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so today's talking to get to be about cold stone disease. Think it's quite common topics. It'll come across student your surgical placement, and I think it's quite common June finals as well. It's not going to be a very comprehensive talk. What we're going to took about very common questions that may come up during finals and possibly is taught will help you have a better understanding of gallstone disease and clarify the difference between different chemical pictures really people some disease. So as my plane, A said weapons have a presentation fooled by some keys based discussion, since more groups. And here are the learning outcomes off the sessions who we're going to describe? The main presentations, of course. The disease, the main little pictures we're going to touch on the different diagnostic pathways, the main investigations that are required to come to a diagnosis also disease and clarify which type of ulcer disease we're talking about. We're going to, and you're not playing about the treatment American options, and finally applying old evolved to some clinical scenario is so here in the clinical pictures were talk about tonight we're going to talk about biliary colic. You cholecystitis political iffy ASUs and ascending Colon Joy. It is. These are no all vehicles disease. Think of pictures and complications, but because of the mosque. Um, once those herbal come out during or vials promises that the whole list, like on an activity you're going to see tonight. But it's just too. I bet we're on the same peach got the liver. It is a big gland that produces bile and then by and flows down each day. Do you deny means the GI Tract and the connection between the liver and the duodenum is something called Be living tree. Now there are different parts of the biliary tree, but the most common parts that I would like you to remember tonight Pharmacist IQ Don't the common bile duct and then the goal bloody, so common bile duct is essentially the biggest part off the main highway. If you want to call that way, that connects, deliver to the dude in, um, it's their white structures that goes all the way down from the liver, down to the beauty. Um, at some point off these structure, there is a patch or a big risk of war, and that's the goal brother, and they go by that is connected to the biggest doc to the biggest start by the system. But now the bile is produced by the liver, and it flows down from the liver down to the beauty in full in gravity. Okay, also story with in the core body, and that's because you're eating big meals. Think about Christmas, for example. You need a lot of bile, and the liver is not able to be used that all in the same ball in in in an instant, you need to have something stored. They can release that one minute so the bile will flow down from the liver, going to the gold Mother and stay there until it's needed. Then it's going to be released from the goal. But, er go back into the common bile that and flow down into the duty, Um, and when it comes to Goldston disease, in order to suffer from goal to disease, you need to go sit in the first place. Now I'm sure some of you may have come across Cholelithiasis. That's a fancy words. Ah, I'm coming from Greek. Just to say that you've got cold sores in your goal, but and I'm not going to going to much details off how you can develop gallstones and have attached a very nice video that perhaps can help you with the debt. But essentially the bottom line for tonight is that one bile becomes oversaturated, meaning from liquid. It starts becoming very dense. Uh, sometimes from a liquid state can become solid. And that's when Goldstone's reach needs. When you've got very over saturate bile dense that when they're more likely to develop gallstones and many people will have Goldstone's and many people want, even realize it of goggles. Most of most of them are asymptomatic. But sometimes the school stones can cause problems and can cause pain. And the most common presentation off someone with as pollsters in the robot, there will be biliary colic, so essentially bottom line of this light is to suffer from also disease unique. Golson's in the first place and Goldstone's originate from another saturate bile. So how can you suffer from really recall? It's a very college is also defining. As Goldston attack, a severe abdominal pain starts in your right upper quadrant. Uh, it got very southern on sits, is very severe it's constant. And then, at some points, it goes away on its own. Uh, I've got here. A picture on the right path can help clarify he sort of type of being. Think, Think you go out? Um, some take away food, perhaps, or burger and some chicks, and that's when you call off. Fact going to your GI tract. And that's when the bile becomes important to try and digest that fat. So the goal blood they will stop. Cook will start contracting to push as much violas possible from the goal bladder back into the duodenum to help with digestion. I might be the case that one of the stones, you can see the picture on the left, moves from the fenders off the gold bladder into the neck and get stuck. And that's that's when the pain starts. So you've got the gold bladder that keeps contracting because he's trying to overcome the obstruction. But it's contracting against a stone, and that's that's what that's the highest part of the off the P, and usually it is quite transit. You think the pain will will seize as soon as the store rolls away. That's usually something that happens in 30 minutes but can last up to six hours. So you've got someone presenting to you. So you have got pain after a fatty meal. Pain is really intense by the pain goes away. That's quite a very clear picture off someone suffering from a little colic. But what happens if they stormed? That's not all the way. Well, that's that's something problematic because from simple put pain Ah, these pictures could evolve into something more complex. The gold bladder might get tired of contracting against the stone and my develop some inflammatory science. And that's when when the go but it will become, the standards will become very inflamed. Okay, because you've got lost by a truck in the gold bladder. Sometimes you also on infection that develops within the goal. Brother eso. At this point, the pain is very severe, is very prolonged, a last for more than six hours. The patient is systemically and well, so they don't only have pain. There might be generally well, then I have a temperature that my B six on the classic sign that you'll find on examination is something called morphine site. So if you place your hand on the right lower quadrant and are still patient. To take a deep breath in you will, you will find that the patient's stops the inspiration, Uh, because of the team. So, essentially, if you think off the tired from when you take a deep breath, the diaphragm is good to contract and by contracting is going to push the lever down, and the liver is also attached to go blad. It's essentially when taking a deep breath in the diaphragm is going to push the lever and ago brother against your hands. And that's why the patient will stop the inspired to effort because the go bladder, we're coming to touch your hand and that's sore. So the bottom line of these ladies were got someone with Goldstone's. The stone will get stuck. At first is a very colic. But if the biliary colic doesn't resolve on its own, it could evolve into a course cystitis and inflammation of the gallbladder. And that's when the patient is systemically and well. But why? If the stone doesn't stop with the next with your bladder and there's still rolls into the common bile that that's destruction, we said and connect the liver to do, do you know? But in the keys day three quarts for that will be political disease, which only means your goggles when you're calm about that. In simple terms, um, you've got someone. In this case, a little picture will be again off someone with very severe and prolonged pain in the right upper quadrant. The difference from the previous presentation or pictures will be that this pain is going to be yellow, but they're going to be jaundiced. And the simple reason for that is that the buying flow in this case is going to be abstracted. If the stone is in the Congo docked, the bile can no longer flow from the liver into the duodenum, and he will go back into the believer and back into the bloodstream. He's does not happen with acute cholecystitis because if you remember in acute cholecystitis, obstruction is just in the gallbladder cystic type, and the common bile duct is going to be free in this case. Instead, when you've got stolen the comma about that, Jonesy's full will start because the file flow is abstracted and again when you've gone abstraction, it can again also be complicated by a superimposed back urine infection. And that's when we talked about sending cholangitis is which can be described as a bacterial infection off the biliary tract. It can be You can have many causes buying the context off course disease. Uh, ascending colon checked. It can also be caused by stones, and you will have some. It can be very, um, well, with pain in the right upper quadrant pain, which is severe and prolonged. They're going to be jaundiced because the bile flow is abstracted on because there is an infection, you're going to have a temperature. And these three pictures that just mentioned pain in the right upper corner Fever and Jones. They're commonly known together as charcoal. Try it now. These tribe is not always present, but he's one weapon. When eighties president is very easy to understand that the cause off, um, the illness of the patient could be an ascending colon joint is so as to recap. We're going up on obstruction that come about, that we got superimposed infection and because of that's the patient is going to be sore. It's going to be joined this and he's going to have a temperature So how can we put all these four clinical pictures together? No, he's a beautiful off a diagram that I hope can clarify at the mean differences between the four pictures that we just went through. So if if if, If you think about a patient coming to you with right recorder pain and known Goldstone's Deep Tendon based on whether the patient has got a fever or is Johnny's, you can allocate a patient to one of those or four boxes. Um, I'm going to give you a minute so that you can think on where you would put, for example, ability. College on Cholecystitis is critical. If he has this and send in common jacks and then we'll we'll go through the results on together. So he had. Here we are. So again, if you think about the universe where you've got a patient with rapid count being in Goldstone's, uh, you can use fever and Jonesy's to differentiate between four clinical presentations working for pictures. There we go. We spoke about a the most coming want you to come across seas biliary colic. So the patient has got pain. They've got gallstones, but there is no joint this and there is no fever. And that's going to be in the a less thought last books, Um, or if they also a fever, So but I got pain, got stones. But then they also developed a fever. And that's when we moved for a billion calling to cholecystitis. So from the top, left the top right box. If we go back to the top left and then we move instead of the bottom left, that's when the store will will move from the existing that mean to the common well back then we'll cause an obstruction of the pee A still there by the patient. You know what? We'll also be John. These will also be yellow. And then, if you look at the bottom right box, that's when all of the three features are going to present. So that is going to be paying. Okay, there's going to be joined this because they come on by that is obstructed, and there is a superimposed infection, so there's a temperature. I think if if you keep these diagramming to mind, it'll be really useful for when we go over the chemical. Sedaris later on and you're in the second part of this presentation, we're not going to have a look at the main investigation that you can use to try and different sheet between these four little pictures. There are some be useful tools that we can use that we can start with some laboratory tests that the first are some inflammatory markers. Uh, they can tell us whether there's any inflammation or an infection going on, and it's very useful. Poor color cystitis or colon Jackie's. We can also look at a liver function test to see whether there is an obstruction of the common bile duct, and that's quite useful for a stone in the common bile duct or a colon giant ease. We've got also some be useful imaging tools that we can use. Uh huh. When you're dealing with patients with Goldstone's, that would always recommend starting with an abdominal ultrasound. Nice, very easy to do, perform as quite weak and has got very good sensitivity in spasticity specificity, Goldstone's remember. The key is that if you're going to look for other complications of Goldstone's ease, ultrasounds on my knocks be able to give you all the answers and think about a stone rolling into the common bile that sometimes the ultrasound will not be able to pick that. But it's simple reason that there might be some look off bowels abstracting the view. And if that's the key, is that we can use some more accurate forms of imaging for a temple. Magnetic resonance cholangiopancreatography is a type of MRI is very accurate for Goldstone's, and Rolls will clearly show the military in much detail and another set of circumstances. Them RCP might not be sufficient to pick up a storm. Come on by Dutch. And if that's the keys, we we can move on to a Ninjas copy technique called in this copy Retrograde cholangiopancreatography. So essentially, you've got scope going down your mouth into the stomach, duodenum, and then you find the A peeler, where the common bile duct interested, you know, and that's where you can. You late the common bile that, and they inject some time to clearly see it come about that time. Whether there is any obstruction now, you can you can realize that you can. It's not just a diagnostic tool, but since you're are you are in the common bile. Documents will take up the stone, so it becomes diagnostic and therapeutic at the same time. Now we're going to see how we can apply these investigations in each other. Four I have pictures would be very colic. We can start with some labs. Were some some blood tests. You can see that there is no inflammation. And because there is no obstruction off the common well date the lft Zerg going to be normal. And ultrasound was going to show ago bladder, which is the black structure that you see it at the center of the picture and you are a white arrow pointing great. And you see that within the school. But there are some white dots and those are the gold stones and the pulse is I clean recognized because they also project a black shadow, uh, behind them. And so this is a very, uh, clear picture off someone that suffers from Ballston disease and as a wholesome singer girl bladder in the case of cholecystitis, with would be 12 raised inflammatory markers. But because there is no obstruction of the common by that, the bilirubin is going to be normal. We can also start from an ultrasound. We're going to see that the patient has gold stones in the gallbladder, and then the gallbladder. This time, because there's an inflammation going on is going to be extended, and you're going to have a thickened wall. Do you see that three. Some inflammatory process going on within the goal, but sometimes ultrasound is know enough the money, the keys that he's also suspect. But there is a stone in the common by that, and that's when you can go forward and, um, RCT or if the patient is really um Well, um, a CT scan is much faster, and he's, ah, more appropriate, I would see so that you can have a quick answer, and then you could start treatment straight away. The only thing to mention about CT scan is a city scan will clearly show. Cholecystitis is clearly sure that there is an inflammation in the whole body. But the CT scan is no good for picking up stones. And so you may end up seeing that there is an influence. Your brother by you may not. You may not see the stones. What about when you got a stone in the common? My back? Well, in this case, there is no inflammation, but the spinal fluid abstracted. So you're going to have a raised a little bit and liver function tests you can always start from with the ultrasound and you're going to I see that there are stones and you go, buddy, and that the channel making the liver to the duodenum. That common bile duct is going to be dilated because of these obstruction. And as we said, sometimes that looks of bowel above the combo. That and if that's the case, and MRCB might be more conclusive, Um, but if you're still struggling to find the stones and you think that there are stones, then it can always go to an endoscopic investigation. And you can always go with an ERCP. I know. Just to give you an idea off what's and in March be in. What's an ercp? Well, on the left you can see are the magnetic resonance Go 100 Pankratov, You a fee. You see all the whites is the biliary tree. You've got all this more channels in the liver at the top, you've got a very big a recent war which is the global other at the left of the picture and wheat, A black doctor within it. That's a whole storm. And then you've got bigger channel connecting to go, brother to the Judean. Um and you continue to why arrows pointing to two black structures within that not And those are whole stones. That's a very clear picture of someone with stones in in the common bile that as well as their blood. And on the right, you can see a very typical picture of how ercp and it looks like you can see the scoop coming at the center off. Just just about this pints of it is coming down from his office, used into the stomach. You do the, um and you consider it stops up at the middle of the day. You do you know where a wire is coming out? That's where the popular off factory is located. You can see the wire going up all the way into the common by that and then injecting dying. And that's why you've got a white contrast within the common by that. And you see the 50 white arrows pointing again too. Some black defects within the structure and those again are stones and finally come into ascending colon. Jackie's. As we said, all the three main features are going to be president, so you're going to have inflammatory markers raised you to the infection. You're going to have raised the building and liver function test because of the obstruction of the bile ducts, and it really depends on how well the patient is for which type of imaging to pick you go first. I will. If the patient is well, we always recommend starting with an abdominal ultrasound for the simple reason that one you're going to find out what their goal still is. The bladder first and to cut also give you an idea whether to come on by that is dilated not most of the time where, as we said, is going to be inconclusive. So you're going to need a second line imaging, which is going to be either and, um, our city or Ercp, something I would like to stress again. These patients should be very well, and he might not have the time for these first line investigations. If if that's the keys, a CT scan is definitely more appropriate. And just to mention what should be the possible management off someone with a full stomach disease. Well, I'm I'm going to check about Cholecystectomy, ercp and Cholecystostomy. So these are three common words that you're going to come across your surgical placement. And so let's let's strain and cloudy find things a little bit. So let's start with a cholecystectomy again. This is a fancy ward for gallbladder removal. It's an operation that can be done through ah, open procedure, meaning a cat's just under your, uh, really marginal on the right, or could be done through keyhole surgeries. Laparoscopic techniques. It can be elective, meaning that you can choose when to do it or it's It's an emeritus, a patient, so it has to be done as soon as possible. And it's the first line management option for people with acute cholecystitis. You've got someone coming with a new infection off their goal bladder, and to make them feel better, you want to take away the go by There. It can also be done in an elective keys. If you want to, uh, prevent recurrence or complications, of course, A disease but a temple. You've got someone with stones in the gallbladder, and you know that they could potentially roll into the common by that, and those political years is a colon, Jackie's or other complications. So if that's the case, you may want to take the gallbladder out before it causes competitions. Or remember the case that these people are suffering from miliary college. And he's very colicky. Episodes are impacting your quality of life quite a lot, and so in these days you take away the go bladder to make them feel better. If you've got someone with an obstruction of the common bile duct than the best management option that you've got is an endoscopic retrograde crunch or if your your CP. So he put a camera down to 13 of the stomach, you know, and then you remove any storms from the date and you drink any infection. If if, if God cholangitis and then lastly and percutaneously course he starts to me. So you may have a patient because he started. But they might be in the eighties in the nineties or the mayor of medical abilities, so they're definitely not great surgical candidates. They may not survive another patient, so if that's the keys, there's alternative solution, and you place a tube through the skin into your bladder to drain all the infected bile and make them feel better. Not very common, but it is done quite often at the oil, possibly because they get many, um, elderly and comorbi patients to his deafness and you're going to come across on the war. So that was good to mention it and just summarize before moving on the clinical scenarios, we describe what goes on disease ease on be described that most people Goldstone's, are asymptomatic. We said the Goldston can get stuck in a cystic that just the neck of the gold brother. And if that stickies may cause really college courses tank, it's In other cases, the Colson's can draw into the common by night, and that's when they cause obstruction and possible cholangitis. Abdominal ultrasound. He's the recommended first line investigation, but go for a CT if you think the patient is very well and laboratory tests are really good. In terms of looking for inflammation, a swell has joined this or raised and fifties, and it is quite important if you want to be feeling she ate between someone that has a stone. The common by that but not And then we spoke about the main management options. Return a cholecystectomy. In other words, the removal of the girl brother or your city when you go down with the camera and take out the stones from the dot So there was the end of the presentation. Yeah, on TV. Two minutes to run to the pool before moving into you. The print cover? Um, if you go any questions? The meantime, a packet, perhaps Ask them if you put in the church. If not, we can definitely answer them when we move you into the recovery room.