Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Everyone to another session today. I know it's been amazing times in the past and um today before was a very, very interesting um topic, diverticular um disease. I know that's the we are going to really enjoy the um session today. And uh teacher for today is Doctor Da Tan. Good evening. Hi, please. He's Yeah, good evening. Good evening. He's also here with us Dr Dasa mm BC HB from in um Ghana and also a member of the Royal College of Soja from and D BOL. It's nice having you. Thank you. You Yeah. So I think you can please commence the um teaching now. OK. Thank you very much, sir, please. If you have any question, you can please put post them on the um chat box and also send reminders to your friends and send the links out to them to remind them on the from your friends you might have invited. So what you doctor Da? All right, thank you very much. Um Like I was kindly introduced, my name is Dacosta um in Scotland at Med school in Ghana. And I would be delivering the presentation today on diabetic disease. I am quite aware, Sega has quite a diverse um group of members in terms of the levels at which we find ourselves. So I have tried to keep this as basic as possible. So then everyone would be able to participate. Unfortunately, we can't have a verbal exchange on this platform, but we will try and keep it interactive through the use of polls, which I will be releasing as we go along. And I would like everyone to participate in the polls. Rest assured your answers are anonymous and no one would know who put up with the answer. It's just to see the general level of knowledge that we have at the moment and see how best we can plan our future teaching sessions if that's OK. So let's just proceed diabetic disease. What do we intend to talk about today? It's going to be a brief overview of the basics, epidemiology, pathophysiology. And in order to make it as practical as possible, I have decided to use a case presentation as a way to go in terms of teaching you guys the different parts of how you see a patient all the way to when you are discharged and the different things that we might have to be aware of when it come to diverticular disease. So the introduction, everyone would probably want to know what diabetic disease is. I'm sure you've had quite a few times and then some might be quite familiar with them and then others might not be so sure what the different terms are. But then I'm sure you've heard about diverticular disease. You've heard of diverticulosis and you've heard of dia bad divertic colitis. So you probably wonder if these are all the same animal or they are different. And so before we start, I will try to just explain what diabetic diseases. And then we would have our first pole. You usually have about 45 2nd per pole. And then I encourage everyone to try and then answer the pool would be available once I allow it. So that would be the first one. What is the main difference between diverticulosis and divertic colitis? So those are options. I'll let everyone just read it for 45 seconds and then we proceed. I think we've had a total of three responses so far and I'm sure we are more than three. OK. Yeah, some other responses coming in. Thank you very much. OK. All right. So I think we would um proceed from now this point on what? So what is diverticular disease? So I'm going to try to explain the, the disease to you guys. So this is, I'm sure we are all aware of the anatomy of the colon. We know we have the mucosa and then we have the submucosa, then we have the secular muscle and then the long sar muscles and especially in the large bowel, we know the long muscles come together to form the tinea coli, you have vessels piercing through to supply the, the mucosa. They usually lie within the submucosa. As you can see in this image, these vessels usually go through an envelope before they enter the submucosa. So what happens in diverticular disease is you have herniation of the mucosa and the submucosa through this envelope and then you have this divertic lymphoma. OK. So you see this in the colon and if you have multiple diverticulum or diverticula for the pool, then it means that you have the disease, if there's no complication, but then if it becomes inflamed or infected, then that is when it becomes diverticulitis and from our pool, it looks like everyone sort of, everyone knew the answer to, to this po I think we all agree that it's mostly that. So that that's very good. At least I'm quite pleased with the level of knowledge already. So I didn't think I'll probably be adding on to your knowledge base just yet. I have this picture here to try and then explain um the same the differences between diverticulosis and divertic colitis. So it's just a compilation of different pictures. The first one is actually a picture taken from a colonoscopy. And as you can see, these are the the openings of the diverticula into the large bowel. So then you see multiple ones in this case. So this would be diverticulosis as we can see, it's not inflamed if, if it is inflamed. However, then it becomes enlarged, the wall become ticky and you can have some fat stranding and then it can also, the inflammation can spread on to nearby structures like the, the, the bladder and then you have reactive inflammation. So this ct scan just shows you the diabetic on the colon. So I I'm sure we can all appreciate this. So there is a difference between diabetic diabetic losis and then diabetic colitis. So the presence of this diabetic is a diabetic disease. If it becomes inflamed or infected, then it's diabetic diabetic colitis. But then if you have multiple diabetic, then it's diverticulosis. I hope I have been able to explain it in a way that everyone would understand if you are, if you have any confusions or you have any questions just now, I hope you put them up on the chart. So then we can answer them as we go along. So the next how prevalent the point is why are we even talking about diverticular disease in the first place in order to, to to really come to this understanding of why we talk about it is to know how common it is, you know, is it, is it something that's so common that we should know about or is it something that's quite read that we will probably never encounter in our life? So this pole, the second pole I will be releasing soon is just to find out what, how common you think it is more or less as part of the reason why we should know about the, about the disease. So I will be releasing this pole just now and we get your input. So you should be sorry. That is the, but is the, this is the pool that we should be answering? How come do you think there are particular diseases in people that are over the age of 60? You can just take a guess, would give you 45 seconds as usual. Ok. So it's varying the answers we're getting so far have, has been very varied. And then I can appreciate why people will have different perceptions about how common they think it is. It's, it, it, the different studies come out with different numbers and then also depending on the population base you are looking at, you would have different numbers. Ok? But generally we have noted that as you grow older, diver disease becomes common and then the differences between male and female. Isn't that significant? Isn't that stack? But then across the different ethnicities, you see that it is quite common in the Caucasians. So Caucasians above 60 would you would have the prevalence of 65 to 75%. As compared to Africans, you would have Africans above 60 I believe 5 to 15%. That's quite low. But overall, when, when you compare the prevalence across a different age group of people above the age of 60 you would expect it to be about above 60. So between 60 69 would be here. So it's usually about between 55 to 6 65 thereabouts. That's, that's the range. So this would be what we expect. That's just to let you know that it's quite common to have diverticula as a finding. And it's actually one of the, it's actually the commonest finding that they find on screening colonoscopies in the US. So people who are fine, haven't had any symptoms but have colonoscopy for one reason or the other. They tend to find they tend to see that diabetic diverticulosis is the most common benign findings that they, they, they see. So that is that for us, we would go back. So then you can see there's a, it's quite a common disease we should know about and then why, why do we need to know about that as being common? There are some potential complications that come along with having the diverticular disease. And these are usually the reasons why patients would present to the hospital and these are how you probably meet them. So some of the complications we find with divertic colitis, I think this picture that um just this to it as a very short summary of what we expect in with the complications. So one it can bleed and if it bleeds, then it means that the patient would probably pass blood pr two, you can have fistula forming and this fistula could be with the colon. In that part of the bowel, it could be small or large bowel. It could also be with the vagina if in females or it could be with the bladder. So you have fistulation as another complication. It can also become inflamed, which would be divertic colitis. This is one of the common complications that we tend to see in patients that come to hospital and then you could have abscess formation and it could ate. So these are some of the common complications that patient might present with when they have diverticular disease that you would be seeing in your practice as you, you progress. So this is why we need to know about diabetic disease. It's common and then it can have some significant complications. So we need to know how to deal with it. So I told you I will try and make this as interactive as possible and I will be using a case study to, to, to, you know, sort of carry my information across. So Mr John X is going to be our patient for today. He is the one we are pulling from admission all the way to discharge. So who is he? He's a 62 year old construction supervisor. He lives in Glasgow. So the reason why Mister E is seeing you in the clinic today, you need to know you can probably take a full history from him, you know that he's hypertensive, he's on medication his hypertension is well controlled. He has not had any previous surgeries. He doesn't have, have any allergies. But then he has a family history of colorectal cancer in his, in his father, lifestyle wise, he is a moderate drinker. He lives a relatively sedentary lifestyle. He's a very busy man. He doesn't have time to eat fresh foods, vegetables or cook himself. So he's always into, you know, processed foods and then fast foods. So he rarely takes any meals with high fiber. So most of his meals are low fiber and he's a smoker. He's been smoking about 15 sticks per day for the past 20 years. So what do we think about Mr Egg so far? When you spoke to him in the, in the Ed, he mentioned that he's had some significant stress at work. He's trying to be some deadline with a contract. He has and they are struggling to meet this and he hasn't been able to do anything a sideway. So he hasn't traveled, he hasn't had any changes in medication and he is coming with pain, but he hasn't had similar pain before. So what exactly are his symptoms? You know? So the reason why he, he is in today is because he has low abdominal pain that is localized in the left, lower quadrant of his abdomen. He has a bit of nausea, not significant nausea, just some mild nausea. And then he, when, when he, they checked his temperature, his temperature was about 38.2. He said he checked it at home before and it was around the same volume. He also mentioned having some significant fatigue over the past few, you know, weeks and days because of the increased workload. He has, he did mention that he's never seen any signs of bleed in his, in his toes. So he's never had any erectile bleed. So these are the symptoms he's coming in with low abdominal pain, a fever, a bit of nausea and fatigue, but no bleeding. Pr so based on Jones before, what do you think would be a possible risk factor for, for his condition? So me to, I think I actually let this pull off earlier than I should have. So some of you will probably have answered this po already. That was um yeah, you've already answered it. Most of you have actually answered it already and I think you, you, you, you have very good answers to be fair. Have you? Ok. So I release the pool now. So I'll just give you 45 seconds to read through. And the question is based on John's pro for what would be the possible risk factor for his condition from what we know about him already. We know he is um 62. We know he drinks moderately. We know he smokes, we know he is, his diet is mostly fast food and then low fiber and we know he's hypertensive on medication that is, you know, relatively controlled and we know he's had increased stresses at work because of increased workload. So, what do we think would be a possible risk factor for his condition? I'm still waiting for your kind answers, by the way. So just feel free to choose any answer. I don't know who answers what. So it's totally ans you can, you can choose whatever answer you think is the right one. OK. All right. So, from what we know about diverticular disease, we know diet is a, is, is a major risk factor for getting the disease. And 90% of the answers we've had so far actually choose diets, which is, which is the answer. So diet plays a very important factor when it comes to developing diverticular disease and, and then the subsequent complications like diabetic colitis you can get from it. Other factors would be colonic dysmotility. But I'm quite pleased that a lot of us appreciate that diet place a significant risk factor. And this might explain the difference in the, in the epidemiology. We saw, we, we realized that with the Caucasian ethnicity, the prevalence was quite high compared to the African Africans living in Africa. And this would mostly be attributed to the diet, the diet in the western world from what people tend to know is more um low fiber diet. But that isn't entirely the case compared to the African, you know, indigenous diets which are heavy, high fiber diets. And do you have interest? Ok. All right. So um CHS has released the website for Sega. So if you have interest in joining Ks, which is a very good organization I believe, has a lot of prospect in terms of your career development. There's a link there that I hope you guys um just try out or look at later on. So what is the most concerning the next go is what is the most con concerning symptom of John's presentation? We did mention that he came in with abdominal pain in the left lower quadrant. He had a bit of fever and then also he had some nausea, mild nausea and some fatigue, but then no um erectile bleed. So what do you think is the most significant symptom that John has? So, I'm waiting for the answers from my dear colleague today. All right. So in 77% of the people who've answered this question believe that intermittent fever is now, it's 80% believe intermittent fever is the most concerning symptom that John has on this presentation. A few of um about 20% believe is fatique. Um oh would want to know the rationale behind some of the answers. But unfortunately, I can't, I can't ask that. But yes, I I agree that for his current presentation, intermittent fever is the most worrying feature based on the symptoms we have here. Um This would obviously signify a possible ongoing um infection or you know, inflammation down there. And then considering his history, we have a strong suspicion that he potentially has have diabetic colitis even though we don't have confirmation yet. So it intermittent fever would be the most concerning um symptom that he would have just now. Sorry. So on physical examination, examine him side the fever, you know about he had tenderness in the left, lower quadrant, no rebound, tenderness, no palpable abdominal masses, bowel sounds are normal. You did the the rectal examination and you didn't find anything of significance. Everything else was normal. So the only positive finding you had was the tenderness in the left lower quadrant. So based on this, what are the differentials? We we we we are considering, you know, we I think we sent some, we did perform some investigations and we did um full blood count. And so the white cell was 14.1 crp of 77. Hemoglobin was within normal range and then his lati was 0.9. His urine dip was fine. This is a CT scan. So the you had read or you were the the the doctor he saw in ed and then you requested a CT scan and then this is a CT scan that um John John John had. It's just one film out of many, it's just one cut. So based on what you're seeing here, what do you think is, is, is the likely diagnosis we would get there. So sometimes I forget you guys can't really speak. So that happens. So, ct scan, by the way, I should show diabetic colitis. But do we manage everyone with diabetic colitis the same? If not, how do we determine who gets, what kind of management? So here comes, this is where we speak about what we call classification of divertic colitis. So it's just a way of grading how bad your divertic colitis is. So you, you, we have different stages, right? Stage one. So you, you, you should think about it as you know, progression from one, one stage to the other. So we'll start with the the the bare minimum. So there's usually a stage zero. Some people talk about a stage zero, but you should be aware that the modified Hinch classification is mostly for complicated diverticular disease. So a divertic colitis. So if it's not complicated, usually hies doesn't apply, but there's a stage zero that this, that there just inflammation of the divertic and just the diabetic. But with stage one, if you have your diabetic colitis, as you can see on these pictures here, you have diabetic, right? If the inflammation is around the diverticula, then this means that that's pericolic inflammation and then this can spread to the mes entry. If there's no pus, you just have the pericolic inflammation along with inflam or with the inflammation of the mesentery, then that's stage one. A right? But then if you have a localized abscess in addition to your pericolic inflammation or mesenteric inflammation, then that would be stage one B because abscess is localized. But if there's abscess is within the pelvis and is walled off, meaning it's, it's, it's, it's much worse than here, right. Then that stage two, right? But then if you have generalized purulent peritonitis, you just have pus all over mix or spread all over the abdomen, then that would be stage three. Then if you have actual feculent peritonitis, meaning content of the large bowel is actually pouring out into the abdomen, then that will be stage four. So you can see the progression first of all, stage zero, which I actually didn't bring here would be just pu I mean, it would just be inflammation of the diverticula. There will be no pericolic inflammation, no inflammation of the mes entry. But once you have pericolic inflammation or inflammation of the mess entry, in addition to your inflamed diverticula, then it would be stage one A in the absence of pus or in the absence of an abscess. Once you get the abscess here and that's one B and once you have a wall of abscess within the pelvis, then that's a stage two. And if this, you have purulent generalized peritonitis and that's stage three. But if you have fecal peritonitis, that's stage four. So as you can see this, the, the, the higher the stage that the worse it is. So, meaning that management would vary based on the stage if the patient comes in with. So from John's CT scan, it was stage one. What do you think this, this is a different question? What stage of Hinch classification is often managed solely with antibiotics? So there's another pool where I'm interested in knowing your thoughts about from what I've mentioned from the stages we've discussed here on hinges. One, which day do you think you can use those antibiotics to manage? So I will give you 45 seconds again. Then you tell me which stage would be amenable to just antibiotics. It looks like everyone think stage one is what would like, you might need to just antibiotics. And I tend to agree with this general as long as that. And we all think it's stage one and that's, it's actually usually the case with stage one if patient requires any management to, to the just antibiotics and then not inside a cough. Ok. There is AC T scan that basically shows the different stages of divertic colitis. I'm not sure the level of the participants just now. But this might be useful to, it's, it's a, it's quite useful to know how to read CT scans. Ok. I don't know how we offer time this now, but at the end, if we do have some time, I would come back and then take my time and take you to the CT scan if we still have time. So, management of divertic colitis, I think from now, we, we, we have a patient, we follow up the patient from history to examination to investigations. And then we've gone through the stages for classifying diabetic colitis. And then we know that our patient is a stage one or has stage one diabetic colitis. So how do we manage so broadly, management of divertic colitis is split into the medical management and the surgical management. And from, from the previous question, I believe everyone believes that the stage one would mostly be managed with medical, you know, care. What else can we do for a patient if you are doing medical management? So, uh it tends to be antibiotics, they might be in pain. So patient might require some pain management. Ok. All right. Um Patient may require some pain management, dietary modification. So for instance, Mr um obviously he had his diet mostly based on processed foods with um very little fiber. So if he doesn't want to come back again to eat it, then it means that you would have to modify his diet. If patient um um is dehydrated, you can give some fluid if you're not tolerating oral fluids or taking oral fluids at all. And obviously, you need to monitor the patient to see how the patient gets along with the management that, that you, you, you give right, then patient education, patient would need to know why they, they, they have to act in a particular way. So if you tell the patient take high fiber diet without explaining to the patient why this high fiber diet is necessary. Patient probably won't comply with you. So it's very important that patient understand why you choose what kind of management you decide on. Ok. It it's really important that we explain these things to, to our patients because I know from from past experiences that sometimes we just tell our patients what to do without explaining to them why they need to do what we tell them to do. So this is the another skill I hope that the participant from today would, would just start slowly and then incorporate in their clinical practice because it's very, it's a very good skill to have. OK, explain in terms to patients surgical management. What options do we have surgically? So that that's, that's th this is quite broad because different people might manage different stages differently. So for peritoneal drainage, if, if you have a localized collection of or a localized abscess that that is wall of and the patient is fit enough, you could have a peritoneal drainage. So Ir Car actually interventional radiologist can actually assist you with this and then the the drain that they put in a drain to try and then get the the pass out of the abscess and laparoscopic peritoneal lava to wash out the abdomen. If, if you have, you know, find some patient who would be in stage three might benefit from this OK. And Homans procedure. So with half man's procedure, you try and then you take out the, the, the bits of, of, of bowel that is damaged or that has, um, no longer viable. And then you probably bring out a stoma and then later you go and then we reverse it and you could have primary anastomosis with a select few patients with or without a diabetic stoma and a septal without colectomy. If you have multiple parts involved, then you need to take a a bigger chunk of both. But I don't think this is what we need to be talking about right now. But it's just to let you know that these are some of the surgical options that patients might, might have. So we all know what John's modified hi stage on CTS because I think I have mentioned that, but we'll move on to the next one. What would be your preferred initial treatment for John? So we know we know we know we know that John stage one. So what would be your preferred initial treatment for John? Is this surgical intervention? Is it diet modification? Is it referred to a specialist antibiotics and observation? Yes, I think this question is one of those MC Qs dots we might be led to. So the initial management for John would be antibiotics and intervention, that would be the initial one. But upon discharge, you would need advice on his diet modification. So even though diet modification is actually true. It wouldn't be the initial treatment for John just now. And I, I think most of you close to 90% of you actually choose antibiotics and observation. So that's actually really good. That's not to say diet modification is, is not done, it's done. It's just that it is not the initial thing you do for these patients. Ok. So what happened to John? So John stayed in the hospital for 48 hours for close management and then treatment and then he was discharged him after 48 hours with some painkillers and antibiotics. And then we you know educated him on his diet modifications, spoke with the dietician who told him to gradually introduce high fiber diet and take adequate fluids. And the plan was to see him in one week for clinical assessment and then we book a colonoscopy for him as well in 6 to 8 weeks. So give John some leaflets on that particular diseases and then sign posted him into some you know, the resources that he can read on that would give him more information as to how best to to take care of himself. And we also explained to John that if he becomes an war, he need to come into the hospital because it's really important that for this kind of patient, you never know how they go. So it's very important that they are well aware that they can come back to the hospital if they are away. OK. But the next question is um after 48 hours of t what are the key elements emphasized during John's outpatient review? OK. So this will be 0.9 I will be sharing that with you. And let's see what everyone thinks. Yeah, I think um 75% of us believe all the above are actually important, which is actually true. So the key elements would be all the above But effectiveness of antibiotics, we have to let them know why they need to take antibiotics. I can explain again, patients need to know why we ask them to do certain things and then adherence, the dietary modification and then monitoring for complications or recurrence and planning for colon. So all the above actually important when we are, we are um talking about patient John's outpatient review. You need to talk about all these. Ok. So but most of you, 62% of you actually chose all the above, which is good. So it's not just monitoring for complications, adherence to dietary modifications. Also important antibiotics is important. Clinical colonoscopies is important. So all these come up together. Ok. So you discharged John. But unfortunately a week later, you were the same person on call and then you saw John in Ed. And the reason why John had to come to Ed was because he he had a fever and his abdominal pain was worse than it was. And then now he had nausea and vomiting his physical examination. He had severe abdominal tenderness in the, in the left lower abdomen and then he had rebound tenderness as well. So we discharged John a week ago on antibiotics based on his hin one. So that's what we tend to do. We tend to give antibiotics and other supportive medical care. But then John has come back a week later with these symptoms and looks like he's quite unwell, way more unwell than he was when we saw him the first time. How would you approach management? The initial management of, of John, how would you approach it? You are the person in seeing John for the first time? So it's a new pool. So I just give um an extra um 10, I guess. So 80% of us believe that we should resuscitate following the ABCD approach and 20% of us um thought we should get a CT scan immediately. But I think I would side with the 80% majority this time because if John is coming on, well, we need to make sure John is resuscitated properly and is stable enough before we get down to do any kind of investigation, like a CT scan. So it's really important that when you see an all patient, you just resuscitate them. Always. If the first time you see a normal patient, the easiest way to go about it is to follow the ABC D, just ABC D. I don't think this might not be emphasized too much as it should be. But it's one of the things that you should hold in your, in your, um, us. Now as, as a junior doctor, when you see a patient, you review them, you reassess them based on ABC D and then as you go along, if you find any problem with either A B or C, you deal with it and then you go along. So that's something that you should always remember to do for an old patient. You don't, you don't rush them to CT scan just because they've come back in, you have to make sure that they are stable enough that you can have the CT scan in the first place because they quite a disaster if, if you, you up to do the CT scan and then something happened in the CT and there's no point of the CT then is there. So it's really important that we follow the ABC D approach for UN all patients, we resuscitate them properly each time we see them. Ok. So yes. Also this is quite interesting because Jo John has come in quite un. Well, meaning that we might have either John didn't hear us properly or he's a stubborn man or we might have failed as doctors to really make sure he understands that we need to see him if he's un well, because sometimes patients who have appointments planned later on in the future, if they have worsening of their condition. They tend to, some patients will tend to wait to the appointment before they come in. And that, that's something you should always explain to the patient that look, you have an appointment with me in a week's time. But if you are unwell before then I would want to see you earlier than that. It's something you should always always, always let the patient know that that is an option for them because sometimes as in because they have an appointment with you, they don't have the option of coming to see you earlier day. And well, there is another feeling that we as doctors or medical professionals might, might. Um it's another feeling that we might have, but it's something we can actually talk about with the patient properly. Make sure they understand, you know, closely communication, you communicate with them, let them repeat. Let me explain to you why you think they think that you've you've told them and then see if you, you're getting the same information that you give them. You know, sometimes it's the easiest way to see if they really understand what you're saying because there's a chance that patient, especially if you use medical Jago for experience in the patient. They just say yes, yes, yes. But we don't know what you're talking about. Ok. Anyway, let's proceed. So this is John's new investigations. His white cell count has come back as 22. His CRP is 287. Remember the first time we saw him, his white cell was about 14.1 and CRP was about 77 and lact it was 0.9 then. But now he's coming with a white cell count of 22 CRP of 287 and lactate of 3.2. And John is unwell, obviously unwell and the he G classification of the CT scan is stage 34. So what surgical option would be most appropriate? Given his progression to him is stage 334. What do you guys think? Oh, no, OK. This is the pill. I intend to, to, to study this month. So I'll give you a minute to think about it and, and see to be fair. I just have to let you know that the answers here might not be entirely just one answer. It depends on where you are the skill of the surgeon or the surgeon. Think so it may worry quite, quite, quite a bit. So I will tell you what we have so far. So 22% of us feel that uh laparoscopic peritoneal lava should do the trick. And um 55% of us also believe Herman's procedure would be the way to go. And 11% of us believe that the primary anastomosis with or without a diabetic stoma should do the trick. And 11 of us think a subtotal colectomy should do the trick to be fact, I think this will be heavily dependent on, um, your ability to read AC T, but this is, um, that's why I put up, that is 34 there about, from the c, from what you can see so far. Um, a laparoscopic peritoneal would not do the trick in this, this instance. Ok. Don't, don't be too, too worried about knowing the fine detail of, you know, surgical management of distance. I, I'm sorry, I didn't know the level of every, I mean majority of you guys, but um more senior people would probably have, you know, more senior medical person. So probably have a better opinion as to what they think should be done for, for the juniors. The emphasis should be based you being able to see an unroll patient recognize the patient is un well and then managing the patient appropriately. So the resuscitation, the ABC D was actually the main that wanted to carry a cause for you. I mean, to you guys there by here, Haman procedure would we do the trick primary anastomosis? We talk about the diabetic stoma, not in this guy who, who has very poor diet. We don't know if he's been compliant with, you know, what we tell him to do. He's a smoker might feel if a primary anastomosis. Really it up total colectomy. I don't think it, it, it's multiple um sections of his colon. So ho pro we do it to go about half of you. I agree that man and I agree with the half, I mean, I'm sure Pinos will violate my experience, surgeons. But I think a Homans procedure would be a reasonable choice. Yeah. Anywhere. So, don't had a, like a man done. Right. So, for complications following surgery, what some of the complications I'm sure meds could be all in that. You have the intra early post post to up and all that. But, yeah, basically if we do a man you could have in, you could have bowel obstruction, you could have nutritional deficiencies following surgery. You could have stoma complications, psychological effects if the patient had a stoma. So these are just generic surgical complications that you should know about. But um what do we know about John? So postoperatively, John recovered quite well from his Homans procedure without any immediate complications and he was able to continue high fiber diet and then had regular appointments, was seen in the clinic. He, he looked very well in a year time and a year later, we actually did a reversal of stoma. So John looks fine. His current state or John is doing quite well. He's asymptomatic, he's back to his regular activities. He's completed. His project is on another project he's doing quite well, you know. So future plans include an all checkups and continue dietary management to minimize the recurrence. So what is the most important aspect of John's continuous game? It's the last one. Sorry. I know there's been a lot of pulls today, but I wanted to make it interactive and this is the easiest way to do that with you guys just now. So what's the most important aspect of John's continual scale? What did you think? Mhm OK. Looks like everyone is saying all the above and I agree. I think all the above is, is, is really important, you know, especially with your monitoring of symptoms and quick action. Considering he, he came back after he was sent home, he should be made aware that if he has any symptoms, it's really important for him to seek care. Ok? I think about 9% believe a regular medical follow up should be the most important aspect. But I actually think it's all the above to be honest. So that's just a um so a summary of what we discussed so far, we discussed what diabetic diseases. So we mentioned that diverticular disease is basically the herniation of the mucosa and the submucosa through the muscle wall. And we know that in the large bowel, it's mostly the secular muscle layer. The long the tidal muscle layer is comes together from the 10 co. So it's not circumferential like a secular one. So you have the Vasile piercing through and envelopes to supply the submucosa and subsequent the mucosa. So these envelopes could be the link where the mucosa muco actually herniates and then from the diverticula diabetic Colo. So if you have multiple diverticula that diabetic divertics and if it's inflamed or infected and that's diabetic colitis. So we do the difference between diabetic disease, diverticulosis and diabetic colitis, which is really good. And we talked about how they present and typically they will present with pain in the left, lower abdominal quadrant like John did. Ok. And then they might have a fever. Ok. So those are some of the ways to come in and then how do we manage them? We talked about just classification. So we said we would have to classify what kind of complicated diabetics the patient has. So it's between stage 1234. And based on the stage, we decide if we have to go for medical management or surgical management, right? So the decision point is how and what is the patient and what stage of um diabetic colitis of the patient have so that we make a decision as to whether we choose medical management or surgical management. And for the medical management, we spoke about the use of antibiotics, we spoke about the use of painkillers and then fluids and dietary modification. So those are the the main points we we we we talked about and then the patient being aware of the potential symptoms that he might have if there's any complications such as diabetic colitis or perforations or bleeding. So sometimes uh we should have mentioned in the slide, but if you, we mentioned it actually for the complications, the patient might bleed. So, bleeding pr is one of the ways that patients with complicated diabetic disease, that, that would be one of the ways they present to you. Ok. And then we talk about the what this, we didn't really talk about the PER C, but it was implied that you would need a dietician involved and then you would be the doctor. And then also if the patient is very un well, and you might need um HD level care, you know, you need a T staff anesthetist if the patient is to have. So it's really multidisciplinary care that we, we, we go for and then long term management, we, we did mention that that was on our last and that patient that have to modify their diet or have regular follow up, they should know about the symptoms look out for and then how to, you know, um seek care when to seek care if they are un. Well. So I believe this is a brief of diabetic disease and it should be an OK base for you to be able to build upon. So you can read more if you want, if you have any questions, you can ask them. I'm happy to be rich if you want to have anything clarified. So and without without much, I do, I think, OK, if cancer patient in hyper state with post infective af bleed, how would you manage perative anticoagulation treatment? Um So this this, this question is from a the action about cancer patient in hypercoagulable states. So it's post infective a then if it is an appropriate question for our lecture, just yeah. OK. How do you manage perioperative anticoagulation treatment? OK. So um kind of set the patient having usually with cases like this, I think I would involve the hematologist to make, to make, to give us the category patient with primary anastomosis be appropriate for OK, you have to choose your patient. You, you choose your patient very well. OK. So let's see, patient has a perforation, a big perforation there that you think won't resolve and the patient is quite fit young, stable, strong and then you, you could, you could attempt, you could attempt it. Ok. So it, it's, it's more to do about the patient with your management. You always have to select your patient properly. Um I wouldn't be doing a primary anastomosis for someone who is diabetic or someone who has dopamine or someone who smokes. No, I, I wouldn't attempt that but for a fit person or maybe just one point that is big, but probably won't close up by itself. And then he said, please express it on ABC D I. OK. All right. The questions are all coming in and then I'm looking at the time I have five minutes left and trying to constitutional good questions to I understand um ABC D resuscitation. So it's the same, it's basic life support, you know, a for airway. So if you see a patient and un war patient, you call to see a patient who is an wall start. A for airway is a patient, you know, airway open is a patient communicating with you talking to you. That's likely to mean that the patient's airway is patent at that point and likely to be maintained, then you can move on to your B which is breathing. So breathing, you want to check the person's respiratory, the persons um sats and listen to the chest and then any signs of consolidation, any signs of, you know, all those respiratory spine and it does anything. So say a patient who has pulmonary edema and you, you, you, so you get to the B and realize there's a problem with the b what kind of about the pulmonary edema. So you can, you can think about that. That's one problem you found if a patient that will probably require some furosemide to try and then you know, get off the flu, take off the fluid, do you set the patient up in bed? Get give the patient some high flow oxygen know. So do the basics, you know, to, to, to try and help the patient that would see circulation, check the person's pulse rate, capillary full time, um um BP. So these are the basic, the patient may require some fluids or blood based on see if a patient comes with lower gib like this person is men and which could be a complication of diabetic diabetic disease. They bleed. Then you would probably need to transfuse a significant drop in HP. That's a patient who is known HP baseline is 166 and then has come with bleeding pr and then it's from a diabetic level and the HP has dropped to 80. The patient requires some blood. So they see that's something you can do the disability um contact the patients, the patient's temperature, you know, see if the patient has any neurological deficit. So um patients who have decreased oxygen um supply would probably have some change in their mentation e for exposure. So exposure will be really. So if patient, you suspect has diverticular disease coming in, make sure you look at the pr area aside, examining the abdomen, you it's supposed to be a full exam, but what you would be interested in would be the abdomen and then also the rectal examination. So if the patient is bleeding pr we do ad ru and then there's from blood there, then you know that there's something going on, then that needs to be sorted out. So ABC D allows you to without knowing exactly what's wrong with the patient, deal with potential problems that could kill the patient. So that's the point of doing the ABC D. OK. So I think that's the level that I actually want for uh medical students who are amongst us or the, the, you know, very new officers. So ABC D, any patient you see, just go through this and then there are some courses um that you can take to actually try and help you be better at doing ABC D assessment and then resuscitation. Ok. So, um any other questions or one that you think I can talk more about from the ones that I've already had one new message? Um ok. All right. Thank you very much. So, it's, it's time two minutes to go. So I just hand about to the moderator to, you know, end the whole presentation. Thank you all for coming and your time. So again, um is a very, very important upcoming, you know, um organization. And I believe that it would be very helpful to if I had known about s or if was in existence when I was a medical student, I'm sure I would have been way better at what I do right now and I would have more tense, have more exposure. So in terms of research, in terms of teaching, there's a lot that you can actually gain by joining up. So II, I actually encourage you to participate actively in our, you know, projects. They are research projects going, you know, they are teaching projects. If you want to teach, it's a very good opportunity if you want to learn how to do research, also network, you know, know about people. I've been trying to put up. Um The president has been sending me some very good links that I've been putting up on the page about, you know, opportunities that coming up that I think you can make use of. You know, for instance, I think that I put up one about um applications for training if you are interested in. So please do all this Alex Stop. Alexa Stop, sorry, sorry about that. Sorry about that. It's, it's time. That's, that's why I thank you very much, Doctor Dacosta. It was um an interesting time. Thank you very, very much. No, no problem, no problem at all. Love. I'm happy to be able to help. Ok? Um We will fill the feedback form so you can get your attendance certificate. At least you can get uh go to the um chart box and fill the feedback um form. That's the only way the um attendance certificate to be um given out. So it's been an interesting session um today in the absence of any other question. Oh, I'm actually seeing a few other questions up here that III I missed, you know, you know, someone was asking about um fatigue. Can we assume fatigue is due to a cold bleeding? Yes, we can, we can. So that's why we did the full blood count. The HB was actually fine. That's why we didn't really, you know, jump on that. But yes, you can assume that fatigue could be from a cold bleed anyway. Sorry. About that, but I think we can possibly schedule another one. So in the feedback, if you feel like you need further discussions on the subject, we are happy to organize another one and have a more detailed discussion about some of the things you might mention in your feedback. That's why it's really important for us to get your feedback because it guides us as to what would be the best, you know, um programs or quest. I mean, um teaching sessions to offer you. OK. So we really appreciate your honest feedback. Just tell us how you feel and what you think we can do to make these, these sessions more beneficial and helpful to you. OK. So uh back to my me about that. Thank you. Also, I think one of the participants made mention of um appreciating teaching of um the CT scan and we will also put that. Yes. So time I, I wouldn't delve into that just now, but we can definitely organize another session to talk about. So we could actually have a teaching on, you know, reading basics of reading a CT scan. So that's one of the teaching. So if, if it's something you're interested in, you can mention the feedback and then we can organize that. So basics of teach and reading of them. Now, ct scans is some of the skills that I think would be useful to everyone. OK? So that's why we need, that's why we really need your feedback or maybe something like soy geography. Yes, like that. So the feedback is really important to us, please. Thank you very much. Um We have come to the end of today's session, please. Um watch out for the next um teaching. It's going to be announced on the, on the page. So if you are yet to join C gap, the link has been sent, you can just search CV dot org and follow the necessary um instructions. Love to have you around. Also invite others, tell your friends, tell your other colleagues, it's um great to be here. And I've also been enjoying C GFF since I joined. There are so, so much happening out there in the world. There are so, so much opportunities to get and um all you need is it just information, information? So you get that information from CGF. You get the collaborations, you get the even the enthusiasm from CG. So I appreciate your coming. Um Everyone. Thank you very much. Thank you and have a pleasant day. Bye.