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Ok, we're, yeah, we're live. Ok. Hi, I'm Barnie. I'm one of the CSI one B crash leads and today we're looking at case 13 and 14 and we have due date here doing case 13. So over to you. Hi, nice to meet you guys. I'm Juliet, fourth year medical student and I'll be going through case 13 of um abdominal pain and biliary pathology. So hope you guys enjoy. Um So yeah, so I'll be going through examples of biliary path and the formation of stones, signs and symptoms, investigation treatment and complications. And if we have enough time I'll go through um cases of the acute abdomen. So, yeah, just um some definitions I think will be helpful for you guys because when I was going through this case, I didn't really understand the difference between these stems. So like anything starts with colleagues to do with the, with the gull or the bile lithiasis is stone cysts, um relates to the cystic duct. I think you guys would be familiar with ITIS being related to inflammation and cholangio is specific to the bile ducts, not just the bile and col doo is the common bile duct So yeah, um knowing those route will help with any confusion. So what might we see on the abdominal ultrasound scan? I think this was your first task. Um So as you can see there are hyperechoic gallstones. Um also the gallbladder that does look distended and the wall is thicker as you can see on the ultrasound scan. It's not usually, it doesn't usually come up as thick on a normal ultrasound with pericholecystic fluid. And these stones would be hyperechoic and I've made notes about this here, um which means lots of echoes due to the air or the, or the fat or excess fluid. Um And there's also posterior shadowing, as I mentioned because the gallstones are very solid and they um absorbed the, the waves very strongly. Um So yeah, they don't allow these ways to be permitted. So they show up as hypo COVID. Um So I have a question later on about CT scans, but for now, um it's good to know that ultrasound is first line. In some cases. CT scans are useful to see um a perforation of the gallbladder because that's not always detectable on an ultrasound. And it can also detect emphysema, emphysematous cholecystitis, which is probably won't come up a new CSI, but it's good to know the different types of cholecystitis. Yeah. So we have um the least severe type of bili biliary disease, which is biliary colic and it's usually asymptomatic. But when there are symptoms, there would be right, upper quad, upper quadrant pain caused by the temporary obstruction of the cystic duct. Um, usually after eating and there is no inflammation. So the obs would be normal and I'll go through what normal observations are and what the atypical or the pathological observations will be on the latest side. So, as I said, um it's usually after eating because this the fatty food, fatty food, especially tri triggers the release of cholecystokinin. And um, this causes increased contractions of the gallstones gallstones leading to very, um severe pain. And unlike normal co colic, this, this pain is consistent and the pressure in the gall and pressure in the gallbladder rises leading to swelling and a lot of discomfort and it's quite a dull pain. It can last for about 20 to 30 minutes. Usually that's usually for less than six hours and then it goes away because the goal, the gallstone is continually moving, um, back to where it back to where it doesn't cause pain and to places where it does cause pain. So, yeah, because it's constantly moving where it moves is where it is, when it, when it's moving is when it can cause pain. Um, when it's back in the gallbladder, it's less, it's, it causes less discomfort, but sometimes when the pain becomes too much, you can, it can cause the removal of the gallbladder even though this might not be, even though this is the least severe of the other biliary pathology, sometimes it's better to, um, remove the gallbladder at this early stage in order to prevent further pain. As we can see here, the, um, in a tutorial from Duncan's folding, I don't know if you've had this yet, you might have recently had it. But, um, if you look at the blue line, that's the line for biliary colic and it's different to normal types of colic where the pain comes and goes. This one is at a constant pain intensity for quite a long while. So, yeah, in your CSI, they might give you diagrams and they might ask you to point to one of them. So, yeah, I remember this blue line of just remember constant pain for colic for biliary colic. Then we move on to acute cholecystitis, which is, which involves inflammation. Now, as I said, previously, biliary, we call, it does not involve inflammation whereas cholecystitis does, which would mean that your inflamma, your inflammatory markers would be up now and it is due to the outflow from the gallbladder being blocked. And yes, this is a permanent blockage causing distension of the gallbladder, severe constant pain, um just like biliary colic, but it does usually last a bit longer and it would um accompany with nausea and vomiting unlike biliary colic, but there would be no fever and tachycardia. Um Yes, as I said, there'd be raise in primary markers such as your um white blood cell count and crp sometimes alps, um, slightly raised. That's a liver enzyme, but it's not always and it's not, the pathology hasn't reached the liver yet. So there should be normal, um, liver function tests and normal bilirubin and it hasn't reached the pancreas. Not much your stomach, um, upset, but you would have like local pain, nausea and vomiting because it is around the stomach area after eating these fatty foods. But yeah, it wouldn't be affecting the rest of the body yet. So, um when I talk about risk factors for developing gallstones, it's usually um referring to cholecystitis. So, um people remember the mnemonic of the four FS, sometimes even the five FS fat, female forties and fetus. Um So in terms of fat, it is linking to the um um hyperlipidemia aspect of it. That could be a risk factor such as um obesity and type two diabetes. And it could also link to the um increase on it. And female aspects can link to the um estrogen pregnancy. And also as I've highlighted here, um OCP the oral oral contraceptive pill can lead to an increase in estrogen, estrogen and um and bili biliary cholesterol secretion. And I think you've probably um covered in your CS I case about the relation between cholesterol and um biliary disease. Also progesterone can um suppress the release of substances from the gallbladder leading to the hypo Mobi hypermotility effect. And also diseases such as Crohn's disease can lead to the development of cholesterol stones, which is a risk factor. And yeah, being over the age of 40 female together can increase the risk. Also, um hemolytic anemia and a disease that causes he hemolytic anemia can um lead to the production of black pigment stones, which is also a risk factor because of the and it can also cause a super saturation of bilirubin, which we'll talk about later. Then we move on to um ascending cholangitis or you can call it acute cholangitis. They mean the same thing. This is um this is where a person would um experience the most severe pain and it's the most um severe condition out of the three because it involves inflammation and infection of the whole biliary tree. So, acute cholecystitis was just the gallbladder. And now this has progressed to the more of the biliary tree involves the common bile, common bile duct and the cystic duct. So it's more inflammation and then if it leads to the pancreatic duct, that can also lead to acute pancreatitis. Yeah. So the stone can migrate from the cystic duct to the common bile duct causing inflammation. And as I said, with cholecystitis, it's there's not much systemic upset, but with acute cholangitis, it's much worse, systemically, infection, tachycardia, low BP, it's a sepsis like picture. Um Yes. Um with the with the increase in primary markers, there's also increased bilirubin. But um surprisingly, no nausea or vomiting because at this stage, the person probably went for like eating anyway. So how can we differentiate between um biliary colic cholecystitis and cholangitis. This is a really good schematic from metics. So hopefully I've covered that. They all involve right upper quadrant pain. Um cholecystitis, itis is inflammation usually with inflammation is a fever as well as cholangitis. And the only one that could have a symptom of jaundice is cholangitis because um some patients from the liver can't get to the small intestine because of that blockage. So you get a buildup of bilirubin. Uh and the other two conditions, there's no, no jaundice because the connection between the liver and the gallbladder is still intact. So I have a question for you. Um So, um so the three things that I ticked here for cholangitis fever, right? Upper quadrant pain and jaundice. What, what do they make up? And what is, what is the term for this? Uh My clue is that it's a type of triad. So if you guys can either shout out or write in the, um in the chart, what the name of this triad is and then we'll move on. Er, someone said wis triad, another person said Charcot's triad. Let me see if we get any more responses. So we've got two so far, any more responses have a guess there's no harm. Another part. So we've got two people now saying Charcot's triad. OK. Yeah, thank you. Thank you. Everyone that responded. It's nice to have responses um be beco triad is related to something different. So the correct answer is charco triad. But um yeah, as long as you know, before CSI Wednesday, it's all that matters. So just to just to reiterate, just to reiterate the three things that make up charcots triad are fever, right, upper quadrant pain and jaundice, which would all make up acute cholangitis on the right hand side here. Cool. Yeah. So hopefully this picture will help you too. Remember those three symptoms, even though some may be part of um say um fever might be part of cholecystitis and they all encompass right, upper quadrant pain, they're usually talking about all three. So if you see all three in a sentence in your CSI question, it's relating to acute cholangitis. So yeah, hopefully it won't cut you out on the day, on the day. So just an overview of what bile is mainly made out of water and the bile acids can aggregate together and they can form stones so they can form cholesterol stones which make up the majority of stones, pigment pigment stones that um I described can lead can be a result of hemolytic anemia. And it's the cholesterol stones that are usually involved in um gallstones and cholesterol gallstones that are usually involved in causing acute cholecystitis, acute cholangitis. And um we call it the bowel composition isn't as important here. It's just good to know. So, yeah, the pigment stones um are usually due to the overproduction of bilirubin, as I've said before, linked to um hemolytic anemia. And just to know that the pigment is black and brown stones would be due to other bacteria. I guess if you wanna read more, read up more brown stones feel, feel free. I wouldn't say it's as related to the CSI. And then when we talk about cholesterol stones, um these are more likely to be linked to the biliary path. So I would learn the three factors that um can lead to the cholesterol stone formation, which are super saturation, which just means that a lot of um cholesterol is being produced. So it's, it is too much for the body Nucleation. Um It's more about the kinetic factors and the proteins that um cause the stones to form and hypermotility is just the um bowel not being flush, flushed out as quickly as it should be. So, things are moving more slowly because usually in healthy people, um extra bowel can be flushed out. But um in this disease, um it's not so it builds up to higher levels and it can be seen in people with um diabetes, uh diabetes, me mellitus and people that have lost weight really rapidly because they've lost this um ability to flush out the bile. And it can also happen in those who are dehydrated. Yeah. Um just to show you some, you know, you have the anatomy of the biliary tract. But yeah, the gallstones, they stay in the gallbladder. That's the bilary biliary colic. But, you know, it can still move about causing pain. Once it gets to the cystic duct, that is acute cholecystitis, then once it gets in the branch between the cystic duct and the common bile duct, that's when it can, um, cause acute acute slash ascending cholangitis. If it goes further into the pancreatic duct, that can cause pancreatitis. And also, um, if it gets in the way of contractions of the intestine, it can cause gallstone ileus. But I'll come back to that because that diagram is somewhere else. Um So as I mentioned, um people with bili biliary colic have normal observations that um I was referring to basic investigations then, so a full blood count would involve um you know, white white cell count, neutrophils, um inflammatory markers. Yeah, then you'd have urea and electrolytes. You'd have your LFT S which are liver function tests, as I mentioned earlier. So rub Aubin is far wrong there and it would also encompass amylase and lipase. So, if sorry, I was meant to watch in the chart if amylase and lipase, if amylase was raised, um what condition would that relate to? If anyone knows, this might not entire, this is like this could be beyond the scope of your um CSI be mean if they asked this, but they could ask it, they could if they wanted to. So what would raise Amylase? Two people? Everyone's has been saying pancreatitis. Oh, nice. Ok. Maybe they will like this. It's good that, you know, um, yeah, let's skip that one beta HCG. Um, hopefully, you know, that could, yeah, that, that would be a investigation to do to test for pregnancy as um, pregnancy can also increase the risk of gallstones. So, yeah, um, we discussed that most of these would be normal in biliary colic, um, with acute cholecystitis, you should, you should see increased white count and other inflamma inflammatory markers use to do with urea. Um Yeah, it should be normal LFT S could be normal slash raised when the L LFT starts to be raised. I'd start to think um aside cholangitis instead of acute cholecystitis or biliary colic. Yeah, just look up for the beta HCG because that could be an indicator of pregnancy as well. So in terms of treatment, this treatment links to acute cholecystitis because I think this is what the woman in your case had. Um at first if they ask for initial treatment or always think of pain relief because this is very painful, very painful, um condition to have and also consider antibiotics. So they might ask you what to give the patient, you could say, you know, surgery, but initially you just think pain relief, keep, keep the person hydrated, especially if they've had nausea and vomiting. They might be quite dehydrated. So, yeah, those are, these are the initial treatments, then there might be a CEC cholecystectomy. Um, if we dissect that word cholecyst chole is, um, you know, gallbladder, cystectomy is the, yeah, the cystic duct. So, yeah, um, taking out the gallbladder basically. And it can be early or delayed depending on the waiting list, I guess. And these days are all, um, laparoscopic just to check on you guys. Are you all still here? Anyone? No, the common word for, uh, laparoscopy or other word for a lap laparoscopy. Nothing so far. But we can. All right. Um Usually when that a keyhole surgery. Oh, lovely. Yes, laparoscopic um, refers to keyhole surgery and that just means that the person can recover quickly because, um, usually two or three holes in instead of opening them up. So as you can tell, as you can probably guess it's a quicker recovery time and it is quicker to do the surgery also. Um, but if the person seems unfit, you can do a percutaneous cholecystectomy, which is not as common as just through the skin. But yeah, it's usually laparoscopic complications of the surgery though can be pancreatitis as we um, of no of complications of um acute, the, the biliary path as well as the surgery can be drawing pancreatitis, pancre, pancreatitis and um, fistulas I mentioned Gall Ius, which is another, um, name for Bre syndrome. Um I wouldn't look, I would read over these um, before your CSI, but we always got told to learn about Maui Marii Syndrome. It didn't come up, but um I would definitely go over them in terms of gallstone. Ileos, as I said, it's about the con the contractions of the intestine meaning that um it's not as mobile. So, um yeah, of course, the intestine is not contracting as much it can lead to. Um, yeah, things not working very well. Um Ileus means there's, there's a lack of peristalsis, there's a lack of muscle contractions of the intestines so that can lead to other things. And um, a fistula is an abnormal connection between two different body parts. So here there's a cholecystoenteric fist fistula. So that's um an, an, an abnormal, an abnormal connection between um, the gallbladder and the um intestines. So, yeah, things like that can form because of the biliary path. So I would just, yeah, I would just be aware of those but, um, I don't read into them too much if there's no time just focus on the rest of the cases. Um, yeah, Mauricei syndrome is, um, when the gallstone becomes, sorry, I just look at this, I'll just go on a picture here. Maiti syndrome is when the gallstone becomes impacted in the neck of the gallbladder like that. Um, which compresses the common hepatic duct. But, um, you won't be able to see the um, blockage in the common hepatic duct. Yeah. And I'll go back to slide MS. Yes. Branco tried to us, we, um, went over before when the gallstones. Um, the gallstones become stuck in the junction between the, um, hepatic common bile duct and the pancreatic duct can cause pancreatitis. So that, yeah, acute pancreatitis. So that's another, um, complication of gallstones as well as these things here. Yeah. And also, um, I didn't go over a gallbladder cancer which, um, is also called cholangiocarcinoma. But this is very, very, very rare. So, yeah, it's good to know the complications and that the fistula can lead to the ileus. The abnormal connection between these two organs can cause it basically to slow down and the contraction, stop moving radiation of pain. What sign is this? Um I'd say his abdomen is very, very um bruised center of the abdomen. Does anyone know what sign that is? Uh Let me see. Oh, someone asked, they had a question that um they asked if do they get nausea and vomiting in ascending? They asked why you don't get it? I believe they might be. Yeah. Um I, yeah, it did say that you don't get nausea and vomiting on the slide. But II would correct that and say that you do. Yeah, that's good. If you did get a fever as well, the nausea and vomiting would come. So, yeah, sorry about that. I was correct that side. Um Yeah, I'm pretty sure you would get nausea and vomiting but you wouldn't get that for um a time. Let me see. No one else in the child has put that sign yet sign. Oh, someone's, someone's put Collins. Collins sign. Perfect. Someone's put Gray Turners. So, yes, there's a different, yeah. Um, I think you learn them both at the same time between Gray Turners and Collins. But, um, yeah, Collins sign. Yeah. Ok. That's it. Um, yeah, bruising around the navel. Which could, oh, I should have asked you what it could be a risk factor for, but it's usually a risk factor for, um, pancreatitis. Yeah. Um, other differentiations of um, pain that is good to know even if it's not for CSI for an appendi for appendicitis. It's sharp pain that usually starts in the center of the abdomen and radiates to the right iliac fossa, um pancreatitis and some, some and anything to do with the abdominal aorta would be the classic epigastric pain radiating, radiating to the back and pain arising from the kidneys, radiates from the um flanks to the loin. They say um, loin to groin pain. Yeah. And right upper quadrant pain radiating to the shoulders. You guys should be, you know, experts at this. Now, um, uh, most pain to do with the liver, acute cholestat. Yeah, acute cholecystitis, just going over the um laparoscopic cholecystectomy. Um, the procedure divides the cystic duct and the cystic artery and this is a keyhole surgery as mentioned before, where they remove the gallbladder. As you can see here. Uh, it's, uh, it's probably about two or three holes inserted the side of the stomach um, looking at the different sections of the liver and they go straight for the gallbladder there, open it up, open up the small section here, remove the gallbladder. And, um, yeah, sorry, in an open cholecystectomy, they would open it up with a keyhole, they would go through these holes as you can see. Um, after the surgery here, they would only be left with three scars, but in an open cholecystectomy, they'd have a massive scar all the way. So it's definitely a quicker recovery period there. Um, some complications of the laparoscopic cholest omy though, as always, you can get bleeding, infection of the wound sites, even though they are small, it's still a chance of infection and also a deep vein thrombosis. Um, there's also injury to the bowel biliary in injury and a syndrome called postcholecystectomy syndrome. So, yeah, um, I've read about that up, I've read about that if you're interested. But yeah, just to let you know these things and, um, I think this was case six out of your six cases. Um, just remember that they will always ask something about ethics if they've taught you about ethics in the, um, part two of the CSI. So, um, just about knowing what someone needs to, um, be told before having a surgery such as a laparoscopic cholecystectomy. It is an elective procedure, not an emergency. So there will, there would normally be time for, um, patients to give consent. For example, if they've just been in a car crash and they're unconscious. Um They may not, there's, there's not time to give consent there or perhaps they'd find the next of kin. But in rush um situations like that, um health professionals wouldn't always have to um ask for consent, but for something preplanned like um keyhole surgery, they would always need to get written consent. Um Yeah, I think some questions ask if it can be verbal or written, but if it's something routine like this, verbal would mean that it was something emergency. So I think, yeah, they definitely um if there, if there's any sbs about written or verbal consent, I would go for the option that has written consent in it. So yeah, the patient needs to know the not um the proce the the post the person asking for consent needs to know about the procedure needs to be able to explain what cec cholecystitis is or what a biliary colic is. What the options are. If the person doesn't want surgery. For example, if there are medi medical options and what the purpose of the procedure is and the risks of it at the risk that we discussed here. So, yeah, anyone that asked for consent needs to know all of these five things and they need to, the patient must have capacity before um, consent is obtained, but just know that capacity is always assumed. Um they don't have to prove that they have capacity it's more of the health professional doubt that this person has capacity is when you would need to assess it formally. But you always start off assuming that the person has capacity until proven otherwise. Um So the meaning of it, of capacity is that you can understand information, retain it, weigh up pros and cons and to communi and you can communicate your thoughts. So you can tell the doctor what you're thinking, you can write down um you can write your own signature and your name that you've understood it if yeah, so that's you having capacity and yes, going back in a different order to um your CSI cases um just going over the quadrants um of the of the abdomen, right, upper quadrant would involve anything to do with the gallstones, the liver. Um So yeah, differential for um right upper quadrant pain. You have cholangitis in there. Hepatitis liver, abscess. Um right, lower quadrant, as I said, right, iliac fossa would be appendicitis, Crohn's disease. Um And ectopic pregnancy is important for the right lower quadrant and the left, lower quadrant. Um yeah, lower abdomen, it would be things to do with the um genito ureteral tract. So like cystitis um could be, yeah, urinary, urinary retention. Um right lumbar left l lumbar lesions would be RNA renal colic, ovarian cyst ovarian mass. Those ones are quite symmetrical pathology. So, easier to remember. Um umbilical is good to remember for appendicitis because of um that's how the pain starts initially, then it moves to the right lower quadrant and epigastric pain can be quite general because it can accomplish um things that happen in the right upper quadrant such as bili biliary tract disease. I would say pa pancreatitis is more um localized to epigastrium. So that's a good one to remember for epigastric pain and the left upper quadrant, not much goes on there. It's just mainly um conditions to do with the spleen. So, yeah, if you learn the anatomy, usually the um disorders in relation to the anatomy, um yeah, uh where it happens, it's just that you can get referred pain sometimes as well. Sorry. Um Do you want me to put the question up? Oh, sorry. I'd just like to go over some of the common scars that you might find. Um this is just extra things. Um So you'd have the peril scarf or um Cesare Cesarean procedure. You don't have any of these for the laparoscopic um cholecystectomy or there are other ones such as the Midlines, midlines scars, the land scar, the cocker, the rooftop. So, yeah, just be aware of these um these days. A lot of things are um um keyhole surgeries. But yeah, common scars that were there before. If you're interested in surgery, I would recommend and no one would like me to explain any other slide before we go into questions because I think I did go through that quite quickly. I'm happy to go over any other slides, especially the one where I described acute cholestat of not having nausea and vomiting. I'm sorry about that. Oh, nothing in the chart so far. I'll let you know if there's any questions in the chat. Ok. All right. Should we go on to questions? Yeah. Do you want to put the the which question do we profess the consent on? Mm. Yeah, we'll do that first. Ok, stop. Ok. Just go back to the side. Yeah. Mm. Oh gosh. Yeah. Ok. The consent form. Yeah. Yeah. So who can ask for consent for a laparoscopic cholecystectomy. So this is the keyhole surgery I was referring to. I gave you quite a lot of options here and there's even more on my powerpoint slide. It's just to get you thinking because this is what they will do on the CSI. You know, there might be more than one that's correct, might have checked you there. So yeah, as long as we know which ones can't ask for consent, I'm happy. Yeah. So far we have eight responses. Um, we have 10 responses. So six of them have picked someone who knows how. Ok, five of them, six of them have picked someone who knows how to perform the procedure. Um, I'm going to assume four of them picked general surgery registrar and one person picked anyone who knows what the procedure is about it. Roughly the most common option is someone who knows how to perform the procedure. Yeah, I think I was a bit mean with this one because there are more than two, correct answers. So, those are the most commonly answered ones which are someone who knows how to perform the procedure and a general surgery registrar. So, um, thank you for answering those. Um, a general surgery registrar should know how to perform the procedure. Yeah. So, um, that was just good because in the CSI, they might ask you to write the letters that are correct. So it might not just be one. So it's good to know multiple answers. That could be, um, anyone that knows what the procedure about is not what the procedure is about is not correct because, um, as medical students, we should know what the procedure is about, but that doesn't mean that we can perform it. So it's someone that knows what it's about. Um, as I talked about someone that knows what it's about, knows the risks to treatment options and knows how to actually do the procedure and can explain the diagnosis. So someone that encompasses all five of those things. So, yeah, well done. Next question. Yeah. Which one do you want me to put the? Ok, fine. I'll do. Why do we use ultrasound instead of CT? Yes. So I'll go back to that slide. So, um, actually, if I go back to that slide, you'll see the answers. But yeah, why do we use ultrasound instead of CT to diagnose gallstones and I just left you with two options there. So, hopefully it's not too bad. Ok. Everyone so far as per radiolucent. Nice, nice, good. Yeah, that's all you need to know. Radiolucent. So, um, they, um, so yes, uh, the stones of a lucent, so they wouldn't be picked up on a CT scan, which is why ultrasound is useful. Um, you'd see the posterior shadowing, as mentioned before. Um um gallstones um strongly absorb the waves and they don't allow the waves to be trans transmitted. So they're easier to pick up on the ultrasound. Yeah. And um yeah, I just have my notes from second year. What I, how I analyze that picture. I will put the last question on the, it's the Murphy sign one. OK. Nice. Yes. In which of these disorders would Murphy sign be present? Um It's nice that they are in a order. So, yeah, ascending cholangitis, biliary colic and C cholecystitis, but they are not in order of severity. So it might not be useful to learn it in that order. Maybe if you learned it BC, we got eight responses. Six people have been chol two people have ascending cholangitis. Oh OK. Let's discuss that one then. And also OK, it's, it's roughly 5050 now. And also, yeah. And also there's another question someone's asked, how important do you think the info in the pre and post reading is especially like you know the articles. All I know for sure is they give you the distribution of what they can ask. I think it's only, it's, it's, yeah, it's only one that they can ask in pray and one that they can ask based off post. Right. And the rest are in the, ok, then there's 61 for each task and then there's two data interpretation. So realistically. No. Ok. How important I'd say the main task is the most important because that's why six out of the 10 questions will come. Yeah. But um if you want to guarantee those two marks, I'd read over it, you know, if you have time, I'll definitely skim over that. Yeah, but they've said thank you. And it's 50 it's 53% cholest as 46% cholangitis ascending cholangitis. So, all right. So collectively you guys have got the right answer. All done. I'll just go over that quickly, which is, I think you guys might have seen it when I uh there it is, Mephine is an important side to know, especially for gastro. So I will go over that. Oh, sorry, good. Oh OK. Just leave it like that. Yeah. So as I've done it in BC, um the order um it is cholecystitis. Yes. If you put the, if you put your hand on the patient's right, upper quadrant and ask the patient to inhale. Um You are basically allowing access for you to push down on the diaphragm and the gallbladder. But, um, in cholecystitis, it's inflamed, it's painful and the patient will just stop breathing at some point and they'll win out in pain. And it's indicate yes, potential potential cholecystitis or inflammation of the gallbladder. Um, it's not cholangitis because that pain wouldn't be localized to the gallbladder. It would, it would have, um, been in other areas also such as, um, where the common bowel duct is, but the cholecystitis is still local pain. As I mentioned, the local inflammation, it's not systemic yet. Whereas acute cholecystitis is so Murphy sign would um help with that specific gallbladder inflammation. So you have to test it, you firmly palpate that um right upper quadrant um push under the um robes, ask them to take a deep breath and if the person is in is in a lot of pain. Um Yeah, that's the Murphy sign and it usually stops the mid breath like you can literally see them like wincing in pain. So I, yeah, I don't even know if you'd have to press that hard for them to for the pain. But yeah, minus for cholecystitis. I should highlight that. Yeah, cholecystitis. Um Is that the end of the questions anyone else answer questions? I'll let you know if there's any more questions in the chat. You can put your QR code up while we wait. Yes. Thank you so much for coming to the presentation. I was afraid that I would have too many slides and not be able to finish and maybe I talked really quickly. But um yes, we have the QR code for you guys there. Um and I have my email there. Feel free to email me. I will hopefully reply before Wednesday. I think that's when your CSI is hopefully to send me any questions. Thank you. Yeah, yeah. Thank you so much for doing this for doing the talk. We'll just leave your, you can leave your screen for like a minute and then you could go and I'll introduce the next talk. Cool. Let me stop.