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Thank you. Should we start then? Yeah, we can, we can make a stop for sure. Yeah. Yeah, fine. So hi, everyone. Um Thanks a lot for joining. My name's Jess. I'm an Fy two doctor at um King's College Hospital in South London. Um Today I've been asked to um do a talk covering lower gi surgery, um which is quite broad. So we'll see how much we can get through. Um I do also apologize um about my voice. I am just recovering from the flu. So yeah, it's been quite hard on my throat. So hopefully you can still hear me. But if there's anything that um I've not been clear about or any questions and um feel free to put it on the chat. Um And yeah, I think this is um mostly aimed at final years, but um if there's any younger years as well, then, um, you're welcome to um, listen along and also any questions, please put it in the chart as well. So our aim for today is to understand the spectrum of causes for lower gi bleeding. Um and also be able to differentiate between the different causes of lower gi bleeding, we'll then look at some benign anal pathologies and then um also, hopefully, by the end, we'll become more comfortable in recognizing and managing surgical emergencies. So, um a bit of anatomy first. So the large intestine starts at the ileocecal valve. Um So after that, you have the ascending colon which goes all the way up and then you have the hepatic flexure, which is that kind of turning point. And then this then turns into the transverse colon. Um And at the end of this, you have the splenic flexure, which is the next turning point um which then goes down into the descending colon after which you have the sigmoid and then lastly, the rectum which then opens up into the anus, the anal um passage. Um as you can see here on the right, um The image shows some Taenia E coli which are muscle bands that contract lengthways. Um And these produce the Hatra, which is the kind of bulges in the colon that you can see. Um And this is quite specific to the large intestine. So this is not something that you'd see in the small bowel embryologically, the um large intestine is made up of the midgut and the hind gut. So up until um two thirds of the way along the transverse colon is all midgut. And then after that is hind gut. And this is important because it relates to the vasculature. So the superior mesenteric artery supplies all of the ace um the colon up until the two thirds of the way along the transverse colon after which um the rest is supplied by the inferior mesenteric artery. Um So first a question, I'm not sure if ans is able to um make a poll for me or thank you. Um So a 25 year old female, sorry, male presents with bright red bleeding that occurs post ef application onto the paper and the pan, his bowel habits is otherwise normal. What is the most likely cause of his symptoms? So I'll just give you a few minutes to put down what you're thinking. Yeah, great. So, um, the most of you've gone for um, three which is hemorrhoids. Um So, yeah, that's correct. So the, um, essentially what you're thinking is when you see a question with, um, bleeding is, um, where is the blood? So blood that's in the pan or that's on um, the paper as you wipe. So the blood that's not mixed in with the stool tends to come from lower down the gi tract. So specifically, this might be caused by anal pathologies. So you're thinking fissures and hemorrhoids, whereas if you see blood kind of mixed in with the stool or streaky, streaky blood um in with the, the, the feces, um then this tends to come up from, from slightly higher up in the um, the tract. So just to rule out the other options. So with colorectal cancer um you would typically see an older patient. Um you might have other symptoms such as weight loss anemia. Um We will come on to colorectal cancer later um with an anal fissure which again could give you bright red bleeding. But the main difference is that fissures are painful and that's kind of the big um giveaway sign between fissures and hemorrhoids on the whole is that fissures are normally painful and hemorrhoids um tend to be painless. Um You then have diverticulitis which would present with symptoms of an inflammatory process. Again, we'll come onto this but you would typically see some fever, abdominal pain, maybe some guarding. Um and an anal fistula which um is obvious is as the uh the term says, is um lower down. So it is in the anal canal or the anal passage um but typically wouldn't present with bleeding. So, um diff there are different causes um for bleeding, lower gi bleeding. I've just summarized them briefly here. So, as I said, um hematosis is the fresh blood on the paper um uh or on the pan. Um and the causes um are in this box. So, um we've mentioned the hemorrhoids in the fissures. Um diverticular disease could also present similarly um as can angiodysplasia, which is a very um rare cause of um bleeding compared to the others in the box. Um But it's essentially a vascular deformity in the gi tract which predisposes someone to bleeding. I've also got here a massive upper gi bleed, um which um as you all know, would typically give Melena, which is that black tarry stool. However, in a very large bleed, the blood can act as a laxative and therefore, can cause rapid transit through the bowel and lead to actually, um bright red bleeding instead of the typical Melena that you'd expect. Um And then you've got colitis, um which is in the table above. So here you might be thinking about infective causes um such as Campylobacter or salmonella um or you might be thinking about IBD. Um Typically, um you see over Crohn's if it's um very bloody and um in this case, you might see some extraintestinal manifestations um in the patient or here in, in the question, um summary might mention this um for colitis, you might also be thinking about ischemic causes. Um So, for example, ischemic colitis, um patients would have risk factors um either of thrombosis or of an embolism. So, patients with a risk factor of um having an embolism in their gi tract might be patients in af um And if you're thinking about uh potential thrombosis in an artery, then the patient might have um risk factors such as high BP hyperlipidemia. As you mentioned, Melina would typically um be the black tarry stool which is indicative of an upper gi bleed. Um Risk factors are NSAID, use smoking alcohol. Um And with all patients with lower gi bleeding it's always important to consider, um, a malignancy, um, which will come on to you shortly after. Um, so the anatomy, um, when you describe the anus, you um, describe things as a clock. So that clock is based off the patient being in the lithotomy position. So this means that they're on their back with their legs splayed up. Um, and 12 o'clock would be up, six o'clock would be down, three o'clock would be to the right and nine o'clock would be to the left. So when you um think about the anal canal, there are two types of sphincter, um you have the internal sphincter and the lower down the external sphincter. So the internal sphincter is formed by involuntary muscle. Um whereas the external sphincter is formed by voluntary muscle and they're both important in maintaining continence. So, hemorrhoids. So they are swollen veins, um that are actually a normal part of the anatomy of the lower rectum. And they're very important because they form a seal in the lower rectum. And without them, we would lose um continence. We have three of these um vascular cushions and they occur at 37 and 11 o'clock. So when we say someone has hemorrhoids, though, it does mean that they have a disease relating to hemorrhoids, not just the fact that they have um hemorrhoids themselves because that's just a normal part of our anatomy. So, hemorrhoids can be internal or external and this depends on where they originate. Um so internal hemorrhoids are higher up. So these originate above the dentate line, whereas external hemorrhoids originate below the dentate line in terms of presentation. So, hemorrhoids can the internal one specifically can become engorged and prolapse down or they can become thrombosed and this is when they can cause pain. So it's not a typical um presentation, as I said, because they do tend to cause painless bleeding but just to be aware that um thrombosed hemorrhoids um can cause pain in patients. Um Otherwise, the typical presentation would be painless pr bleeding in the pan or on paper. Um and also itching risk factors um for uh disease relating to hemorrhoids includes anything that increases your intraabdominal pressure. So, pregnancy constipation, obesity and heavy lifting. So, in order to diagnose um a patient as having um hemorrhoids, you would want to do apr exam. So this is to visualize the area and this can quite easily help you diagnose external hemorrhoids which are lower down anyway, or prolapsed, internal hemorrhoids. However, it is harder to diagnose the internal hemorrhoids that have not prolapsed yet as they are further within. So for those you would want to perform proctoscopy, which is um essentially this little uh image here. So it's using a um a proctoscope which essentially looks like a speculum and you insert that in through the back passage to visualize the internal hemorrhoids. So, with management, um we break them up into conservative medical and surgical. So first you're looking at conservative management. Um so a sitz bath is something that we recommend to patients. So this is when you sit in warm water and it soothes the itching and helps the hemorrhoids also to retract back in if they've prolapsed out. And as well as that to also increase your fiber intake in your diet. So you're less likely to become constipated, moving on to medical management. So, topical anesthetics such as anusol are really important um because they can relieve the itching symptoms. And as well as that topical steroids are really important. And if the hemorrhoids are thrombosed, then you'd consider GTN as well looking at surgical management, um which is, you know what we're here for. Um There's two main things that you could do for hemorrhoids. So one is to let you go in and cut them out, which would be a hemorrhoidectomy or you can do something called a band ligation, um which is where you put a band around the hemorrhoids and you tighten them up. So essentially they fall off or they stay there and they shrivel up. Um But the mainstay would be um hemorrhoidectomy. So another question, I think you might find this a bit easier now. So a 36 year old lady with a background of Crohn's disease presents with painful pr bleeding, bleeding is bright red and tends to occur after defecation. What is the most likely cause for her bleeding Yeah, just give you a moment to respond. Yeah. So um we've got a mix of answers, but the majority of you have gone for an anal fissure. So here, where's the bleeding? So the bleeding is bright red. Um and again, tends to occur after defecation. So we can rule out the colorectal cancer. Um and the diverticulitis, she doesn't really have symptoms of that. Here. The main um giveaway here is a background of Crohn's disease. Um because patients with Crohn's disease are um susceptible to extraintestinal manifestations and also perianal disease, particularly ulcers and anal fissures. So that's the answer here, anal fissure. Um The other option is anal abscess. Um which again, patients um with fistulas can get. So patients with Crohn's disease are also susceptible to anal fistulas and anal fistulas increase your chance of having an abscess, but it wouldn't present with this bright red pr bleeding that will come on to fistulas shortly. So, anal fissures. So these are a tear in the anal canal and they cause excruciating pai, excruciatingly painful pr bleeding. It is mostly idiopathic. Um but there are other risk factors such as constipation and inflammatory bowel disease, but in particular Crohn's disease. So as I said, Crohn's disease can cause perianal disease such as skin tags, anal fissures and anal ulcers. And this is something that differentiates it between um Crohn's and ulcerative colitis. So, man, uh diagnosis, sorry, again, we want to be able to see what's going on. So you would uh offer apr exam. Um a big giveaway sign for patients with anal fissures are that they are in excruciating pain. So they really won't let you have a proper look because it is so painful for them. Um And if you were able to see it, that you would mostly find them in the posterior midline, which is something um I know comes up in SBA S but that is the typical um location for an anal fissure. If you, if the patient cannot tolerate the examination due to the pain, then you can do something called an eu A which is an examination under anesthetic. So this um means you're giving the patient some anesthetic and therefore you can visualize the area properly and then treat them there. And then according to what you found in the examination. Now, the reason that the um fissures are painful is that this part of the canal is ectoderm. And so the innervation is thematic and that's why it's painful. Whereas if you go higher up, um you wouldn't feel pain because it's, it's not, you wouldn't feel the tear because it's not ectoderm. So looking at management, um conservative. Again, increasing fiber intake, medical management is topical GTN which is a vasodilator and a muscle relaxant. So it should help the muscle relax instead of being all tight and cramped and painful. And also using a topical anesthetic and Botox can also help relax the muscle um and help with healing. Oh, sorry. Um The surgical procedure most often performed is a lateral, internal sphincterotomy. So it's quite a mouthful, but all it is is you go in and you cut the internal sphincter from the side and this opens that area up. So you have a bigger wound. So instead of it being small and tearing and healing and tearing and healing, it's kind of flatter and more open and this allows it to heal better. But the main risk of this procedure is the risk of incontinence because you're dealing with these sphincters. Um and I think it's about one in 10 people um will um get this complication. So, moving on to anal fistulas. So a fistula is an abnormal connection uh between two epithelial surfaces. So here the two surfaces are the rectum and the skin, but there are different types of um er fistulas. So you have, if we go from bottom up, you have the submucosal which doesn't involve the muscles, it goes kind of be beneath them. You have the intersphincteric, which goes in between the two sphincters. You then have the trans sphincteric which goes above the, which is through the internal and the external sphincter. You have the supra sphincteric, er fistula which goes above the internal and then up and around the external sphincter and then you have the extrasphincteric which goes well above both sphincters. So, does anyone know the most common type of sphincter. Sorry. The most common type of fistula? No. And if you do, you can put it in the charts. The most common type of fistula. Yeah. No worries. If not, it's, um, intersphincteric. So that's the most, um, common type of fistula that we see. Uh, so I've just seen some mucosal. Yeah. Um, good try is, is, so it's the intersphincteric, um, fistula. So, it is the one that goes, um, in between the, the two sphincters, the internal and the external sphincter. Um So how does it present? It actually doesn't present with pr bleeding. Um, it would present as discharge. Um So, oh, I just see more answers. I think there was a bit of a delay. Um But yeah, it would present um as discharge rather than bleeding. So you see foul smelling fluid which can become infected and can form an abscess. Um, risk factors include diabetes. Um HIV. So anything that can um suppress your immune system and also IBD, so specifically Crohn's disease. So, in fact, anyone with recurrent fistulas would be investigated for Crohn's disease. So again, the diagnosis is having a look first line and the kind of scan that you'd want to do to track the fistula would be an MRI. So this is to see exactly the passage that the fistula is taking, um and helps you classify what kind of fistula is moving on to management. It tends to be surgical for anal fistulas. So the mainstay, if there is an abscess would be incision and drainage. So this is where you go in, you cut it, open, drain the pus and you leave it open, pack it up with aqua cle and put a dressing over it to allow the area to heal slowly. So, that's incision and drainage. If there's an abscess, otherwise you would either use a seat on or perform a fistulotomy. So Aceton essentially is a piece of thread. So all you do is thread it through the fistula, um tie a knot. So you've made a little loop. Um But you don't tie it too tight. So there's a bit of tension leaving the tract open, um which allows it to drain, drain freely and eventually the, the amount of tension that you've got in the strings, pulls the two surfaces together, leaving scar tissue and pulls it closer and closer and heals the fistula. Um If you ever get a chance to see this, it is really cool. So, um yeah, that's, that's the seton. Um Or otherwise what um they could perform would be a fistulotomy and this is where you cut the tissue between the internal and external sphincters. Um And therefore because you're cutting quite a lot of tissue out, it's more useful for the superficial sphincters. So, like the submucosal and the intersphincteric um fistulas, they are, this procedure is contraindicated in Crohn's due to the inflammation and also for any sphincters have any, um er, fistula, sorry, having a high tract such as the extra sphincteric, er, fistula. So you'd want you, it's more used for the, the ones that are more superficial, the fist, the more superficial fistulas. Ok. Um, so, uh, another question now, um, I'm not sure if we've got a poll for this one, but I'll read it out. Oh, great, thank you. Um, so a 70 year old lady is admitted with a history of passing brown colored urine and abdominal distention clinically, she has signs of large bowel obstruction and is most tender in the left yuck fossa. What is the most appropriate investigation? So I'll just give you some time to think about this one. Mm. Ok, great. So most of you have gone for the ct abdomen and pelvis, um which is the right answer. So this question is a bit trickier. Um It's got two parts to it. So you first need to understand the diagnosis and then know kind of the gold standard of investigating for that um diagnosis. So this lady is um got is in large bowel obstruction. Um And one of the causes for large bowel obstruction is um diverticulitis and this would go with the presentation of her being tender in her left iliac fossa. She also has this history of brown colored urine. And what the question is alluding to is that she's um essentially got fecal urea, which is a consequence of diverticulitis which we'll cover in detail. Um, and so because this lady's got diverticulitis causing the obstruction, um, the main investigation would be a CTA P which is important for people in bowel obstruction. Firstly, and also to investigate, um, for where the stricture is that's causing the, um, obstruction. So just going through the other answers, a cystogram is essentially a procedure to, um, look at the bladder better. Um, the ultrasound ku would just, um, see the kidneys, ureter and bladder, a barium enema um allows you to highlight the large bowel um using barium um liquid which is passed through the back the back passage. Um It is really important in diagnosing IBD. Um and a flexi sig er is er using a sigmoidoscope which is like the proctoscope that we mentioned, but this looks at your rectum and your lower codon um before we move on to diverticular disease, um I've just got here the QR code. Um it would be really helpful if you guys could scan it and give us some feedback. Um Just so we know if we're giving you content that's useful. Um And also it's just really helpful for us as well for the speakers um for our ports as well to, you know, to see if we've done if we're giving you the right content and pitching at the right level. So, um if you guys would give us some feedback, that would be really helpful. Uh I think we'll paste the um link to it if your, if your QR code isn't working at the end. So don't worry if it's not working. So, um looking into diverticular disease, so the muscle layers in the colon are actually in a mesh. So this leaves kind of little pockets um of weakness in the inner layer which can then poke out, causing these little bubbles that you can see. And one of these bubbles is called a diverticulum. So that's essentially a single out pouching. So, diverticulosis is having these outpouchings. It's this herniation of the mucosa and the submucosa through the muscularis. Diverticular disease is a state caused by symptoms pertaining to the colonic diverticulae. So it's having symptoms as a result of these diverticula and then diverticulitis is inflammation of a diverticulum and it's the cause for any acute presentations. So, risk factors for um diverticular disease include having a low fiber diet, um older age, decreased physical activity, obesity, smoking, and also alcohol. So, diverticular disease is a spectrum. So as we said, the diverticulosis itself is asymptomatic. So that's just having these diverticula, they don't cause symptoms. But what does is the diverticulitis? So, anything with itis means inflammation. So here you've got inflammation of the diverticula, which is a little out pouchings because of the weakness in the mesh. So it causes symptoms such as left, lower quadrant pain, fever, pr bleeding and also can give you an abdominal mass if there's an abscess. And this is uncomplicated. Diverticulitis, complicated diverticulitis means that there's um, a resulting consequence of the diverticulitis. So this could mean that the bowel has perforated. So this means that air or fluid or fecal material has come through the bowel wall. Um, and is in the peritoneum causing peritonitis, which gives you symptoms such as guarding. Um, the patient could be in shock and also rigidity. Another consequence of diverticulitis is a fistula. So again, it's an abnormal connection, but here it involves the bowel and different, um, other anatomical areas. So, between the bowel and the bladder could lead to new mauria or fecal urea, which is air in the urine or, uh, stools in the urine, which is the brown discharge from the previous question. Um, it can also lead to a fistula between the bowel and the vagina in late in females causing, um, frequent PV discharge and could also lead to, um, a bowel to skin fistula. So, as we said, common complications include the fistula perforation, sepsis, um, but also obstruction, which is what this patient was in can lead to large bowel obstruction because if you're having this inflammation, um, it can lead to a stricture which means not all of the, the bowel is expanding like it should be and you can get episodes of obstruction and we'll go through the symptoms of that later. So, in terms of investigations, uh, if we go bedside bloods, um, imaging and any special tests, so anyone coming to Ed, um, will get an E CgA urine dip and in females they'll get a pregnancy test as well. And if they uh have an E pr bleeding, you'd offer a APR exam. You don't want to do bloods. So, or you know your full panel of RBC FBC. Sorry, E um LF TSC RP. Um, you'd also do a clotting and a group and save. Now, this is really important because, um, for any patients for which there's a chance that they could go into theater, you'd want to know their clotting profile and make sure they can actually go into theater um and a group and safe. So we know their blood group as well. In terms of imaging, the diagnostic imaging for any patient with um your query diverticulitis for is A CTA P and you have a low threshold for this co A CTA P is really important to see if there's a perforation and abscess how big it is. Um And it is the diagnostic investigation. Um But if you're querying perforation, then you might want to do an erect chest X ray. So this is where you get the patient to sit up for at least a minute before doing the imaging. And if they have a perforation, any gas leakage into the abdomen um has time to rise up. Um just so it's under the dia uh diaphragm. Um so you can see it on a, in a chest X ray. So in terms of management we'll split it up into conservative medical surgical again. So conservative would be treating the symptoms. So, nausea and vomiting, you'd want to give antiemetics for pain, you'd go through your ladder um starting it, you know, paracetamol adding in an NSAID. Um more codeine um Buscopan can be really important for colicky abdominal pain and for patients when you're discharging them, you'd want to give them lifestyle advice. So this includes increasing fiber, increasing exercise, um stopping smoking, reducing alcohol intake, uh improving their hydration and also is the furcular husk, which is essentially um just a type of fiber that patients can take in tablet form. So, medically, um if the patient is a bit more unwell, if they're um septic, you'd obviously do the septic sepsis six. in terms of antibiotics, you'd consult your local guidance on that in my trust. Um For uncomplicated diverticulitis, we were giving oral coamoxiclav. Um and for complicated diverticulitis, um IV Coamoxiclav interventional radiology are also um really important um for patients with diverticulitis, they can do really cool things such as draining any abscesses, um and coiling bleeds as well. So, uh you'll find that if you have a surgical job, you actually um do liaise with them a lot in um helping managing your patients. Um and then sur for surgery, um this can be emergency or elective surgery. So, elective surgery would be if the patient has had frequent flares of diverticulitis. Um So, uh so if they've had frequent flares or if they've, there's been a previous episode of complicated diverticulitis. And this operation would involve removing the section of bowel that has the diverticula. Um, and that would be something that you would plan in, in advance. So it would be elective. But most of the times when you're thinking about someone having surgery during an acute flare in the hospital is because they've perforated. So the emergency operation you would perform is um a Hartman's procedure. So this is where you cut out the sigmoid colon. And we say sigmoid because this is normally the part of the colon that has perforated. So you remove the sigmoid and then you use the proximal loop of bowel to make a stoma. So you bring it out and you make an end colostomy. Um So a Hartman's is essentially a sigmoidectomy. So you're removing the sigmoid and you're bringing the proximal loop out to form a proximal end colostomy. And that would be the emergency surgery. We'd also follow up patients um with an episode of diverticulitis um in 6 to 8 weeks with a colonoscopy. Um to also have a look at the bowel and visualize it and to rule out any malignancy as well. So just something to be aware of. So moving on um to large bowel obstruction. So this is an important um general surgical emergency and this occurs due to a mechanical or functional obstruction of the large intestine. So this prevents the normal passage of bowel content in terms of symptoms. Um, it normally presents with colicky abdominal pain, um, bloating or abdominal distension, vomiting, um, which tends to be a late feature of large bowel obstruction. So it tends to, um, appear later than in small bowel obstruction, just purely cos it's lower down and also absolute constipation, which means that you're not passing stool or flatus in terms of signs that you might find on examination, they might have generalized abdominal tenderness, um and also tingling, bowel sounds might be heard on auscultation in terms of the causes, the main cause for large bowel obstruction is colorectal cancer. Um But you might also find um that they have a stricture. Um This could be secondary to diverticulitis as we said before or due to inflammatory bowel disease or it could be due to a evolvulus. So, so a volvulus is essentially torsion of the colon around its mesentary and this results in compromised blood flow and can lead to obstruction. So, there are two kind of weak points in the bowel that um tend to um taut in that way. And this is the sigmoid and the cecum. Um I've got a little table here just about the, the differences. Um So if the sigmoid, um volvulus is normally seen in older patients, patients with chronic constipation or those with neuropsychiatric conditions. Um, cecal volvulus is a lot less common than sigmoid. Um, and seen in patients with um adhesions uh and also pregnant patients as well. So, when we're thinking about risk factors for large bowel obstruction, they would include the risk factors, for example, for colorectal cancer and um for volvulus as well. So, um can anyone tell me what this abdominal X ray shows? Um So what sign this is and also what this sign indicates? Yeah, exactly. Um So this is the coffee be sign um which you can hopefully see here, um, which is a sign of sigmoid volvulus. So whenever you're doing an abdominal X ray for patients with, um, that you're querying large bowel obstruction for, um, this is something to be, um, aware of the other rule that's really important for patients. Um, with bowel obstruction is the 369 rule. Does anyone know what that is? It's a bit more difficult to explain via message, but if anyone knows what it is and can give it a go. So it's essentially the upper limit for the normal diameter of the bowel. Yeah, exactly. So it's accepted that the upper limit, um, for the normal diameter of the small bowel is three centimeters for the colon is six centimeters and then for the cecum is nine centimeters. So that's a 369 rule. So anything over that and you'd be concerned about an obstruction. So, looking at investigations again, um, bloods wise, you would do the full panel, the FBC using these LF TSC RP clotting, uh, group and save. And then also VBG is important because this will give you a, a value for your lactate, which is really important in patients that you're worried about if they're in going into shock or not. Um In terms of imaging, you would first line want to get an abdominal x-ray. And as we said, you might see um distended bowel loops or you might see um a VV like a knee image before the gold standard. However, for imaging is act abdomen and pelvis. Um So that's what you would, you can see here. So that's the um abdominal X ray on the left and then that's the CT on the right, which will clearly show descended bowel loops and can also show exactly where the point of obstruction is. If you're worried about perforation again, then you would perform the erect chest X ray. So, in terms of management, you're always told in med school and in um kind of all these revision question banks um to do drip and suck. Um which in reality is what you would do. So you'd make the patient nil by mouth, so stop them from eating, give them IV fluids and um, put an MG tube in. However, the caveat of this in large bowel obstruction is that in patients with an obstructed colon if the ileo cecal valve is working and patent. So this is the valve that separates the ilium and the caecum, the ili and the caecum then the valve will stop decompression from the colon into the small bowel. So what this means is there's increased pressure in the colon due to the obstruction, but the valve will stop it from moving into the, moving it into the small bowel. So if this valve is working and the pressure of the codon is really high and that can lead to an increased risk of perforation. But what it means in terms of management is that if you put an NG tube in, it won't actually be of that much help because the obstruction is only in the colon. So it's quite low down and the NG tube obviously doesn't go down that far. But if the valve is not patent and the colon and all its contents can decompress into the small bowel, then the NG tube would be of benefit and decompressing the small bowel if that makes sense. So that's just the practicalities. But in exams, you would always say drip and suck, which is IV fluids and NG tube for decompression. But just something to be aware of if you do a surgical job of why NG tube isn't always that um useful for large bowel obstructed patients. The other um aspects of management would be analgesia because there are a lot of pain, um antiemetics. Oh Sorry, antiemetics and also IV antibiotics um due to the risk of infection and perforation in terms of the definitive cause. Um this depends on the def definitive treatment. Sorry, this depends on the cause. So, if it's, um, colon cancer just going through the table, if it's perforated, then you do a Hartman's procedure, which we'll come on to, um, or else we might just stent the colon. Um, so this allows the bowel contents to move around the, the mass for rectal cancer. We would do a defunctioning colostomy for diverticulitis. We'd be looking at a Hartman's again, if it's perforated for a sigmoid volvulus, we would use a rigid sigmoidoscope um to kind of deor the the bowel er for cecal volvulus. Um we would look about doing a right hemicolectomy and for anything unclear, then you'd be looking at a an exploratory laparotomy for the patient. So our final part um which of the following may be used to monitor patients with colorectal cancer. Yeah. So um in the interest of time, I'll just tell you, but most of you have gone for the right answer. So that's C EA so just looking at the others quickly c A 125 might be raised in ovarian cancer. Um A FP would be looking at a hepatocellular carcinoma. Ca 199 is seen uh to be raised in pancreatic cancer typically. Um I always got told that the nine looks like the pancreas um which is how I remember it now. Um and then ca 153 is typically raised in breast cancer and essentially C ea um is um a protein that is uh not detected, um, usually but may be produced by the cells um in colorectal cancer. So, in terms of the features of colorectal cancer, um this typically depends on if it's on the left side or the right side of the bowel. So left sided, um, tumors tend to present with an early obstructive picture, um, fresh red, uh bright red bleeding, um, as they're further down the tract, um, tenesmus, which is a constant feeling of having to open your bowels but being unable to constipation, which is actually a very early sign of left sided cancer, colicky abdominal pain, which is the pain you get as the bowel wall contracts and tries to move the stools down and also an abdominal mass if the tumor is large enough. So, right-sided, um, tumors however, tend to present with um, anemia, especially cecal tumors, um, weight loss and also diarrhea and this is seen, um because it's further up the colon. So it typically presents with diarrhea as opposed to constipation. But the important thing here is that it could really present with either which is why anyone with a change in bowel habit, whether it's diarrhea or constipation should be um, investigated for colorectal cancer. So, the risk factors um, can be inherited or modifiable. So, inherited causes include genetic syndromes such as F AP, which is familial adenomatous polyp polyposis, um, which is where the bowel has over 100 colonic adenomas. Um and these patients are actually surveyed from, I think about 15, they get an annual sigmoidoscopy just to ensure that none of the adenomas have um transformed into a malignant um carcinoma. And then also HNPCC, which is Lynch Syndrome. And these patients are also offered a colonoscopy every year or so from the age of 25 you might also hear about Lynch syndrome because it's associated with endometrial cancer as well. The other thing I've not included here to be aware of is IBD. So patients with ulcerative colitis are also at an increased risk um of colorectal cancer more so than Crohn's disease. Family history is another important um risk factor. So having one first degree relative increases the risk threefold. Um and also certain ethnicities are at increased risk of colorectal cancer in terms of the modifiable risk factors. So, having a diet high in fat and cholesterol specifically from animal sources um as well as um a high alcohol intake and obesity. So, in the UK, we have our national screening program which is done every two years from 60 to 74. And this is when patients are asked to give a sample of their stools. And um this is um analyzed for fecal occult blood. Um So the test essentially uses antibodies that are specific to human hemoglobin um to look for any blood in the stool that isn't visi visible, sorry to the to the eye, essentially. So, any test that shows occult blood in their, in their stools, um, is immediately, um, eligible for a two week wait according to nice. Um, and the other criteria I've got down here as well. So anyone 40 or over with unexplained weight loss and abdominal pain would be eligible. Anyone 50 or over with unexplained rectal bleeding and anyone 60 or over with iron deficiency anemia or a change in bowel habit. So, this is strictly for the two week wait. But anyone else that you were concerned about, then you might want to organize some tests which will come on to, um, in the next slide. So again, in terms of investigations, um, anyone, um, if they were coming through Ed would get the E CG urine dip, um, a pregnancy test for females and also apr bloods, as we said the same as before. Um, tumor markers are not diagnostic. They have a really poor sensitivity and specificity for colorectal cancer, but it can be used for monitoring progression of colorectal cancer. So it wouldn't be used to diagnose. Um, so you definitely wouldn't do it in the first instance, um, bone profile can be important as well. Um, as you might, um, see deranged calcium levels. Um, and you might be worried about Mets specifically in terms of radiology. So if the patient is presenting an Ed and they're obstructed and you're worried about colorectal cancer, then you would go through what we said before with an abdominal x-ray and act abdomen pelvis to look at what the obstruction is. Um However, in the nonacute setting, the gold standard for diagnosis is a colonoscopy. So you can clearly visualize the bowel and take samples um for biopsy. If a patient is not suitable for colonoscopy, then you would want to do a CT colonography which essentially again images the bowel but using CT instead. Um so this might be more suitable for patients who are frail and for whom an invasive colonoscopy wouldn't be ideal. And if um they are found to have colorectal cancer, you can kind of move on to staging as well. And in that case, you'd be thinking about a chest abdomen, pelvis ct to look for any distant Mets. So management, this can be elective um or emergency again. So, in the elective setting, we can either do a laparotomy or a laparoscopy and we can either do a primary anastomosis or use a defunctioning stoma. So primary anastomosis essentially means you're connecting the two ends of bowel. So you remove um the cancer of the mass and then with the two ends of bowel, you are able to anastomose and rejoin them again and um reintroduce a blood supply or you can put er, do the defunctioning stoma, which means you bring out a part of the bowel. Um, and this leaves the area that we've just removed the tumor from to rest and heal and later we can perform an anastomosis and that would be the defunctioning stoma. Um The exact management um depends on the staging. So, for colorectal cancer, we use the Duke staging, which is ABC or D. So for Duke stages A and B, um normally um it would just involve a surgical management. So this is where the tumor is just in the mucosa. For Duke stage A or for Duke stage B, it's just invading the bowel wall. So it's still very locally confined for Duke Stage C. We would be looking at surgery but also adjuvant or neoadjuvant chemotherapy. And this is where patients have um lymph node metastasis. Um And for anyone into stage D, this is why they've got distant metastasis. It is really a case by case um discussion, but they might just be more suitable for chemotherapy um or a stenting procedure rather than a resection. And you would also um involve palliative care as necessary in the emergency setting. You would um if the patient has perforated. And again, most likely, if the colon, if the sigmoid colon is perforated, then you would perform a Hartman's which is the sigmoidectomy and, and colostomy. Um Other parts of the bowel can perforate although this is um much less likely. Um And therefore for your exams, you'd only really be um asked about a Hartman's procedure and this is where you remove the sigmoid colon specifically. So looking at the surgeries for um any tumors in the cecum, the ascending colon or the proximal transverse colon, you would do a right hemicolectomy. Therefore, you would remove all this area in blue. And then you would do an ilium and colon anastomosis. For any tumors in the distal transverse colon or the descending colon, you would perform a left hemicolectomy. And then the anastomosis here would be colon to colon. So it would be part of the sigmoid colon to the transverse colon. And then for any tumors in the sigmoid colon, you would perform a high anterior resection to remove the sigmoid um and the rectum and this is also the same procedure that you would perform for any high lying rectal tumors. For any low lying rectal tumors you would perform um or any tumors in the anal verge, you would perform an A a which is um an abdomina perineal resection and this involves removing the sigmoid, the rectum and also the anus. So before we finish, I just have a quick slide um on stoma. Um So I'll just quickly run through this. So a stoma is essentially um a surgically created opening into an organ. So here is the bowel and then um which is brought out and then covered by um some sort of pouch system that collects the output for disposal. So, if the stoma is seen in the right iliac fossa and it's spouted like this image um on the left, um You'd be thinking about an E IOST toy. So the content of this is normally liquid. And so it's a lot more watery than in the colostomy. And this is why the, the colon, the stoma sorry is spouted. Um because the contents are a lot more bilious and watery and this is a lot more irritant to the skin. Whereas if you see a stoma in the left iliac fossa, which is more flushed to the skin, this is more likely to be a colostomy and the contents here are a lot more solid and resemble um more like stool rather than what you see in the ileostomy. In terms of types of um ileostomy and colostomy, they can either have one lumen or two. So for the ileostomy, if there's just one lumen, it would be an end ileostomy and this might be created if the rest of the bowel has been removed, for example, in familial adenomatous polyposis. Um or if there's two lumens, this is loop ileostomy and this might be done to defunction as distal anastomosis as we said before. For example, if a tumor has been removed and you want the area to heal slowly and to give the bowel some rest, then you might perform the loop ileostomy um with the colostomy. Um Again, one or two lumens, uh one lumen would be the end colostomy as you see in a Harman's um or two lumens would be the loop colostomy again to defunction. Um part of the bowel. Um For example, if there's been um a resection due to obstruction or malignancy. So, the formation of a stoma can lead to many complications. I've just got a few down here. Um So some of the common ones are bleeding, infection, necrosis, um and also a high output stoma. So this is where a stoma produces more than 1000 mil of output a day. And this is really important because it can lead to electrolyte imbalances. So, in patients with high output stoma performing a bone profile is really important to check their magnesium and their phosphate levels. Um Stoma complications also include bowel prolapse. This is where part of the bowel moves further out, um or retraction when it pulls further in um or also a parastomal hernia, which is where you've got this bulge of abdominal contents under um or around the stoma. And this is really important if um there are complications of having the hernia such as obstruction as well. So just something to be aware of and then other um complications include skin excoriation, um fistula stenosis, and also all the psychosexual issues around um patients having this new collective system that they kind of need to manage um and get used to as well. So I think that's the end. Um I hope after all this, I know it's been quite quick. Um But I hope um I've been clearing, giving you a bit more of understanding in all the causes of lower gi bleeding, um being able to differentiate between um some important ones. Um also looking at benign anal pathologies um and also helping you get more comfortable with surgical emergencies. Um So, yeah, thank you very much for attending guys. If you've got any questions, um then there's the email address on the slide here um that you can uh email any questions to or um if you've not filled out the QR code or the um feedback form yet, then please do so. Um and I think you get a, a certificate as well, which is really useful for your portfolios. But yeah, any questions um feel free to put it on the chart, but if not have a great evening. Thank you so much. Yeah, thank you guys. And yes, as his certificate of attendance will be supplied once you've completed the form. Thanks Jess for that. That was really good. Thank my mother for persevering with um sore throat. It does all I think it's actually getting quite annoying now. So I'm gonna be quiet for the rest of the evening. I'm not gonna say a word, I think uh if we're happy we can uh end it here. Yeah, great. Thank you so much. Thank you so much again. Thank you. Thank you. Bye bye.