CRF 16.05.23 Krok Session, Dr Peter Dogbe, Ukraine Qualified Doctor



This on-demand session is a must-attend for medical professionals looking to expand their knowledge of the four conditions related to dietary fiber deficiency, to learn more about the effects of lack of fiber on stool content and consistency, and to understand the necessary protocol for patient examinations, including verbal consent. Discussions about rectal bleeding, such as rectal 10 isthmus, diverticulosis, colorectal cancer, and paraneoplastic syndrome, will be presented in a knowledgeable and accessible manner. Don't miss out on this opportunity to better prepare for patient dialogue and exam topics!
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Learning objectives

Learning Objectives: 1. Describe the combined effct of dietary fiber deficiency on stool content, consistency and transit time. 2. Explain how a lack of dietary fiber can lead to various disorders. 3. Describe the red flag symptomsof colorectal cancer. 4. Explain the two-week rule, the 10-day rule, and the importance of patient consent, courtesy, and privacy when performing rectal examinations. 5. Explain the three stages of performing a rectal examination and the importance of being gentle during the process.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Do we normally ask uh ask uh the candidates? Um uh So those are the uh the uh the hemorrhoids and uh perianal sepsis, that those are the two things that we normally ask you the questions. So, and the other thing is the examination, you won't be asked to examine these patient's uh in the exams. But you should say that I would like at this stage to uh do a pr examination and doing a pr examination is also important and also the, the courtesy and the privacy of the patient and uh and the humane way you should approach the condition. Uh It's, it's, it's very important because uh sometimes you see medical students pouring in when the patient is under spinal anesthetic, awake. And uh uh 10, 15 medical students walk in and start talking about unnecessary things. So those, all those things has to be uh thought about and also the preparation of the patient without causing any pain, right? Uh We'll start with uh very important message for you. Uh This is about the various syndromes or uh the four conditions that the patient's have uh because of the high fiber deficiency, you have to always think about the four condition. Uh one is constipation, the other one is hemorrhoids. Another one is diverticular disease and colorectal cancer. And this is due to lack of fiber. All these syndromes come together. The important thing is that if you have hemorrhoids, excluding the other conditions, especially colorectal cancer is very important. And when you start answering how we do three TEM A roids, it's very important to say I will exclude any serious pathology such as colorectal cancer. We have faced disastrous condition even in our hospital here in Wales that uh we have missed because the patient may have this association, you know, these uh these conditions may come together. So you need to think about that. Okay. So the combined effect of dietary fiber deficiency on the stool content content and the consistency and the transit time you must, whenever you talk about fiber, you must talk about the transit time. So that is very important because uh you cannot present your case uh without using that word. And the uh it is the same message given here in this slide also. So the increasing the bulk of the stool uh by retaining water by the fiber and the decrease of colonic transit time. Uh not always but most of the time uh reduce the exposure of the colon E capital E um two cars in audience. So when we talked about colorectal cancer, we will do that in a couple of weeks time. Uh an alteration of the colonic bacterial flora and the partially degraded by bacteria. The fiber I'm talking about produce the flatus and uh it dilutes and absorbed Luminal toxin and the reduced again, uh stressing that reduces the carcinogenic capacity uh of the Luminal contents on the epithelium. So that is this uh you should be able to talk about the hyp high fiber situation. Uh a lack of fiber, what the damage it causes. So I'm sure you know about, you know about various types of uh fiber, soluble fiber packed in semi cellulose, insoluble cellulose and lignin and resistant starch come under that. It is uh it is an indigestible part fiber. So increase is the bulk by retaining water. I keep repeating this but it is the word transit time that you need to talk about in the exam. Uh Herma Toki, Jha hematochezia is rectal bleeding, fresh blood perect um through the anus, it could be on toilet paper. So you should know exactly what you have to get from the patient or is it toilet bowl turn slightly pink because few drops fell off and then or mixed with tool, which is almost a red flag sign because once it comes from a bow, so lower git with shock is usually diverticular bleeding. Uh We are going to talk about diverticular disease on Thursday uh and upper G eye with shock and because of upper gi bleeding and that is usually due to heavy bleeding from duodenal ulcer. So it's just not the Melena on top of Melena, the patient may have fresh bleeding whenever you talked about uh in when you write your history, uh when you say pr bleeding and the uh you immediately must talk about the the various other paraneoplastic syndrome, weight loss and pain, vomiting, distention and constipation we'll be talking about instead, intestinal obstruction and the classic for symptoms and signs are pain, vomiting, distention, and constipation. Even though the patient may not complain to you. You must, you must mention that no pain, no vomiting, no distention or constipation. So, uh you must do that okay. The okay. So 10 isthmus system is really a symptom. Uh, the feeling of having to defecate uh without any result. So, uh, and the straining pain and cramping is a very distressing symptom. Um So a spurious feeling of need to defecate but nothing comes out. So you, it can be rectal 10 isthmus or with cycle 10 isthmus. We call it strange urea, few drops of blood comes out and it's excruciatingly painful, almost dysuria. So that is where cycle. We're not going to talk about that today, right? So, uh, red flag symptoms that we, again, we'll talk about that in, in colorectal cancer. We've got two sessions on that. So, the persistent change in bowel habits, uh, diarrhea, alternating with constipation and change in frequency change in consistency of the school rectal bleeding. Uh, uh, we have special clinical RBC clinics. Uh So uh there is a thing called two weeks rule that you must refer this patient to see a specialist, especially MDT uh kind of clinic and they should be seen. There's a protocol that you should see the patient within two weeks. Once you get the letter from the general practitioner and same thing with the breast, uh any suspicious breast lump should be seen within 10 days And that is known as the 10 day rule. So uh cramp gas pain, that abdominal discomfort, uh feeling of incomplete evacuation. We just talked about that weakness and fatty. These are the week what we call the para news plastic syndrome. It is the systemic uh effect on uh of the tumor's on the general body. So uh we, we talked about that this already. So uh doing a pr examination, uh you, as I said, you will not be asked to do a pr examination, but doing a pr examination, you should know that, you know, uh I'm not going to talk about will, will consent and the appropriate place and the chaperone with you when you are doing a thing like that. And the Balian Lau, there's a, is a famous book here in UK. Uh and they said it said that uh if you don't put your finger in it, you may put your foot in it. That means you will be in real trouble. Uh So privacy, confidentiality, gentleness is very, very important how you do that verbal consent. We already said that and also shaft Arone uh or your runner, but the runner should stay with you. That's always, you know, when you ask for something from the nurse and you make sure everything is there, you know, gel the tissues to wipe and, and the proctoscope if necessary. So, uh you cannot put your finger there and get your runner to run. Uh and it will be embarrassing for you as well as the patient. So, uh you, you make sure that you uh after the consent, you insert your finger in the correct way. And the uh the uh you just have, look at the inspection around the anus and it's very important. And there are two stages today because everybody's asking me, how can you feel a tumor at eight centimeters as you can even up to nine centimeters? We we we can feel a tumor hitting your tip of your finger. So, what are these two stages? So, uh your first stages to go around with the uh with your finger, sometimes you may have to turn your finger and go the other way as well and make sure you do uh you do a proper fee or examination uh and uh make sure you feel that, feel the prostate and in females, you may feel the cervix and the position of the cervix and then uh cloud finger. I'm not going to talk about that, I'm sure, you know, and the uh and then of course, that is the first stage and make sure you do not, uh you do not press and pull the finger to one side because that is the one which caused terrible pain. And even, even some of the seniors are doing that. And I have seen that and I've, and I have screamed at them because that is uh that is the incorrect way to do that. You gently feel it, don't pull it sideways to try and feel deliberately, you know, so you can feel it without pulling on it. And the uh the second stage is there, uh what is the second stage? You, you asked the patient to bear down and nobody seems to know about these stages of doing that. So 1st, 1st is inspection around the area, you can test the sphincter, then you put, put your finger and go around the lower part because it's important to feel the prostate in a, in a man because you may not get the chance to do that again if you are done an abdominal perennial resection. So that has to be recorded correctly and you get the patient to bear down. Uh Not to worry about you being there, your face being there, ask the patient to bear down and something may hit like little bit of grapes and once you fail it, you know, uh that it is a tumor. So uh so almost those three stages has to be there. And of course, once you finish that, you must make sure you wipe the gel off and a lot of people just leave it and the patient has to go home and the so wipe it until the, until it's absolutely clean. Uh And also then, uh I normally give an apology said, uh saying that, you know, I'm sorry if I hurt you. Uh But there is, then of course, you have to tell uh what you found, get the patient to sit down and then talk to the patient afterwards. So, so no, you're anatomy. Uh This is just a joke. My registrar put uh this is the man uh compartmentalized uh the abdomen from a laparotomy and obese man. Uh It is just a joke, I think so. Uh So magic word is the bear down. Uh Don't worry about it, bear down and, and, and feel for whatever coming down from the top is very important. So, and it's very attend and be careful as well. I just put this slide on because diverticular are not very common in this uh in rectum uh particular, more common in the sigmoid colon and you will be talking about that. So, one condition that uh not many people talk about is proc cal gee a few jacks. So what is proctology? A project? This is severe pain in the rectum and the Parini um and it comes suddenly without any reason sometimes wake the patient up and usually it's a final exam for the medical students. I think, I don't know why they say that it was written in the book. So I just put it there. So maybe just a stressful situation and you may get this pain. So spasm in the perennial muscles, especially the pupil rectories. So it rises to a crescendo. And the uh that is uh so again, the main thing is to exclude serious pathology in the Parini. Um So always say that in the exam, I will exclude any serious pathology. Do uh do a proper examination. And if necessary, you do a eu a examination under anesthesia. Sometimes we can do a uh stretch which is not really recommended by the modern surgeons. DTN may help. So, proctology, a few jacks is a stressful condition and difficult to treat. But once the stress situation goes, the pain settles down, sometimes we do give us a small dose of amitriptyline and it does help. But of course, if you are doing exams at the time, you'll be sleepy and that is not the best time to give amitriptyline. And the the next one important one is the hemorrhoids. So, uh what are hemorrhoids? And uh it is normal, anal cushions are normal. Remember that anal cushions are normal, it is abnormal, disrupted uh prolapsing. The uh cushions are abnormal. So there are three consistently placed sub mucosal vascular plexus formed by an estima otis of rectal wane within the anal columns. So, uh there are internal hemorrhoids about the dentate line and external hemorrhoids. So, anyway, anal cushions are normal structures. Uh and the structure is made of mucosa submucosa fibroelastic can connect you tissue smooth muscles. And uh Mr Parks uh uh used to lecture us uh in, in Dublin. He used to uh talk about this quite a lot about parks ligament. Tried's muscle which is divided into two, the superficial part and the deep part which is the Park's ligament. And that holds the hemorrhoids, uh hemorrhoid uh cushions to the muscles, to the uh to the internal sphincter as well as the longitudinal muscles. And once that ligament gets stretched, uh it fills up without any uh any problems. So, uh so, and these normally the cushions are responsible for continents. So uh these are the cushions, that's the internal sphincter, external sphincter, you know that and the in, in we normally, when they are together, we call it in tero external hemorrhoids. So, it's a physiological seal because the NNNS is collapsed normally. And the with the cushions, uh cushions absolutely seals it off. So usually there are 37 and 11 in relation to the uh to the uh the inferior rectal blood vessels, especially the it's a venous plexus, but it is supplied by the, by the three branches of the superior rectal artery. So, degeneration and prolapse of supporting structures, which we talked about now is tried's muscle. You know, there is a tried ligament at, at uh the uh the Ordina jejunal flexure is not that. So this is the uh try, it's muscle is divided into sub mucosal part and the deep part. Uh and it's very important that when you're doing a hemorrhoidectomy, that you do not damage the internal sphincter, just uh divide the parks ligament close to the hemorrhoid uh to liberate the hemorrhoids when you're doing an open hemorrhoidectomy. So the indeed the position of the anal cushions correspond directly to the location of the terminal principal arterial branches in the sub mucosal tissue. So the left, left branch of the superior rectal artery and the right anterior branch and the right posterior branch at seven o'clock. So when you put the patient in the lithotomy position, that's what you look at. Okay. So it's the same thing here. I'm not going to go into details about that. So, uh the anyway, we did talk about that. Uh right. So that is the park's ligament. You can see that and that is the internal sphincter and you should not damage that either. And you just get to the hemorroidal bulk of that by dividing the parks ligament. So it is the structures uh So in a sub mucosal part and the mucosal suspensory ligament of parks, right. So there are four degrees uh the first degrees bulging only within it does not come out, but they all bleed So whenever you ask about second degree or third degree, you can say there they all bleed, so they all bleed and but you cannot say I will put my finger and feel the hemorrhoids, you cannot feel the hemorrhoids degree one. So and that you are lying to the patient that if you say that. So when it protrudes, patient knows and you know as well and uh when you pay, when the patient defecate, then it and then when, when the patient's finishes, it reduces spontaneously, then the third degree the spontaneous protrusion any time of the day, I don't have to defecate with patient how to reduce manually. Fourth degree uh strangulates sometimes painfully reducible and it's not possible to reduce. So remember, the four grades is very important and the uh anyway, you know, this is below dentate line about dentate line is make sure that, you know, you don't put your band ligation balanced band ligation, any part of the external, external hemorrhoid. It is so important to make sure that uh because if you put the ban in the clinic on the external hemorrhoids patient, she'll scream and maybe may even hit you and you may, you cannot really remove that without taking the patient to theater. So it is so important to do that. So what we normally do is when we put the band, you pull it backwards, we call it uh used to call it with an again, Mister Milewski tag because we, we both discovered that uh independently. Uh and uh when you, when you pull it back, after sucking the hemorrhoids in and, and then you pull it back, then there should not be no pain, there should not be any pain there. Because if you're pain, don't put that band and always put 22 rings. Because if one falls, the patient may not bleed to death. You know, um, sometimes, you know, you see that our junior doctors put these bands, one at each, at each hemorrhoid and then suddenly it falls off and the patient bleeds. And uh I think there was recently a patient with uh hemoglobin A four. So, uh and you have to just rush the patient to theater and stitch that up. So that's what you have to do. So, make sure this is below the dentate line, don't do anything without anesthetic. So, uh and, and make sure better to do banding banding without anesthetic because because of this fact that you may get this band even, even a millimeter of the uh sensitive external hemorrhoids, right? Anyway, you have seen this already, you know, this is through the proctoscope, you put the proctoscope in and let it and remove the proctoscope and let it fall into that into the thing before you start doing anything to this, either inject it. So, uh so normally people say that 1st and 2nd Ingley could be injected. Uh and, and uh and uh maybe balanced bands, ligation can be done for that. And this one just needs the modern methods of treatment or, oh, the, the, uh, the open, open hemorrhoidectomy, which is the most painful operation in surgery as far as I'm concerned. So, uh, so, uh, think about that. So anyway, I'm not going to go through this, the four degree, obviously don't try to reduce its patient. It had been there for months when the patient comes to you. So uh this, this need uh outset packs and try and reduce the size of it uh to for the patient to be comfortable. Um So the, so number one, again, when we are talking about treatment, please make sure you tell the examiner, I will uh I will uh exclude any serious pathology because of those associations, you know, so serious pathology uh such as uh colorectal carcinoma. So that is your number one use for a lot of marks by just saying that. So, uh then of course, uh dietary regulation is the second one, you know, uh stool softness, high fiber diet. There's a bit of controversy about high fiber diet. Once the hemorrhoid is formed, uh they say it may cause more problems for the patient, but I think nobody is going to fail you if you say high fiber diet and uh shoot softener like lactulose. Uh So, and then of course, regulate the bowels and make sure get rid of all the books from the toilet uh because people just sit down there and just keep reading and lose concentration and they get more constipated. So, uh so that is another one, I think a lot of people talk about that and the so uh the other one will be uh injections uh phenol in Arman oil then make sure, you know, you look at it uh what you inject because do not inject local anesthetic into the hemorrhoids. I think we had last year, one of our prophesies, uh uh the private sector uh managed to inject hemorrhoids with local anesthetic by mistake and the patient died 34 year old. So, so uh he was apologetic but what can you do? We all felt sorry for him and and of course, the patient and the family. So because if you inject any local anesthetic, remember that uh out of this lecture that that there is no antidote to that, maybe you can give uh fatty infusions all these uh lipids. But by that time, the patient may have had a cardiac cath is due to arrhythmia. So uh make sure what you know what you inject and you actually don't inject right into the hemorrhoids. You inject this onto the apex of the hemorrhoids, you, what you want to do is to stop that arterial supply onto the venous plexus. So I I think the basis of the modern treatment is, is that something like halo operation? So, sclerotherapy and rubber band ligation, barons band ligation and the classical hemorrhoidectomy where you have uh you excites the hemorrhoids gently and leave three wounds. Uh And it's important that you leave the, leave the bridges between the hemorrhoids. Otherwise you end up with the anal stenosis patient will be dilating this for the rest of his life. So uh yeah, and it could be criminal. It should be criminal. Although when you leave thus bridges uh problem is that uh the uh the it may look like hemorrhoids to the patient afterwards, but you, you must explain it. So the Millican Morgan Hemorrhoidectomy, you, you leave three areas of wounds, especially because you have to leave that bridge and it looks like shamrock because I did work in uh in, in Dublin uh and the props of Fitzgerald and the uh so, and it's a very painful, I don't know how to settle this pain. It is so difficult for the patient and don't discharge the patient home without having the 1st 1st bowel motion and make sure you use to softness and this is not the time to give high fiber. Uh but it is after the operation, I think still softness what you need to be kind for the patient. So, uh and the balance band ligation is no problem. You can do leg assure, just catch it and burn it. But it's, we don't know because we send this patient home. Uh and never think about the pain and the patient come back to you or the wife bring the patient is at least trying to commit suicide because it's so much, so much pain. And the uh for the same reason I stopped doing an open hemorrhoidectomy. I somehow managed to do the modern operations. So a staple in. Oh Pexy uh OK. Is our methods. Uh We'll be talking about in the mid uh this uh my register up with these pictures is how painful it is. That's what I said. So PPH procedure for prolapsing hemorrhoids using the, the longest channel technique. Uh And the, this is the open MRI deck to me afterwards and imagine trying to defecate through that. It is, it is so, so painful. Nothing really works. Uh Complication of hemorrhoidectomy is pain, bleeding, encourage fickle impaction, stenosis, incontinence and all that. And also sepsis is a problem and urinary retention, etcetera anyway. So uh staple in. Oh Pexy corrects the primary pathology. Uh So what, how, how can you say that? So you excise, the redundant lower rectal mucosa are disconnecting the blood supply. We said that the blood supply, it fills up the channel cushions which has lost this structure. Uh So, and the uh this avoids excision of the skin is like the staple gun. I'll show you in a minute. Uh The patient selection is important. And again, the problem is because it's a circular scar. You exercise a strip of mucosa uh and then bring it up and that is your a know pexy and, and pull the whole structure up. So, so that is your uh that is, that is the math, this is the gun you use. So you put this purse string about purse string below, but all done within the uh about the dentate line because it is so painful otherwise. So this is the gun um and the uh strip of mucosa is excised here. Uh And the uh you pull thing up because you are not doing anything to the hemorrhoids. Uh So, otherwise the patient will be very uncomfortable still. Uh And then of course, once you pull up, it goes back in. So once you go back in the, the edema of subsides and the patient's get better. Um So, uh so, so you take the strip off with the arterial supply and, and the uh the uh so that's how you do that. And uh it's a circular stapling anastomosis. Um I never liked it because I was really worried about after doing colorectal surgery, staple gun anastomosis, you know, I didn't want to do anything like this, but my colleagues are doing it successfully, right? So staple in a Pexy that is known as okay. So the most modern method is the halo operation, hemorrhoid largely ligation operation and N OPEC see. Uh So what you do is you locate the uh so hyper vascularies, Asian of the anorectum contributes to the growth of hemorrhoids filling up of that, uh, poorly structured in a cushion. And therefore, uh, we are just locating the artery and the, uh, so you, you look at the artery and then of course, you start cobbling it up from about downwards. You keep this end outside and come down until the dentate line don't go into the external hemorrhoid. And the, I think apex is enough. Uh, so make sure you do not go below that because it will be painful after the surgery and then you tie the two ends and pull it up. So that's the thing. But a lot of patient's, my patient's complained about not having dealt with the problem they came in with which are the hemorrhoids. So what I start doing it now is to uh not just halo. And uh what I'm doing is uh I will ban that internal part of the hemorrhoids and, and there is no pain whatsoever for the patient. I do under law under general anesthetic, but the patient goes home in the afternoon. So because there's no cutting. So the patient's are happy and the uh and, and, and that is a good operation. So, hello. And you know, Pexy, I add, I don't think it is published anywhere. Uh It is my own preference. Uh So they don't tell that in the exam, uh halo operation is the one you have to say in the exam. So that is the, the most modern method operates. So start with the, with the, uh the, the excluding any serious illness, etcetera. And then go on to injections, uh fennel in uh an oil in fennel. And the, the uh, the uh halo and the modern operate and open hemorrhoidectomy talked about uh this is the way how you do that halo operation. There is a window here. Uh You locate the artery, uh and then of course, put a stitch around it, uh and then keep one end and then come down and do an Opex E by tying the two together like this. So, so you start from here and then the tie two together and pull the whole structure up. That is you're in a pexy and that is your halo. So two parts to the operation. So, hemorrhoids lottery ligation, I was looking for this word director and repair. So that is a raw means. Anyway. So now we ask you what is a perianal hematoma? Everybody says this is a hematoma in the hemorrhoids, not really, this is a perianal skin and and there is a hematoma. Suddenly it comes, you know, it has nothing to do with hemorrhoids and it is very easy to treat. You just make an incision under local anesthetic and remove the, remove the, remove the clot. So, perianal hematoma is the hematoma in the perianal region. What is a perianal region? It is an inch around the anal verge. So uh right. So very in an EMA toma okay skin tags. Of course, again, another benign conditions, sometimes it gets trapped in the sphincter, we just snip, snip, snip, snip. So uh sometimes could be distressing but no need to stitch it, it heals up quite well then various anal votes. And I'm sure you will be uh studying that in the uh you, we, what surgeons do is just to snip them and the uh human Papilloma virus six and 11. Anyway, you will be taught this separately in the steady uh lecture in Al Condyloma. Now, when you ask about this is the other other message I want to give other than the hemorrhoids. When you ask about perianal sepsis, normally you're talking about uh talking about uh perianal abscess and ask your rectal abscess. What's the difference between them? Uh Pain is the same. It's terrible. They can't sit, they can't do anything. It's very painful condition. And the, but exc your rector lapses is a large area. You know that with the, with the recess at the back and the uh I'm not going to talk about the anatomy. It's a huge area. Perianal abscesses, a very small uh centimeter area, but the pain is the same. So because it is a large abscess, the white cell count will be high temperature will be hyper patient, maybe even shivering and, and, and the patient is very ill. So that's the difference, clinical difference of that. So uh and then of course, we asked, we asked the candidates. Uh What is the cause of perianal uh sepsis? And everybody says poor hygiene. I mean, medical students get it. It's not poor hygiene and the patient get very annoyed. Uh It's not poor hygiene at all. Then somebody says health articles. Somebody says that uh it could be sebaceous cyst for 31 years. As a consultant. I have seen only one sebaceous cyst infected in the perianal region. So the answer has to be cryptogram and Euler sepsis. Where does it come from? Is anal glands, anal glands in the interstim victory plane. Uh You should know what is interesting trick plane. And that is your interesting trick plane. And the, and it opens into the crips here around the dented line and sometimes it gets blocked and causes infection. It's like the, as, as Mr Park said, the, the favor surgeon who did a lot of work around this. He said that this looks like the, like the anal tonsil, er because it is a lymphoid structure uh and it get infected and then of course you get sick, your rectal lapses if it goes that way, if it goes submucosa Lee, it could a submucous obsessed or it could be, it could be uh perianal lapses uh because of the scepter uh coming from this finger. It is very tight, almost like the pulp of the finger. When you get, get an abscess here, it is so painful uh than any other area. So anyway, So there are it burst into uh some play all those areas and the abscess may come from uh super elevate area from the pelvis. So you need to know about what's happening in the Pelvis. Crone's disease, diverticular disease or sepsis may come down in the super elevator area. You have to treat that condition. Sometimes you may even if you have a fistula, uh sometimes you may even do uh do you have to do a colostomy? Uh patient is not very happy about it. So, so you it can have a low in el fistula. So main thing is uh it is due to infection of this. So I think if you say the word crypto glandular sepsis, that's enough for me. So it is glands, anal glands, which is well developed in the dogs and uh special sexual uh kind of attraction, etcetera. But in may, in humans, it is rudimentary but caused havoc for us. Uh And that's what you need to know. So, perianal pain, swelling, discharge fever carefully. You weigh uh make sure when you ask him how to prepare the patient for theater. Uh Perianal do not say I will give you various uh I will shave the patient. I will. That's a terrible thing. I think it is uh these are FRC SMD question as well that how do you prepare this patient? Uh other than consent, etcetera uh that you must not do shaving. I think the shaving word has gone out of practice now. It should be uh because when you share it causes damage to the skin, etcetera. So normally, uh you, you use the machine and, and uh and take off this, take off the, uh the word doesn't come to me now. So forget about shaving altogether, especially without an anesthetic because it is violation of human rights uh in order to hurt anybody. So it makes sure that you don't do that in a rectal abscess is so anal glands location is inter sphincteric. Don't forget that that's what I want to give the message. It. So low, anal, you lay open the fistula high, you put a suture around the sphincter because you cannot really cut it and keep, keep on tightening it and it will cut through without causing damage over a period of time. And the super elevator abscess is coming from the pelvis. So Perianal versus curx little fistula in no is the condition we talked about and that is how you do a low in al fistula. You put a probe in through and open it up fish too low to me, it's not fist elect to me fish too low to me. And the uh if you think about cross disease become multiple fistulas, be there from crone's disease, uh you may have to take a biopsy from the uh fistula tract or maybe it's tuberculosis. So, uh depending on where you work and where uh various disease prevalent uh this is Crohn's disease and multiple fist elations and scars from previous uh you, you treat it the same way. So, Pilonidal, the other one, I think we got time to talk about it. Uh Every time you ask the, ask the medical student, where is this? You know, they are trying to show on themselves, don't ever show anything on yourself. So you have should be able to, you know, is it where exactly you're abscess or the sinus? It is uh pilonidal means hair, nidus, meanings, nest, nest of hair upside down. So, sacrococcygeal region, uh you can say anal cleft, intergluteal pharaoh and, and there are various other places you get that in the barber, you can enter digital and this was called uh Deep Bottom in the Second World War because a lot of the British soldiers got it. Uh And the uh and the that is the midline. So the midline there is a problem with the skin, you know, uh and the hair get pushed in and the carry darkies gave us the uh new concept. Uh So the George carry doc has said that uh there, there is uh invader, the loose hair from the hairy back goes inside upside down and the force of the Viibryd Torrey, Forceful Axion of the uh of the buttocks. So this is how you talk about it, etiology and the vulnerability of the skin, sweaty, macerated skin. Imagine in the Second World War, these people were there sweet sweaty, contain their clothes and it's the war situation and it is terrible for, for the soldiers. Um And the uh the number one is sinus or abscess, sinus one without any infection, abscess should be, I think my medical students answer should be, should be uh excision and late open. So that, that should be the medical students answer. But I normally inject dye and cut the whole thing out and uh and then late open. So, so carry doctors procedure is the one that most people do getting rid of the, the midline scar. So you if you take your apex of the, of your excision away from the midline and your scar will go away from the midline and you have a good skin in the, in the vulnerable area. So, so that is the anal fissures that to gain a problem for medical students in the stress period. The stress and the uh and the uh the lot of stewed our students got this and the is very painful is a can you shape also with a little uh sentinel pile at the end. Uh We don't know how that forms. Maybe it's just granulation tissue causes it, but it uh skin seems to be more, more, more square mus. So it cannot be granulation tissue. So anyway, so anal fissure is a painful, usually midline and it's a canoe shape ulcer. It, if it is more than three months, you call it chronic ulcer, chronic fisher, uh very, very painful. And then of course, the uh uh the 80 ologist, they say internal sphincter hypertonia or poor blood supply. One of the two. So we are using lateral sphincterotomy and this is uh this is the anal fissure here and it's very painful and, and that's why you need to, when you do a pr examination, uh you have to look at it because if I see this one of, I do not do pr examination that is violation of human rights. So, because it is so painful to do a pr with a fissure like this, especially acute fissure. And uh so uh we do lateral sphincterotomy uh for this because of reduce the hypertonia of the internal sphincter. But you don't cut the whole sphincter only up to about dentate line. You, you uh with the lateral, you expose a little area and look at and then you turn your knife and cut the lower end, lower end below the dentate line so that you won't cause any uh any uh any incontinence. So people say never do this uh loads procedure which is the anal dilatations, four fingers, four minutes is terrible and it may cause uh incontinence as well. So, uh the other one is the uh is using the uh GT anointment. Uh and the we call it nitro fees uh or you can use guilty is um cream and Botox injection. Various things are called, but patient needs. Uh it's a quick uh so Botox injection is used in a bit release of acetylcholine calling etcetera. Anyway, so the last resort is surgery which is the lateral sphincterotomy radiation proctitis. I don't think it's treated with steroids. I think we are coming to the end of this prolapse. It's uh it's divided into complete prolapse or uh incomplete mucosil prolapse when you get that in, in a child. What you do is you take a Kleenex tissue and uh gently put that in with your little finger and leave the tissue there. So once you do that, once the child grows up with the sectoral holloway's uh informed because initially it is straight and that will treat itself. The other one is the, you have to excite it, complete, perhaps it won't get killed. And the uh so uh the procedure is called deal arms operation. You uh deal arms operation here and you strip the mucosa and placate the muscles. So that's what you do. And there are areas of the methods, laparoscopic recto pexy uh by you know, rib stain method or wealth method. But I don't think anybody's going to ask the medical students about how to do that, but you must know about how to manage this patient and not to hurt them. So that is the, that should be the final message to you that you do not do various uh various uh washing and, and, and, and shaving and etcetera. Clipping of air. That's what I was looking forward. I forgot about it. Nowadays, we stopped talking about shaving. Remember that we, we, we, we don't talk about shaving, it's hair clipping because it won't damage the skin and it should be done again, close to the operation so that you won't cause infection. Uh, and the, uh, solitary ulcers syndrome is a difficult one to treat is usually on the anterior wall. Uh, foreign bodies is a real problem, especially among homosexuals. And the uh usually uh they cause a lot of damage to themselves. And you can see whole bulb is uh inserted. They usually come and tell you that I sat on it and sometimes caused tremendous damage and the sphincter damage and uh you have to repair them and it is, I don't know how they managed to do that. Okay. I don't know my registry apple that veritas and I sometimes you may be asked about it. Uh And the infection, it returns dermatologic conditions like psoriasis dermatitis. So I think we have come to the time that uh sorry that my registrar is making havoc here. Uh Okay. Thank you very much for such an amazing presentation. Professor. There's any questions. We've got two more minutes. Anyone wants to ask any questions, please go ahead. You can ask questions from previous uh lectures as well. And the uh the also uh I think the next one will be diverticular disease, colorectal cancer and breast surgery. So the next three lectures by me, hope you enjoyed that. And the important one messages I have given those four conditions. Remember, you know, constipation, diverticular disease, hemorrhoids, and colorectal cancer. And never missed to say through the examiner that you will impress him by saying I will, I will Exclu include any serious pathologic. You do that for the breast as well. A breast pain. You say I will exclude serious pathology. So that is your think, I think that is the message and don't hurt the patient and also unnecessarily don't walk into the theater when the patient is under, under spinal anesthesia. 10 medical. So walks in that really annoys me because it it is not right. You know, it could be your sister, it could be your brother, it could be your father. So uh usually the best to come once the any studies given full screen is put in and you come behind and don't talk right. Thank you very much and hope you enjoyed that and you understood it. It's a simple letter. Thank you very much, professor. Thank everyone here. Hope everyone has an amazing evening. We've got a lesson off to this. Exactly. Crop to. Thank you very much. Everyone. Have a lovely day professor. Thank you very much. Ok, bye. You too. Goodbye.