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Things been. Yeah, things have been pretty good. Um uh, just so busy with stuff. Resting, girl, it's great. I've only got like 2.5 more weeks left. Wow. Never goddamn done. Right. I think we're, I think we're live. Um, so home life. Okay. Yeah, I think we are alive now. Hopefully. Okay. So, hello, everyone. Welcome to this week's uh, session, um, on colorectal surgery. Um, so we'll just give it a few more minutes is for a few more people to come in. Um, so for those of you, I can see some of you have been here for the previous session. So you guys know how this usually goes about their polls and then we'll be discussing questions as well. Um, and you guys will be sort of answering the questions using the polls and then we'll walk through the questions together. Okay? And if there's any questions for either me or Josh can just type it out in the chat. All right. Just give it a couple more minutes. Okay. So I'll just quickly run through this session again. Um, so there'll be questions taken from past med. I'm pretty sure some of you have are a lot of, you have used past Met before, but for this session, I included one or two questions from quiz med as well just to see how, how that would work out. Um Maybe you guys would, would like it um covering the major themes as well. Um You'll get 80 seconds to answer the question. But of course, if the question is really short, we'll just cut it down to about 60 or maybe even less. You know, we'll try to finish in time, uh for, for this session because the previous sessions have, have overrun by quite a bit. Um So we'll try to finish it within, within time, essentially. Um I won't pick on anyone. Um, we'll just use the polls to ask to, to answer the questions. Um And then we'll talk through, through the learning points. All right, right now. So before we actually start with the questions, um, sort of like one of the main symptoms that comes with, um, a lot of the things associated with colorectal is rectal bleeding. So, um, there's a few questions you need to ask when someone presents with rectal bleeding. Um You know, and, you know, always start with open questions, ask about the timeline of the bleeding and then you Socrates, the bleeding as well. Okay. So you asked about if the bleeding is actually coming from the anus, how quickly they noticed it, how, what's the color of the, of the bleeding. Um, if they notice the bleeding on wiping or if they notice it in the pan, any other associated symptoms, the timing is, is it bleeding all the time? Is it only when they are taking a pool? Uh, and how severe is the bleeding? How much they're bleeding? And then you go down the systems if you ask about pain, uh, lower gi tract symptoms. So, anything wrong with their stools? Um, are they different in anyway, have their bowel habits changed in any way? Any mucous, any itching? You also asked about upper gi stuff. So like nausea and vomiting any blood in their vomit as well. You ask about IBD symptoms, mouth ulcers, eye problems. Um because those are associated with things like Chron's and ulcerative colitis. And you also ask about foreign travel, you know, they could be having gastroenteritis and that's why they could be having rectal bleeding. But of course, that would be usually associated with severe diarrhea as well. And of course, to rule out things like colorectal cancer, you need to ask about weight loss and fatigue and appetite. Okay. Here's some differential diagnosis for rectal bleeding and we will be going through some of these uh today. Um, so hemorrhoids very common, always go for the most common ones, hemorrhoids, very common. You know, fisher is very common, uh not very common, not as common as hemorrhoids, colorectal cancer, very, very, very common. One of the more common cancers definitely uh gastroenteritis, diverticular disease. I begin ischemic colitis. Okay. Just a quick run through um of what we'll cover today over here and now we'll start with the first question. All right. So you have, I'll give about 60 60 seconds for this one. Alright. 10 more seconds have a guess if you don't know. Okay. Right. Time is up well done. A good majority of you got the right answer is an urgent referral to local colorectal services. Okay. So this is all based on basically the nice guidelines for um colorectal cancer referrals. So if you see from this patient, he's 62 years old, um he's got no other symptoms, but he's got a palpable right mass in the right lower quadrant of the abdomen. You also see that he's got pale conjunctivae as well. So if he's got pale conjunctivae to basically, they're pointing towards a possible iron deficiency anemia. So you've got a 62 year old man with no other symptoms, but a right lower quadrant mass and uh iron deficiency anemia. So if we go based on the nice guidelines, you see is over 60 with possible iron deficiency anemia um and a change in bowel habit. But the thing here is that there's a right mass in the in the right iliac fossa. So that would uh that would mean that he would just need uh an urgent referral to colorectal services. Um Blood screening including LFTs and U N E S can be helpful, especially in confirming the iron deficiency anemia, but you should never delay an urgent referral. So you don't wait for results of, of the full blood count. If you, if you think he's got iron deficiency anemia and he's got a right probably mass, you just, you just send him straight away for colorectal services. Okay. Yes. Yes. He's got a storage impala indicates anemia, palpable mass in the right lower quadrant of the abdomen. These are all signs of colorectal cancer. So why did they say nonpulsatile? Well, that is just to rule out a Tripoli. Okay. So if it's pulsatile, it could be a Tripoli. But since it's not pulse, it'll, we've, we've basically rule that out. And why did they say it doesn't move with respiration? Why, why are they pointing towards in the question when it doesn't move with respiration? So if it moves with respiration, it tends to be a liver mass because the liver can move with respiration as well. And if the mass doesn't move with respiration, that means it's not attached to deliver. So these are all pointing towards colon cancer, which is why he needs the urgent referral. Okay. Well done. Move on. Uh This is a quick one. So I'll just give about 40 seconds for this one. All right. 10 more seconds. I got 10 more seconds. Okay. All right. So well done. A lot of you got this answer right. So it's Carcino embryonic antigen okay. So the list of answers here what they are, they're basically tumor markers. So they're markers that can be found in blood when you take blood tests to indicate certain severity zor presence of some cancers. Okay. And for colorectal cancer, the answer is C E A or carcino carcino embryonic antigen. And it's basically just a protein found in the blood that's released by certain cancers. And in this case, it's colorectal cancer. See a 125 is uh if I'm not mistaken, if it's for ovarian cancer. Uh alpha fetoprotein is for liver cancer. See, a 19 slash nine is for pancreatic cancer and see a 15 slash three is for um breast cancer. Um So these are the tumor markers. Again, it'll be, it'll be good to just have a run through of the two different tumor markers. And just, just remember for colorectal cancer, it's carcino embryonic antigen. Okay. Yeah. So it's C A can be used to measure the recurrence of the cancer POSTOP and also to assess the response to treatment as well. And as I mentioned before, it's just a special type of protein produced by um colon cancer specifically. Okay. Well done. Question. Three, 60 seconds. Mm Right. 10 more seconds. Right. Just pick an answer if you don't know. Okay. All right. So well done. A lot of you got this right. You do a fit test. Okay. So if we go through the question itself, there's a 53 year old woman attending with vague abdominal discomfort for two months. Um, she's, she's reported a one month history of loose stools up to three times daily. And she previously had passed solid stools once daily. So there's been a change in bowel habit. You know, when you're asking about, um, you know, their bowel movement is always good to ask about their baseline. Always remember to ask their baseline. So if there's been a change from baseline, she denies any weight loss. So she doesn't have any weight loss nor blood in her stools. So, if you remember from, um, the nice, uh, sort of referral guideline, um, which will go through after this. Uh, she actually doesn't meet the criteria for, to wait, wait, referral. Okay. So we've got the nice guidelines on the left here. So, patient, more than 40 with unexplained weight loss and abdominal pain, she's got abdominal pain, but she doesn't have any weight loss. Um, patient, more than 50 with unexplained rectal bleeding. She's got no rectal bleeding. Um, she's, she's got change in bowel habits, uh, and fatigue, but that's only, that, that's only the criteria if they're over 60. So she's less than 60. So for patient's who have symptoms, but they don't meet criteria for two week. Wait, referral. You do a fit test, a fecal fecal immunochemical test. Okay. Um, so what is a fit test? Okay. So, if the fit task? Oh, sorry, I'm just gonna repeat. So if the fit test comes back positive in this case, then she would be referred for it to eat weight. Okay. So what is a fit test? Can anyone tell me, uh, in the chat? What if it test is or what it tests for? Okay. I'm just gonna move on. Okay. So a fit test is basically, yeah, that's correct. That's correct. Thank you. So, it's a test which uses antibodies to identify blood in the stools. Okay? And it can, yeah, called blood. Yeah, that's right. So it tests for blood, human blood in the stool samples, not animal blood, you know, because if people eat meat, um you know, animal hemoglobin being there. So this is testing for human blood in the stools, okay? And if the result is abnormal, then they would need a colonoscopy under the two week referral pathway. Okay. So that's a fit test. So if a patient comes in, they've got all these vague symptoms, but they don't actually meet the two week wait referral, just do a fit test. You can do a fit test. It's very, it's very easy test to do. They can you can send the test through post and they can send the results in um through post as well. Okay. And this is what it looks like. So you literally just, you know, after you take a poo, it's just a small sample taken from the pool, you put it in the in the sample bag or box and you can just post it and then they can measure the, the fecal occult blood there. Okay. Um, now, is there a screening program for colorectal cancer? Yes, there is. Okay. And it uses the fit tests which are sent by post to patient's okay. Um, and it's done every two years and in England it's offered to both men and women aged between 60 to 74. In Scotland. It's a bit different. I don't actually know why. I don't know why England doesn't do the same thing, but they offer it to men and women aged 50 2, 74. So yeah, you, you, you'll be offered by the G P and every two years, you'll be sent sort of the fit test by post for them to do it. And then that, that's where, that's how they will check it. And after the age of 74 you can just request uh for the, for, for the fit test if you want it to. Okay. So there is a screening, uh screening program for colorectal cancer. All right. Hopefully, that makes sense. Um Let's quickly just move on to question four. Can any questions you can just ask? Ask Lee in the chat? Yeah, I think I accidentally give the answer away for this one in the, in the previous explanation. Um But never mind you guys have, I'll give about 10 more seconds and we'll talk about it. All right. So yeah, as you can tell this man needs an urgent colonoscopy. Okay. He's a 51 year old um man and he's had rectal bleeding as well as weight loss. So he meets the criteria. Ok. Remember. So it's after 40 with abdominal pain and weight loss after 50 with rectal bleeding, after 60 with changes in bowel habit, okay. So this guy is after 50 and he's got rectal bleeding. So he qualifies for a two week. Urgent wait, wait, referral and for every two week wait, referral, you will need a colonoscopy. All right, you won't, you won't need a fecal occult blood test in this case because he, he meets the criteria. It's the same thing. Yeah, it is the same thing. Um, uh, fit and fecal occult blood is the same thing. I don't know why they call it the different things. I guess one is just like the scientific term. So fit, I guess it's just a scientific term. But yeah, in this case, you would do a colonoscopy. All right. So these are the investigations that we usually be done in colorectal cancer or if you're suspecting colorectal cancer. So what exactly happens in a two week week referral? Okay. So when, when they say a two week wait referral, do you know what, what that actually means? What needs to be done within two weeks? Just whilst we wait very briefly for anyone to put a message in the chat. Yeah, I think the difference between fit and fecal occult blood is just that it's, um, it's specific for human blood, for fit test and fecal occult blood is just blood in general. Um, see. Okay, thanks, Josh. Yeah, that's right. So, in two weeks you need to be seen by a specialist or bio surgeon. All right, it's not two weeks to actually do a test. It's two weeks to be seen by the surgeon and then the surgeons will organize the test for you. So, yeah. So the investigations um would be a colonoscopy and a biopsy and then a CT scan for staging. Um And then in some occasions, they might want to do an MRI as well just to get a more accurate location and size for the cancer if they are planning surgery for resection. But the two main ones would be a colonoscopy and a biopsy and a CT scan for staging. So that, that's usually what happens in a two week wait referral after you've been seen by the specialist. Okay. All right. So hopefully that made sense. Moving on to question five. Um So it's just 60 seconds, right? 10 more seconds. Okay. 321. Okay. The answer is be okay. So, as you can see the patient um, is having a hemicolectomy for colon cancer. Um, and there's no lymph node involvement and December Tacis is. So, what they're using is the dukes staging for colon cancer. So, for colon cancer, they use. Um They tend to use Duke staging um which is in A B A B C D. Usually Cancers, they use a different type of staging called TNM staging. So other cancers, what you can still use TMM staging for um for colorectal cancer. But Dukes is specific for colorectal cancer in terms of staging. Okay. So we'll talk about Duke staging really quickly. These were pictures taken from Cancer Research UK. Uh And they're really good at explaining sort of what the Duke staging is. Um So there's four stages A B C and D. Um And it goes from a is the best outcome and these, the worst outcome as you can see from a, the cancer basically does not infiltrate. The muscle layer is only within the epithelial and the inner lining of the bowel. Okay. So this one can be easily resected. That's Dukes type A Dukes type B is already invaded into the muscle layer slightly as you can see there. And this one can still be resected. Um uh This one can still be resected and removed. Um But it depends on the histology of the cancer itself. Okay. For Dukes C is the same as Duke's B except there's involvement in lymph nodes. So at least 11 lymph node close to the bowel is affected. Uh And the cancer has spread there. So that's Duke. See, and Duke's D means that it's spread to other parts of the body. Basically, it is metastasized, okay. It spread to other organs like the deliver the lungs or even bones. Okay. And this is advanced bowel cancer. And usually the only option if you have dukes key is palliative care. All right. Um But yeah, but a lot of people can use TMM staging as well. Um So tumor uh no node involvement and metastases, but deuces specific for colorectal. Okay. Okay. So this is a question for you guys. Do you do any of you know any hereditary causes of colorectal cancers or tumor's typing in the chat? If you know the, the two main ones are the ones that really interest us actually. Well done. HNPCC. And there's one N F A P. Yeah. Yeah. Well done. So it's hereditary nonpolyposis, colorectal carcinoma and familial adenomatous polyposis. Okay. So, yeah. So Lynch syndrome is another name for HNPCC. All right. Um So the next few questions are going to be regarding these, these ones. All right. So let's have a go at question six. Okay. I'll give you guys 60 seconds from here. Okay. Right. So, well done having ago, you definitely chose between the two that were most obvious, but the answer is actually HNPCC. Now, the reason this is okay, I'm going to ask, uh I'm going to ask a question to you guys. Does anyone know the difference between sort of F A P and HNPCC? Like how, how can you tell, how can you tell the difference? Yes. Well done. So F A P usually has more than 100 polyps. And if you see this question on colonoscopy, there's only four suspicious looking polyps in the ascending colon. So if there's very little polyps, usually it's HNPCC. There's another key thing that they hinted at here. What other cancer is HNPCC associated with. Can anyone tell me it's very common in like questions? They always tell you, oh, aside from colon cancer, what, what other cancer is people with HNPCC at risk off? Yeah, well done. Endometrial cancer. And if you see from the question, she's also waiting to be seen by gynecology for postmenopausal vaginal bleeding. So HNPCC, endometrial cancer and colorectal cancer have the same risk. So if you have HNPCC, you're at equal risk of both actually. Um So yeah, that's a, that's a, that's a quite a popular question to ask around. Well done everyone for answering also called Lynch syndrome. And there's a mutation in two genes. You don't really need to know this. But it's basically the M S A M S H two gene and M L H one gene increases the risk of colorectal cancer and it increases the risk at even a younger age. So people tend to get it at quite, quite a young age as well. Okay, well done. Uh we talked about this endometrial cancer. Yep has the same risk. Now, this is a list of Polyposis syndrome soap syndromes that cause polyps in the colon and can cause hereditary colorectal tumor's the ones you really need to know, I feel are HNPCC and F A P I guess puts jaggers. You can, there have been questions about it, but I doubt you'll be asked in actual questions. Just know that puts Yeager's has the classic pigmentation around the mouth. That's, that's classic in, in exam questions. Cowden disease and Gardner syndrome. You, you can read it in your own time. What's the risk for Children of developing HNPCC with an affected parent? Okay. I'll get back to you on that. I'm actually not very sure. Well, Josh, Josh will get back to you on that one. Hopefully. So we'll just move. I'll just have a look. Now, the one thing I know off the top of my head is there's less of a risk of you getting a cancer with that than if you have like familial. I don't know, I don't know Martoma, this polyp citosis for that one is like colectomies just recommended straightaway basically because the risk is so high. But I don't think that's the case with HNPCC, but I'll look up now. Thanks, Josh. All right. Well, Josh is looking that up. We're gonna, we're gonna move on. All right. Question seven. So the next few questions is, is basically just going to be asking about resections essentially. All right, 45 seconds, just briefly in the last second. Um So it says, yeah, the risk of developing cancer with HNPCC ranges. It just says um passing it ranges from 30 to 70%. So it's, it's very likely but not guaranteed. Whereas for F A P it's 100%. So. All right, thanks Josh. All right, we'll end it there. Okay. So the answer for this one would be a left hemicolectomy. Okay. And okay. These next few questions are simply just about sort of the location of the tumor in and which reception it that that should be done. Okay. So recent colonoscopy has shown a mass in the distal part of the descending colon. Okay. So the mass is still in the descending colon is on the left. So ascending colon, transverse colon and then descending colon and the uh masses somewhere here. OK. Well, if you're, yeah. So if you're looking at me, it'll be on this side. So if the mass is here, then you need to get rid of the descending colon. And that's a left hemicolectomy. Quite a few of you put a high interior resection, but an interior resection is usually for masses um near the rectal sigmoid function or in the sigmoid colon itself. Not in the descending colon. Okay. Um So we're just gonna move on to question eight. There's another one on resections. Mm 45 seconds from here, right. Okay. All right. So I'm gonna end it there. So there's been a split between a low anterior resection and and an abdominal perennial resection. Okay. So, the answer for this one is actually a low interior resection. Okay. So quadri is also asking what's the difference between a low and a high interior resection. So low interior resection involves removing just part of the rectum and only just a bit of the sigmoid. Whereas high interior reception, we would involve more of the sigmoid and less of the lower rectum. Okay. So I can understand why some people would go for an abdominal perennial reception in this case. Um But it's a mid rectal tumor, abdominal perennial receptions tend to be from a low rectal tumor. So I think it's five centimeters from the anal verge is when you would actually do an abdominal perennial resection. And when people say mid rectal tumor is usually not low enough to do an abdominal perennial resection is usually low rectal tumor is close to the anal sphincter or with anal sphincter involvement that, that you actually need to do an abdominal perennial resection. If they, if the question asks up to mid rectal, you're still doing a low interior resection. If they, if the cancer is in the sigmoid or in the low sigmoid, then you would do a high interior resection. Okay. So it's descending colon, sigmoid colon and then the rectum. So if it's in the mid rectum, you do a low interior section. If it's in the sigmoid region, you would do a high interior resection. Okay. Um But well done. So we'll move on another question on resections as well for this one. Um say 45 seconds from you. Okay. Alright. 10 seconds. All right. So well done, well done. Um You guys correctly decided to do an extended right hemicolectomy. Uh No quadri, a high interior resection is not the same as an abdominal perennial resection. So high interior resection removes the distal sigmoid colon and the upper rectum. A low interior resection removes the upper part of the rectum. And an abdominal perennial resection removes the very end of the rectum along with sort of the anus. And then you create an end colostomy with that. So that's an abdominal perennial resection. So high interior section, low and high interior section, low interior section, abdominal perennial resection, okay. So it's like it goes down like that. Um Now going back to this question. Okay. So you can see here that he's got cancer of the transverse colon. Now, it doesn't actually specify where in the transverse colon. Um The uh where in the transverse colon, the cancer is okay. But usually if it's in the transverse colon, what's done is an extended right hemicolectomy. And this has to do with sort of like the n est imuses of it. If the cancer is near the distal end of the transverse colon, then left hemicolectomy would have been the answer. But because they didn't actually mention where it is, we can assume, I guess that it's somewhere in the middle. Hopefully, that's what they're trying to get in this question. So if the, if the cancer is more to the proximal part, then they would do an extended right hemicolectomy. And I think in this case, it would be an extended left hemicolectomy as well if it was a distal colon. So the only right answer in this case would be an extended right hemicolectomy. Does that make sense? Does that make sense to you guys? Hopefully, hopefully, that makes sense. But if it's a transverse, just remember if it's a transverse can call on in the transverse cancer in the transverse colon, it will be an extended, right hemicolectomy. Okay. Right now, the next question again, I think this is the last one on resections. Hopefully. Yeah. So I show you wouldn't usually do both at the same time. So if it's, if the transverse, if there's a cancer in the transverse colon and it's more distal, you would do an extended left hemicolectomy. But if it was more proximal, you would do an extended right hemicolectomy, you wouldn't do both if you do both. That's basically a pan proctocolectomy where you remove most of the colon. Um And that's usually done for things like IBD. That's, that's untreatable with, with medical, with medical causes. You wouldn't do both at the same time like uh extended left in an extended right for a transverse colon. As far as trends for a cancer in the transverse colon, essentially, you do one or the other depending on where it is. Okay. All right. So, I think that's enough for this. That's enough time for this question. So well done. A lot of you got the right answer and that's a Hartman's procedure. And the reason we do a Hartman's procedure in this case is because this is an emergency and the red chest X ray was performed and it shows air in the left hemidiaphragm, which means he's got a perforated bowel, um, due to his colon cancer in this case, um, he's also got a fever as well, which means it's pretty knittig, he might be sepsis as well. So it needs to be, um, so it needs to be, uh, so it needs to be handled sort of immediately essentially. Okay. So a Hartman's procedure is what you need to do in this case. Uh, and the reason for that is because Hartman's procedure allows for quick access and it allows, uh, sort of the functioning of the bowel and then it can, you can reverse the, you can, and it's a harmless procedure will end up in a colostomy which can be reversed later on. So you just need to solve the problem right now and then you can reverse the colostomy later on for any emergency procedure involving the colon that, that needs a section of bowel removed. You always do a Hartman's procedure essentially okay if you're doing it. So I was just asking me if you do an extended right hemicolectomy. Does that mean the patient will have a stoma that can be reversed later? You will definitely have a stoma whether it will be reversed later. I'm not very sure. Uh, Josh, could you help you help look that up? Yeah, I've just been having a look. Um, I think, I think because your, I'm, I'm, I, I'll have a look but my guess is that it would be reversed because you're only taking a section of the bowel out so that you can collect, take to connect the rest up. I'll double check that for you. I'll just be a minute. Okay. So in the meantime, we'll go through question you're living. All right. Oh, hold on. It's just a question. Oops. Sorry. Let's see if I can just find, hold on. Give me a minute. Sorry guys. That's my bad. Mm. Mhm. Mhm. Okay. Never mind in the way. Sorry guys just give me, just give me a minute. So I just, just had a quick look online. Um, but yeah, so it's like what I was saying before. So I'm one of the NHS leaflets for extended right hemicolectomies. Um It says there's only a 2% risk that you are left with the stoma bag and in those cases of in those 2% of cases, it's often just a temporary thing. Um and you just, you have a stoma so that you can just allow that an estimate otis to heal up and then once it's healed, you take away the stoma. Um So hopefully that answers your question. All right. Sorry guys, I actually forgot to include the question for this one. But basically what, what the question is asking is that the patient has colorectal cancer and it's got uh nodal involvement. So it's a Dukes c essentially. Okay. Um So, yeah, I'm just gonna move on to the, to the answer again. I really apologize for this. Um I should have went through it again. Um But the answer is the left hemicolectomy oppose our particular therapy. And what I want to get out of this question specifically is if it's a Dukes C uh staging for colorectal cancer, you always perform a postoperative chemotherapy as well. If it's Duke's A or Duke's B, you don't usually need chemotherapy. But if it's a Dukes C, then you do need chemotherapy for it. Okay. Again, I'm really sorry. I the, the question was just not there. It was literally just the options. But so this is um this is a summary of the receptions for the colorectal cancer. Okay. You can have a read of it once we're done with all the slides. Here's a, here's a uh here's the, the types of receptions that you can be that can be done. This was taken from zero to finals and I think they did quite a good job of visualizing sort of why. Uh well, why each therapy uh sort of what each resection means in this case. Okay. Um So what is POSTOP chemotherapy usually needed as I mentioned before, uh when there is dukes C lymph node involvement or duke B plus features that increase the risk of it coming back. Um So what they mean by risk of it coming back, it depends on the histology and the type of cells. Some cells for colon cancer can be very aggressive and that's what they mean by increased risk of it coming back. Okay. So that's what, so that's when chemotherapy will usually be needed. Um It's usually eight cycles of chemotherapy and each cycle is 2 to 3 weeks, essentially. Okay. All right. So now let's move on to question 12. I'll try to pick up the pace. This one should be quite quick. Okay. Soma thank you were asking why not radiotherapy. Um I think you can give radiotherapy. Um, but it's just more common practice for chemotherapy to, to be given and I'm not exactly sure why it might have something to do with like more difficult targeting because, you know, for radiotherapy, um usually people are strapped in and they really targeted for, for specific structures. Whereas the colon does kind of move around, it's difficult to isolate the colon, which is why we, they don't use radio. You can, you can still use radiotherapy and you can use radiotherapy even before surgery. But I think it's more common practice to use chemotherapy in that case, if that helps. Um Oh, yeah. Okay. All right. So I think that's enough time for, for question, for question 12. Um, so the answer for question 12 is HPV infection. Okay. So this one, now they're all actually sort of risk factors. Smoking is definitely a risk factor. Past history of cervical cervical cancer can be a risk factor and immuno suppressants or they're all risk factors. But the biggest risk factor is actually HPV infection. Now, does anyone know what the other, what the other cancers that are caused by HPV infection? It's another big one that HPV infection causes well done. Cervical. Yeah, it can cause anal cancers as well. Rectal cancers, head and neck cancers. Yeah. So it's cervical colon cancer. Uh sorry. Um Cervical anal cancer and head and neck cancer. Yeah. So that's the main ones. So a little bit on HPV. Uh it causes about 80 to 85% of squamous cell carcinomas of the anus is usually HPV type 16 and 18 can cause cervical cancers. Uh And you usually give the HPV vaccine in boys and girls aged 12 to 13 years old. So you learn about this in women's health. Um And Pete's if you haven't already done it. Um and that's just a bit on, on the HPV vaccine. So this is a summary of colorectal cancer. Essentially. It's just a short summary. You guys can have a read a read of this later. On. Okay. But we'll move on because I, I am just aware that we're running short on time. Now. Can anyone tell me what kind of stoma this is? And let's say the storm is in the, and, uh, you know what, I'm not going to tell you. Well, let's say it's in the right, right. Iliac fossa. Let's see. Yeah, it's an ileostomy. Um, and the reason it's an ileostomy is because it's, it's spouted, uh it's in the right iliac fossa and usually the output from the ileostomy um will be more liquid than uh than uh yeah, than, than a colostomy. Okay. So this is just a quick difference between the within the stoma is you can read this yourself. Um The reason that ileostomy spout it is because um the contents of the output can be irritable to uh skin surrounding the stoma, which is why it's spouted. Whereas in a colostomy, um it's less acidic. It's been, it's basically feces at that point. Uh So it's more solid and that's why it's more flush to the skin. Okay. Right now, in question 13. Yeah. Alright. 60 seconds. Okay. Well done. So uh let's move on. So the answer for this one is diverticulitis, okay. And I don't really want you to focus on the CT scan because the CT scan doesn't show much and you don't actually need a CT scan to decide on something like diverticulitis. Okay. You can see from the prompt itself. Okay. The patient, 55 year old, non specific abdominal pain and constipation, okay. Um, he also had an egg sort of bleeding. Correct. Um, uh, he's Tecca Kartik. Uh, he's got normal blood blood pressure. He's got very slightly raised temperature. Okay. So changes in bowel habit and slightly raised temperature with a bit of tachycardia. These are signs that he could be having some infection going on. Okay. He's also 55 years old. He's quite old. Well, he's, he's, he's in the age range where diverticulitis is a risk factor. Okay. So from the prompt itself, you can see that, oh, he might be having something like diverticulitis, acute appendicitis wouldn't usually present in someone his age and he would have sort of like a mid or right iliac fossa pain. In this case, diverticula osis wouldn't usually present with pain, which is why it's not the answer in this case. Um Alternative colitis. Yes, he does have bleeding, correct. Um um But this is his first uh sort of uh it's come on over the space of two days, which is very, very acute, especially for, for and it wouldn't match the history of someone with ulcerative colitis, ulcerative colitis usually presents with someone at much younger age as well. Okay, which is why it's the answer is diverticulitis. In this case, if you see from the CT scan, basically, what they're trying to show you is that from in the right, in the left in the left region. So on the right. So if you're looking at the CT scan is like looking from the bottoms on the right, you can see like very small outpouchings, but I can, I can appreciate that. It's very difficult to see on this, on this CT scan which is why and they wouldn't usually give you a CT scan as well in an actual question. Okay. But just focus on sort of like the prompts in the question in the question itself. Yeah. The answer is that particular case. Okay. All right. So, question 14. Okay. All right. 30 seconds. I'm just gonna pop the feedback form in just in case some of you have to leave. Um We've got about 18 questions total. Um So we've got about five more left. There is a much more left. We've got about 18 questions. Okay. All right. So we've got a very good variety of answers for this question. Okay. So, what's going on with this patient? So, this patient has two day history of lower abdominal pain, rectal bleeding to three months. Box of intermittent lower abdominal pain opens bowels once every four or five days, passing hard stool. So he's had a change in bowel habit. He's got a raised temperature as well. Um And he's got uh normal BP and then tenderness and guarding in the left iliac fossa. Okay. So, again, he's a very old man. So it's very unlikely that a case of ulcerative colitis presents in someone at the age of 70. So in this case, it will most likely be something like diverticulitis. Okay. Someone who's seven years old, um presenting with these symptoms in the left iliac fossa, almost always diverticulitis. Also typical ITIS will present someone much younger, much more episodes of rectal bleeding. Okay. And the first step in managing someone with diverticulitis is always increased dietary fiber intake. Um uh Yeah. Yes to shower, of course, of course. Um So it's increased dietary fiber intake is always first line. Okay. You can give intravenous antibiotics. But um they're actually asking for long term management of this, of this patient. If they were asking for short term management of the current of the current uh sort of illness, it would be intravenous antibiotics. Laproscopic reception would be too invasive and there will be no use for it. Intravenous hydrocortisone. You wouldn't use it as well. And Perry or perianal metroNIDAZOLE is actually used for Chron's disease with perianal disease. So it's not used for diverticulitis. Okay. So now a question 15. So this one should be a quick one um 35 seconds. Ish. Mhm Yeah. Yeah. So the benefit or rationale for long term high fiber diet would be to reduce constipation. So a lot of patient's with diverticulitis will have constipation and then if there's constipation, there's usually it can usually cause a lot of irritation in the diverticular. Um and diverticulitis happens because there's, there's like a bacterial infection of the, um, di particular, you know, some feces get stuck there and good bowel habits and golden bowel motions can usually solve that problem essentially. Which is why the, that's the rationale for, for a high fiber diet essentially. Okay. 10 more seconds for this one. All right. Well done. Yeah. The answer is sigmoid colon. Okay. Um, and the reason for it is just the sigmoid colon just tends to have a slightly weaker wall, which is why the outpouchings can occur. I think, I think I will reconfirm with you guys, but just know that for diverticular disease most commonly, it will always happen in, in the sigmoid colon. Okay. Really. This is a really quick summary of diverticular disease is out pouchings in the bowel wall, typically affecting the same way colon. Um That particular diseases when patient's have symptoms due to the diverticular such as changes in bowel habit, for example, um an abdominal discomfort, but there's no inflammation and infection. If the patient has a fever has, tachycardia has severe left iliac fossa pain, that's when it becomes diverticulitis because that's when the diverticular get inflamed and infected as well. Okay. Um So some of the some of the risk factors for diverticular disease include age, lack of dietary fiber, obesity and sedentary lifestyle. So people with older age tend to tend to get it. Diverticular disease and diverticula osis. Yes, they are the same. Well, diverticular disease means there's diverticular diverticular cyst means there's just a lot of it essentially. So, yeah. So it is essentially the same thing. It's just, it just has to do with the number of outpouchings. Um Yeah. So if you have chronic diverticular disease, you have intermittent left, lower quadrant pain, bloating and changes in bowel habit. And as I mentioned before, acute diverticular acute diverticulitis will have severe left lower quadrant pain, fever, um, systemic upset like tachycardia as well. I'm even possibly pr bleeding as well. Okay. So usually for diverticular disease, there's no specific investigations unless it's an acute disease. So if they, if you have something like diverticulitis, then you would do an F B C which will show race white cell counts, crp. Um divert diverticular disease does have a predisposition to perforation. So you can do in a righteous X ray if you're expecting if you think they're paternity and there's a and there's an a perforation as well. Abdominal X ray will show dilated about lose if there's an obstruction. Um CT will show the same thing but don't try to avoid doing a colonoscopy because it actually increases the risk of perforation as I mentioned before. Okay. So management, as I mentioned before, high fiber, high fiber diet and clot forming laxatives and for diverticulitis, you can give them antibiotics and analgesia if it's severe. Of course, you have to admit them. Um And maybe you can start the sepsis six protocol. All right. So if you just got three more questions left. Um Again, I'm so sorry. We're running over again. Please do feel in the feedback form but it shouldn't take too long to shower. In that case. I think you would send him to the hospital because um in acute diverticulitis, it can be pretty bad. Um And it sounds like it could be borderline severe in that case. So I would say you would just admit him in that case. Yeah. Okay. 10 more seconds. All right. So going through this patient is a 23 year old patient presenting with for the history of pain in the rectal area and it's shooting pain when defecating and having anal sex essentially. Okay. So, and he's got history of constipation. So we're looking at a guy who has uh possibly an anal fissure and it's an acute presentation of an anal fissure. Okay. And he's come with a history of constipation. So loperamide is an antidiarrheal. So you wouldn't actually use that in this case, you actually want the stools to be looser in this case because an antidiarrheal would just make the stools harder. So you wouldn't use loperamide. A lot of you chose topper topical glyceryl trinitrate, which would be correct in chronic anal fissure, but he's had an acute anal fissure. So for an acute anal fissure. So he's only presenting me four days, you actually just give them a bulk forming laxative. Okay. So at the start, I was, I was wondering why, why would you give bulk forming laxatives, um, because, you know, wouldn't, wouldn't that, like, wouldn't that, like, make it sort of like, more ball can sort of make it worse? But no, it actually helps, it softens the stools and it's actually the first line for, for, for, you know, Fisher, essentially try topically, glycero trinitrate would be used for chronic, uh, you know, Fisher. Okay. So, just keep that in mind. Uh okay, really quickly. Next question. Well, well, I, I basically just told you the, the answer to this question but, but it's okay. Just give it a go. Okay. Yep. So well done. The answer is topical glycerol trinitrate, as I mentioned before, 27 year old man, persistent pain upon defecation for the past three months. So this patient has had an in a fissure for the past three months and he's actually already tried laxatives and dietary modification. So you always try laxatives and dietary modification but modification first before you try the other stuff. So it tries to the topical Glycerol trinitrate is the next step. And if that doesn't work, then you can actually do something like botulinum toxin injections and that should help with the, with the anal fissure as well. Um You don't really use the other stuff on, on the answers here. But yeah. Yes, you were still placing on the laxative. Yeah, you would still do that. All right. Ok. Last question guys. Yeah. All right. 10 seconds from here. Okay. Let's stop it there. Right. So, I was trying to catch some of you out with, uh, with this question. So he does present with an anal fissure. But the thing is he's got the anal fissure, um, at a three o'clock position. Okay. Uh, and the fact that he's got possible weight loss as well in a few months. So the weight loss and the anal fissure at three o'clock position are actually red flags with the weight loss is definitely a red flag and the fish are being at three o'clock position as well is a bit odd because if someone presents with an anal fissure and it's a benign fisher, it'll usually be in the posterior position. So at six o'clock, so if you, you're looking at the anus in like a clock position, it will be in the posterior part of the anus. Okay. That's where like 90% of anal fissures should be. And if it's not in the, in the, in the six o'clock position, have a high suspicion that it could be something more sinister. Uh okay, such as uh an anal tumor, for example. Um Yeah, so that's, that's the, that's the uh that's the reason why you, in this case, you would refer directly to a two week wait pathway. Okay. Um So that's the end of the questions. Um I I still have some summary tables to include in this uh slides that I will give um uh I will hand out to you guys after you guys filling the feedback form. So don't worry, uh it will be handed out to you, but thank you so much for coming. Um I'm sorry if today's session was a bit all over the place. Uh Please fill in the feedback forms and I will send in um the slides to you with some, with some summary table with some extra summary tables uh in it as well. Ok. Um Me and Josh will stay back for a few minutes. Um Well, me and Josh will stay back in a few minutes just to just still have answer any questions that you guys may have may have. But hopefully that was useful. I really, really hope that was useful to you guys. Uh Please do come for our next session which will be on plastic surgery this Thursday. Thank you so much for answering the polls and getting involved and thank you so much for coming. Um Please feel in the feedback forms as well. Mhm. All right. I don't think there's any more questions. Oh, there is a question. I'll let you answer this one, one month out to progress. Any tips to your fourth yourself? Well, it really depends on how you sort of study to be fair. I used to do, I used to use Ankie a lot for, for my studies and then I, I found out that Anchia didn't actually work well for me. So I ended up just writing notes from past Met. Well, I do a lot of pass Met and then, um, writing notes from past Met. Sort of like just the important stuff is what's what I did. I know Josh uses Ankie and flashcards a lot. So it's difficult to say honestly. Um, just try and cover, yeah, just try and cover like, as much stuff as you can, I guess one month away from, yeah, I, I did Ankie um an anti work quite often me but I think when you're like closing in on exam times, um just do pass med like pass med is or Quest Med if Quest Networks for you, but pass med for me was the one I used. The big thing I'd say is just don't neglect year free topics. Um because obviously I'm sure, you know, like everything comes up, I'm assuming you're a Manchester student. Um But, but yeah, um just do year free topics as well, even if it's just like 100 questions of gastro 100 questions of cardiology just to see how well you know stuff, right? So if there's no more questions, you guys, you guys know our emails can just drop us an email about anything can be about exams, it can be about fy once applying for electives, whatever it is we were always just open for, for any questions. Ok? Um But again, thank you so much for coming. Hopefully that was helpful. Do come and join us this Thursday for some plastic surgery questions should be quite good. Um But yeah, thank you so much for your evening. Um, have a nice dinner guys. All right. Bye bye.