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Hello, everyone. Welcome back to the year for academic provision tutorials, which is a week long series that covers all the specialties relevant to the Edinburgh medical school curriculum. We're covering G eye today and we're very lucky to be joined by Alba, a final year medical student ever to you, Alba. Hey guys, I hope everyone's doing well. So I've just been asked to step in a bit of last minute to do this G I presentation. So I hope it's okay. I've never used metal before. So it might go completely wrong but bear with um, if you have any questions, I think you can put them on the chat. So just let me know if I've missed anything too. Um So I think we can stop going. So this is G eye liver and we're starting off with questions. So a 73 year old man presents with difficulty swallowing. He struggles with solids, swallowing is not painful, but his wife has noticed that he has a very bad breath even worse than usual. Sometimes he regurgitates undigested food in the clinic today. He has a super water and unit gambling noses of counseling or it would be useful if I had actually shared the question beforehand. Right. We can do that. Um Right. So out of which of the following investigations would be the most useful. So if you guys have a go at answering, I think I can see how many of you have raided. So ct and head and neck suffered. Your manometry barium swallow anti ttg antibodies or the H pylori breath test cool. It's not anything I can stop pulling but and then we can continue. So a barium swallow is performed on this. Another patient that has had problems swallowing, giving the most likely diagnosis. What is an appropriate step management? So, if you guys can answer this one as well. So Botox injection, conservative management and worsening advice, long term treatment with Nifedipine balloon dilation, endoscopic ablation therapy or lower suffocates. So balloon. Uh huh. Uh Let me know if that's too quick. A song. Um Right. Okay. And finally 56 year old man was admitted to the hospital. Let me just share the question again. Um So 56 year old man was submitted to the hospital presented with difficulty in swallowing. He has had type two diabetes with hypertension. He suddenly fell done well, subsequently notice he could swallow solids but not liquids. So he came to a hospital for evaluation within the 1st 24 hours. But after the onset of symptoms on examination, he was alert and oriented, but he liked answers and was very concerned about his haringey of discomfort. The patient had no dysarthria. Oh, would it be possible to go slow? Yes, of course. Sorry. I'm just rushing through, but I wasn't sure. Of course. Yeah. So the patient had no dysarthria, sensory and deep tendon reflex examination was normal. No dysphonia tosis or facial muscle weakness was found or the cranial nerve examination was performed and was normal fire and jewelry. Fleiss was not examined. What is the next most important investigation for this patient? So we'll just wait a bit. Um So barium swallow ct head ct C C A P or esophageal gastroduodenoscopy for O G D. Um So if I just went to bed for you guys to file, so um sometimes it updates itself very quickly and other times it doesn't, he's saying cool. So I'll stop calling. Let me. So these questions had to do with this feature. Um If there's difficulty with swallowed, then liquids, you would think it's a stricture stricture stricture. Uh You can have those for nine. So it's offered your ring, find your pouch or called san close diverticulum. But you don't really need to know that or they can be malignant yourself. A dual cancer, lung cancer, lymphoma. If it's both solids and liquids from the start, then you think it's a motility problem, for example, equal Asia bubble palsy or system excludes it's etcetera. And this is a really cool like barium swallow um showing another uh found your pouch. So, dysphasia, you can divide it uh um into these kind of or found you're, you so found you or found you occur soon after eating and it's associated with coughing. This can be motility ones. So, dementia stroke Parkinson's or als or structural. So, cervical osteophytes or cancer and something that actually like impedes the flow. If they feel that something stuck in the chest behind the sternum is suffered. You so solids, solids and liquids, you think of spasms, uh achalasia scleroderma or if it's solids more than liquids, then you think it's much more structural. So such as extreme causes. So, mediastinal mass or intrinsic. So, plumber Winson syndrome, but I think you get iron deficiency, uh the rings, there are some feel like esophagitis. So in the blood test, you will find higher cinephiles, strictures once again from peptic horses and cancers. Um approximal gastric and esophageal. If they're acute, you would think of stroke. Um Kind of I think it's um yeah, uh that's a pneumonic for it. Like the whole like you, you can't speak, you can't move and then it's time to call 999 or a subsidy or obstructions. So for example, if somebody is actually like coughing, you can't move. Um And then yeah, cool. So there's different pathology behind it and we can go through a few of the most important one. So, Benign Barrett's esophagus is due to longstanding reflux smoke. So found in kind of obese men smokers. Um, and this video is where they normally complain of kind of difficulty after eating meals. So do two gold, basically differential investigations. You would do gastroscopy and biopsies be biopsy to differentiate between the nine and Barrett's and strictures and then metaplasia or dysplasia invasive cancer because that would, uh, lead to a different kind of management, whether it's actually like, uh, kind of just watching out and PPI S or whether it's actual surgery, if it's of a nine peptic structure, uh you would have chronic reflux or kind of slow progressive dysphagia. And you've got Kustra gastroscopy, got all these times to confirm like the actual appearance. If it's a chalasia, there's no history of reflux, but there is a long history of regurgitation. So you've got a conscious swallow to reveal a typical bird speak. And then you can differentiate between regulation, studio regulation, not really that important, but yeah, I would focus on the contrast solid. The esophageal manometry can be like the second line test to reveal in complete relaxation of the lowest of the juro structure. I hope that makes sense. So, esophageal spasms are very painful and symptomatic they're normally found in people who are a bit more, I guess hypochondriac or until os of stress they manage with oral costume channel blockers initially. So I think probably Nifedipine, but don't trust me on that. And PPI if they're scored symptoms from the reflux, I hope that made sense for dysphasia. So maybe you can move on to the next topic and I'll start the pool now. Um, cool. So a 65 year old man presents with, there's a message. Oh, no, that's the pole. Never mind. 65 year old man presents with difficulty swallowing solids or dinner Fadia, retrosternal chest pain. He has last 5 kg of weight in the last six months and his B M I is south. That past medical history includes hypertension, hypercholesterolemia type two diabetes, asthma, Gourd Barrett's esophagus and appen debt to me, he drinks around 20 units of alcohol by week and does not smoke. No endoscopy is performed and biopsies are sent to a lab. A barium swallow is performed and shows the lower esophageal structure with an apple core effect. What is the most likely diagnosis? So, we've got gastric cancer like chalasia, squamous cell carcinoma of the esophagus, found your pouch or adenocarcinoma of the esophagus. So we'll just wait a bit more. So I might close the poll now if that's okay, but let me know if that's too quick again. Um We can go on to the next question. So question five, 56 year old man comes to the G P. He has a long term history of heart burns that was treated by G P with PPI for eight weeks, but this remains and has no improvement. He says maker and has a B M I of 35 but his weight is stable blood cells, hemoglobin. And it's 250 mean cell volume is normal platelets and normal slightly on the upper range. White blood cells. Wait, this is it was done differently for one than for the other white blood cells. Unnormal neutrophils. Sorry, this slides were not done by me so I can try to read them right. Hey, mclovin is normal, meaning blood cell volume is normal platelets and normal white blood cells are normal. Neutrophils are normal and emphasize and normal. So everything seems to be normal. Uh What's the correct answer for the previous question? Does it not come up on the? Oh, am I supposed to click answer? I'm sorry. Um Albo uh um the answer won't show on the end. So you sort of have to explain what the answer is. Okay. Sorry. Oh, sorry. I thought the answer came up automatically. That's why I've been rushing through. Okay. Cool. Um I don't have the answers with me, but I'll try to go through the most. Well, right. So do you guys have the chat for this one then I think? Right. Let's go back then to last question. So he comes in with difficulty swallowing solids and this is question five. Now, I don't know Lucas, which one are we on? Um One second, I'm just checking. So if you check the power point that I sent you, there should be the answers in the notes section. Uh Under present the notes Oh, this is what you said. Yeah, I think it's, it doesn't keep track of the questions versus answers. But, um, right. Uh, should we go? So, this is question, right. 65 year old man presents with difficulty swallowing solids. Okay. Um, okay. It doesn't come up because, but we can, we can just wing it and see how it goes. Um. Right. So the most likely, um, diagnosis would probably be adenocarcinoma seeing as he has a background of God, he's male, he's lost weight. So all the signs of um kind of weight loss and cancer and he has hypertension, hypercholesterolemia and diabetes. And the previous Barrett's esophagus, which can turn into cancer. I hope that makes sense. So that's question for you can do question five and I can stop the poll now for it, if that makes sense, 56 year old man comes to the G P and he has a long history of heartburn that was treated by G P. Um He has been treated with PPI but that's still constant. He's more than 55 which is the cut off age for the NHS. So the answer to this one would be a two week referral for an O G D just because it is like uh urgent symptoms. So it's more than 55 you refer for a two week. I hope that makes sense. And then we can see how this goes more. So esophageal cancer. Um A demo carcinoma So happens in the low one third of the esophagus. Common risk factors include good obesity metabolic syndrome. So like question for was kind of talking about. Um it's much more common, especially now with kind of obesity and gold going up, especially in western countries. Treatment depends on search line if possible. And then chemo and radiotherapy if it's stage four surgery is not indicated and you do kind of alienation and kind of stenting as well to see if they can still eat. You've got Screamers cell carcinoma in the upper esophagus, which can be due to smoking alcohol, nachos. Um It's red meat. So you sometimes found especially in like southern Asia countries due to hae diet of like fresh and like nitro Sammons, which is quite cool. Um But it's less common. So question I've lost track now but questions six. So a 54 year old when I go to the G P with heart ban, epigastric pain, the pain is just worse just after meals. She's able to swallow solids and liquids normal and does not have any other symptoms. She's otherwise. Well, you have no past medical history of any note and does not use any regular medication. The GP advice is otc antacids but she returns four weeks later with no improvement of her symptoms. What is the next best step? So we got four week trial of omeprazole. So PPI start long term raNITIdine. So refer for endoscopy, continue anti assets or H pylori serology testing. Okay. So I can wait for a bit but wait, let me close the pole. Right. So I haven't closer cough but we can continue as we go. So for this one, the correct answer would be a four week trial of Microsoft. So PPI raNITIdine is really, is like one of those H two are a no longer used to, to, it was a link with cancer made. So that one is not normally made. Um Each biology serology testing would be done if the PPI S were not offered. And like if the PPI S did not work. So anti assets is normally things like Gaviscon which cooked your, they work rather than inhibiting like the PPI like the H plus secretion into your stomach. They work by kind of doing a covering after you eat a meal where it's a PPI actually work with like the actual stomach acid. So I hope that makes sense. So after the PPI, then you would do the H pylori pylori testing effect and work. So, next question and each pylori test came back positive, which of the following is the most appropriate treatment. So you got PPI Metronidazol Theft, Triax on PPI plus Metro, PPI plus Clary plus metro PPI plus amox plus metro PPI plus co one box. So we'll just wait a bit cool. All right. So the correct answer is normal triple therapy for H pylori. So PPI plus are marks plus metric. Um I think the second line you can do. So people are kind of penicillin a logic. You don't use amox, you can use. Um I think you can use Claritin mitten and Metronidazol instead. So I hope that helps. Uh so normal triple therapy PPI just to cover the, the stomach and then two antibiotics, which of the following features would be an indication for urgent upper gi endoscopy. So, hemoglobin of 85 epigastric pain, um fresh red blood in the stool, positive H pylori test or vomiting, we'll just wait a bit kind of waiting for the territory responses like there's around 50 view. So I think once we get to like 35 we can close the pool. Mhm. Oh and then at the end, we can also go back to the start and I can tell you guys the correct answers for those ones too excited to realize. Um So we can stop the poll there if that's okay. Um So the correct answer would be a human blooming off 85 just because that would share anemia for both men and women. Um We can go through the rest of them. Epigastric pain. You can happen a lot of cases and I think you would do kind of first line other things like testing for infection, testing for, I don't know, appendicitis. If it's referred pain, there can be a number of course, is fresh red blood in the stool. You would kind of think probably a bit more kind of either hemorrhoids or if it's like really red or kind of black stools, you would think more like a colonoscopy, positive H pylori test. First, you would try eradication of H pylori and then if that doesn't work, then you would do a gi endoscopy to kind of check if there's any damage but definitely not urgent vomiting. Um mhm. No, unless you thought vomiting was kind of youtube like um of ruptured fairy stays like from kind of never like alcohol and take um high like intra portal hypertension and things like that. So I hope that makes sense. Um Right. More questions. Question 9 45 year old patient presents with recurrent epigastric pain. This is typically worse when they are hungry. They say that they have already tried snacking as this helps with the pain. This means they've gained a bit of weight with the most likely diagnosis. I feel like this was me during exam time except I had no pain. I was just constantly hungry. So appendicitis duty know also gastric also or liver abscess. So I can see everybody's deciding between duodenogastric which is good. Um Just wait a bit cool. I think we can stop the ball that so the correct answer is a Judy know also um the way I thought about it was so in your stomach, you secrete um kind of the gastric acid and that normally collects at the bottom especially when there's nothing. So when the stomach is empty, collects at the bottom you got, and also there is going to be more likely irritated when this you got gastric secretions and they're all collecting at the bottom. Gastric ulcers are normally like at the top of the stomach. So there's normally only irritated when you're eating something is all getting digested and mixed up and the food actually touches the top of the stomach. So, do you, do you know when you're hungry? Gastro, when you're actually eating? And yeah, appendicitis and clear perhaps is hopefully know. So when is screening for bowel cancer offered in Scotland slightly different than in England? So this is quite interesting. Um, 52 74 years old annually, 50 to 74 60 to 74 annually or biannually. Interestingly, you can actually request it whenever you want to. Um, hi, it keeps cutting out for some reason. Does it keep cutting up for everyone or is it just so is it my wifi? Ok. Cutting up to me? Oh, sorry. It might be yours. Um, ok. Back to the question guys. When is bowel camp, uh, bowel screening, bowel cancer screening offered in Scotland? Okay. I think we can try to stop the poll there. So the current Act answer is 50 to 74 year olds bi annually. Um, in England. I think it's slightly older. So, I mean, I think it might be 60. Um, and I always think that Scotland just has a larger demographic that can be affected by bowel cancer due to like lifestyle. Um So that's the way I thought about it. Um So we can go through this perhaps your management and kind of the questions. Um So when somebody goes to the GP, more or less, no more new messages, um sorry, there was no question. It's just we're just going through the diagram. So first thing you should do is is their alarm signs that say we kind of talked about anemia but also kind of weight loss. And so can't any cancer changes. Um tightness, etcetera. If uh they're less than 55 there's no alarm signs, then you try lifestyle changes. That was so weight loss, smoking cessations, more regular meals. You can also put some pillows in bed at night, weight after eating Boit irritants such as alcohol, coffee. Unfortunately, Chock, it's NSAID and calcium channel blockers. So you can change the medication that you're on as well. Um, remove any triggers and OTC over the counter anti assets. So we've talked about Gaviscon and review in four weeks if this is not resolved. Then second line test, like we said, it's H pylori. If it's negative, you do PPI or H two anti assets mainline is PPI and then if that's not resolved, then you try even a longer course of treatment and if not, you do upper gi endoscopy, if it's positive from the start, then you do the eradication therapy we've talked about. So the PPI in the two antibiotics and then review after four weeks, if they're positive, then you do the H pylori test. Um And then if that's negative, then you do an upper gi endoscopy because you definitely think there's something a bit weird going on there that the bacteria are able to last that long and not be eradicated. So, district your alarm symptoms. So this is a good Pneumonic I, which I had known I always sort of fills anemia, um cancer symptoms, so, loss of weight um and swallowing difficulty, but here is anemia, loss of weight, anorexia, recent onset or progressive symptoms. Molina hematomas is so melena, if you find blood in your stool, mama's is if you're coughing up blood and swallowing difficulty, I think the slides will be sent out or available. Lucas correct me if I'm wrong. But so don't you guys don't feel free to take like any notes? Um Timelines, very G D referral if it's not urgent, if it's so like six weeks, if there more than 55 year results. And so I'll finish it, I'll read the side and then we can do the question. So, more than 55 with treatment resistant dyspepsia, other abdominal pain and lower your hemoglobin. Or if they've got high platelets and any of neat uh nausea, vomiting, weight loss, reflux dyspepsia, appar abdo pain. Basically, it's a weird combination and some, the guidelines can be found on the Scottish like cancer referral guidelines. I wouldn't recommend to learning all the like different combinations because you can go a bit crazy. But I would definitely learn the alarm symptoms and the two weeks referral. So dysphasia and or more than 25 years old with weight loss and one of the upper abdomen, plain reflux or dyspepsia if that makes sense. And question six was the answer H Pylori test will give them episode. Um Let me try to find what was question six. Um Oh, uh So it was off for a four week trial for meprazole. And then if that doesn't work, then you would do a longer, even longer course of PPI and then if not, you would do h-pylori serology testing. I hope that makes sense just because they had, they had symptoms of reflux, but they didn't have. Um So if we go back two, the, oh, that's a bit weird if we go back to the question. Okay. So she came in with heartburn, epigastric pain. The pain is just worse just after meals. So, symptoms of reflux, she's able to swallow liquids, solids and liquids. So there's nothing to do with the esophagus. You, you're not thinking anything with cancer and she's otherwise. Well, she's tried over the counter antacids, but then returns four weeks later with an improvement of her symptoms. It's not more than 55 it's got no alarm symptoms. So you would then go for PPI and if that doesn't work, if they need to start to worry, there's something a bit more weird going on rather than just plain reflux. Yes, sir. The diagram says H Pylori, I think so. The diagram is more than 55 or alarm symptoms. Um Yes, the diagram is slightly not incorrect, but I think is talking about doing over the counter anti assets and I would adhere PPI most of the time, especially for GPS. And then review if that doesn't work, then you can go to H Pylori testing. I hope that makes sense. Sorry about that. So if that wasn't clear, lifestyle changes removed the triggers, Gaviscon PPI more P P I H Pylori testing. So, cancer of red flags. These are, I would then once again refer you guys to the national like cancer referral pathways which are really good for. They go through kind of um pancreatic cancer and they show you the symptoms and they go through the whole body like top to toe, but we can go through this too. So over 14 emptiness progressive jaundice, you would think of carcinoma, head of pancreas until proven otherwise. And they need an urgent two weeks for a while just because it can be quite bad, palpable liver mass, you need unexplained, um palpable unexplained liver mass, ultrasound in two weeks. Um colorectal cancer. If there are over 40 unexplained weight loss and abdominal pain, or if they're over 50 and explained rectal bleeding over 60 iron deficiency and email changes in bowel habit. Um, I've been focusing, especially the 1/60 especially because older people don't get I B S. So it was an elderly person comes to the stomach problems and thinks that's due to kind of stress is worth investigating and tests show a cold blood in the feces. So, we've talked about the bowel screening program. Um, and I'm not sure if I don't think we go further into it. But what you do is basically send a sample of your poop and they check for any like microscopic uh blood and if you can do it as a G P or you can get it sent to your home address too. I hope that makes sense. Right. We're moving on further down. Um So which is the following most common cause for cities, cancer, cirrhosis, heart failure, renal failure, reduce album and synthesis in the lip up. And once again, when you think about it might be a bit different in sight. Um Oh no, we've moved on which is the most common cause of that city's cool. Um So I think we can stop the poll there. So you guys are cracked a roses is the most common cause of facilities just because cirrhosis can be caused by a number of things that can affect the liver, ranging from mainly alcohol but also medication or two immune things infection. The list goes on. So, anything that affects the liver cancer as well. Um but cancer in itself um needs to do kind of liver cancer, not just cancer in general, heart failure and renal failure can sadly cause it. Um and reduce album and synthesis and liver will be as kind of as a result of cirrhosis further on. But they're less likely you're more likely to get other symptoms, faster heart failure, especially kind of pitting edema, those legs renal failure. God, I'm just on the reno and now and the royal renal failure, you're more likely to get bladder and also many other problems apparently. But serosas. So liver is the first one in terms of treatment of societies, which one is the first line treatment. So S inhibitors, hypertonic saline furosemide, spironolactone or basic present. Now, that's a very quick replied by a bill. Cool. So spironolactone is correct. Um So in aldosterone antagonist, um well, this is still cooler. Um I'm not sure if we go into it further on, but it's for an elective acts on both the kidneys and that's a feedback mechanism of the angiotensin protected to system. So at least a lower accumulation of fluid in general. So acting as a bit of diuretic um furosemide you wouldn't use because it's a loop diuretic. So it doesn't work as well and it might lead to kind of electrolyte imbalances much might much more than spirinolactone. Vasopressin is 80. The anti anti diuretic hormone. So it makes you not be. So you would accumulate more food and ace inhibitors is more with heart failure rather than ascites. So this is a very complex style dividing the various courses of abdominal pain. You can divide it into kind of these four areas. But you can also do in the way you guys were taught probably from the start of the nine different areas. There is overlap, but it's important I've admit um especially if there were women. So that was quite important to add or they're kind of gynecology, cool issues if they've got exercise. So something's might point you towards. Um so cirrhosis if they got a kind of spider knee by things like that or, you know, sometimes they say lots of her um splenic disorders um or pancreatitis if uh formatting loads, um chronic pancreatitis, if they got other signs, things like that. So there are various thanks and it is important why they can be found not going to try to read them out. The slides are tiny. Um courses of societies that may more like we talked about the cirrhosis cancer. So liver cancer can lead to it. Heart failure TB can also cause type of societies dialysis, especially if you talk about peritoneal, also done through his stomach pancreatic disease and other causes. Sit versus um this is kind of the mechanism behind it. So it can lead to portal hypertension leading to ascites at least decrease intervascular volume leading to renal sodium retention and increased volume, which is where sparing, electing ads on it can cause peripheral material, basal dilation. Also an increase in traverse volume or leading to just increase blood volume in general. But the body doesn't register it start if that makes sense. Societies management. Um You do firstly on a to eat just to make sure they're okay and they're able to breathe more than anything just so it's not causing pulmonary edema as well. You've got no threshold for IV antibiotics because of the complications that I think will cover later on. But so you might give them, I'd be the food trucks. I mean, I can't say that uh if SVP you talked about it here is suspected you can do an ascites, tap and sample fluids, the most common organism, this echo light. And I think you need to find more than there's a specific number of neutrophils that you can diagnose it. So I think it's 100 and 50 but it might be worth checking. Uh life cell uh factors. You would restrict sodium and ask them on a low potassium diet as well. You would give them diuretics. So, spironolactone's first line furosemide if more serious, but you commonly use any combination, worse case scenario. Just talk about societies. You can also do uh portal shocked. So kind of join um kind of bypassing the liver essentially. And that can be done also for various is like more esophagus but it can also be done if a site teeth is really bad. Right. Question. 13, 34 year old man comes to a new complaining of pale stools and dark urine for three weeks is a long history of alcohol excess on examination. There's ankle and abdominal swelling, heart rate of 93 BP and 90/60 in, in an abdominal ultrasound for this likely to be observed. We were just reading it. It seems to be a competition between the top one and the bottom. All right, I think I'll close the pole then. So the correct answer is small liver and large Spain. Yeah, you guys have all understood. It's the enlarged screen that's causing the main problem. But the history of alcohol access would point you towards the small liver. Um So roses can work in a way that at first it can cause uh shrinking of like kind of due to this kind of toxic nature, it can actually cause delivered to shrink and then once it cells start to proliferate again and proliferate and cause the roses, then it can cause. Um hypothetically, I hope that makes sense. Uh But the main key thing here is the pale stools and dark urine for three weeks, uh which is caused by the enlarged spain. He's been diagnosed with cirrhosis, which of the following treatments is more important. So, proof from been alcohol, abstinence steroids, counseling or antibiotics. So I can stop all the. So the correct answer is alcohol abstinence, correct if they wrote us is causing this problem. So the main thing you can do is stop drinking, which is the cause of the problem. Um Alcohol is actually the only drug you can't stop like t total. So, um he should be given, have Dia sopon. Um you can go through that. Uh he can be given kind of like dyas upon um popper next. So to replace all the vitamins that he's lost, if you're making somebody go through alcohol abstinence, you should probably give them counseling to prefer. At the same time, steroids can be done for a kind of autoimmune um autoimmune liver and it can also be done for cirrhosis, I think, but it's much later on. And the most important thing is the kind of to stop the trigger that is making the cirrhosis. So alcohol abstinence, there's no sign that he needs to replace liver factors. So prove prove from him there's no need for antibiotics because he doesn't seem to be infected with anything. Why is the amount has been the main problem here? Sorry. So portal hypertension. So the pale stools and dark urine when there's been enlarges, it impedes on the bio duct. Um it to say impeding the products. Yes, it does because then you don't get bilirubin cannot be metabolized. So then you got pale stools and arguing the least the bilirubin goes through €2. Build a village in as Well, I'm not sure if we've got the pathway here later on. I hope we do because it's much. There we go. I hope that makes much more sense. We can go through it. So do answer your question tiny bit earlier. The spleen is a problem here because there's a mechanical biliary obstruction leading to kind of, you don't release uh, bio isn't bilirubin congregated in the liver. It's an contributed liver, of course, is pale stools and dog urine. Yes. But the un conjugated Philip Rubin also goes into your regular Juve in in the urine. Hence the dark urine. Sorry. Is this making any sense? Does that make sense? Why it's the screen causing a problem and causing obstructive joint? Is it's all next to the most sense, right? I hope that makes sense. If not, we can go back to the questions. So, question 15. Yeah. 35 year old woman presents her G P. After telling yellow, her medical history involves severe Raynaud's disease. She states that she is also very sensitive to some has a problem with intermittently swollen joints given the likely course of uh jaundice, which is the following test beyond LFTs, which an isolated with elevated bilirubin, which test will also be done initially to help investigate this lady's jaundice. Cool. So I would say this question is a bit tricky. Um So let's just focus rather than the history in itself to help investigate the course of the jaundice. And then we can go on to what you may actually have your Tomlinson's. So maybe you can stop the pole then. So the correct answer to investigate the ladies jaundice would be to do a full blood count use and these bloods mail and direct Coombs test just because you want to check for humanizes as well. So humanizes can lead to more bilirubin being produced and therefore turning yellow. So just a likely more like more delivery than production. Um I agree that there is a need to do anti centromere of antibody testing here just because it looks like you might have like crest syndrome. So the calcinosis re nords um suffered you'll and then is it what is the tea? Yeah. Um But when you're investigating jaundice is important to the direct Coombs test before anything else? I hope that makes sense too. Um So here we can talk about kind of the different courses of jaundice. So, prehepatic intrahepatic and prehepatic prehepatic can be due to human license of what we were saying. So G D G six PD deficiency sparrow cytosis or an effective every through paralysis. So either loads of blood cells being broken down or the blood cells that you do have are not good enough for centuries. So, thalassemia or pernicious anemia, vitamin B two are deficiency, you've got other symptoms to do with that one too. Um uh No, I can't really explain the cream test. I think what you do is check if the thing's aggregate or not. Uh I don't think we'll be asked to interpret accuse test or at least I don't think we were, but I'm sorry, I can't explain it. Um, intrahepatic uh jaundice. You do non obstructive biliary disease. So, hepatitis cirrhosis PVC and then mechanical biliary obstruction, tumors of the liver intrahepatic Goldstone's or PSC, perstorp, attic, um bile duct obstructions, cola low Theseus. So, stones information or malformation, which is quite better, right? It John does which is the century high bilirubin. Why you turn yellow, you can have indirect or direct. This is another way of kind of looking at. So within the actual intrahepatic jaundice, you can have this is a different way of explaining the previous diagram and sometimes they're different, they're different things work. So more bilirubin production. So humanizes Huma Touma. We've talked about ineffective for rueful breezes, impaired conjugation. So most of the time these are genetic and found in neonatal. So most of tankard nature don't really survive. Gilberts are found in people that either when they get under lots of stress, ill run American then data and yellow. It's a noticeable recessive condition which um is fine you can do for that or do two more than have like lower hepatic intake. So, heart failure, portosystemic chance. So things that we've talked about salt varies is or drugs suggest revamp Athene which affect the metabolic activity of the liver direct conjugated. Uh you've got intrahepatic courses or extra hepatic external strictures all in one. Uh I would focus on the ones that are kind of stones, parasites. Maybe you can usually autoimmune or cancer, especially with the pancreas and ampullary, which was the last bit of the pancreas. I hope that makes sense. I didn't make these sides that I don't know what this means. Um So we can skip past that if that's okay. Let's talk about from my primary biliary college ITIS which is important not to confuse with ps uh let's see. So primary biliary cholangitis pasta has a good, great way of remembering this one which is to the rule of the ems. So most of the time is um I, so I am a antibody and smooth muscle antibody. So just think of the ems. Um you got association with uh basically autoimmune diseases and the mainly female examination, you can find some something asthma's so hyper across from ST me around um clubbing part, it's Magaly investigations. You were to reveal following antibodies and you do an MRC P to exclude biliary obstruction. And E ERCP would be that's the difference between M R C P and E R C P M R C P is used for PBC, whereas E ERCP is used for PSC management is your diastolic asset for the itch. You give Colas Jeremy and then they are at risk for hepatocellular cast members. It's important to keep an eye out. So it's important to differentiate between PBC and PSC because for PSC, you don't give them the, you diastolic acid because that makes no difference and they don't have the same associations. And whether you start off with M R C P, you can then progress to do E ERCP. This is mainly found in males. Uh, the risk factors with UC and crims HIV. You got the same type of, uh, symptoms sometimes. So right up according pain, fatigue, collar status, but the investigations share a P ANCA which is also found in, you see as well. Um So that's uh and this is a good table to kind of show the different things. Sorry. Could you please repeat? Yeah, M R C P and E ERCP, it was explained to me that you used M R C E P to diagnose and E ERCP to treat. You don't really need to know that much detail. Um But MRCPI would be used for PVC and like high cases and PSC would start off with M R C P then ERCP if you needed to treat, I hope that makes sense. Cool. So next question and we can take a break at seven just because I like my throat's very, very dry and then continue. So 46 year old woman presents to the emergency room with an episode of Mattis. Is she is transferred to Reza's BPS. 100 and 12 80. His heart rate or her heart rate is 100 and 10 BPM. Breast rate off 16 CRP less than two. She denies that dough pain on Molina. She has no past medical history. She's given to large whiteboard IV, Cannula and Plasmalyte. She remains stable with pulse chopping to 100. Her bloods come back. Timothy 11, normal MCV, normal white blood cell count, normal platelets, normal urine, normal Kratt. Any normal. But what is the most important appropriate next step in management? Mhm. All right. Maybe we can stop the. So the next appropriate step. So first of all, we wouldn't do the song steak in big more tube. That's very kind of uncontrolled cases of bleeding. If they're completely just non stop bleeding. And you think it's more like a rupture to esophagus. Next one, I don't know how to explain this the best way. So it depends on what you think is the cause at the moment she's got no past medical history. So you don't think is gastric ulcers and you don't think is various is. So at the moment, you wouldn't really give her IV PPI and you wouldn't give her IV tail depressant. What you would do is wait, it's not that urgent and you would do an endoscopy within 12 hours. I hope that makes sense. You can use a Glasgow school to determine if the endoscopy needs to be done urgently or it can be done within 24 hours. Our patient's because she seems stable. Um She's got like no abdo pain, heart rate like BP is a bit low but then it comes back up, heart rate goes down or her investigations are normal. Urea is not high. So showing there's been like no, um how do you call it? Like new blood cells have gone into the stomach and have been processed. Otherwise that would rise, then you think she's more or less. Okay. This has been one episode of matter assist and she does need an endoscopy but it doesn't need to be urgent. Now we can talk about suffered. Your various is in which case you would have done an IV tail a present. So these develop in most patient's first cirrhosis and as a complication of portal hypertension, only one third will bleed from them. You do your 80. So make sure all that. Then you give fresh frozen plasma. When would urge an endoscopy be carried out? How many hours? I think it's under 24. That might be less. Yeah, I think it's our patient 24 hours treatment. You give proper channel prophylactically and you do the endoscopic varicies allegation entirely present infusion at the same time. The that weird name tube for uncontrolled bleeding and tips to the transgender intrahepatic portosystemic shunt for chronic cases that haven't been solved and continue to have ligation that continue to have bleeding despite ligation, Propenerol and all prophylactic and alcohol absence as well. The BMJ has a really good summary of what to do with upper gi bleeding. Um I think here you guys can see the Glasgow Blackfoot score, which I was talking about. So if your total score is 0 to 1, then you can do endoscopy an outpatient clinic if score is more than two. But the hunt human dynamic in police stable, they will, they will have a different path line. It's a PPI um or and baal ization surgery or therapy. Um I would have learned the scoring system. I would just no more or less following your gut if they look relatively okay and then they are okay. S outpatients. If you think they've got risk factors, then um great more arginine. Cool. Correct. Maybe you can just pull through 42 year old abuse woman completes of an episode of modern and intermittent right upper quadrant pain lasting 30 minutes which radiates to her shoulder blade. She usually start shortly after dinner. She stressed at home looking after two young Children while her partner works abroad, she's otherwise. Well, an abdominal examination is remarkable. Bloods were no more than you discuss further investigations with your senior. So what do you think is the most likely diagnosis? Acute Collinge Collinge itis Judy, not also cute class cystitis Biliary colic or God. And let me just quickly grab a coat whilst you guys answer this question. Magic. Cool. So maybe you can stop. Uh So the correct answer is biliary colic. So we can take away good and do do no, also scored. She has no reflux. Do you do know also because we've talked about it's pain before, like before you're eating and then the difference between biliary colic, acute cholecystitis and acute Collinge itis. So, biliary colic happens intermittently is not only the future of uh the five F. So I'm not sure if you guys will talk about so female fat, 40 fertile and fair. Uh So Scottish scare. Uh sorry, I'm not reading too, I'm sorry if there's many Scottish for you for the group there. Um Then acute cholecystitis is inflammation of the gold bladder normally caused by a stick. Although it can be a calculus, but that's very rare. And then acute cholecystitis is infection of the bile duct and sometimes the gold bladder, um sometimes due to a stone, but other times can be caused by other stuff. So I hope that makes sense. So here, uh if we see it as intermittent rate up the courting pain, she's got no other symptoms, no jaundice, no fever. So it can't be acute cholecystitis, acute Collinge itis, right? An ultrasound scan confirms the presence of gold stones in the gallbladder. They're non in the common bile duct. What is the most appropriate immediate management? So, would you do nothing conservative management only? Would you do an immediate cholecystectomy IV fluids and algesia and then a laparoscopic cholecystectomy. IV fluids, cholecystectomy in two weeks, time or IV fluids, analgesia and whipple's procedure. Two cool. So, maybe you can stop them. So, I'm glad none of you went for the whipple's procedure because that's kind of taking up the head of the pancreas and several bit. So, a bit of an extreme measurement and we're actually dealing with the problem. Um, so the correct answer would be that, uh, you give IV fluids, analgesia and you can send them for a laparoscopy, uh, cholecystectomy during this admission. Um, the difference between, so you wouldn't do nothing. Um Because she has, if we look back to the history, she has been getting intimately right, upper quadrant plane, this has happened recurrently. Um You can't just do nothing. At least you would and even pain medication, it's not really going to solve the underlying problem once you got um, stones in the gallbladder is very likely that they go on to move and then create fellow problems like acute cholecystitis or acute common Ghitis. So it's better to just get rid of the gold bladder in general. Just yourself issue. You don't need it immediately because it's much better to plan ahead surgical operations. So that's why um you can wait a bit, then consent the patient and then like explain the procedure and go ahead. Um You would do a laparoscopy and you can do it in two weeks time that has just been shown to the sooner, the better essentially. So it doesn't need to be urgent, but it, it's just better to it right then why does she need floats? I don't, I think for, it's, it's something you give to everyone that comes down this century. Um, I think if you're going to, um, so the answer to this is, um, IV, fluids, analgesia and consent for a laparoscopy cholecystectomy is. So the third one, if you're going to start somebody and give them surgery, then you would probably give to put them on IV Candler just because you won't be able to drink before the surgery. So I'm guessing that that's why they went for IV folks. Um Yeah, exactly. Presumably going nil by mouth for such a cool. I hope that makes sense. Um So question 19 53 year old female care home worker assistant compares of increasing debilitating fatigue for six months she believes and maybe her hashimoto's. So she wants to discuss altering her dose of levothyroxine. Further questions. She real, she's also been experiencing an occasional severe itch on her limbs and torso. She denies weight last night sweats and no other symptoms of net past medical history includes Cash Motors disease, mild asthma, couple tunnel syndrome and sub total hysterectomy. Medications include live with Arabs in style, beautiful inhaler. She has no known drug allergies, nonsmoker and drinks in the occasionally infect the order range of bloods and her results are shown below. So T four is normal. TSH is normal A OT, the A S T to A OT ratio is elevated alkaline phosphate ease is elevated to bilirubin is normal. So she's not druggist and G T U. It doesn't give you, I think, but it's normal album and is not given, but it's also normal given the diagnosis. Which of the following is more likely to confirm. How would you check the diagnosis? Um Oh, and it's in this admission, the laparoscopy um cholecystectomy. Cool. So which one this would most likely confirm the diagnosis and my antibodies, endoscopic retrograde cholangiopancreatography, anti LNK antibodies, upper gi endoscopy or the M R C P. So, which is most likely to confirm and thinking about being less invasive and the fact is diagnosing not treating it. We'll just wait for it. Cool, maybe we can stop that. So the correct answer is ana antibodies. So um this is probably a likely diagnosis of um primary biliary cholangitis. So we've talked about um the Emerald. So I G M S M A for it. Anti RMK antibody is normally found in autoimmune hepatitis. Uh So she would normally higher have a high bilirubin, she would have debilitating fatigue to be fair and a history of fort immune disorders. But um she would mainly have like hepatic center and like symptoms, no upper gi endoscopy good. And then you wouldn't really do E ERCP or MRCPI at this stage just because we're thinking about likely diagnosis. Simple first line investigations you would do if it was for diagnosis, then you do M R D P treatment would be with E ERCP, I hope that makes sense. So here we have the five s that I mentioned the female fat 40 Fattal fair focal focal stones. It's good to know the different names. So I always used to get this confused. So colored lithia sis's stones in the cold platter. The other one which I'm not going to try to attempt to say is once they've moved on to the bile duct. So from the gallbladder to the bile duct, the gallbladder, they can cause problems but is in the bile duct and they can become uh lodged and then causing a problem like further problems even though like leading to infection and information. So crosses slightest and Collinge itis. This is a good table showing all the different okay mechanisms, clinical features, lab finders, diagnostic and treatment. So for example, we've talked about um colelithiasis. So we talked about that woman that had read up accordion pain parent, she had normal lab findings and then what we did for her with analgesia, an elective cholest septa me. Um I keep cholecystitis. Uh you would give supportive care and all Jesus IV antibiotics and cholecystectomy. Again, acute Collinge itis, you're thinking about the chocolate triad. So right, upper quadrant pain fever and jaundice and Raynaud's spent add so all of those plus hypertension and kind of mental status change. This one is much more severe and you need to urgently decompress the biliary system. So first you do you essentially do nothing. You give IV antibiotics and you decompress and then you do a cholecystectomy further on um how I viewed it was very colic mild acute Collinge itis extreme and learning chocolate strad and Raynaud's pen toed any anything in between colecystitis. So perhaps a bit more. This was why. Um So does anybody know what Murphy sign is? I can wait to put in the chart but not. So um when you press, I feel like I can't show. Yeah. Yeah, I feel like I, I can't show it but like, yeah, when you press on the right upper cordiant uh yep pain when asking them to breathe cool. Uh So that's important to know um because they will probably ask it on kind of any examination. So patient with a history of Goldstone's plus cents with acute upper gastric pain uh along the back along alongside nausea and vomiting, given the most likely antibiotics uh diagnosis. What is the most important next step in management? IV? Antibiotics. IV calcium replacement. I'd be sorry. That was questionable. Irene magnesium, I be plasmalyte for E ERCP. So we can just wait a bit more cool. So um what we're thinking here is pancreatitis, right? Because of uh epigastric pain and radiating too bad with nausea and vomiting. Um The thing here with IV calcium replacement is they normally have low calcium, which is why sometimes you try to replace that. You shouldn't really play around with it and they've got electrolyte disturbances. So I do magnesium E ERCP would be if they've got. So, the correct answer here is I be plasma-lyte. You don't really do anything with pancreatitis. The only thing you can really do is wait for them, nail by mouth, make sure they don't eat and give them rows of fluids and hope the pancreas calms down and stops. OK. Digesting itself just the century what it's doing at that point, you wouldn't give IV antibiotics because they don't necessarily have an infection. And that can actually aggravate the pancreatitis. So you just need to wait and see. Is this the same for acute and chronic know? So for chronic chronic pancreatitis mainly found in elderly, they, so if you would think of it, it's like new onset diabetes that we really thought. And um for example, nuan nuances diarrhea or like due to being enable. So if pancreas has two functions under crying and extra crime, um I can go into that question later if they cannot perform jury structure, it's like in the long run, you would do chronic chronic pancreatitis, you would give them um you would give them Creon, I think it's Creon. So things that all the enzymes that the the pancreas normally produces, you can give it to them. Um by like eating, uh you make sure they get loads of like vitamins that are fat soluble that don't normally get absorbed and you give them good glucose control you also give them an Al Juicio because apparently it's quite painful. How do you know, is pancreatitis over acute cholecystitis? So I think it's particularly the history where assess radiating to the back. So, pancreas is retrosternal. So that's why most of the time if you got information there is going to go to the back where is acute cholecystitis is more at the front in front of your intestines. I hope that makes sense. So the pain would probably refer that way. Um Yes, and it's also a pill gastric. That's a good point. Cool. I think that makes sense. Um So which of the following test is more useful in the assessment of pancreatic exocrine function. Well, I should probably read this before 100 before I start talking about endocrine and extra brain functions. So three day fecal fat test vehicle last days, abdominal ct you fasting blood glucose and lactose hydrogen breath test. Okay. Cool. Maybe you can stop that. So the answer for this would be fecal last days. So we talked about the pancreas having exocrine and underground functions. So, exocrine um even though it's counter counterintuitive extraprin is when it goes in the intestine, endocrine is when it goes into the blood. So, endocrine would be things such as insulin and Glucagon. So you would mention fasting blood glucose for exocrine function. You think about digestive enzymes. So here you would measure vehicle last days, the lactose hydrogen breath test is to measure small bowel bacterial overgrowth just because the bacteria produce hydrogen and that could be measuring your breath. So answer for this one is speaker last days that makes sense. The acute pancreatitis severity prediction can be done by the modified Glasgow criteria. Once again, you guys don't need to know this, but there's sometimes interesting to note like the correlation. So think about elderly high neutrophilia even though there's no infection, uh calcium problems, renal function, liver function and sugar plug glucose. So that's been dysregulated. So all those can give to like a severity prediction. Um The several courses you guys must have heard of get smashed before. I think it was drilled into us. You never see a scorpion venom bite. Um but it is important to note most common is Goldstone. So ethanol uh steroids. So think about medication that it might be on steroids. And I think also another list of drugs that can cause it. You also need to think about courses that can be caused by us like I tra genic. So E ERCP is quite an important one and why we don't do it first line for many things. So that's why MRCPI is done for diagnosis and you leave it at that and it's only an extreme events where you do want to remove the Goldstone that you used ERCP just because it can irritate the pancreas and also mumps and kind of Children or adults. Um cool. So acute pancreatitis column sign and greater than a sign. Uh I had a really terrible way of remembering this, which column sign like Edward Cullen and Twilight. So I thought of like vampires like in blood and that's, you know, around the umbilicus for some no reason that reminded me of that angry Turner's run to the side. These are quite late. So you will probably like late signs. So you will probably never see it in the clinical practice. Quite cool management of acute pancreatitis. So re said a two e know by mouth and I be floats and large volumes, analgesia antiemetics, antibiotics preserve for later line only of high fever and science suggesting localized infection. So common side and but occurs. That's quite Kulti. Um So antibiotics after pancreatitis, you can have several problems such as like um abscesses within the pancreas that can then get infected. So I would give antibiotics for that. You can also have um hemorrhaging with the pancreas. So it's important to keep an eye out for that start over or diet as soon as possible because you want to get things moving and if related to Goldstone's, then you do a cholecystectomy. So thinking again back to port like the pathway of biliary colic and everything like that. I hope that makes us so more questions. Um We're nearly at the anti promise you guys. Um A 20 year old woman visit her G P for the last month. She has been suffering from abdominal pain, which is worse in the right iliac fossa. She's also had diarrhea for the past month and has had to run to a, to a few times, but it's never been incontinent. Her girlfriend thinks she's been, she's lost a lot of weight too, but she doesn't regularly weigh herself so she can't be through, she denies nausea, vomiting, dyspepsia, abdominal distention and does not recall seeing any blood in her stools on examination. You note an ulcer in her mouth and a tender abdomen, swollen tender lumps on her chips, which of the following investigations would definitely confirmed the diagnosis. Uh So no need to further investigate as it's a clinical diagnosis, clotting screen, fecal coal protecting, ct colonoscopy and colonoscopy and biopsy. Was there just a tad more? Um So they just uh cool say the correct answer here would be colonoscopy and biopsy. So you you fecal cold protecting would be useful to determine to exclude other things, but to definitely confirm the diagnosis, you need the biopsy particularly. So then you can look at all the changes that can be done and we can look at the difference between UC and cranes later on. If you only do a CT colonoscopy, you might see like all the in temptations and you might see signs on it. I'm not sure if the I don't think the slide has pictures of the two differences like the cobblestone and the ulceration, but that's pretty cool. Um And you do need to further investigate because you can't just do a clinically diagnosis. There's many things from celiac to you see two creams. I hope that makes sense. Um So this patient is referred to a gastroenterologist and the diagnosis of current disease is made which of the following is used to induce remission of mild creams so we can stop the poll there, right. So this one Crohn's to induce remission the way I remembered it. Um I guess you can use bread. I think what the question was trying to do is currently like, well, do you guys know that don't Dennis side is also a steroid. So for cranes, you use steroids to induce remission fast line, you can then use other more like intense ones like masala seen and methotrexate. And finally, you can do use inflicts math or all the autoimmune regulators. If it's very severe. Um, so maintaining remission, then you would use a thought I print or methotrexate. In comparison. You see to induce remission. It depends about where a where point in the like ballot is. You've only got the end, then you can use topical. I'm in a salad side if you've got so like proctitis, I think it's called if you got the further up the bowel, you go. So after you go back, then you need oral and then you need like actual medication. So high dose like, I mean, your salad sides oral and a topical and corticoid steroids to maintain remission for you. See, you use um um it's Allah sites and then, and then you can use apple Cider brain. I hope that makes sense. I think there is a table later on which will hopefully, which of the following is not a feature associated with Chron's disease. So, PSC, yeah, that's a good summary. PSC dermatitis hub for this uveitis monor article, arthritis or finger clubbing and the old one out is associated with something else instead. So we can just wait a tiny bit. I think we can call it today. That right. So the one that is not associated with Korean cities is dermatitis, herpetiformis. That one instead is associated with celiac disease is where you get kind of rush. I'm not sure if I can bring up the picture actually. So this is what I don't know how to share my screen. Um Yeah, it's fine. Never mind. It's a rash uh that you get in gluten. Um Yeah, gluten intolerance. So see like you guys can search up pictures, but the rest of them are associated with current just because it is an alter immune disease. So you get PSD. Uh PSC we said was associated mainly with UC but also all cases of IBD, you be ITIS monoarticular arthritis and finger club. So here it's a good overlap of the things. Um So diarrhea, arthritis, earthy mendoza, pyoderma gangrenosum associated and all of them, the most important things to remember is that you see is mainly bloody diarrhea or creates disease is mainly nonbloody and effects or parts of the gi tracts including your mouth. That's where you can find ulcers. Currency c shows clobbered cells in granulomas. Whereas you see shows um crypt abscess is, and it's much more like a superficial inflammation that continues rather than current disease, which is jumps but can be in several places. More questions. There's only 30 questions. So we're nearly er um so a 25 year old man with a background of Gilbert syndrome, ankylosing spondylitis depression is referred to the gastroenterology department. The two month history of diarrhea fighter is a day urgency, frequency and rectal bleeding. He's a marine biology is pretty cute, nonsmoker drinks, 14 units per weekends, two pet cats, domino examination is normal blood results show and mild and he ran a race. Er E S are still cultures were negative. The colonoscopy's arranged what it's the most likely diagnosis. So Gardasil is infection hemorrhoids I B S select disease or you see? Yeah, so we can just wait a bit. I think we can call it a data. So um the correct answer is UC um so we can talk through all of them. So, goddesses infection would be kind of a parasite. Um You would think of they've been on holiday, they've got bloating diarrhea and also stores uh blood in the stools, hemorrhoids. You would think it's more with constipation rather than diarrhea I B S. You wouldn't think if they've got rectal bleeding. Once they've got rectal bleeding, you're, then you're thinking more IBD. And therefore we conclude this, let me see which of the following is not like complaining of true love's and which criteria for assessing the severity of UC or that's mean. Um, so a number of bowel movements per day, fecal cold, protecting hemoglobin, resting heart rate, esr cool. So true, true love and which criteria can be used to then determine management. So the severity, I can't say one of the things because then I will give away the components that severity, you would admit them mild. For example, you would just give some medication to induce remission and send them home. Um What was you have the one you would admit? Uh So we can wait a bit more just to remember which one is not component just in case. Yeah, which is kind of sneaky and the med school won't do this type of questioning. They'll do you like um because this one is like a false negative ones. I don't think they don't like this but it's going to test. So I think we can stop that. So the one that is not is fecal calprotectin. So fecal calprotectin can be used as a kind of exclusion criteria and two point you in the direction of IBD, but it's not used to indicate severity. The most important ones I would base it on would be a number of bowel movements that day. So for example, um mild is like less than four, whereas severe is more than six and hemoglobin and resting heart rate, which gives you an indication of how much blood they've lost and how well they are. So, if the like inflammation is getting to the point, they are seriously unwell. Yeah. So that's also end up. So the 25 year old marine biology's is prescribed a course of oral method, Pregnisolone, sulfaSALAzine and steroid animals to induce remission office. You see business failed has developed update, swelling and pneumoperitoneum a seen on the right chest rate. Sorry, we can't put it up. Which of the following is likely to be required in the management of the patient's condition. So would you monitor for blood count? Use the knees at the start three miles and annually after procto locked me and the last to me. Hydrocortisone. Same IV Super foxes um met Metro an insertion of a suit him and inflict them up. So we can wait a bit more. Perfect. Cool. So wait, let me close the pool. Um So the correct answer is Proctor locked me. Um So here's U C has gotten so bad that um he's got an update selling a pneumoperitoneum just actually means the bowel his best and now there's uh within the diaphragm. So you can see it on chest X ray because you can see like bubbles underneath the diaphragm. Therefore, it means he needs surgery and he needs, um, a repair off the bowel. You do, you need monitoring if you start that kind of medication that, but that's more like a long term first of facility. And there's also something in particular that you need to look at. I'm not sure if anybody knows, hide your cortisone, you would do it if that's, um, creams rather than you see, and inflicts them up as well if it's um more severe. However, what we want to do is manage the actual condition. And at the moment, that's the best bowel if that makes sense. So that's why you would do proctocolectomy and ileostomy. I hope that makes sense. So, what's the maintenance therapy that's used? First line of uh um left sided UC. So if we think about left side as you see and where that would be, I mean, I kind of talked briefly over it, but I'm not sure. How are you guys for listening to my raps? So, at the Syprine oral Mesalamine, topical, mesalamine or Meto Carp Ewing? Cool. That was very quick. Um So the answer here is our a massage seen before you guys tell me off for saying um my rats. So topical mesalles own needs to be topical. So it needs to be something that you can essentially reach with your finger. If that makes, if that's, you see it to visualize. If it's completely left sided, you see, then it like it will go further up into your bowel and therefore you need topical massaging to give you protection of the whole thing. That doesn't mean you wouldn't also give Oremus Alazine. You would probably give a combination of both. I hope that makes sense also. So here we is the actual table chew loss and risk criteria. So, bath movements, rectal bleeding temperature, resting heart rate, hemoglobin E S are like we talked about so more than six severe I think there's systemically and well, so especially hemoglobin like loss of blood and very systemically and well say high temperature, high heart rate and high esr it's a sign of inflammation, management of surveyed. You see. So you give IV fluids and electrolytes because they will be probably very dehydrated and sometimes have lost loose blood. You give may help red IV. You take blood and stool samples. You give heparin and thrombin for prophylaxes and surgery. If severe attacks do not respond to medical treatment, megacolon perforation that you've seen or malignancy or display shin. I hope that makes sense of fits in with the questions, maintenance therapy. So to treat practical proctitis, you give oral masala, topical muscle seen. So as best you can reach with your finger and then your muscle seen with maintenance you give um and if more than two relapses for a year, you can give a thigh brain on medical poor in uh and this is you need to test TP empty prior to initiating treatment because some people have the deficiency and lot and sulfaSALAzine would cut was like problems in it or azaTHIOprine um management of currents. On the other hand, the induction is just mainly steroids, you get spread uh first line, but like somebody pointed out in the chat with the genocide. It's also a corticoid stone uh to maintain remission after five green or medical prone, then methotrexate and flexible and surgery required in 80% of cases. But these years because Crohns is kind of, it's not continuous. Like you see, it's like all over the bowel surgery can actually be a bit more complicated. All these guidelines are constantly changing. So it's important that like maybe not for this year. But for next year, you guys look at it again because that might change too. Methotrexate is side effects, mucositis, milo suppression, human itis pulmonary fibrosis, liver fibrosis. So you need to do a liver function test before you start full blood count weekly. A chest X ray, foot blood count need to be weekly due to milo suppression. So, um and tell them that if they got a sore throat, they need to come and see you immediately and you need to do chest X ray and then function tests every six months or so just to check how those are going. Currents maintenance. So stop smoking. That can worsen it. A thigh, preen methotrexate and anti TNF cool. We're nearly there. So 30 year old woman presents with chronic diarrhea. She reported that her stools float and are difficult to flush away. Although there is no change in the color for you in. She does not smoke nor drink the table. Sure you have blood results. So low hemoglobin, normal MCB, normal calcium. No albumin. No more. HB A one C hi A L T was slightly raised no more. A client prosperity's high bilirubin and normal creating what is the most likely diagnosis? PBC PSC, Cholangiocarcinoma, IBD or Celiac disease. Cool. I didn't make this up bad. So the correct answer is celiac disease. So firstly, she's got no blood in her urine, like no blood in her stool. Um chronic diarrhea. So we can take away IBD because it's not current or UC. Then cholangio carcinoma is normally called um if you've got painful mass and penis genders. So it's more or less the similar symptoms to pancreatic cancer. So we can take away that because what she has is chronic diarrhea. Um there's no change to a color for urine. She does with my goal. Drink. The key here thing here is the low hemoglobin which kind of shows as a bit of like and uh lack of absorption of things. So that's why, why I would say that points to celiac disease, the bilirubin is raised but not to the point where she presents with jaundice. So it's not PBC or PSC. Is this making sense? The alkaline phosphatase is normal. So you wouldn't think there's anything wrong with kind of the biliary track or anything like that. Why is the bilirubin raised? I'm not really sure. But I would guess is due to the anemia leading to higher kind of, um, production of red blood cells that are not really good and therefore ineffective and therefore killed more often. That's my understanding. I'm not really sure. It's a bit of a weird one. Uh, but she doesn't have any presentable jaundice, which is what would otherwise it would occur with cholangiocarcinoma. Yeah, it helps. So serious disease. First line investigation is an I G T T G. You need to check for IGA deficiency and then do a different type of test. They got to the Matitis have performance. This is the picture I wanted to find. So it's very itchy and scratchy those uh patches gluten free diet and you can sometimes give Dapsone a but that's not common gluten free diet. Actually, for your asking, you guys should mention that patient's can get gluten free products from their GP. Um So the answer with celiac disease. Um Thank you. Uh So yeah, gluten free diet and that's long term. Um Do you test it? You can also do your biopsy that's quite intense than normally done in Children rather than adults. And okay, I think his last question. Um So a 40 year old homeless man has developed difficulty breathing and has palpitations. He's recovering in hospital following an alcoholic bench for over 100 units several days ago, he's been encouraged to eat and drink normally prior to discharge, he's very in kept B M I of 19. The stats which single pair of test is more appropriate chest X ray and difficulty and sputum sample E C G A troponin level, full blood counter coaches, allergies and calcium views the knees and cause it. So this one's a bit more tricky. But then that means we finish on a high note because it is the last question. So right, a bit more time, but I think we can call it there. So the correct answer is using knees and frost fate. So this is because the diagnosis for this one would be a re something called re feeding syndrome, which we will talk about in the next slide, but we can go through kind of the other answers and talk about that then. So you would do a chest X ray and sputum sample if you think he had pneumonia. Although yes difficulty breathing, he's sat 90% on like on four liters, which is not that bad and he is recovering in hospital. So it could be the hospital acquired infection but normally not do to kind of palpitations and temperature is normal E C G entrepreneur levels. You would normally think in a heart attack, difficulty breathing and palpitations. But nothing else about that. History tells you about like, you know, chest pain going to one side and all of that flood prone count and coaches if you think of sepsis, sepsis, but his temperature is normal LFTs and calcium bit more tricky because you could be thinking about re feeding syndrome. But you could also be thinking about like pancreatitis and the modified Glasgow school that we talked about. But, um, he seems to be okay and there is no retrosternal pain. He's had aspiration. He's had 100 units. Oh, I guess you could have 100 units. But then um I would ask for if a history of mom eating, if you're thinking aspiration know mania, um if that makes sense because he could have just had 100 units and been completely fine, relatively okay as much as somebody would be with 100 units. Um But that was several days ago. Um He wouldn't recall vomiting if he got treatment for it. Fair enough. I'll give you that one. But I think the main things here is not like the focus is not on the lungs, it's just on his general metabolic state if that helps. Um So for re feeding syndrome, you would test you sneeze and false fate. So re feeding syndrome bit difficult to kind of even explain. So starvation malnutrition can lead to kind of your muscles and your body looking for resources from anywhere you can. So you can need to like lack of muscles, protein, fat, mineral electrolyte, and vitamin depletion, salt and water intolerance. Once you get free feeding, then you give a major source of kind of fluid sultan nutrients. There's loads of insulin secretion, there's loads of protein and glycogen synthesis. And that uses happe thiamine, it uses up potassium, it uses of magnesium and phosphate. Therefore, you actually get ironically enough hypochelemia, hyper magnesia, hyperphosphatemia and a thiamine deficiency, which is why you also give Pangburn ax. So it's important when patient's have been kind of fun. Well, for a long time, if he's been homeless, if he, he's been drinking loads to ease into a diet, which is why it's important to talk to a dietician. Why many patients on the ward will be drinking those weird flowed things or will be on N G tubes and things like that. So you don't really need to know higher risk factors. But I would think about low B M I has been homeless, little nutritional intake and history of alcohol excess. And I think that's it. Any questions. Can we get the slides, please? I think you will, but I'm not sure because I do. Yeah, the slides will be made available. Um Once you complete the feedback, which I'm going to send in the chat in just a sec. So you should be able to find it now. Um But thank you very much I'll with for the presentation. Um Please don't forget to fill out the feedback form. Um And we've got one last session happening tomorrow on Infectious Diseases and Psychiatry. Um So be sure to register for that otherwise. Thank you very much for joining and have a good evening. Um I believe I will be sticking around for all. Yeah, I'll be happy to be contacted by email as well as any questions, Elizabeth. Yes, I would make catch up content available. Thank you guys. Good luck with your exams. Cool. I think I'll probably leave too then. Bye guys.