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Especially before your Aussies. We'll also go into some radiology, looking at a bunch of x rays. Um We'll look at most likely conditions given similar presentations, how to appropriately escalate um in your real life scenarios. Um We'll summarize and there'll be a chance for feedback and there will also be another chance for feedback in the middle as well. All right. So, um let's get started then. So we'll start with an SBA while on call covering the medical wards, you are called to assess a 45 year old male patient on the acute medical ward with severe abdominal pain. Nurses are concerned as he has developed a tachycardia at 100 and 20 is currently using a two. What is the single best next action? And I'll give you 30 seconds for that. Ok. Crazy. So that's from a ask the nurses for a full set of observations BBg and E CG before attending the patient b rush to the patient's bedside to perform an A to E C, gather more information on the patient's hospital admission to triage this patient amongst your other jobs before attending to perform an abdominal examination. D prescribing pain medication appropriately and book an abdominal X ray remotely assessing the patient once back from his scan and f treat empirically for sepsis. Completing the sepsis. Six following trust guidelines, advice and antibiotics and calling the mag call registrar for further advice. All right. So let's have a look at the pole. We've had a, an even split between A B and C. No one's gone for D or E and the answer is C. so gather more information on the patient's hospital admission to triage the patient amongst your other jobs before attending to perform an abdominal examination. So firstly, this patient has an ab abdominal pain and one of the most crucial things to do in that situation is to put a hand on the patient's tummy. Um Now a is a valid option. Many would do this given that you would be gathering information. However, you don't actually know what's going on at this point. You don't know what's causing the pain and you don't know why the patient has come in. You only know that he's tachycardic at 120. You can always gather more simple information. First, knowing that the nurses are very busily and you should manage their workload better. For example, you might find out information that the patient is constipated and then you wouldn't necessarily need to do uh A V PG um or you might find out that they've also been vomiting blood and then you need to be attending a lot more urgently rush to the patient's bedside to perform an at e while this is safe. Could this be a less urgent job? And given the fact that you'll be called multiple times um for abdominal pain often with no clear cause it's always important to triage this especially given the fact that you might have other jobs that are more urgent um for you to be doing. Um for example, you could be informed of a patient who has a HB of 70 a drop from 90 that would be likely more urgent than this. Um See is the correct answer as it's crucial to put a hand of the patient's abdomen when they present with abdominal pain. But also because it allows you to triage this situation a lot better d although none of you went for, it isn't a bad idea, but you can't put scans without sort of having an idea of what's going on. You can't just put abdominal pain on the um radiology request and I'm sure it'll be rejected, treat empirically for sepsis. Again, you're jumping to conclusions as a diagnosis. Um and it's safe. However, the medical registrar will just tell you to go examine the patient anyway. Um So what sort of things do you want to know from the nurse on the phone? Just put whatever in the chart? I Yes. No. OK. Clearly, this was a bit harder. Um So the thought sort of things you'd want to know is why they were admitted. Um, what medications they're on the remaining obs given that the news two. But however, the new score categorizes things based on sort of a set criteria. So for example, the patient could be febrile, but if they're not above 38.3 I believe, then they won't use for it. So if a patient has AAA temperature of 38 for example, um and with the tachycardia, you know that this is something to be a little bit more worried about. Um and what they've been ba at, at Baseline this whole day. So for example, if they've been at baseline of a tachycardia, um then you know that the difference isn't quite so significant. And I always ask personally, er, if the nurses are particularly worried about this patient, sometimes they'll call you just because it's best practice to, to get a doctor to review. But a lot of the time they have a good sense for when a patient is off their baseline or it's just the observation that they're a bit more worried about and in the end you're treating the patient. So what we gathered from the nurse was that the patient had attended for an infected exacerbation of CO PD had been started on nebulizers, doxycycline steroids and IV fluids and is recovering well or was recovering well. Other s show saturations at baseline of 90 uh a BP of 100 and 9/68 a temperature of 37.8 and a respirate of 19. Now, if you notice all the rest of these obs the BP here wouldn't necessarily score on the news chart. A temperature of 37.8 won't score. A respirate of 19 won't score. So, but they are somewhat deranged given that the, the normal respiratory rate for, for individuals would be about 12. Um I didn't give you a baseline here, but if you were to ask a baseline, I'll give you a lot more information. Um And then what would you ask specifically specifically about when do you perform an at e on this situation? Um Any thoughts simple, yes or no question about whether you would perform an A two E in this situation? Ok. Cool. A couple of you would, I think that's very safe, especially when you don't know what's going on. Given the fact that you came in for an effective exacerbation of CBD, you want to assess the airway very well and the breathing. Um you might as well do a cardio respiratory system as well. Um And then when you go to ask the patient, um what it is that's going on, you most likely want to know where, where their pain is, whether they've opened their bowels. Um and sort of the nature of the pain, you obviously Socrates, the pain at the same time as well. Um And then you'll ask them what their personal background is the nature of the pain et cetera where they've had anything like this before. Um And then going on from that are some more specific questions. Do you guys know what sort of signs you're looking for on examination to be worried about a surgical abdomen or the couple of signs that would worry you the most. Sure. Yes. Perfect Liam guarding and rebound tenderness. Um If you don't know what guarding is, um, it's when the abdomen is quite tense, when you press on it, the patient kind of moves away or tries to avoid the pain. Um, and rebound tenderness is when you remove your hand from the abdomen, the patient also experiences pain. Uh, um, let's have a look exactly what else you'd be worried about. So, um, the kind of things you're asking why they came in what medications observations baseline, we've already set it up. Um, and the patient attended, we already went through that and then the sort of things you're looking for in examination, rigidity and guarding definitely distention, the location of the pain where there are any bowel sounds and the hydration status of the patient. Um, the most concerning one would be the guarding. Um, and that is sort of the, the basis on which um, a lot of surgeons will make their assessment about whether a patient needs surgery or whether they needs further investigation, et cetera. So this patient is guarding, distended. The pain was originally epigastric and is now generalized bowel sounds are present percussion, tympanic hydration status, normal warm and well perfused. The chest is wheezy with bibasal crackles. So the sort of things that you want to know, you need to break it down into bedside bloods and imaging. And then you progress forward by doing an E CgA VBG blood sugar, full set of observations in a urine dip. Essentially when you've got a patient who is quite so unwell, you want to throw everything you can at them in terms of investigations that are possible at the bedside. This is pretty much your, the, the whole set of things that you can do at the bedside. Um And then you go on to your full set of bloods here. You've done an amylase because you're looking for a pancreatitis as it's possible. And given that it was epigastric pain LFT S as you know, a whole bunch of sort of H PB related issues can also, uh come to light from this ACR P to look for information. Of course FPT S and uses just cos they're generally good at telling you if there's an infection or if there's anything else that's going on that you need to be correcting. Um I put in racketeer lipase as in practice, an amylase is generally more often used, but lipase I think is a more sensitive, um to pancreatitis sort of investigations of imaging that you would request abdominal X ray and specifically an AE er, an erect chest X ray. Um, and we'll go into that a little bit later. No, his ECG shows sinus tachycardia. His blood sugars are seven and the BBg shows a lactate of 2.1 a urine. The urine dip is nothing abnormal detected FBC S show a white cell count of 14 A HP of 100 and two and ACR P of 201 using these show a creatinine of 100 and 30 LFT S nothing abnormal, detected, alys nothing abnormal, detected urine. MTA is not back yet. All right. So, um specifically here, what you can see from these bloods is there's some form of inflammation. The white cell count is there may be some form of infection, lactase rays, which also is worrying uh which could show signs of ischemia. Um The C RP of 201 is quite high. So you would be worried about this. Um And the creatinine of 100 and 30 shows, I think depending on their baseline. Um some form of AK I now, if I saw that having not had any previous context, I would consider an AK I um but you do want to look back to see if there's any previous results. And although you'd send off um all forms of cultures, blood cultures, urine cultures, um you don't expect them to be back yet. So if you were going to treat for any infection, it would have to be empirical and the top differentials here would be obstruction, perforation, pancreatitis, upper gi bleed and cholecystitis, um, obstruction. Given that the patient is distended, perforation, given that the patient has some form of uh guarding pancreatitis. Given the location of the pain, an upper gi bleed, given that the HB is 100 and two, it could also cause pain. And if you're going to further investigate for an upper G IB, what's the most crucial investigation that you'd then ask for next or perform yourself next? So that was if you are going to investigate for an upper gi bleed, what sort of examination would you like to perform next that I haven't done here? Yeah. Lovely. Yep. Exactly. APR exam. Um You'll find yourself calling thinking, calling a medical registrar, considering a gi bleed. And the first thing they ask you is have you pr the patient um And what you're looking for when you do that is Melina. Um And then cholecystitis is a good differential here as well. Um Although the LFD S show nothing abnormal anyway, moving on. So those are the wrong way around here is a chest X ray, specifically an erect chest X ray. Um And what is the most obvious sign present on this chest X ray, pneumoperitoneum, specifically air under the right hemidiaphragm here. Um So that sign there is worrying and so given that what is the next best action? Um So I'll give you another 30 seconds to have a read of that. Um So a fast bleep the on call medical registrar. B fast bleep the on call surgical registrar, C put the patient in for a CT abdomen and then call CT two triage as urgent. D prescribe IV PPI V Amox Metro and Gent IV, fluids and high flow oxygen and e put out a medical emergency call. Yes. Yeah. Yes, it, yes. Yes. Ok. We've got a 5050 split between B and C. Um and the answer here is fast be on call registrar. Now, I understand the that booking in act is incredibly important. It is the definitive diagnostic mentality and the surgical registrar may ask you to do this, but it might be the case that there isn't enough time or it isn't required. Now, another thing with when it comes to booking in these scans, they take time and you need to consider that, but also when it comes to bleeping someone they have to call you back. Um and this is the person that will book them in er, for theater, very lightly, the person who overnight do the actual surgery, er, and given that this is a surgical emergency, you need to call for help. Um The other ones unless the patient is medically unstable bleeping the on call registry, call registrar, it's not your first port port of call, it's the on call surgical registrar um and prescribing. So, Amox Metro and Gent is your standard sort of uh antibiotic set for any intraabdominal sepsis. Um And over here we've got IV. So essentially starting the sepsis six and it would be very important to stabilize the patient. However, the patient was stable at the time given the previous obs um and getting definitive management is much more important at this time as you perform in a, you should also be doing these sort of things, putting out a medical emergency call. It's a good port of call. If you're confused, you don't know what's happening or overwhelmed, but a, a senior help is required from the surgical registrar. Um If the patient is unresponsive and deteriorates, it becomes much more of a valid option. Um So I think when we prioritize escalation uh in these sort of situations, if the patient is stable, um, definitive investigations might not necessarily be required and that sort of assessment can be made by a surgical registrar. Um And having said that um a lot of the times when you called the radiologist or ask them for, for example, for these scans, um you might be stonewalled by the fact that you haven't had a senior review into it. Um So, yeah, any questions on that? Ok. All right. So, diagnosis here is a peptic ulcer which is a break in the lining of the question. If a patient, I would say what would be the pathological appearance on a supine radiograph. Um There is a sign. Uh I think it's called R sign if you saw on a, oh, do you mean on a chest X ray? Um If you see it on a, a chest X ray, you probably won't see air under the diaphragm um on a, on a Supine radiograph. The point of when they put them into, um when they set them up is that the air pools at the top um of the um uh of the diaphragm of the abdomen. So it goes underneath the diaphragm. Uh Anyway, um Yeah, so peptic ulcers are breaking the lining of the gastrointestinal tract extending through to the muscular layer of the bowel wall. Common causes are nsaids. H pylori smoking. Did anyone happen to gather the cause for our patient here that we've um discussed? It was very briefly mentioned here and it could be a possible cause um from his medication history maybe. Yes. So smoking increases the risk and given the fact that he was in your CO PD patient. Um No, it wasn't necessary either. Um It was a very small line there that um was maybe to hint at it. It's not written here. It's not as common as H pylori smoking nsaids, but it was the steroids, Peter. Yeah. Um He was on steroids there and I didn't note any PPI cover for the patient. Um So that's uh another one of those things that, that didn't cause sort of um ulceration if the ulceration gets bad enough or you had a history of ulcers. Um I think it can result in a perforation. Um, so normally there's a history of ulcers with epigastric pain reflux gout, et cetera and they're key things to ask about in your history. Normally the patients will just directly tell you. Um, so I remember seeing a patient on the ward and I go up, um, have, have you at all heard of any, had any history of sort of heartburn when you've been eating? They tell you straight away like, yes, I get heartburn all the time and it sort of leans you in towards um, an ulcer. Um And there's the main way for differentiating between the two types. Gastric and duodenal ulcers which both fit under the title of a peptic ulcer. Um, his pain is worse after meals for gastric ulcers and better after meals for duodenal ulcers. Now, I haven't looked into why this is, um, but in my head, the reason is because when you eat a meal, your stomach produces acid. Uh And so this acid then irritates um, your stomach lining and the gastric ulcer. Um And then it's the opposite for duodenal ulcers. Um I'm sure there's a, an explanation out there if anyone wants to find out. Um Yeah, and then the alternative complications that you could, um, um, end up having due to peptic ulcers is hematemesis and gastric outlet obstruction. Um The other one is you could have an, a gi bleed, um, as a result of a, an ulcer. Um, and this will very often present with a, a patient with a low HB or you'll be called by the nurses because the patient has a low hb, um, amongst other symptoms or confusion, et cetera. And then you'll pee are fine Melina and proceed that way. But that's sort of a, a lesson under gastroenterology. No peptic ulcers. So, um, this is for sort of if you have an ulcer, um, oh, maybe came in at the wrong spot one second. Mhm. If you have an ulcer, um then the red flags that you're looking for. If that's the case or if the patient has reflux or dyspepsia, uh or any upper abdominal pain with weight loss and greater than 55 years old. That's a two week wait, a new onset dysphasia, two week wait. Um And if the new onset dyspepsia is not responding to PPI treatment, then also two week wait. Um And then the treatment afterwards is a PPI with H pylori testing given that H pylori is such a significant cause. Um And that's normally done with a, a carbon 13 urea breath test or a stool sample. Um If that comes out to be positive, then you give them the, the trio ver molar and metro for 14 days. Um And if the symptoms persist after they still require an endoscopy. All right. Um I heavily recommend that you learn your two week wait, rules for exams. Um, they're a bit more obvious in, in anky if you need to do a two week wait. Um, but in an SBA, you can be sort of, um, they come up regularly, uh, and you can forget that that's what's required at the time. Um, but the main thing here is to, is to consider a PPI if they have a peptic ulcer without a perforation, obviously, um or after the perforation. OK. OK. Right. And then here is a spot diagnosis for you on this SBA. We won't be on it for very long. Um So I'll give you 30 seconds to answer this one. I think there has to be a pole that comes up somewhere. There we go. So, right, heavily in favor of the hiatus hernia, which is correct. Um So the, the main giveaway here is the, the fluid level that's not always present, right? Middle zone, consolidation is just a very vascular lung. Um aortic dissection, the mediastinum is wide or higher up. Um pneumoperitoneum, the gastric bubble is under the left diaphragm here. Um So you're not worried at the moment uh about the pneumoperitoneum because that's just the gastric bubble. Um And then CO PD with cardiomegaly, possibly this lung is hyper expanded. Um But the heart is around one third of the lung width. So there is no cardiomegaly there. Um So, yeah, hiatus hernia. Now whiz through this as it's probably a minor aspect of your exams, but it's important to know the radiolog, uh, findings. It's often found I've seen it quite a few times in practice, um, as an incidental finding on a, a CT chest or a chest X ray. Um, mostly they're asymptomatic, they might have some, uh, symptoms of gord chest pain, epigastric pain and some dysphasia. Um, here we can define a hernia as a, a protrusion of the whole or part of an organ through a wall of a cavity that normally contains it into an abnormal position. What I want you to know is that there are two types of hiatus, hernias, sliding, which is type one, type two is rolling, which is also paraesophageal. Um And what I mean by that is that with the sliding, the, the, the stomach and the um and the esophagus are continuous and so part of the stomach following the esophagus rides up into the abdomen into the thorax, sorry. Um Whereas through the esophageal hiatus, um whereas a rolling one is if you imagine that the, the esophagus remains in the same place. Um but part of the stomach goes in next to it. Um And so type twos are, are a higher risk associated with the gastric ischemia and ulus. Whereas type ones are more associated with gord. Um first line investigation bearing swallow gold standard endoscopy. Um risk is obesity and increased abdominal pressure such as if you have an ascites. Um and the management is mostly weight loss plus PPI um, if not, then you might require surgery. Um And for that, you would do a uroplasty and a fund application. Um And there's a picture here very nicely. So here b shows you a paraesophageal, a type two and A shows you a type one. And the surgery here, this is fundoplication on the left. Um And, and the cruroplasty is essentially when you make sort of this, um, hiatus smaller by putting in a few more stitches in, uh, essentially making the hole through which this, um, the gastric contents fit through smaller. And the fund application makes the, the sort of, um, junction larger. So it doesn't sort of slide through and rubs up against it. Um, you noted here that sort of the, er, the complications of this can be burping some swallowing issues and difficulty, um, or it might just not work. Uh, all right, it's an opportunity to give feedback. Um, and we're also get through it at the end as well. Cool. All right. Well, that's about halfway through. Um, here's another SBA missus JSA, 55 year old female presents with a cramping, abdominal pain, nausea and bilious vomiting for around 17 hours. She is distended on examination, her bowels last opened yesterday. What are you most likely to find in her past medical history? Um, a, a recently diagnosed colorectal cancer ba history of hyperparathyroidism. C background of Crohn's disease d previous gynecological surgery, um, and e femoral hernia, I'll give you 30 seconds for that. Ok. So previous gynecological surgery just edges out as the winner there from you guys. Um, and that is correct. Sorry, I put it down as previous Hysterectomy here. Um, and that is correct. So, um, what we've got here is a small bowel obstruction. Uh, now the reason you're thinking small, not necessarily large is because there isn't a large history, a long history of, um, constipation and you've got quite early on vomiting. Um, now, if you think of it sort of anatomically, if the obstruction is more proximal, um, then you sort of have a blockage much earlier on. You've got some feces later on that can still pass. Um, and when food gets sort of to the to duodenum or the small bowel, it gets obstructed early. And so you start vomiting earlier. Um, now, here you've got some possible causes of obstruction. Colorectal cancer is not in keeping with a small bowel obstruction. It's in keeping with a large bile obstruction, parathyroidism, hyperparathyroidism. The hy hypercalcemia can present similarly, um, especially given that the, the, the cramping, abdominal pain could be stones. Uh, the nausea and vomiting is also common in hypercalcemia, although not necessarily bilious. Um, bilious vomiting is much more common with an obstruction. Um, but it doesn't really explain the distension. Um, a background of Crohn's disease is a less likely cause of small bowel obstruction. Um, a previous hysterectomy now or previous gynecological surgery, this is the most common cause of a small bowel obstruction is intraabdominal surgery in general. Um, so small. So K TRS whether to repeat that bit about small bowel versus a large bowel. So a small bowel obstruction presents with a shorter history with earlier vomiting given that it's about 17 hours here and bowels last opened yesterday, meaning there's no significant history of constipation. A large bowel will present with a larger, um, with a longer history of constipation and vomiting later in the presentation and there'll be a longer history, um, of obstruction. Um, and why this is, is because with a, with a small bowel obstruction, the obstructions earlier on. Um, so essentially you've still got feces present in the bowel and the large bowel that can pass. But with the obstruction being earlier in the gastrointest intestinal tract pathway, um, there'll be a blockage earlier from food that's coming in and that will result in vomiting earlier. Um, whereas if you had a large bowel obstruction lower down, you'll have a longer history of sort of constipation, there'll be more space for food to build up in the abdomen. And eventually, once you have sort of when you reach maybe seven days or so or a longer period of time, you could start to vomit. Um, but people tend to present with a cramping abdominal pain and a long history of, um, constipation. Um, the cramping abdominal pain is common to both. Um, and a femoral hernia again, is a possible cause of small bowel obstruction, but it is also less likely. Um the statistics being that um hernias cause about 5%. Um And uh uh the cancers will cause about 5% of small bowel obstructions. Uh with the majority being uh intraabdominal surgery resulting in adhesions. Right. So, you've completed, um you've done a, an abdominal X ray for this patient. Um And this is the appearance of the abdominal X ray. Um with this, the, the radiological sign here is called a stacked coin appearance. Um And uh one thing that you can sort of definitely visualize here is the valve con event is sort of extending across the, the whole of the small bowel. Um whereas in a large bowel, I don't have a picture to show you, but the, the sort of indentations don't extend across the whole way. Um And the um the size is normally about three centimeters two. Yeah. And uh you've got many large small bowel loops there, small bowel obstruction. Uh It accounts for a majority er of the emergency laparotomies er done in the hospital. The major cause is adhesions. The other two most common causes are hernias and cancers accounting for 5% each. Um One thing you need to look out for is an electrolyte abnormality causing an alkalosis due to the vomiting and an alkalosis due to the vomiting. Sorry. Um Over time, this can cause ischemia. Now, the way to think of it causing ischemia is if you sort of stretch out the bowel further and further you, it begins so stretched that it starts to sort of lose the blood supply and the, um, the blood supply begins to be blocked. And so you get sort of this ischemia over time. Uh, the pain is colicky and intermittent, um, before the onset of the vomiting, that the pain occurs before vomiting. Um Again, as mentioned, vomiting happens earlier before the constipation, unlike large bowel obstruction where constipation comes first. Um And it's not very common, it might, it might come up in your SBA S. But, um, uh I spoke to the surgical registrar at my hospital about this. He's only ever heard bowel tingling bowel sounds which are essentially just high pitched bowel sounds once. Um But that is uh, one that's noted, uh, a sign that's noted in the literature, abdominal distension as you might expect, given that they're backed up with uh food inside the abdomen. And so it's also tender. How would you investigate it? Um Again, moving with the, the sort of um system of bedside bloods and imaging. So, a V VG will help determine if there's any ischemia and then this determines the urgency of the situation. Noted. I haven't mentioned um an ABG yet as a VBG gen tends to, to give you most of the information you need. Um And I was discussing this with some colleagues of mine at sho who thinks that VBG S are ABG S are almost never required because A AV VG and some OXY and the oxygen saturations will tell you most of what you need to know. Um Anyway, uh A VBG will show you a lactate which would help you determine if there's any ischemia, um your blood's standard full set. Um but especially using these FBC S and ACR P imaging, initially an abdominal X ray. Um but the gold standard for diagnosis is ct abdomen and pelvis. Uh in practice, a gastrograph and swallow is used if this is not deemed to be acute. Um that gastrograph and is a, a radio oac substance that's um given orally and then they'll take serial x rays to determine um if there is an obstruction. Um a reason that surgeons like to give it a lot in practice is there's some very weak evidence that it might sort of help gastric motility. Uh And so it's somewhat therapeutic as well. Your differentials that you'd consider are a large bile obstruction, appendicitis, pseudo obstruction, and a paralytic. II, sorry. Um Again, the pain location might help guide you as to whether it's an appendicitis, whether the constipation is present will help you guide you for a large bowel obstruction. A pseudo obstruction is essentially like saying that you've got an extreme constipation um uh and poor gastric motility and a paralytic ileus. It is post surgical Now, um, so again, the, the background of the patient help guide you in this direction, the management, I'm sure you've all heard of before Drip and Suck. Um Now it's, it's not quite so clear cut in practice. So, um, you wanna sort of categorize small bowel obstructive patients into two types, conservative versus active surgical management. Um And so essentially what you, the reason you want to, to categorize them into conservative or active is with, will this obstruction resolve by itself? Um So, for example, if you have an obstruction as a result of adhesions, then there's a possibility that this resolves by itself. And so you would give them conservative management drip and suck and see if it works. That's not to say that you don't sort of give everyone drip and a suck, which is uh by the way, that means just giving them IV fluids and putting an NG tube in um to decompress the bar. Um That's not to say that you wouldn't give all of them that, but whether it's sort of therapeutic and manages to treat the, the, the obstruction only really ever really works in adhesional obstructions as they can resolve by themselves. Whereas if they've got a cancer, for example, then there's no way that that can resolve uh by itself or if they've got a hernia, then there's no way that that will resolve by itself. And they will require those patients will require some form of surgery All right. Um, and the surgery I is for those who don't respond to drip and suck if it's adhesional or if it's cancer or if it's, if there's any evidence of ischemia, um, or if there's a hernia, um, and if it's adhesions, you do an adhesiolysis plus minus a resection. Um, if it's, if it's cancer, then you could stent the bowel if the patient isn't necessarily fit for surgery. Um, or you can do a bowel resection if they are fit for surgery. Um, and often you can do this laparoscopically and you might not need a laparotomy, uh, a laparotomy being um, an incision in the abdomen, uh, often midline. Um, whereas laparoscopically, obviously with, with cameras coming in and smaller incisions, any questions here. And finally, the most important part for your sort of practice as doctors in the future. Initially, at least is that you may need to make sure that they have adequate VT E prophylaxis and pain management. Um, now, when it comes to prescribing VT E prophylaxis, there's always a guideline. If you think they're gonna have surgery soon, then they might not need it. Um, but post surgery, especially after day two, they'll need VT prophylaxis whether they require parenteral nutrition. Um, so if, for example, that they're gonna be on a, a long time, you anticipate they'll be on a long time on, um, an NG feed. They can't tolerate any food and IV fluids, then you might consider parenteral nutrition. You won't necessarily make that decision, but you will need to escalate for such a thing. Um I think if you had an Osk station on this writing down, consider parental nutrition um, would be very reasonable and definitely something you will need to do is prescribe pain management. These patients tend to be in quite a lot of pain. Um, so there's no harm in starting a little bit higher, um with, with a morphine. Um and if they can't keep anything down orally, then it might be necessary to prescribe this subcut. Ok. Any questions? Yeah. Cool. Moving on another SBA, a 41 year old male presents with a history et oh, means essentially a, a background of heavy drinking. Um or alcoholism presents the to the emergency department complaining of hematemesis. He's been vomiting for, for five hours. His observations are stable. His bloods come back as n ad what is the most likely diagnosis? S Yeah, absolutely. Give you a few more seconds to respond to that. Mhm. Ok. So most of you have gone for a mall revised tear. A couple of you have gone for bleeding viruses. Oh, there we go. Most of you gone for a mall revised tear. A few have gone for bleeding viruses. Some have gone for bore hers and some have gone for a peptic ulcer disease. All right. So the answer here is a mallory vice tear. Now, if you've never heard of this, it can be quite a, a confusing one, or at least, um, it sounds quite daunting although all it means is essentially a self limiting tear um, within the esophagus, minor tear. Um, and here you've got a, um, a history of hematemesis. Um, now, uh, the key part of this question is that it says he's been new hematemesis after he'd been vomiting for a few hours. That should instantly direct you to two, to two differentials here. Bo halves and a mallory vice. Um, bleeding varieties are possible given that he's got a history of alcoholism, but he's much more stable given that his observations are stable and his bloods come back as nothing abnormal, detected. Um uh And so you'd expect someone to be a lot less stable if that was the case, if you had bleeding viruses. Um Pepticol disease again, but they would result in a melena or coffee ground vomiting and they're also unlikely to be after a bout of vomiting like you to start the vomiting. Um, esophagitis is probably the second most likely uh answer here. Um, but a long standing history would be present not just after vomiting. Um And yes, esophagitis can cause a hematemesis, um which leaves you with mildly revised tear and boar halves. Now, um Bohs is a, a full thickness tear in the esophagus similarly after vomiting. Um, but where it results in abdominal contents leaking into the thorax, resulting in sepsis or um uh sort of um inflammation in general and presents with a triad of chest pain, respiratory distress and subcutaneous emphysema. Um The subcutaneous emphysema is one of the, the less common symptoms that they um that you find or examination findings, but you will see chest pain and respiratory distress. Um don't need at stabilization, urgent CT with oral and IV contrast. Um and surgical management often. And uh this is also less common than a mall revised tear, which is similar, more likely in those with ae th history. Um but this is much more self limiting. You treat it conservatively. They do need an endoscopy within 24 hours due to the etiology um uh due to to define the etiology of the bleeding in case this can be more serious. Um and it tends to streak the vomit as opposed to be just hematosis, Frank. Um but it can also present in other sorts of hematemesis. It can present as coffee ground, it can also present um as Frank as well, but most likely to streak it's one to be aware of. Again, this is the sort of thing that comes up for uh one SBA um but very quickly now that you'll know it um for the future. Um and it's a good differential to throw out when it comes to any form of hematemesis. A 60 year old male gentleman presents to the GP with three weeks of abdominal pain and weight loss. He has a past medical history of reflux for which he takes omeprazole and smokes around 15 cigarettes a day. Um What is the most urgently required investigation? Cats A and O GDB full blood count CCT cap du barium swallow and ea colonoscopy. Mhm. Yeah. Yeah. Yes. Yes. Yes, it is. Mhm. Ok. 80% of you have gone for an O GD and that's correct. Um Now the key thing here is the most urgently required investigation. Now, O GD is the most appropriate initial investigation for diagnosing an esophageal cancer. Now, you're considering this because he meets the two week wait criteria for esophageal cancer. He smokes has a history of reflux and takes omeprazole. The CT cap will be acquired later for staging but won't confirm your diagnosis whereas an O GD can as especially because it can take samples and send them off for cytology. FBC S won't show much uh a barium while it is useful but won't confirm the diagnosis. Um And a colonoscopy. If considering colorectal cancer, then this is the go to but it is not the go to for when considering um esophageal cancer. All right. So there's from an upper gi perspective, at least there are two cancers to be aware of gastric and oesophageal. Um They're both generally managed by gastroenterologists, but surgical management is occasionally required. Um Esophageal cancer is broken down into adenocarcinomas and squamous cell carcinomas. The risk factors for adenocarcinomas being gored and barrett esophagus. Um and these tend to occur. Adenocarcinomas tend to occur in the lower one third, um, of the, um, esophagus. Uh, and then squamous cell carcinomas, um, tend to be the risk factors for those are smoking and alcohol and they tend to occur in the upper two thirds of the esophagus. Um, the way I thought of it is that you smoke and you drink from the mouth and so it affects the upper region. Um And when there's reflux, it comes from the abdomen, um, or there's any gourd or barret's and it comes from the, sorry, from the, um, from the stomach up into the esophagus and that hits the lower one third. Um That's how I remembered it and I hope it helps. Um, adenocarcinoma is more common in the UK, but squamous cell carcinomas are more common abroad or worldwide, at least. Um You're presenting complaints of generally dysphasia, adephagia, which is pain on swallowing. Um, dysphasia is obviously difficulty swallowing hoarseness, um which is uh often missed. Um, occasionally a patient will come in and like my voice has changed. Um And that's something to be worried about. Um, they'll also either for, for the two week wait criteria present with weight loss and one of either reflux dyspepsia or abdominal pain. Um, upper abdominal pain that is, and they have to be also over 55 years old. Um So they come in with either a very significant symptom or a combination of age weight loss and uh a more minor symptom for them to meet the criteria. Uh and sort of the, the gold standard investigation is in O GD as we discussed earlier. Um if it's caught early, which is much less likely, um then it can be endoscopically resected. However, if not, and there is no metastasis or nodal involvement. So that would be a at one or two but um N zero M zero, in your um, criteria, then you can do an Lewis esophagectomy, which is, well, at least you can do an esophagectomy. The most common procedure used is an Lewis which essentially require, which is a, a very large undertaking which requires a thoracotomy um and laparoscopic er, surgery in the abdomen. Uh and essentially what they do is they, they cut the esophagus off, um, or the part of the esophagus that they need of, um, reconnect it and pull some of the stomach up into the, um, into the thorax to fashion in your esophagus. Um, it's a surgery that has a lot of high risks, a high mortality um and is not for the more unwell or um functionally uh lower status patients and then gastric cancer. Um, what I want you to know is that it's most commonly caused by H pylori um, but also nitrate heavy diets which can, um, and so can atrophic gastritis. Um, it can present with abdominal pain, nausea and vomiting b symptoms, um, and rarely upper gi bleeds. Um you always feel for a ver node and abdominal examination and this is commonly um where um gastric cancer spread to. Um the other node is a system chain node. Uh that you might want to know about. Um an O GD is ano again, the gold standard investigation which shows sign ring cells. Um that's um when you sort of biopsy it and look at it under the microscope. Uh and management involves either endoscopic resection or gastrectomy. That may be a partial gastrectomy. And again, the two week weight criteria is simi similar to esophageal cancer. Any questions so far? Ok. Another SBA um, you're covering the er general surgery wards. Um, over the weekend when you are called to assess a patient four days POSTOP for a laparotomy with a small bowel resection, um, f for a laparotomy with a small bowel resection for a small bowel obstruction. Um, the patient is nauseated with some pain in the right hypochondrium. The patient is afebrile distended tachycardic. Um This is one of the last slides of the session will due to be finished in about five minutes, um, distended, tachycardic, tachypneic, desaturating and drowsy. Um A BBg comes back in A ad um, yeah, V VG comes back as N AD E CG comes back as ST which is sinus tachycardia. Um, prophylactic and Oxin has been given from day two POSTOP and a full set of bloods have been sent. Um You've bleeped, the medical registrar. What is the next best step they are likely to advise you? Mhm. Right. Yes. Yes. Give you a few more seconds. Ok, thank you. Ok. So the answer here is, uh, a CTA P plus IV fluids. All right. So I've added IV fluids to most of these are in, in IV fluids to be included in the, in the sepsis. Six. Now, um, because obviously if the patient is nauseated or vomiting, they can't keep any fluids down. So they're gonna need intravenous fluids in general. Um Now, furthermore, uh let's work through it, the other options. Now, a C TPA would identify a pe, um, you don't have enough information yet for a pe to be the most likely diagnosis. Now, if you remember your er, wells score, your pe wells score, um, there's four points given for pe is the number one diagnosis there. Uh And so there are other things that could be caused this. Now, p is possible, um, given that this patient is POSTOP, but it's made less un less likely by the fact that he's already been given prophylactic and oxy. Um Now moving on to NG plus IV fluids, if you're considering that the patient would be re obstructed or has an ileus, um A reobstruction is less likely so soon after surgery. Um, an ileus is very common. Um, and quite likely. Um, however, um, a CTA P is used to sort of rule this and compare this to an osmatic leak, which we'll get to sepsis. Six. The patient is afebrile and we don't have any inflammatory markers at this point. You've done your bloods. If the blood's come back with a raised white cell count or a CRP, then you can start your sepsis. Six. Now, I understand um here that I've said that the patient is tachycardic and tachypneic and desaturating. But if you re remember, but I would point to the Q sofa score, um which it has three criteria is the patient newly confused has a raised respiratory rate greater than 22 and a systolic BP of less than 100. You need two out of those three to be considering sepsis as your main diagnosis here. Um While the patient is tachypneic, I've not pointed out that he is at all. Um He is at all confused and I have not given you a BP here um to guide you uh in the way of thinking that it's sepsis and he's uh afebrile sepsis is a good one to consider in all of these patients. And it's possible that the patient could be sepsi septic given um an osmotic leak, but it's not your first thing to go for. And it wouldn't be what rules out the most important things to rule out. Given that it's a surgical patient, chest X ray plus IVF. Now you'd be considering here, atelectasis and a chest infection and if this is negative, then you'd consider a C TPA. However, it doesn't explain the distention. Um And again, we've already mentioned that the, the reason for the IV fluids, um and you would need to assume that the patient has a POSTOP ileus. Now, day four is the most common day to have an anastomotic leak. Um and a leak would explain all the symptoms and is dangerous. It would explain the tachycardia, the, the tachypnea, the desaturation. Um It would explain the distention, um the nausea and the vomiting. Um and it would be in fitting with a small bowel resection and a laparotomy. Um If he was to have a um a uh a POSTOP ileus, those two sort of come hand in hand present really similarly. And so when there is a patient, you're considering that has a POSTOP ili, you would still do a CTA P to rule out an an osmotic leak if you call the General Surgical registrar at this point, um they would likely advise you to um request a CTA P. Um And then if that comes back as negative, you would then consider going for a chest X ray and then there's CTPA. Um Otherwise, so you need to kind of put it into context um with what's going on. Um Any questions there, this is quite a tough, uh quite a tough question. Um Less than 100 systolic is what would give you AQ sofa score of one yeah, respiratory features in anastomotic leak. Um If you consider that a, a patient sort of um has pain, then that could also cause him to have a, a raised respiratory leg, um general inflammation or if there is any form of um bowel ischemia uh as a result of the leak, et cetera um or causing the leak. Um then it's possible that that uh can cause a raised lactate and your, your body would compensate um to blow off carbon dioxide and cause the respiratory features in an anastomotic leak. Um Inflammation generally comes with that sort of um increase um in t uh in breathing rate. Does that answer the question if not just pop another question in the chat? Um And so then on her last slide here, um regarding postoperative complications, probably the thing you'd be managing most is an F one especially on your, on calls um on general surgery. Uh And they come, I've named here five of the main ones. Um But there's others that you should be aware of as well. So a POSTOP infection, chest urine abdomen rule those out. Um Often A V PG can guide you in the right direction with, with a pyrexia um and prescribe antibiotics appropriately. A VT E especially if a VTE prophylaxis has been missed uh in the process. Um Given that can be sort of a um A DVT or a PE um atelectasis. Again, very common most common within 24 hours of surgery, make sure that you've prescribed analgesia to help the patient breathe better. As sort of, as you can imagine, sort of pain when you're breathing. Um, as your diaphragm pushes down into the abdomen, um, if you were given analgesia, you might not necessarily feel this pain. You can take deeper breaths in expand the lungs and prevent an ectasis. Atelectasis can also cause a chest infection. Uh given the build up of secretions and the lack of movement of sorts of fluid around. Um any form of stasis will cause this. And then an osmotic leak. Again, look for guarding and guarding and rigidity around days. 3 to 5, um can be very severe and can also cause a sepsis. Um So look out for that as well. POSTOP ileus presents similarly to obstruction. It's very common. Um and can also present similarly to an anastomotic leak. Um given the distension, nausea or vomiting. Um but it's not quite as painful as a leak, but you need to rule this out with a act outer and penis. Again, the management drip and suck just like an obstruction, reduce the opiates and consider any electrolyte imbalances that could be causing this. Now, POSTOP electrolyte imbalances are very common. Um Magnesium is often one that's missed and that can cause your POSTOP s and the other POSTOP complications that you need to be aware of pain, make sure they've got adequate pain medication, prescribed nausea and vomiting. Um prescribe an antiemetic um pyrexia. Um POSTOP pyrexia is common. I've seen quite a few patients on the ward with a pyrexia that no other features sort of an infection just monitor uh and pre prescribe paracetamol um to reduce the the fever. Um POSTOP bleed again, very dangerous, very worrying escalate if you think that's what's going on AK is again, very common IV fluids and hold any medications that could precipitate an AKI I will worsen it. Um retention by, I mean, by that urinary retention, it can come in after surgery, catheterize um electrolyte imbalances that could be sodium high or low potassium, high or low calcium, high or low and magnesium. Um And remember you can't correct magnesium without correcting the calc. Uh sorry, you can't correct a calcium without correcting magnesium wound infections, which can also in themselves cause death sensor, which is essentially um when the, the repair breaks open completely. And now this is a surgical emergency. Um And if you see this come up I in SBA S II, suppose it's unlikely to come up in an osk. Um The treatment here is saline soaked gauze and immediately booked in to return to theater to close the wound. Um And an infection can cause this prescribe antibiotics appropriately as for the infection and send off your wound swabs. All right. Uh And that's pretty much it. Um for, for this, uh, for today. Just to, to, to summarize your first job on call is to uh by the nurses on call. Um is to triage your jobs and gather any information that you need. Um to allow you to do this. Don't forget to be able to interpret your radiology and remember to, to revise it before your exams. Remember to escalate appropriately after gathering information and stabilizing the patient. And even then if you need help stabilizing the patient, then of course, escalate then as well, get a good past medical history will guide you to a diagnosis. I know a lot of the time you practice your at es um you practice your at ES have it on a, on a, a dummy or someone who doesn't speak often the patient can speak. Um And so you can very quickly determine a lot of information from, from them. Um by taking a very quick history. Uh I think the, the acronym that I use then and you still use now a sample, look it up. Um Remember your two week wait rules, they come up for a lot of questions in your SBA S and they easy marks, although not very easy to remember, I guess, um, escalate your management investigations appropriately. Um So start with bedside bloods and then imaging and try and predict what a medical slash surgical registrar will ask about before you call them and sort of pre empt that. So you say that you've already done this. Uh, it makes you feel a lot better about yourself when you're a doctor. Um, do your at ES and DV GS, um, and POSTOP complications of the bread and butter of all onco surgery as an F one. Um, and to summarize the, the, the conditions we covered, we covered a perforated fiscus. Generally, the manager would be similar for other, um, perforations, hiatus, hernias, small bowel obstructions, mall vice, tears versus Bohs gastric andal cancers and POSTOP complications. All right. Thank you, everyone. Um, references if you wanted them and then, um, feedback form for a certificate of attendance. Thank you very much. And so thank you for that comprehensive whistle stop tour throughout upper gi surgery. That was a really good session with some really good questions and thank you for interacting. Um, we'll close it off here, then I'll, um, end the call from down below if that's all. You. Sure. That's all good. Thank you. Goodnight. Thank you all. Yes.