinoma in other sites. That's the Lynch syndrome. So it could be a female uterine carcinoma, bladder carcinoma, uh stomach carcinoma. So it is important know about Lynn syndrome, especially a younger patient. So the risk factors uh uh athletic colitis, we said that that is the dysplasia cancer sequence. So use these words uh given you when you talked about ulcerative colitis, how or cancer formation, whether it is adenoma cancer sequenced, Wardle stain model or dysplasia, cancer sequenced. And uh other risk factors could be crones colitis and also ureterosigmoidostomy. It is not done anymore. That is for bladder cancer. You divert the, the we used to do that. I used to that do many as a registrar in, you know, the kingdom but that is a long, long time ago. We have better methods now. Uh So uh I will conduit and also uh so we are not doing that. Yeah, chronically is important because it's uh well known condition. And uh they, they have polyps and colorectal cancers. Uh They are morbidity and mortality is very high because they got other problems like diabetes, cardiac problems, uh etcetera. So uh risk factors again, I keep repeating this about transit time. I think you should know who introduced this is Burkitt's fiber hypothesis. Uh Carcinogen spend less time in contact with the bowel wall and bacteria have less time to which produce the cars in audience as well. So existing Carsen audience and new cars in audience. So uh yeah. Okay. Right. Carry on. Uh Right. So uh about uh you will be asked about the spread of cancers, you know, the various lim lim for cardiogenic lymph uh through the lymph vessels, through the through blood, through direct contact. All that you are all in the books. I'm not going to go through that, but you will be asked about duke's classification of spread of cancer. So A Dukes ABC is the one that we normally use. Some people use D as well when distant metastases there. But it's, it's really uh simple. Uh It's so it is within the uh mucosa submucosa A and B is, is gone into the uh going into the muscles muscular is appropriate and it has spread through uh so in the wall, through the wall, outside the world. So that's what I have told the Cardiff medical students to uh say that first to buy time until you go into details. Okay. And TNM classification, it's in every book. I'm not going to go through that. Uh whether, whether I think they may have taken off the, the uh TNM classification, uh whether they have taken T four off, I'm not really sure of that because uh I have retired 10 years ago, but keep these things keep changing, right. So uh benign polyps and I'm not going to go through all that. And uh right, Pizzey pets, Hiedeh syndrome, we just talked about journal polyps and all that. Uh Let's forget that. Okay. So family L polyp osis is an important syndrome, but it's only about uh less than 5% of carcinomas and, and the screening and convincing them to have a uh Colectomy. Uh an idea rectal anastomosis. There are various pouch formation, etcetera as well. Uh It's an autosomal dominant condition. Uh And uh these are the, these are the Lynch syndrome I'm talking about. So the it is also so more dominant and Lynch syndrome, one is only colorectal and uh the uh and the mostly right sided lesion's and other malignancies present uh in Lynch syndrome too. Okay. And uh there's various criterias we don't going to ask about this uh radius syndrome from the medical students. Uh So this is what this is the spelling I was going to talk about. So, carcinomas benign uh begin as an adenoma and it converts into adenoma carcinoma sequence known as Wardell stain model. And the, the other one, as I said is dysplasia cancer sequence, especially in the case of uh ulcerative colitis and Wardle stain model against. We just said that and in the presentation of right sided colon, I think there will be uh this famous question from every medical student in the world. You have a 55 year old lady present with you with iron deficiency anemia and weight loss, some flatulent dyspepsia, right? I'll be back for some ass. So, investigate and, and, and, and uh what are we going to do? So, so it's a classical lesion. They don't come with obstruction because the because of the fluid, the feces and they comes very advanced carcinoma, sometimes it test penetrated, perforated uh and sometimes present as an appendicitis. So the left sided lesion's uh comes with abdominal pain, the early present because mostly they are stay noting lesion's and rectal bleeding's early and 10 is mus is early and it's an income is a feeling of incomplete, incomplete evacuation. So various methods, especially the left side of lesion, you get this a new like tribulus, uh ulcerated and cauliflower lesion's. That's why the pr examination is important in for rectal cancer. As I said the other day, the both stages of pr examination should be carried out. The first stage is just examination. Second stages, ask the patient to strain otherwise humor, they miss it and you can do it. You can do a proctoscopy and you can do a disposable redid sigma this copy and take a box, see if it is if it is in the recto uh up director Sigma junction, you can do that in the clinic itself. And remember I was talking about what is the length of the uh uh length of the rectum is uh for medical students, you know, to varies from 12 to 16 centimeter, but 12 is a nice number to remember. And I say that again and the rectosigmoid a junction is at 16 because the anal canal is four. And when you do a high anterior resection, it is the upper six centimeters below the, below that rectosigmoid a junction, upper six centimeter, lower six centimeters. Uh if it is uh the first three centimeters uh of that lower rectum, uh you can do uh anterior resection. Interior resection means that you, you uh do a resection using a laparotomy or laproscopic technique. But from the abdomen and if it has come to the last three centimeters, it should not be done as an anterior resection. Although a lot of surgeons do try but end up with losing the reflexes, the the rectal anal reflex and the sensory sensation is gone. And what happens is that patient can't hold the feces or even patient can't hold the gas is flatus, etcetera. So it is important that, you know, a little bit of anatomy of that. Okay. So flexible sigmoidoscopy up to is done up to up to six, up to up to uh splenic flexure and uh colonoscopy. It's about 100 and 60 centimeters scope and you can go all the way up after bowel preparation to seek them. So we said about the spread, direct spread, lymphatic spread Hemet, a genus spread trans emmick, trans ilam ick implantation and direct implantation. And the uh the uh you probably heard about uh sister Joseph's nodule. I think a lot of surgeons like to ask in the exam, what is Sister Joseph scenario is the trans anomic spread from within the abdomen? Any carcinoma comes through the uh the uh obliterated umbilical rain uh to the uh to the uh to the uh to the umbilicus. And uh it was observed by Sister Joseph in Mayo Clinic and everybody should know about, about Sister Joseph. No audio and uh of course, there could be direct spread, etcetera. So, so full blood count years are CLP is important. Um is important. LFT is important. Now, we are doing ceo levels. Carcino embryonic antigen. Is that important to diagnose, know if it is very, very positive. Yes. Uh but if it is negative, it doesn't mean anything because the uh tumor becomes uh polic clonic afterwards. And the virulent clones will start uh losing the cohesion. That's one of the uh one of the reasons for spread this, the cancer cells lose cohesion and they spread away. And those are the most virulent one which loses the cohesion. That's why it is very important. Uh We'll talk about the breast disease. We'll talk about the cohesion and doing the C one to C five levels in the, in the breast uh discussion. But it is important in order to follow up. So this is, this is a question we do normally ask, is it important to diagnose if it is negative? Is it not cancer? And actually the pathologist in our hospital normally writes that this is not uh this does not confirm or deny uh whether it is cancer or not. So don't depend on it. That's what I'm trying to say. So see a levels to done to further follow up. If it is say uh more than five normally and if it is, if it is 10 at the time, then if it becomes 100 and 60 or of course higher up, then of course, you know, the cancer has come back. So uh see a levels are very important for the follower. Of course, LFTs. If there's any lefties changes, you know that you have to either do ultrasound of the liver and or do a CT scan, you will be grading these tumor staging these tumor. So you will have to do a CT scan anyway. So uh Sigma last copy should be done even if you are doing a barrier minima. If you send the barium enema request to the radiologist, he will just throw it back at your face saying that have you done uh done a thing more a Skopje, at least the proctitis copy should be done because because when you put the barrier, I mean, you may miss a anal cancer, you may miss cancer at the low end of the rectum. So nobody uh will do that. Uh if you haven't done a Sigma this copy and confirm that rectum and the anus is free. So and so pr examination is important and local proctoscopy. Sigma to Skopje, we demand that they do a disposable. So rigid stigmatise copy before they send to a barrier minimum. Uh colonoscopy, maybe you can excuse. But even then I have seen people just put in the colonoscopy in and missing anal carcinoma and actually fungating carcinoma. This happens only once but I always say that. So barium enema, we call this apple co appearance. I will show you there's a picture somewhere there So apple co appearance is, is the, is the tumor. This is the tumor in the apple co here and the barium goes through leaving an apple co appearance. So that's what, what, what the apple co appearance means. And the at operation it looks like a napkin in the ring. I will show you that in a minute. I think it is somewhere here. Ok. So ultrasonography is important, especially in, in, in age in, in underdeveloped countries where they're uh they cannot get a CT scan done. So, uh if the liver functions are abnormal, it is important to do uh ultrasonography of the liver. Uh uh huh. Um and also uh the another investigation you must do is the endo rectal ultrasound, uh especially up to the level of the peritoneal reflection because ultrasound really doesn't work well uh about the reflection uh because it has to have something in contact. So the lower two thirds of tumor's uh you can do uh uh in the anal ultrasound. Uh and the uh you can look at the sphincter's, you can look at the spread and uh MRI for anything about that level. Uh So uh about the politic nial reflection and the pet positron emission tomography is important, especially looking for lymph loads, but not every hospital has, not every country has it. So I think uh that usually after surgery, if the patient come with recurrent elevation of uh ce levels, then of course, you can do do that. So uh this is the apple co appearance. So that is the uh vary um goes through that and usually the tumor is right here. So, so Duma is right here, here and here all around it. Uh And that is the apple co appearance. Uh it is important to do uh the supine, I'll be talking about this. Uh When I do the intestinal obstruction to do a supine abdominal X ray uh rather than erect abdominal X ray, elect abdominal and we normally they have three fluid levels physiological with fluid levels, we call it. But if you do a Supine abdominal X ray patient lying like that, the gas will spread to the areas where it can spread to. So that is your argument. And if you come to UK and ask for erect abdominal X ray, you will fail the plum exam and you will be thrown out of the unity uh because we are not doing erect abdominal x rays since 1978. So remember that. So you may be still doing that and your examiners maybe still demanding that. But we think it is uh if it is obstructed, distended, patient, vomiting, patient patient got absolute constipation. Uh You don't need to prove that there are a few fluid levels there. So that's why that is the argument. Why re irradiate the patient for unnecessary information, you can say, argue. Uh I used to argue when I came to this country uh in the eighties. Uh uh it is not done anymore anyway. So uh this is a classical example why you should do uh should do uh Supine Abdominal. Actually, I think if I even try to stop this and send you home, I think I have done good enough for the day. So that's why I will tell you. So this is a Supine abdominal X ray. Uh I'll talk to you about how to look at X ray in the intestinal obstruction uh lecture. Uh So, uh so the fluid and gas will go to wherever they can go to. So they can't go beyond an obstruction beyond the tumor. So there's nothing here. There's nothing here on this side of the, there's no call on nothing seen. Uh So there is something there and of course, hugely dilated transverse colon. I don't know whether you can see a hugely dilated cecum ear, massively dilated seeking here. So, uh no small bowel seen. Why is that? It's because Hi Leo Sickle val is competent. This is closed off there. So you can see there is something at the splenic fracture. So you can see the level. So that's why it is important to do the Supine X ray. And because there is a competent, well, this is known as closed loop obstruction. And uh remember, look at this one is not seen in every X ray. If it is not seen in the nex ray, I will send it, this one has properitoneal line. It should be on either side of your X ray. And this either otherwise, I will say inadequate. Why is this important? Suppose this call on perforated, there will be white shadow here and the colonic shadow will go that way. So properitoneal will uh line will tell us, I I wanted to just say that because we just came across it. So if the colon ear's uh seek a mass displaced, that way, that means it, there is some collection here. So, so, so see the importance of doing a supine abdominal X ray here it is. So this is a close loop obstruction. So you do not wait for uh peritoneal signs. You go and operate on this patient. So uh because it will perforate in within the next hour or two and that's what we did as well. So I'm going to stop there. If you have any questions, we'll talk about it and we'll see you in the afternoon for the breast lecture, right? Any questions we'll continue this in the next part two of the colorectal surgery. I want to talk about the various resection, done, etcetera. Okay. Hello, the city Emily. Hi. Thank you so much. I'm just going to stop the recording and then you can answer any questions anyone may have. Thank you.