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And to start. Ok. Ok. All right, thanks. Um Good evening everyone. Um So, um I'm Rawa Ahmed and I'm one of the widening participation Medics Network, um uh organizers and I've got doctor a Hasan who is an ST two in less hospital. Uh who's gonna be talking to us today about uh ct scan, um abdomen, um and pelvis. Um sh I can everyone hear me. Can you write in the chat box if you can hear me, please? Uh I don't have access to chat. Uh Let's see. Uh Yes. Um So, um I think we, we can start straight away. Ok. So, hi, everybody. Uh My name is Ab and I'm currently uh an ST two in uh university hospitals, Leicester. So, uh I've made a short presentation today uh to discuss abdominal imaging and I've been told that uh most of our participants will be foundation trainees. So I've uh added a short bit about um anatomy, relevant, anatomy uh while we are reporting abdominal uh or maybe trying to understand them and also about different phases of scans. So whenever, as af one or F two or any doctor, whenever they are requesting, uh scans. Usually in the UK, you have to call the radiologist and to get the scan that and a lot of, a lot of junior doctors feel an anxiety before calling radiology about what sort of questions are they going to ask? And many times because I've been through that, so I know that I didn't really know what sort of scan uh we needed to request. So I'm just going to talk a little bit about contrast and the different phases. So you can have a better idea about uh requesting scans and the questions the radiology team might have for you. OK. So let me just OK, so whenever you're calling radiology, we uh it's a good idea to have in your mind, like what clinical question are you trying to answer? Because that's going to dictate what sort of scan we are going to do. So we think uh usually as juniors that uh if we do an abdominal scan, it's going to give us lots of information about different things. But actually just there are so many different types of abdominal scans and it's really important before calling radiology or before requesting a scan to understand what sort of clinical question is this scan going to answer, right. So let's say if we are thinking about ruling out a renal stone, we don't really need to give contrast, right? And if we are trying to find out a source of bleeding, it's a separate scan. So we'll go more into that. So, whenever you're calling radiology, it depends if you're working in ad GH you might not have registered. You're, you're directly talking to a radiology consultant or a radiology registrar. So they're going to ask you about what are your differentials. And so what we're trying to do in that case is not trying to be obstructive. We, uh we're just trying to find out what's the best scan which we can do to answer the question. All right. So uh the contrast we use, uh so today's talk is just going to cover CT and we are not going to discuss MRI. So the contrast we use is iodinated contrast. And uh we can give this to most patients unless uh they have like an allergic reaction or if there are, if they don't have any allergies, they can usually have this contrast. Another thing to keep in mind is the renal function. If the renal function is really uh low. Uh nowadays, uh we can sometimes overrule eg fr uh because the risk of contrast induced nephropathy has been uh overplayed in the past. So it's always a discussion and just have a discussion uh with your local radiology team about uh whether this scan will need contrast because many times we can answer questions without contrast as well. So again, it's important about it's important that what sort of clinical question you have, right. So for, let's say, if you are just trying to rule out a real stone, we we are not going to give contrast. So uh contrast can be oral contrast as well. And uh IV in most cases, right. So this is a very good slide uh because it shows how contrast can the same contrast bolus can give us different information based on times. So when you give us the information that this is a clinical question we want to answer, we are going to vet the study. So as as it is, we wet the scan in a specific way and by wetting the scan, we write as a protocol on the scan. And that protocol lets the radiographers know what sort of delay to add, right? So let's say if we give IV contrast bolus in uh one of the veins and if you image after 20 seconds, it's going to pacify the pulmonary arteries, right? And after 25 seconds, it's it's in the systemic arteries, right? And after 35 seconds, we have delayed arterial phase. And after 60 seconds, we have the portovenous phase and after 5 to 15 minutes, it's the delayed phase. So let's say if you're trying to rule out a pulmonary embolism, then we need to add a 22nd delay. So it will opacify the pulmonary arteries. And let's say we want to rule out an aortic dissection. Now that will be a 25 2nd delay. So as you can see from the slide, if you want to rule out a pulmonary embolism and a dissection in the same scan, it won't be really possible because you can see in this image that the aorta is not specified. So I won't be able to tell you that does this person have a dissection or not? So that's where your clinical skills come in the picture that because aortic dissection and a pulmonary embolism both can cause chest pain. So you have to narrow down your differentials to uh make sure we do the right scan for the patient because you have to remember every scan is associated with a lot of radiation as well. So, um again, uh let's say if you want to rule out uh intraabdominal mass, right? So that will be a portovenous phase, it will be. So, in the portovenous phase, we can see abdominal pathology really well. And let's say you want to rule out uh uh let's say a bladder mass or urothelial sort of obstruction, that will be a delayed phase. So that's why uh I put these slides in just to make you aware why we ask so many questions when you're calling radiology and to have just uh just this question in your mind that for why am I requesting the scan? And what question are we trying to answer? And if you just communicate that we are going to guide you to the best scan possible. So, uh again, yeah, so that is just uh contrast in different places just based on time. So this is the pulmonary artery, which is a specified, this is the phase we used to rule out pulmonary embolism. And this is uh an arterial scan. So you can see contrast in the ascending aorta and the descending aorta. So this is what we use to rule out a dissection. So again, um so this is a precontrast phase, this is arterial and this is portovenous. So before contrast, you can see there is no contrast in the aorta, it all looks gray in the arterial phase. The contrast is just beginning to flow into the abdominal aorta and this is the portovenous. The contrast is diffused all into the abdominal organs. So you can see the liver is lighting up, the spleen is lighting up. So we use different phases to answer different questions. So contrast can also help to. So contrast will go everywhere where the blood is going. So contrast is a really good tool to tell us whether there is ischemia. So you can see in this picture uh that the bowel wall is not enhancing. So this is all dead bowel compared to this bowel. So this is a normal appearance. So this is uh this bowel wall is enhancing. So we can say there is good blood flow and then you've got some dead bowel here as well. So uh I'm just going to uh uh review some relevant anatomy. Let me just get out of this and I've got this from case tax. So, uh the way we are going to do this is I'm, I've just uh written a few headings down. So we are just going to uh review the bones, the muscles and then the solid organs, then the major vessels and I'm just going to scroll through the CT. Can everybody see, uh can everybody see me scrolling? Yeah. Yes, I can see it scrolling. OK. So, so this is uh these are eggs and slices and we have given contrast. So the element muscles are, we've got the muscle here and uh this is the rectus abdominis. These are the transversus abdominis on the bilateral sides and this is the external oblique. So, uh these are the relevant muscles. You've got the paraspinal muscles at the back. The relevant bones in the abdominal pelvis are just the uh the spine, the lumbar vertebra, the lower thoracic and the lumbar vertebra. And then you've got in the pelvis, you've got the iliac bones and the sacrum. I'm sorry, I just can't see them. The pointer moving. You can't see the mouse. No. OK. Uh Is there like a laser pointer or something? Uh like uh like some Softwares have like teams has it, but I can't see an option here. Mm I don't think so. Let's see. Um Can you see it now? Um No, I don't think. Yeah. No, I don't think I can see it moving yet. Um I don't know uh any way around this. Mm So uh I, I'll just talk to them. OK. Um So bones are usually best seen on the croon and then sagittal slices. And uh you've got the lower thoracic and the lumbar vertebra here and then the femurs and the neck and this uh these sagittal slices are the best to review your vertebra. So, coming to the major vessels. So let me scroll up. So you've got a dominal aorta here coming down. The first branch to come uh of the abdominal aorta is the celiac axis, which is coming here. And the celiac axis gives branches to the spleen and the liver, the second major branch. This so there are unpaired branches and the period branches of the abdominal aorta and the pa branches. So let's talk about the unpaired branches first. So this was the celiac axis coming off and then this is the S ma. So the S ma supplies most of the uh small intestine and uh the large intestine as well. And after that, the unpaid branches to come off are this inferior mesenteric artery, which is this very tiny artery here. So whenever you are scrolling through uh the abdominal exit slices, it's very important that you check the vessels for any thrombus, especially if you're concerned for any ischemia. So then the period branches are the renal arteries. So these branch sideways, let me find the renal artery. So that's the renal artery bilaterally going, this is the renal vein. So at the back of the aorta, the there are some very tiny vessels supplying to the lumbar vertebra. They are very tiny and usually. So you can just see some hair but they're usually not visible. Now, coming to the major veins. So this big vein in the middle is the inferior vena cava. And you've got the portal vein as well, this bright bit which goes into the liver. So this the abdominal vessels, the superior mesenteric queen and all of them, they there's like a confluence into the portal vein. And this so all the vessels check, check them for any thrombi, right? And uh let's just have a quick glance at the major organs. So you've got the liver here. This is the portal vein coming up. So the liver is divided into different segments. Uh There's some really good illustrations on radio pia. So um that's the pain kidneys. The sw muscle slices are usually really good for the pancreas. So go up and just below the liver. So this is the pancreas, you will see it wrapped around the splenic artery. So this is the head of the pancreas, the body and then the tail is more posterior. So this is the, this is the pancreas and then uh adrenals. So I forgot the gallbladder. The gallbladder is, this bit is slightly collapsed in this patient. So, uh so for the adrenals, just go to the superior pole of the kidneys and usually you see them now you're going down. So, so these are the adrenals this and desperate. So they are very tiny. And uh so now coming to the gut. So, so there uh some people start at the bottom and scroll up. So, uh this is a urinary bladder. So if you've got the rectum, the sigmoid colon, so the, the sigmoid is coming up. So you've got offer you the sigmoid, you've got the left-sided colon, the descending colon. So it's not very uh well seen in these images, but you chase, uh you chase, chase it here until it. So this is all uh descending colon. No, it, it's a transverse and you're losing it behind the liver. So this is, this is the Phosphorus colum and then you've got the, the uh ascending colon and uh C A. So at the CM, you will usually see uh so at the CM, we usually try to find the appendix. Let me see. So I think, let me see if we can find the appendix in this patient. So another thing about CT is uh the more thin a patient is uh it's really difficult to, the more difficult it gets to look at their anatomy because if uh you're looking at the scan of a big person, so there's a lot of fat to separate their abdominal organs. So it's uh makes delineation really easy. Now, everything is back together here So it's uh hard to see. So I'm not sure if, uh so usually, uh we find the cecum first and then you find the UC cecal wall and right next there is the appendix, but I can't really see it in this one. So the small bowel, we just eyeball it, you don't chase it because the loops are too numerous to chase individually. So we just cast an eye over it and then you come up look at the stomach. So this is the stomach and then got the duodenum wrapping around the pancreas. So this was just a review of um uh just like a short review of the relevant anatomy. Does anyone have any questions so far? Uh No questions on the chat box yet? OK. So another thing uh which is really relevant to anatomy is intra versus retroperitoneal structures. So this space, the anterior perirenal space is really important in terms of anatomy. So the anterior perirenal space contains the descending colon, the pancreas and the ascending colon. And this space really helps us in understanding uh whether a lesion or any sort of mass is intraperitoneal or retroperitoneal. So if there's anything in the peritoneal cavity, it's going to depress the space. But if there's a retroperitoneal mass, it's going to uh cause a mass effect on this space from the posterior side. So I've got a very good example of this in this image. So, so we've got two masses here and we don't really know whether they are intraperitoneal or retroperitoneal. But if you look at this mass, it's causing pressure over the anterior perirenal space. And we can see that the uh the colon is uh displaced to the posterior side. So we can conclude that this is a intraperitoneal mass and this is a retroperitoneal mass because it is uh displacing the colon and the duodenum anteriorly. So the anterior perirenal space is really important in terms of uh localization of the lesion. So I've just got a few different examples of uh different sorts of uh abdominal CT s uh that we do. So this is act with oral contrast. So uh we can give oral contrast to look for any postoperative sort of leaks if they've had any gi surgery. And the surgical team are worried about any POSTOP leak. We give oral contrast another use case for uh oral contrast or is to look for any tumors. So sometimes you might, you might have heard about uh patients getting uh CT colon. So what uh what did so patients who are unfit for colonoscopy sometimes have act virtual colonoscopy. And what they do in that case is that they insufflate the bowel with CO2 and also give contrast indirectly, I shouldn't have said oral contrast but uh intrarectally and uh that's he that helps in uh delineating any tumors. So this is act urogram, this is different from Act K UB. So this is done in a very delayed phase after like 15 to 20 minutes of delay. So, um, this is to look for any sort of blockage within the ureters or within the urinary system. So it's usually done in three phases. But, uh, this is the phase in which you can see the ureters. So this is, this is an unannounced ct which we usually do for looking for renal stones. So renal stones are usually radioopaque. So you don't need to give contrast and uh I'm just going to open this. So this is a uh radio video is really good. So when we are looking for gi bleeding, we do three scans. So I'm just going to walk you through the findings on this one. So, so we usually do three phases. So we do a non-contrast phase, an arterial phase and a portovenous phase. So on the non-contrast phase, we are just looking for any sort of hyperdense sort of areas to look for any blood. So you can see here, I'm not sure if you can see my pointer, but you can see some hyperdense sort of material in the ascending colon here layering down over on in this bowel loop. So this is very suspicious for blood. So, uh fresh blood is hyperdense. So we are worried about bleeding which might be laying here and then on the arterial face, we are looking for the spurt. So we are looking for any contrast blush uh which can show us active bleeding. So you can see this tiny bit of contrast like as in this bowel loop. So this is uh active contrast ization. So this is actually the bleeding point and then we do the delayed phase, the portovenous phase and what you want to see on this phase is pooling. So we can see that now, the contrast is pooling here. So all these three things in combination helps uh help us like to show where the bleeding is. OK. Going back to the presentation. So, and uh so I've got some S pa s now I don't have access to chat. So what do you guys think about this question? Have you had any responses yet? Um Let me just check the chart. I don't think we've got any responses yet, but I can create a poll. OK. LA uh can uh can uh everyone answer in the poll, please? OK. I think we've got um an answer. B OK. So, uh let's discuss the different uh uh options. So, uh this is like a really bo or sort of pancreatitis. So, uh the question was do when to do imaging, right? So, um CT is uh the correct option, but usually when, so uh pancreatitis is like a clinical diagnosis. We've got uh alas of 12,000, you don't really need act at this stage. So CT is really good to check for complications uh of pancreatitis. So CT can show us uh So in this image, if you have a look here, so we can see this bright echo uh bright uh hyperdense bit. So this is like a pseudoaneurysm which is a common complication following pancreatitis. We can also see this hypertense area which is a pseudocyst and we can see uh pancreatic edema. So all of these changes are not really evident right at the start of pancreatitis. So guidelines say that we should do CT after 48 to 72 hours after um admission to check for complications. So, you've got a second question. OK. So we've got a second ball. I uh we've got most answers as a. So, uh yeah, uh this is uh this picture basically just shows a really huge bladder and uh there's uh some hyperdensities in the left kidney as well. So this patient has urinary retention. So you review a 49 year old man who was admitted for a recurrent dislocated shoulder and they mentioned passing that they recently lost three stones of weight and have an altered bowel habit. Let's show microcytic anemia we're concerned for bowel cancer, which would be the most appropriate investigation. So I can. So we've got 5050 on A&E. So, uh so this question goes about like uh the main idea is what sort of study is appropriate for the clinical question. So, for a 49 year old man, in which we are suspecting cancer, the best uh study would be to do like a colonoscopy because uh CT is usually reserved for those uh patients who are unfit for a colonoscopy. A colonoscopy will also help us in getting a tissue diagnosis. A tissue sample. Uh ultrasound is not usually good for bowel because uh ear is like the enemy of uh ultrasound. So ear really obstructs ultrasound. So ultrasound is not like uh the best modality to look at bowel, we can look at the bowel wall uh but it's not the best modality. So the correct answer is colonoscopy. So a 21 year old woman presents to the emergency department with abdominal pain and vomiting for the last 11 hours. She has previous history of Crohn's disease and multiple bowel surgeries. So we are suspecting additional bowel obstruction. What would be the most appropriate investigation? Uh It looks like most answers are b So yeah, the correct answer is uh B CT uh C. So uh abdominal x-rays are not advised for obstruction anymore. Uh because even if uh the appearance is equivocal on ab and an abdominal x-ray, the patient still goes on to have act. So CT S are like first slide now. So you've got a 21 year old female who presents to a and with four hours, four hour history of right leg pain radiating to her groin. There is dips hematuria and the pregnancy test is negative. What would be the most appropriate investigation. So I can see a 5050 split between ultrasound and CT. So uh uh in this case, the answer would be CT uh I can understand the rationale uh why you would want to pick ultrasound because uh we want to save her from radiation, but ultrasound is not really sensitive for renal stones. So in UK, we try to do ct when the question is uh renal stones because uh CT is a 90 to 95% sensitive for picking up renal stones. So the most appropriate test would be CT we can see in this image, uh there is uh left-sided hydronephrosis and we can see an really uh large obstructing calculus uh in the distal ureter. So a 21 year old woman presents to A&E with severe four hour history of right flank pain radiating to her groin. There is dips hematuria and the urine pregnancy test is positive. What would be the most appropriate investigation. So, um 5050 split between CT and ultrasound. So there's dipstick hematuria and the urine pregnancy test is positive. So, the main differential in this case would be an ectopic pregnancy. So the most appropriate investigation for that uh initially would be ultrasound. So in this image, we can see a distended urinary bladder and there is a hypoechoic sort of cystic mass in the region of the ovary. So, uh this is really suspicious for uh for an ectopic pregnancy and we can also see an empty uterus. So a 46 year old man presents to A&E with a two day history of right-sided abdominal pain that started centrally, but now is centered on it. Right. Iliac fossa inflam markers are raised. A CT abdomen is performed. What is the most likely diagnosis? So, uh the most likely diagnosis in this case is appendicitis. And uh we can see this fluid filled distended, uh blind tube which is coming from the cecum. So you can see some edema as well, which is uh which can be seen from the fat stranding around the appendix. So it's periappendiceal fat stranding. So this is highly suggestive of appendicitis. So, 45 year old woman presents to A&E with a two day history of right upper quadrant pain and vomiting. Her inflammatory markers are raised and she has a negative pregnancy test. An ultrasound abdomen is performed which is the most likely diagnosis. So, right upper Cordran pain, uh the picture sort of gives the answer away. Um So yeah, uh the answer is uh cholecystitis, you can see uh So a Murphy sign will be positive and you put the, when you put some pressure over the right upper corner and the patient will uh they, they hold their breath with pain and that's due to gallbladder inflammation. And we also have got a Sonographic Murphy sign when you put the probe over there, the patient uh uh it's painful for the patient. And uh so we've got a positive so graphic Murphy sign. Uh what we see on ultrasound is a thin of fluid usually around the gallbladder, which we call pericholecystic fluid. There's some wall thickening and we can in this image, we can also see a gallstone lodged in the neck of the gallbladder. So we've got a 78 year old man who presents to A&E with two-day history of rightsided colic abdominal pain, inflammatory markers are normal. A CT abdomen is performed. What is the most likely diagnosis? Ok. So it's a split between bowel cancer and Crohn's disease. So what, what can we see in this image? So a big big clue in this uh question is the age of the patient. So, if you've got a 78 year old uh patient who has presented with uh new onset right-sided colic abdominal pain, now, we can see some distended, uh small bowel loops. But uh what's really catching uh the eye in this uh is this lesion? So this is an apple core lesion which is highly suggestive of cancer. So you've got a shoulder lesion. Uh and there's like a constriction in the middle. So this is highly suggestive of bowel cancer. Uh Crohn's uh would have an early age of presentation and uh we can't really see an inguinal hernia in this image. So let's move on to the next question. 72 year old male patient presents with pr bleeding and fever. The CT scan shows a diverticular abscess, diverticulitis, active bleeding or ischemia. Ok. So, Yeah. The uh most of uh the people have clicked diverticulitis, which is the right answer. So, what we see here is fat stranding. So fat is usually uh this shape on CT. And then you've got this sort of dirty fat, we call it fat stranding and this is usually a marker of inflammation. So, what we see here is the sigmoid colon, which is the most uh usual site. Uh We get diverticulitis in and you've got these diverticula which are inflamed. And so this is diverticulitis. 54 year old male, uh, 54 year old patient presents with a previous history of cholecystitis and they've got no bowel movements for the last few days and vomiting, the CT scan shows a small bowel obstruction, a large bowl obstruction and an eyelid or mesenteric ischemia. So, yeah, uh, the correct answer is gallstone ileus. In this case, uh, we see fluid distended, uh bowel loops. So, uh, it's a bit of a like a trick question because it is small bowel obstruction as well. But the right, uh, because it's due to an obstructing gallstone, uh, we will call it Galster ileus. So we can see a fist rating track between the duodenum and the gallbladder as well. So, 37 year old female patient presents with right ELISA pain for last one day, inflammatory markers are normal. The CT scan shows appendicitis cholecystitis, diverticulitis or enteritis. So, uh, we've got a split between appendicitis and diverticulitis So, um if you've got in the right ili Phosa, you've got a thickened fluid-filled distended loop, which is blind. So, and we see uh really dense uh structure obstructing the lumen. So this is an appendicolith obstructing the appendix. So this is appendicitis secondary to this appendicolith. Uh what we usually do after like we have diagnosed appendicitis on x-rays to look for any signs of complications. So, the complications can include an appendicular abscess, perforation, localized lymphadenopathy. So, uh this could be the complications. So this is just a slide going through uh the findings. So you've got more than six millimeter of dilation. There's some periappendiceal inflammation which is evident by this fat stranding. So this dirty fat again. So usually f fat is black and then you've, and you've got this grayish fat, it means there's some inflammation going on and sometimes we can see this dense appendicolith. So, uh we only have around 10 minutes left. So I'm just going to go through a few cases now. So we've got the key history is right, upper quadrant and right Ili FSA pain curi appendicitis, cury, cholecystitis. Hello. Uh Doctor Aab. I don't think I can see your screen. Are you still there? Ok. Um Hi, everyone. Um Sorry, I'm not sure what happened there. It might be just a network problem. Um So we'll give doctor a, a couple of minutes to see if he's gonna be able to come back. Hi, can you hear me. Uh Yes. Yes, I can hear you. Uh Did you see the case or did, did I lose contact? I think you disconnected. Oh, sorry. So I'll share the case. Uh We only have like 10 minutes. So let me just share the we can discuss one case. So can you see it now? Yes. So if you've got um axial slices and the history was right up recorded pain. So immediately the differences which uh start running through your mind are cholecystitis. So, the first thing to do is just to have a general look. And then you've been taught that just look in the lung window first to look for any intraperitoneal air. So I'm just going to put lung window here and just checking for any free gas in the abdomen, any pneumoperitoneum and can't really see it now. So I'll focus on the right upper quadrant. We can immediately see that the gallbladder is thickened, it's inflamed and we can see some radiodense calculi in the neck of the gallbladder. There is a thin rim of pericholecystic fluid as well around the gallbladder and you can see the fat again. So this is the normal fat and you can see this fat stranding around the gallbladder, which basically is a very good sign that there is a lot of inflammation going on. This is uh oral contrast, which they have given. So some hospitals give oral contrast as well. We don't uh give it a lot and lesser to diagnose uh the normal pathologies, but only if you are like trying to find out the leak or something. So it's always important to look in other planes as well. So, so this is the gallbladder and the coronal sections, you can see some local lymph nodes as well. And let's have uh another thing to look for is any perforation, any sort of neural discontinuity. So the wall, I can't see any focal defects in it. So we can say that there is no perforation and these are just the sagittal reconstructions. So it's always important to look in the bone window as well to and just see if there's no bony issue. So this was that one. So I've got this case as well. Do we have time to discuss this? Yes. Yes, we still have seven minutes. Ok. So uh let me just check just a second. The history for this is uh pr bleed for last four hours curing perforation. So, so the history is uh pr bleed. So what we see in this case is um this is an arterial face scan which they have done to look for the cause of pr bleeding. So I'm just going to window it slightly so we can look for the vessels. So let's just have a look in the lung window first just to check. Is there any free air? So a few things are catching our eye, but we can't really see any free hair, there might be a tiny locule hair and let's go to the soft tissue window again. So immediately what catches your eye is this appearance of uh the bowel. So this is hematosis and uh this tells us that the bowel is in trouble. And usually, uh when there's bowel ischemia, you start to get pneumatosis and this then tracks up into the portal vessels and sometimes you can see it in the liver. So this is portalvenous gas. So this is uh it's really important to differentiate it from pneumobilia. So this is gas in the portovenous system. No, if we have found bowel ischemia, WW, we have to interrogate the vessels to check if there's any clot. So I'm just going to, I'm just going to look at the aorta and just check if there's any. So let's look at the branches. So you can see that the celiac axis origin is heavily calcified, but it looks patent. So we can see contrast through it. And then, so this is the S MA and we can see contrast filling, but then there's an abrupt cut off. So you can see that the S MA is gone from here. So this patient has had likely had like a S MA thrombosis, which is evident by this filling defect here. So there is some backfilling. So if you see it come off, uh but in this, in this slice, we can see there's a filling defector. So the diagnosis would be acute uh ischemia, acute bowel ischemia secondary to an S ma clot. So again, uh satisfaction of search. So you have to basically look at everything in all the windows. So if you just want one abnormality, it doesn't mean that you stop looking. So look for everything and look for. So we usually look at bone windows last. So yeah, that's it. So we are out of time. Uh II had like a few other cases but uh we are nearly out of time. So uh I hope you um guys find, found it useful and uh yeah, I'll appreciate any feedback. Uh Yes, thank you very much, Doctor Aab. It was a very good, well put together uh presentation. Um I hope everyone fills in the feedback forms. Uh You will get your certificate as soon as you fill the feedback forms. And uh we have uh our next uh webinar on the 28th about uh the uh musculoskeletal um radiology. So uh please make sure to um attend that webinar as well. Um Thank you very, very much and good evening. See you next time. Bye. Thank you. Bye, goodbye.