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uh, my name's also Bill. My name's Oz bill. I'm one of the new doctors whose just started to work in London. I'm also one of the new people involved in six PM Siris, and if you're engaged with the social media, you'll probably see me posted on there quite often, as well as I'm leading Social Media team over there as well. And hopefully I'll be quite involved in teaching throughout the year. Um, I gave the talk on chest X rays a couple of days ago, which I hope you guys enjoyed. And if you haven't yet, you can always reach. Are recordings on metal azaleas. You have an account, but today we'll be talking about abdominal X rays. Before I begin. I just want to prime it pre face. That's like saying abdominal X rays aren't quite as tedious as chest X rays. They aren't quite as many pathology is that you need to be aware off, and there's less things that you're looking out for. So if this lecture doesn't quite take the full hour, that's the main reason why, however, I'll be hanging around to answer any other questions you might have, and I use also around to help us out when I ah, don't know anything. Um, as always, please do floors and social media like us on Facebook floors on Instagram. These are the main place where we're hosting about everything that we're doing throughout the year. This serious is ending this week, the state of relationships serious ending this week. I believe on Thursday, however, will be launching our next Siris really, really soon. So keep following us to keep getting more information about when everything is and receive all the links and see all the questions that reporting on social media and hopefully we're going to have a good year old together teaching your lots and lots of things. Or least we'll try as much as you can. If you scandisk your coat here, you should be able to reach the social media as and a quick shout out to our sponsor mg. You, um, given look a well, they come in quite handy. Um, so that's about it. So abdominal X rays with any X ray that you see that there's you always need to have some kind of routine procedure for looking at them because unless you know what you're looking at, they can get quite daunting and you will know where to begin. So the first thing you should always do is introduce the film to where you're presenting to. How you do this is by looking at the film Seeing who it is for the patient is their data birth all that kind of stuff. Um mentioning why this film was taken and if there are previous films to compare, then you mentioned qualities of the film. If you can stop the mosque, leg and amount of abnormality, then you can kind of brief you mentioned this. But if you can see this, that's completely okay. And if you stick to your systematic approach at looking at the film later down the line, you should be able to spot abnormality, even if you can't support it but your first look. But if you do think that you know what Doctor Maliti is, feel free to kind of mention it to whoever is examining you. Then we're going to go through the main ways in which we structurally go through abdominal X ray. This is the BBC method, and I'll go through those in a little bit more detail later, and then you briefly really quickly summarize your findings in terms of the introduction. Teo Abdominal X rays you should never present. This is an abdominal X ray. I've told this to the in the chest. X Ray Electra's Well, people do get quite a note when you call X rays X rays. Their X rays are meant to be the actual radiation rays that you send off, and the film itself is the radiographs. Always start your presentation by saying, This is the abdominal Grady. A graph of patient export in this state taking on the state If you're aware of the indication for the test being taken, always mentioned this. You should be aware of the indication because unless you have a history behind where scan has been done, it's not really worth much. And again, as I said, compare your findings So previous imaging The next thing you should do is to have a look at the technical qualities of a film. It's always good to know where this film is. A PA or an AP Film PA being posterior interiors were taking from the back or the patient to the front or a P which is until your posterior, which is taken from the front to the back. This doesn't quite matter as much as it does in chest X rays. However, It's good to know as, for example, if a patient can kind of give you an indication of how well patient is. As an AP from tends to be done with patients who aren't able. Teo mobilize quite as well as people who can turn their back for a PA scan. Um, without them electric is the other thing that you need to hear a look at for is the exposure. This is to make sure that, um the entire abdomen is kind of visible with the picture, so you should be able toc the whole abdomen from the data from to the pelvis. And you should also be able to see enough of the small and the large bowels to be able to maids actual comments on what's going on in there. Now we're going to briefly talk about the BBC method BBC, some for bowels and other organs than bones and then constipation and artifact. In terms of the organs. The main organs that you're looking for is obviously going to up the intestine, the intestinal track. However, as you're aware, there are many other organs within the abdomen, such as the liver to go by the stomach. The kidneys screamed. After all, these kinds of other organs that don't quite take up quite a much space that you should always be aware of them, as these might sometimes present with pathology with abdominal X rays, it is it isn't very usual toe order abdominal X rays to look for pathology. Within these other organs, however, you would be able to pick up on some random things that we're also going to go over today in terms of bones. With any film, be a chest X ray, abdominal X ray or anywhere else. Always be on the lookout for any unexpected fractures or anything like that, or or tumors or any other things that you might be able to see on the bones as this might also point towards what's going on with inside the abdomen or the chest or wherever as well. And we're going to go over classification and we've done the line. So before we go through the BBC method and the talk about the organs themselves I have a couple of questions for you guys. So if you can kind of put down your answers in the poll, that would be great. Couple more seconds to give some more opportunities for everyone votes, right? And then I have another question for you guys before you're going to discuss the further, um, before you that won't be able to see again. Please put on your answers on the on the pole in when your screens. Okay, Yeah, yeah, I'll give Give you guys about 10 more seconds before we carry on. Excellent. So there's more of a definitive answer here. Compared to the previous question where you have a mixed of answers, we'll go through the answers in a bit after a cover. The pathology that might be related to the films that we just discussed. Okay, Um, similarly to my chest X ray electric couple of days ago, I could just go through this, slides on my own and just talk through whatever I'm seeing. But I believe it's just more useful if we talk about what's happening together. So before I give you the pathology that's being shown in this slide, I just want you guys to you quickly popular answers down in the chest for me. So if you could tell me what you think is going on in this film, if you can see any specific signs, pop them down. If you just want to throw the diagnosis, that's also fine. If you guys don't want to share your name's publicly feel free to DME The, uh, answers. Well, it doesn't really matter for me. I just like you guys to think about stuff before I took them through, so I just find it more useful for everyone. So the few ounces I got in the chat are correct. So good job guys. So this is indeed small bowel obstruction. Small little small bowel obstruction can be defined as allocation off small bowels more than three centimeters in diameter, And you can kind of make sure that this is small bowels by checking a couple of things within the film itself. The first is what we call velvety convent. These these are the straight lines that go across the bowel loops that can be seen, um, slightly different compared Teo large bowel. Usual cover in a little bit of time. You can also know that this is small bowel as this quite medial and just on atomic clean, large bowels more likely to be found bit more peripherally in the in the in the human. The main causes for small bowel bowel obstruction include occasion and hernias. These are the main two things that you need to, uh, keep in mind before you, um, diagnose small bowel obstruction with someone obviously can also be stuff like cancers and that kind of stuff. But it is not quite as common to see small bowel cancer as much as it is in large bowel, and I just want to quickly talk about what occasions are so adhesions mainly occur post surgery. This can happen many, many years down the line as more scar tissue kind of forms where you've had a had an operation. And when these got issues happen, they can kind of cause the different bits of the bowel to stick together, which causes obstruction so much. The kind of surgeon you have also kind of matters when it comes to adhesions. So if you have an open surgery, there's obviously a greater surface area for there to be scar tissue formation, so if you've had a laparoscopic surgery than your risk of, um, risk of developing adhesions to the extent that, because you obstruction is going to be different if it's open procedure in addition to having abdominal surgery, that other things like having IBD or endometriosis, or even potentially stuff like pelvic inflammatory disease or having long term peritoneal dialysis will also contribute to your risk of developing adhesions, which in turn over time can lead to small bowel obstruction and just to provide some context. This is the kind of thing that you see when occasions form so you can see there's gonna be like sticky glue be scar tissue kind of things that are connecting the different parts of Al together. And when you go back in, in the case of, for example, an obstruction or if you undergoing operation for a different dermatology. If a surgeon kind of sees evidence of adhesions, the English is quit them away. Ah, and kind of solve the issue quite quickly. So it's really cool, and solution is quite easy in terms of laparoscopically managing it. Another thing that I want to talk about with you guys hernias. So roughly hernia is anything that passes through, um, a space or a defect into where it shouldn't be. Are you guys aware of any different kinds of hernias that you can tell me about in the checks? So that's good. Inguinal and femoral are definitely two of the kinds that you should definitely be always keeping in the back of your mind. I can also see some things like, um, biblical, mentioning in the chaps. Uh, but there are a couple of things that you can kind of have a look for. Hiatal hernia. That's a very good example. Um, it's not related, Teo, we're going through today. But obviously that's another thing that you should always be considering for different kinds of pathology and different presentations. So some of the main hernias, as we've demonstrated here are inguinal femoral umbilical. You can also have incisional. Hernia is where you've had previous operations and all these different other funny kinds of hernias that I'm not going to go into today as I believe. It's just not the scope of this luxury right now. I will briefly touch upon the different kinds of hernias, but again, I don't think that's this is the right medium for it quite yet, So I'm just going to make it quite brief. Inguinal hernias is it is suggested by the name passes through the inguinal canal where is really hurting and passes through the femoral canal. I'm just on a chronically When you think of the location of the inguinal and the camera canals the neck off the the hernia sac is located above a medial to the pubic. Typical inguinal hernia. Where is an ephemeral hernia? It is going to be below intellectual to the typical, um, family hernia. They're more likely to be struggling to, um however, they're also more likely to be treated, um, surgically, really hitting a conservative management and inguinal hernias can come in in two different forms. Basically, it can be direct or indirect. I always find it really hard to remember which kinds which one? But these diagrams quite pretty. So I just want to include them here so I can briefly talk about them. So the right Tony is, um, occur when, instead of going through a deep enough, the inguinal canal, the bowel loops or anything else that's radiating goes to a defect with the posterior wall directly and then leave through this professional ring, whereas an indirect inguinal hernia A cures when the bowel loops antistress deep ring and then exits through the superficial ring. So both types of hernias within directly Rainiers can exit through the superficial ring and then emerge wouldn't describe him. But this is more common in direct inguinal hernias, as there's less resistance as it's not actually pushing through something like a muscle. Okay, moving swiftly on from hernias, Please put in the chest what you can see in this film. Over here. It's I've given you a quick into on the screen as well. Okay, so the people who said large large bowel obstruction are completely correct and for the persons that they have no idea, Um, that's completely okay. We're all here to kind of go through this together, so it's completely okay not knowing what's going on. Um, we'll go through it together as well and just means I'm being usefully five and teaching you something so it's good that you don't know for me. So this is, I said, is like, well, obstruction. As you can see, that's because it's large than six centimeters. There is an indication off the size here provided on the film itself, which indicates that this is lateral obstruction. And unlike small bowel obstruction instead of the valve, you take one of entities you can see hasta, which I don't quite go all the way across the thickness of the bowels. As you can see here, for example, it kind of goes a little bit into the the bowel surface that doesn't penetrate through the entire lining of the bowel loop. Some cause of level obstruction include stuff like Correctol cancer diverticulitis and once again her nears and valvular I, which all of which will go through briefly so correctly. Cancer is the second most common diagnosis cancer in adults. Um, and all those surgical resection is, um, possible. In some cases, it doesn't particularly have the best, best survival rates of all the cancers, with about 40 to 50% off survival after 55 years. Can you please put in some risk factors for colorectal cancer in the chart for me so I can see lots of answers popping up in the chat, they're all definitely correct. So the things that I wanted you guys to be aware off are things like high protein, low fiber diet history of IBD and especially family history. Can you guys think of any specific syndromes that increase your risk of developing correctly cancer down the line? Good. So by these symptoms what I mean it's stuff like Fab, the family that enemas, polyposis syndrome, poots, Jagger's syndrome, heritage number, process calling, cancer syndrome and these kinds of things that, unfortunately most likely lead to a little cancer down the line. Um, always keep these in your mind. I don't think you need to know particularly insane amounts of detail about these syndromes. However, It's always good to know that these things exist and they will contribute to your risk of developing cancer, especially in young patients as well. These are always good to know. And if they do come in with one of and patient who has colorectal cancer, it might be quite, uh, important. Teo. I'm testing for it and see if you can kind of do anything to help them with their future family and all that kind of stuff is, well, the next time for that I want to discuss with you guys is diverticular disease. Both me and my colleagues have had trouble understanding difference between the vernacular when it comes to that particular disease. So there's these terms like that particularly, and diverticulosis and diverticulitis and the rest of your disease. I'm not gonna make you guys pop your answers down in the chat one by one, just because it'll take forever. If I do this for every single little thing, However, I just wanted to slowly take a moment to go through what these words mean in simple terms. So hopefully it sticks because I've had to learn these medicated times back and forth throughout medical school as well. So a diverticulums is an outpouching of a structure in the body, so any kind of a punching, regardless if it's symptomatic or not, can be considered to be a diverticulum diverticul. OSIs, however, is specifically presence of multiple multiple patches within the colon that are not get inflamed once they do get inflamed, then these are now known is eventually litis itis, obviously, in fact, inflammation. So it kind of makes sense. That particular disease, specifically is when the diverticulitis become symptomatic and become probably becomes problematic on the background of things like bleeding or strangulation or anything like that perforation of the bowel. Can you guys think of anything else in the body anywhere else where you can get that, particularly put them down for me? There's a couple of things that you should be, um, aware of, even if you don't know massive amounts of detail about them and even they're not at the direct scope of this lecture itself. I just wanted to make sure that we're gonna touched upon them. So you have a background awareness of them. So the two types of directly from chronic ones that you should kind of know our Meckel's and Zenker's. Some Meckel's is an embryonic remnant that's present in about 2% of ablation. It can present quite salute of similar to the appendicitis, and it can kind of mislead June to taking the theaters to not find any inflamed appendix. Um, this ankle is a particular, um, is what you know as a foreign Jill pouch. So what this is is when these patients present with kind of bits of food going into this little patch when this follow building up there and rotting and then causing disgusting, disgusting halitosis, bad breath and again, this is in theory and out push out pouching off the, um, for anginal tissue. So in theory is and that particular moving on once again swiftly. Can you guys tell me what this is? Great again. I'm getting a lot of really good responses in the chat. This is what you would call the coffee bean sign. This is not the kidney being signs. So I know you've made a type of there that's completely okay. I just want to make sure we know the difference between the two will go on to discussing the other one in a second. But this is the coffee bean sign, which is a sign of sigmoid volvulus. Um, and here's a nice little diagrammatic illustration of what the sigmoid volvulus looks like. Yeah, enjoying basically, what about this one? It the people who have said pregnancy and looks like an embryo. These are valances. That's exactly what the sign is named after. Anyway, this is not a baby. This is another. Volvulus is a secret lobulus, and it is known as a fetus sign on. But it is also known as a kid to be inside to some people. I prefer fetus sign for really know why, but I always got the fetus sign, but you can choose what want to call it. Um, and this is a sequel, obvious. So this computers in the cecum And here's another diagrammatic representation of what's going on that's causing the sign over here. But I hear you're asking what is involved us. This has always been a quite a bit of mystery to me in my medical student days, so I just wanted to make sure that we're clear about the definition of a volvulus. Volvulus is the twisting of the bowel when it's Ms Mesentry. Causing obstruction basically most commonly occurs in the signal in the cycle, as we discussed already. And while sigmoid colon this occurs, Um, while present is of coffee bean appearance in a a normal X ray, the cecal one presents as having a fetal appearance. So people who have said this was this looks like a baby. You weren't wrong. So before we move on about from the small and large bowel obstruction, I just created a very quick, brief summary slide for comparing small and large bowel obstruction with abdominal X rays. As we said, small bowel tends to happen More immediately, however, large bottle seems to occur more laterally and in the slow that one you can see value could've NT's, which go across the full thickness of the bowel loops, whereas hasta, don't go all the way across the bowel. And that's another way you can distinguish between small and large bottle and abdominal X ray. Also our advice if we have a good back when awareness off the 369 rule, Um, these are the approximate measures off a cut off for how big different parts of the bowel should be. So small bowel loops should not be larger than three centimeters. Where is corn should be less than six centimeters. Seeking another hand, it can go up to about nine centimeters. So if you see a film where there is alliteration beyond this, then you should be worried about actual dietician in the in the abdominal film and have after a squeaky as possible Uh, do you guys have any ideas? What this film is showing this is a difficult one. Um, yeah, right. So there are again lots of good answers is, um where the where the actual pathology maybe on the back one of the things that you've mentioned here. But the main thing that I wanted you guys to pick up on this X ray is the double sign, also known as regular Sign. This is suggestive of new opportunity. Um, so if there's obstruction and if there, if the patient's abdomen is distended, this sign, maybe one of those things that can be seen. Um, when there is, when the bowels report, basically and when everything's gonna let loose, how you can distinguish. This is when you can see gas on the both sides of the bowel wall. So is he can see all over the place. You can see lots of pockets of air all around the place, and it doesn't look very appealing. And here's another representation off what it looks like. Um, the highlights wear these double wall appearance occurs. It's mainly along this line. Over here is you can see. What about here. What do you think is going on here? Okay, a couple people are saying there's fecal loading, which I'm not sure I'm not convinced. Um, but what if I told you this is showing a specific sign relating to specific pathology again? We're getting two more of the nitty gritty of being able to pick up individual signs that relate to different pathology. So if you don't know, the answer is, don't feel bad, and this is why we're here to kind of go through these together so I can make sure that you know it for later when it matters. It is so good at the veil. A second a couple of people came through with the correct answer is showing some printing. So this is when you have thickening of the large bowel wall, usually cold caused by inflammation. Dema. And you can see this by, um, you can see that's when the hostel get thickened and you can see it from bits of kind of individual shapes that looked like you just pressed it with your thumb. That's why it's called some printing. What about this one again? I'm looking for the name of a sign. This is indeed the left Colon, and you can see that this is exactly that by looking at this loop about over here, and you can see that it has no definition to it whatsoever. So you cannot see any kind of house trail you cannot see anything that resembles normal bowel tissue, and it's just lost all of it's defining features. Finally, if you ever look at this film and tell me what you can see here, if you put down in the chest for me, we'll go through the clothes in a minute. Yes, the start picture is indeed showing Toxic Mega Colon. This is when obstruction happens. Ah, dietician happens without any evidence of obstruction. So do you guys have idea what these three films have in common? All these three mythologies. So that's good. So all the all the all of the three things that we've discussed so some printing toxic megacolon and left my bowel they're all futures off IBD. So before you go back to those pictures themselves, I just want to take a quick second to talk about the differences between Chron's and ulcerative colitis. So you see happens. It continues pattern where just keeps moving up and up and up and up, and it's on the effects that because and stuff because up, whereas Crone's does happen in patches, but it does affect the full thickness of the battle, so it goes through the entire thickness. Um you see is more likely to present with bloody stools, Um, whereas you'll get stuff like, um kind of mucusy barrier kind of things in quantities. So as we said, um, the pictures here are all indication, or in our only hitting that there might be a IBD happening. So some printing, first of all, can occur in both causes, or you see as well as other things like infection and diverticulitis. However, it's not quite as common to see in them. Let's have appearance again can occur in both CD and you see, But it can imagine. Since you see happens in more of a continuous pattern, it is way more commonly seen in you. See, then chromes and toxic megacolon once again can be seen in both. You see in crosses ease as well. That's sometimes infection colitis. However, this is not quite as common, So if you can pop in the chat, what you can see in this film right here? Um, someone's asked me in the chat which one of the scans before was a couple cobblestone appearance in, um IBD. So that's not something you see in a dental X rays. That's more of a um, endoscopy sign. Okay, this photo going back to the specific slide here shows fecal loading. I appreciate it. Is it difficult to combat that directly? So fickle loading is effectively, just bad constipation. Um, so when you have a large volumes of poo within the colon off any consistency, it doesn't have to be particularly hard stool. Um, And again, as I said, it happens mostly due to a longstanding bad episode of constipation. Happens very commonly in all the people who have had long hospital stays. So I'm working and your actual court. Right now, most of our patients have had stuff like this at some point during their long hospital states. And I've highlighted the areas where you can see bits of poop stuck in there is again. See, it's kind of more Children Just got me looking grossly in the abdomen. What about this one? Any ideas possible on the side? Just feel uncomfortable looking at it. I e If you have this, your very unlucky and you're not gonna have a good time. So this is showing fecal impaction. So the difference between fecal loading and fecal impaction is that fecal impaction is way more severe. This is really hard, really tough stool that's kind of filled up in your tummy and just won't come out. It is very solid, immobile, just a bulk of poop in it, very uncomfortable, and you can see how grossly dilated and kind of settled into the abdomen. The bit of poop is it's is actually horrifying. It's very uncomfortable, and we'll make you really, really, really unwell. So going back to the questions that we've covered before that I want you guys to answer, Um, before I got, I just got a question asked me, How do you treat fecal impaction and fecal loading? If you're lucky, some laxatives off any kind will be able to help. If that's not helping, then you're going to go from stuff like simple, the trees where you put the off the bomb and kind of hope for the best. If that's not working in this stuff like enema, it tends to be a phosphate enema in clinical practice. And if that doesn't work and if this is long standing and it's just not being fixed, then the left is all might be surgical intervention or manual evacuation by hand, and then surgical intervention. Um, as the longer the poop stays in there first of all, the higher the risk of the patients developing stuff like delirium and just being really, really grossly and well. And second of all, eventually you're going to develop just sepsis and just being really, really, really freaking and well, going back to the questions the film here showed no really thought. It was pretty normal abdominal X ray for people who said stuff like lateral obstruction. I understand why I think it's this region over here that's made you guys say that. I think it's just like different myths about overlying that's making it with dilated. But on the whole, the gas pattern here kind of appears to be quite normal with normal pockets of air. And you can't really find a lot of causes for the patients. Um, symptoms here the patient had I B s, which is irritable bowel syndrome, which is not the same thing as IBD, which is you inflammatory bowel disease. So do you keep the keep this in your mind when you come across films like this and thank you for going through some questions in the chaps that I haven't seen and think you're covering it. The second question here. Waas This patient came with PR bleeding. So this image showed thickening of the hospital, which we've discussed is a sign off thumb printing. As you can see here, the how strong are grossly thinking. They're know nice little smooth lines. They're big and second rough. Um, while, um, hum printing can happen in both you see and CD as we've discussed before, Um, you see is the main one that's will present with PR bleeding with CD, you're not as likely to present with PR bleeding, which is why the U. C. Is a more likely answer here. Um, before we move onto the next bit of lecture, I just wanted to briefly touch on the other workers that you can see with the abdominal X ray. So with the lungs, if you're lucky, you might be able to see things like the lung basis, which might help you make a clinical diagnosis potentially stuff like fluid overload and that kind of stuff. Um, you might be able to really visualize the gold butter. Um, you might be able to see the stomach, the kidneys if there are stones will cover these a second. You might be able to see some stones here and there and just be aware of the other organs that are kind of along the way. And before we carry on a couple of questions for you guys, if you could pop down your answers in the fall, you guys seem to be mainly stick with in two ounces, which is fair enough. We'll go through the courthouse in a little bit. I'll give you guys a bit more time to submit some more answers for me, and we can go to the next question. Okay, thank you for submitting your answers. This is the next question that I want you guys have a look at for me, please. And again, some insurances in the poll if you have a second for me. For a question like this, try to visualize like those human diagrams of the internal organs and try to think about what might be in the location where you're looking at a tonically, which argon, even if you can see what the organ itself is, what might be the organ that you're concerned with when it comes to you. What's going on here. Okay, couple more seconds again. Seemed to be divided between To answer is and we'll go through. Why? The correct answer is the correct answer in a second, Um, but first I want to talk about some general concepts within abdominal X rays. So calcification. There are many organs that you can see calcification, and this can be stuff like gall stones, renal stones that can be within the pancreas within the vessels. You can be all sorts of things and always be on the lookout for stuff like artifacts, which might be stuff like lines or clips or jewelry or a belt that the patient's wearing. You never know what you're gonna find. Fine. I'll heavy guys put back into the chart, if that's okay, Um, I know it's quite tedious, Teo, for me to stop every two seconds to ask you another question. But thank you for bearing with me just makes it more interesting for me as well, to be fair. So if you have a second to help the answer that you can think of in the chest, that would be really nice. Thank you, yes, the people who have said stuck on Calculi are correct. However, um, that is not the only thing that you're looking at here. So on the left, that might be a stuck on calculus, but on the right, there is another bit of kind of stone that might or might not be a staghorn or any other kind. I have a suspicion. Is that what it might be? We'll go through it in a second. So I've highlighted the the calculi here for you to see. So the different kinds of renal stones there are some kind of stones that will show up on X rays. Some will not. The ones that will are things like the second cycle. I would have Strovite triple for state, and anything that has calcium in it will also pop up in abdominal X rays. In terms of the most common kind of stones, it is most likely to be calcium oxalate and or phosphate, which will cause that three quarters off all of renal stones, uric acid stones will not be visible at all in films, and 16 stones were all there are rare will be somewhere in between. Um, the calcium stones and the eucrisa's stone is going to be kind of scene, but, like, not quite as clearly as you would be able to see things like calcium stones. What about here? If you've engaged with us on our social media, there was a question on this posted a couple of maybe like, a week ago. Um, so I'll just plug my social media count here as well. We are posting questions relevant to the topics that we're covering with lecturers. So do for us to kind of me in the loop with the questions as well. And I can tell that something. We have been engaged with me on the social media as well, because the cord cancer here is indeed pancreatic cancer vacation. Do you guys know what causes pancreatic cancer vacation? So just on the interest of time, I'll just go through it. It is going to be things like quitting pancreatitis and specifically in the background of alcohol. So the people who have written down creeping pains and alcohol are completely correct. Thank you very much. And I've highlighted the little be off pancreas that is calcified in this picture as well. What about here? We're slowly approaching the end. I just want to make sure that I've come in all the important basis. Before I let you guys go, What do you guys think is going on here in this film? So excellent being able to recognize that this is indeed the abdominal aorta. That's really, really good. I don't think I would be able to do it. That well is a medical student s. So that's really, really good guys. There is one person who said this like being a ruptured Triple A. I kind of doubt it in the sense that if someone has a ruptured Triple A, they're not going to well enough to be sent for another one. Next, Ray, they're going to be going straight into theaters or will be pretty much almost dead within minutes as it's going to just believed out really, really quickly. And they're gonna gonna be really, really unwell. So this is indeed showing, actually, constipation. Um, So if the abdominal aorta is dilated beyond three, sentiment is, then you are beginning to suspect validation and in turn and in turn triple A basically, the larger the Triple A is the risk of it rupturing increases, and if it is ruptured, then you're probably going to die. There's about an 80% chance that you're going to just bleed out really, really quickly. If the Lyrica is over 5, 5.5 centimeters, then the chance of rupture Warren's really quick intervention, in which case we can either treat them with open an open procedure or endoscopically with an aneurysm repair. If it is calcified, you'll be able to see it a little Malek straight. But that's what I guarantee. You won't be able to see every single Triple A in abdominal X ray. It has to be calcified for it to be able to see it. And importantly, you should be able to see both sides of the Triple A so both the left side on the right side to be able to make a judgment about the size of the Triple A before you can diagnose it. If you can only see constipation on one side, then you can't quite assess the size and new country. See, this patient is a Triple E. They might be calcified, but it doesn't mean they have Triple A And again, here's the highlights showing where everything is so the questions that we're covering the first one is clearly showing gall stones, which are also known as clear facets. So if you hear the term colitis is, always think off Goldstone's. That's exact same thing. Philippot. I'm not sure what your questions on, sir. I I don't know. I don't think an X ray is the conventional way to assess, um, as are you missing? A. Quincy's well, extra plate is conventionally assessed with X ray. So if you just by chance have a visualized a, um, usual eyes, constipation around the around the Triple A, then you're most likely either going to do an ultrasound of the patient or put them in the CT scan, where you'll be able to see really, really well and really clearly to be able to make him more educated, more comprehensive diagnosis. Going back to this question, um, going back to the question here, as I said, as I covered already, you can see little bit of stones here which have cut, which are calcium rich. Rich is why they're showing up. Um, and these are Goldstone's Atomic Lee. You can kind of imagine the Goldberger being somewhere been beneath deliver somewhere on the right up recordin of the abdomen, so it kind of makes sense. Um, you won't be able to see every single gallstone in a abdominal X ray. You might be able to see about 10 to 15% off them. The the question here You guys were between enough for us to me tube. In the ureter extent, the correct answer here is in the the ureter extent. As you can see, the line goes directly from what, where the kidney should be to where the brother should be. Um, the reason why it's not in the first Met you is because in the first time it kind of goes out of the chest him out. It doesn't go through the the union shacks out from the down below. It's kind of direct line from the kidney to the rest of the body to kind of decompress it. What the stent is kind of doing is it's got its first little pigtail, um, with the kidney and the second pigtail in the bladder, and just buy it kind of holding everything open. Nice and straight is allowing continuous drainage from the kidneys down to the other. Done two expression. Basically, um, we call this pigtail pick up Catherine because it kind of looks like a pigtail, but more, more conventionally. It's also called a J J stand, as both ends looked like one J E church. So it's J and J. So that's why it's called a J J stent as well. And here's another dog. I'm showing where everything is. This is where you would expect the kidneys to most conventionally be in healthy to kidneys, individuals, and obviously goes down to the where the bladder should be before, if your PSA session I have a couple of really quick questions, what do you think is going on here? Couple of fun ones for you guys Very spoke back. Nose is kind of thing here. This is in nature, your fetus inside a lady. So, yeah, there's not much else I can say about this. This is just a baby that probably shouldn't have been filled. But it was. There you go. What about this one? No. Yeah, indeed. I sit on it, isn't it? It's always this is on it. So, yeah, I wanted to end the lecture on a fund note. So this is most likely kind of after shave or some more air freshener or something like that in the rectum. So that's about it for me today, guys. Once again, thank you very much for joining. Thank you for sticking through the entire world with me. I'm surprised that it to exactly one hour, So I'm really pleased that I turned He's quite well. Turns out um, please do provide us some feedback. You can scan this crackle here too. Um, going to the feed that form? Um, if you feel if it from, well, to be sending you the slides to your emails. 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Sometimes you're just really hate humanity from some of the stuff that you see, especially people are coming up different things up the backside. Well, we'll leave that for for for another day of traumas. Uh, so, yeah, please fill out the feedback. Make sure you spread the word joint Facebook group during Instagram Group and, you know, join us tomorrow when he's going to be doing a teaching on in India and iron Studies. I believe we have three more lectures left in our data information Siris. They are anemia by Lilly tomorrow. Clotting by Doctor, are you here on Wednesday and then LFTs on Thursday and we'll be sharing with you guys. Further updates on further coast, of course, is really, really soon. So keep your eyes peeled on our social media, and it should be on. 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I tried to do the morning that out, and it doesn't open mind. I'm sorry about that. I'm only video available now. It's like so well, the chest X ray one the only the only the videos been available were posted up the slice today. But everything else the slide should be available. Guys, I believe, unless anybody else thinks differently. Yeah, that's a you know, and And the link the link that you follow. So send it again. The link that you follow up with some from the truck. It takes you to the metal website s. You can follow that stuff. Is medicine the bottom yet? They still are. They still they are, I think, lots of new things every single day, new new things. And we are relying more more matter because they are getting better and better doing more things for us. So there will be new metal features in future is, um just a side note to be able to view are lectures on metal. 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Fine, um, unless anybody else have any other questions? Lost minute takers stunned in to silence. I don't have any questions again. If you want to reach out to us in any way our social media is always available. We're always happy for a chat if you have any questions. If you want any clarification about anything, that's great. If you need any kind of advice about anything in life in medicine, he has, he gets up, will try to point you in the right direction. And thank you very much, Gang. Some fans also. All right, Now you're gonna have your own fine cruise. Soon s Oh, I will end the chat there. I'll see tomorrow, six PM, guys. When ladies teaching me on iron studies take care of yourself by yeah, door.