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and it's just kind of the core stuff, which you need to kind of get on with your with the job day to day when you start. Or if you've started, feel free to ask any questions on either during on the Facebook life, Feed will have some monitoring that and feeding it back to me on Dalser if you want by email as well. So the general format of the session of all our sessions will be there'll be a case will briefly describe the same on the pathology. Associate it in this case with Goldstone's, we'll talk about the different disease presentations, how they come about the ideology on talk about core principles with investigation on management on, they'll be some questions at the end. Eso bit about myself. My name's Mark, um, an academic If I to doctor based in London with a surgical interest on the teaching interest as well, that's the learning points for this talk. I'm going to be that way for for Made. Once it will be understanding that kind of science behind Golson's just enough toe appreciate how the disease is present as a person kind of getting nitty gritty, preclinical sorts of things. The second would be appreciating how Goldstone's can present the spectrum of presentations that they can have. Understanding key concepts for investigation and management on then applying these skills. Teo Case Onda also going through some sort of less common presentations of gallstone disease at the end, I'll try to take up not the full hour, because I'm sure you'll have busy things to do. But we'll try and be a brief. Brief is weak hand, so we'll start with the case. So your surgical if I won on take When a 45 year old female presents with a background of Type two diabetes, hypertension and obesity, she complains that she's hard, ah, number of intermittent right upper pain, right up quadrant pain episodes, usually after meals, and I'm sure you're already thinking about what this could be. She's been having for a while. But over the past week, it's been getting worse, and particularly over overnight since her dinner yesterday, she now feels very unwell, kind of shivery shaky on her partner has noticed that her eyes have gone a bit yellow. Eso have a little think for for 30 seconds to a minute about the different things this could be I know you're probably jumping toe one thing already a Z. All we do when we start clocking if it's fairly simple, but try and cost of it wider and think about other questions that you might want to ask before we carry on on, um, and talk about what? What? What else is gonna come up? She can use the chat function or right on the piece of paper. Or just have a think for the next few seconds. I'm sure there's some stuff coming up, so some of the questions that I would want to ask is, uh, it's a fairly simple presentation, but you really want to get an idea of the timeline because it does make quite a big difference. If, for example, the patient has been having pain on and off for the last few months and suddenly has got worse, or whether this was a you know, it's a lot of symptoms are brand new, and it's just been going on over the last few days because it makes a difference in terms of what it could be. The pain obviously do. A Socrates history on each letter of that Socrates will really, really help in terms of your differentials. So the site I know with his ability a gallstone disease talk. But you know the site is important. You know, if it were more central, you might be thinking dyspepsia. Pancreatitis, right? Upper quadrant. You think you out the biliary system. The onset. When did it originally start their character? So what does it feel like in this case? It would be, you know, wrenching or stabbing, which would then come and go. And there might be a dull ache in the background. The radiation is important. So whether whether it radiates to the shoulder tip, for example, if you're affecting the phrenic nerve around through to the back is very common as well associated fetuses. So you're nausea, you're vomiting on and brief systems review the timings. In this case, it comes and goes, which is different to you know something like pancreatitis. Make sure they're constantly and then exacerbating the features and severity as well. So each each bit of that will really help you narrow down your differentials. So there's a set of symptoms that jaundice you to ask you a little bit more about trying characterize when it started. How bad is on the associated things with jaundice because of the you had the talked last week about, uh, you know, the the biliary system and and dramatic circulation familiar with the fact that that will cause you to have pales Stools on dark here in the jaundice can affect your the whites of your eyes, which we call actress on it can affect the skin, which is doing this. The systemic symptoms is important in this case, so that that's the fever, the shivering, the kind of being unwell. The malaise. Which, uh, we'll we'll get to the diagnosis state of that. That's important on whether they've had any previous episodes like this, what they've been like on whether they've had any abdominal surgery. Of course, if they have their goal better out in the last year, but whenever then, that makes a big difference to what you think it might be. Yeah, to carry on. So she's had these episodes of the last year, but and and and it's in that kind of post prandial so after meals, particularly when they're fatty and it's always in the right upper quadrant. So just underneath her rib have written that the cost a margin on the inter in the mid axillary line. Um, the urine is recently only recent in the last few days become dark, the stores have a whole bit pale, and she's a bit itchy. She's not seeing him about it over the last year when you ask because she just thought it was indigestion because she gets after meals. But now that she's become, you know, sweaty, shivery and yellow, she's thought that she got she would go to get help. Okay, so keep having to think about what you the different things that could be. We're gonna do a little bit of ah besides, step now from the case and talk a bit about and ask me so very generally we'll start off. You've got the elementary canal you've got the stomach on in the second part, the medial aspect of the second part of the Judean, and you have the Ampulla Varta, which is guarded by the sphincter of oddi. So that's think my mouse works. So this area right here, which is the opening of the main duct, which is a combination that pancreatic duct on the common bile duct. The common bile duct, if you follow it up, splits into the cystic duct, which goes to the goal. Bladder on goes up to the common hepatic duct, which then splits into the right and left. That the cystic duct is a is a branch on day, it's often a lot more, uh, curvy and a corkscrew like. Which, then, is how the goal better is. Have a bowel gets to the goal, but in order to fill. And then when you eat with the Colace is to kinda, which is the hormone, which will call it to contract the Bible, then flow out of it down the cystic duct, come out into the elementary canal. That's the general asked me important thing on the kind of cellular level in the liver which my carpet exams or war drowns. You'll be in quizzed. Is that the? You know, the fat sites are arranged into hexagons at the center of ahead skin, there's a central vein on. On the outside is the portal vein hepatic artery in the bowel duct. What's the blood flows from the intestines through the portal vein? It will flow towards the central vein it's getting filtered, and it's going that way. The bile will go in the opposite direction, and then we'll collect in the bowel duct and go out the liver. That so if it was specifically, you've got the stomach below that you have the greater omentum, which hangs down like a drape over the intestines. You have the less omentum, which connects the lesser curvature of the stomach to the undersurface of the liver. And behind that, if you have to poke a hole through it, you go into the lesser sac. There's one natural way you can get into the last attack, which is through the Framan of Winslow. So imagine you could put your finger through that hole and it would then disappear behind uh, the the lesser mentum. So the gallbladder is up here. It's a fiber muscular sack with the capacity of about 50 miles. It's lined by Columbia epithelium, some important relations eso on top. Anterior, you have the liver posterior. It's covered by peritoneum. You've got the transverse colon on the first part of Judean. Post eras well, on on the side, you have the right side, right? Lateral, You have the right lobe of the liver. On Medially, you have the quadrivalent with the liver. It's supplied by the cystic artery, which is in most people a branch of the right hepatic artery, and it directly goes into the liver in terms of venous drainage. Importantly, there's something called the colors triangle, which will be mentioned by most people on, You know, most consultant. If they're in theatre on, do well come up in exams, which is the triangle bounded by three things immediately. You have the common hepatic duct in fairly have the cystic ducks on Superior. They have the inferior edge of the liver, and the reason it's important in in theater is because that's the area that surgeons will need to appreciate on be, say, appreciate. You mean we'll have to find all three of those features in order to be sure that the cystic artery is running in between it. Because the contents of of the hepatic Billary triangle colors triangle is almost always a cystic artery, which, when you're taking out the gallbladder, needs to be clipped and secured. It's just another view of the celiac access. Yeah, last week, he went through the him at the the mechanism for bilirubin and how that creates jaundiced or just a very, very brief overview for those who might not have been here last week. You have the break breakdown products over about cells, which goes into he broken down into Billy Rubin, which is in conjugated in the liver from unconscionable driven, which is less soluble to conjugated bilirubin, which is then excreted and it forms thie yellow of your urine on the brown of your stool. So, back to the case 45 year old female presented of God in pain. She's having jaundice and malaise. A few more things for you must when you're set her. Uh huh. So observations heart rate is 110 on Have BP is 89/40. So really, that's not a great sign. You've got a heart rate, which is above the systolic of the BP, which is, you know, the reason that the heart rate is high is because your body has compensated to maintain cardiac output. The BP is low, so you want to maintain the perfusion pressure by increasing the heart rate, the temperature very febrile on slightly tachypnea very tactic neck as well and saturating well on their so on the examination got steroid well, victories present. No jaundice in the skin, Um, but so you just have it in the ice heat. Expect the the bilirubin to be in the region of thirties forties. You wouldn't be kind of sky high in in in in the eighties nineties because then you would see some jaundice on. Importantly, they're no signature of chronic liver disease when you feel the tummy abdomen is, uh, soft, so there's no guarding. There's some voluntary guarding with, which is a bit of a misnomer, but it's maybe distractible. Guarding is a better term, which means that when you're pressing on it, it will hurt and they'll tense. But you might, you know, start tracking to them about something completely unrelated. And it might soften up just a tiny bit, eh? So she's Murphy's sign positive. So that's an important sign which everyone will be familiar with, which is palpations of the right upper quadrant. During a deep breath in which forces the diaphragm lower on their four presses, the goal bladder up against the abdominal wall, which will then hit your hand that causes pain which is a sign for, uh, you know, coolest isis and cholangitis. It's a sign of inflammation of the gallbladder, but we'll get into the differences in a short while, though, assign positive, so that is slightly less common. It is hyperesthesia so pain when they shouldn't be pain on light touch. So if you just stroke the inferior area of the scapula on the right hand side, so if you strike the back on the scapula, it it will hurt them, which is obviously not a normal a normal thing. And it's to do with the referred pain on dermatomes of the bladder course of our sign negative, which is painless, which which was covered last week. And that's when you have painless mass in the right upper quadrant, but usually signify is pancreatic cancer. In this case, it's painful, so that's why it's negative, right? So the diagnosis, I'm sure everyone has appreciated by now, but it is cholangitis on. We're going to go through the differences between all of the different gallstone presentations, and there's a spectrum, and it goes from a symptomatic Golson's through to cholangitis across biliary, colic and Palestine. This a few definitions you have cholelithiasis, which is goal stones in the gallbladder. So that's just the presence of your stones in the gallbladder coli Dokle if isis. But the extra doke a bit in the middle is that there's Goldstone's in the CBD in the common bile duct, which we talked about certainly earlier. Curly's status itis being the Suffolk's for inflammation is inflammation of the gallbladder cholangitis. Again, the Suffolk's for information, but of the perfect Pearland, which is the bile ducts. You have inflammation of the bowel ducks Cholestech. This is when you have failure of the normal amounts of bile to reach the small intestine. So you have Stasis. I stagnant stagnant bile in the CBD, which is a risk factor and will cause eventually infection. There are some other ones about some more weird and wonderful presentations, which really cover but slightly quicker, which will go through a bit later. So cause dents the definition presence of solid stones within the goal bladder. There's a photo on the right there for you. 25% of women and 10% of men will have these across their lifetime. Only less than 2% per year will actually develop symptoms So that means that a minority, not a majority of people with gallstones, will ever have anything. You know we'll ever have any symptoms, and that's important to appreciate. So there will be lots of times what you might have scanned their abdomen for completely unrelated reason. Um, and you'll find gallstones in their goal better, but you won't be doing anything about it so clearly. Lift, Isis continued Pathophysiology, is that we have the different types of gallstones. They could be made up of different things. They can be made up of cholesterol. They usually bit larger and fewer, and the Onda well, they could be made up of pigment, which is usually more more. He minutes, so they'll be smaller but more regular, and they'll be darker. Mix is the most common where it's a little bit of both but predominately cholesterol. They usually form in the gallbladder and then contractile through the cystic duct down the common bile duct, which is more common in the West. But in the Far East, you can actually get Goldstone's, which developed in over in the common bile duct itself. So why does it happen when it comes to the cholesterol you have an increased dietary cholesterol on that will cause the bile salts, which Acuna in the good about it to be super saturated, which means that they can't form myself, which is when it's kind of acts like a soap. And we'll, uh, and and for may, sort of very structure. It can't do that properly because it's too saturated with cholesterol ready and therefore it forms of precipitant, which over time will form into stones. You could also have excessive hemolysis, which we usually cause the pigmented type, of course, ends toe form on um, they will, because in the pigmented type of gallstones, and that's because you get excessive heat and breakdown on. Even though the rest of it is normal, the system can't keep up. And if you get precipitation, yeah, so some risk factors for cholesterol You have the five s, which people may have heard about. So female 40 I slightly okay, fat. So being obese, overweight, um, fertile, because exposure to estrogen is a risk factor or his is part of the pathogenesis. And there, as in being light skinned hematologic good conditions, which will, you know, we touched on with excessive monetise s her rotary tear A little research cytosis G six PD and sickle. Also, rapid weight loss, which surprised me the first time. I don't know. But if you lose weight too quickly or that cholesterol you know all the fats which were in your kind of adipose tissue. Suddenly go into your blood stream and then suddenly have to get get rid of, you know, get get excreted by the body. If they're not burnt up, you'll get a, uh, increased chance of them precipitating in the gallbladder. So pregnancy as well, because you get bad Stasis. Andi Other types of information infection In general, you get problems, problems with interface it circulation. So if you have crone's disease and you resect, you know the terminal bit of the island where a lot of the ball is a re absorbed. As part of that enter a plastic circulation and then you get kind of gallbladder, which is having to deal with because you're losing so much. It has to produce more to keep up, and therefore you get high charts of the precipitating in form. Of course, there's a well, so it's talk about the spectrum, Of course, in disease, a synthetic or stones that we touch on. It happens. A lot of people, you leave them alone. Billy Colic. That's when you have gallbladder spasming against the obstruction so you have a stone, either in in the global itself or maybe in the cystic cystic duct on the gallbladder is trying to squeeze against that, and it can generate up to around 20 millimeters of mercury of pressure, so it's quite powerful. And if it's and that's why you get the colicky sensation so bit like renal stones, when you have something contracting against obstruction, it causes waves of pain so that presents is right up the courtroom. Colicky pain after fatty meals and the reason that fatty meals is make you know brings out the symptom is because that's when bile is needed most. So violence used to, uh, help digest fatty fatty foods. So when you eat a fatty meal, you get a higher release of code. Is is to kind of on day four or higher release of high increased contraction of the gold bladder to try and digest all that extra fat that you've eaten and it's self resolves, so it's just it's squeezing and then it being painful. And then it will resolve after that about so you don't have any jaundice or, you know, systemic symptoms you might want to use. Um, lft is an ultrasound to actually prove that there is Goldstone's on most people. If it's just, you know, one or two episodes, they'll choose to leave it. But if it's happening very frequently, it will be cumbersome for the patient, and it will be very painful, so they might want to help a cholecystectomy and also, once you know recurrent bouts of biliary colic on lots of gold stones in the gallbladder. In that context, you'll be a higher chance of developing cancer status when you was getting discharge advice, you know, to reduce fatty meals to lose weight and exercise and things like that. So next one up killing cystitis is this is a step up because there's inflammation of the gallbladder, so you have everything you had colic, but in this case, at some point it's lead. It's lead to inflammation and sometimes infection of the whole bladder, and that means that you have fever as well as all the things you have for biliary, colic and you'll be tender in the right upper quadrant as opposed to just having pain there. And that's because when you press it, you're touching something which inflames that causes pain. So in this case, you that that the that you give antibiotics, you get fluids. You through everything you know, you treat with the symptoms and you treat there, uh, that pain with analgesia and things like that. But the gold standard kind of the thing that needs to happen is, you'd say, a little better out. Over the last decade or so, there's been conversations in the literature about whether that should be done. Electively, once about of coated cystitis, has died off, or whether that should be done in the acute phase. Most people that I've seen on most things that are written about now advocate for what they call hot gallbladder is they're taking out the Diegel better during the active phase of of information. But that should really only be done in the 1st 48 hours or so. If you wait longer than that, then all that inflamed tissue will become will stop. You started at adhesions, so little fibrous bands, which would make everything very matter down. Which would mean that a it's very hard to appreciate colors triangle, which we talked about earlier and be much more likely to accidentally, you know, tear off a bit of the common bile duct accidentally evolves parts of things because you haven't because it's the anatomy isn't as clean. It's in that case, if you're kind of presenting, you know, in the five days to a week sort of thing, then you'd wait and do it electively afterwards. The reason you want to do an MRI see people operation is because the last thing you want to do is take out the door better Onda. Then they come back later on with symptoms of cholangitis because actually, there was a stone in the common bile duct which you hadn't realized on. So even that you've taken out the goal better. They still that can indict. It's that's not ideal. So most centers will advocate the use for and MCP preoperatively and if they do find a stone in the combo, but then they have to do an e ercp to fish out. But we'll talk about these things in it in a minute, so that aspect um, the last the last one on the spectrum is cholangitis is when you have infection of the whole biliary tree, and it's usually most commonly E. Coli, which makes sense because in the same way that you know, utilize the most commonly e. Coli because of, um, uh, echo, like coming from from from the intestinal tract up through the urethra into the bladder. This is E. Coli coming from the intestinal track up the belly tree on causing infection on. That usually happens when this Stasis. So there's a Stasis of the stagnant bile and therefore the E. Coli can travel up on cause it to become infected. And this presents with fever, dourness and right upper quadrant pain. Importantly, there's jaundice because there's a blockage of the biliary tree. And those three things, of course, shockers. Try it when it's very severe. It's Reynolds Penta. When you get hyper, when you get confusion and you have shocks, you have hypertension again. The investigations, the prime investigations to the same LFTs on ultrasound on the initial management will importantly, include sepsis, sex, and that's primary thing that needs to happen in order to save that person's life because their septic usually, or and if they're not septic, they will become septic very soon on. So you need to manage that infection and each hospital have different guidelines, but you'll have to have some gram negative cover in that, and you need to be speaking toe HPB have a two pack rats of biliary doctors. Urgent because what they'll need to do is in the ercp. So any OCPs times for endoscopic retrograde cholangiopancreatography? That's when you put something through the mouth and endoscope. You go all the way to the Ampyra of Arthur, a new instrument. You put a device into the military on the inject dye through that so that you can see a nice picture of the military, and you could also the same time fish out the blockage. So it's both an investigation and the management, and then ultimately they will need a laptop. Kind of stepped me as well. Once this whole thing has settled because it doesn't want, you don't want it happening again. So to talk a bit more generally about some of the investigations, you know, whenever you're, you know, going back to the case, what sort of things we want to do things. Person presenting their February. They You're the parking doctor and you're the first one there. So are there any D or compulsive? The the they're medical of the general surgical team on Do arriving. What's the test would you want to have done? So you can think about it as bedside bloods and imaging, which, if you're doing Oscars or exams in general, that's how you should frame your answer because it makes you look. I'm like, um, it's just more structured, which these events were like. And in real life it's a full back. So if you're panicking, you don't know what to do. Just think. What can I do? The bedside, what blessed I want and whatever you want, And often things will just pop in. Having that structure in your mind will make you not miss things. So any CG, you're the one that everyone on a lateral flown in these times with a fever, even though it seems unlikely they may have out at the same time. And if they're going specially for procedures where they might need intubating, or at least have an element or something, then you'll need to make sure they're negative. You can do a urine dip on, but in this case you could look for conjugated versus unconscious gated bilirubin, which will help you determine whether it's pretty pathetic posthepatic doing this and a urine pregnancy test as well. Because especially the game for the better. So blood tests you want to do a one on ones that he sees you sneeze. A lefty's would, of course, be very important that we weren't going to the specifics of how they're present. But you'll get a cholestatic pictures. You have a higher LP than a L T, and that's because you have Stasis of the dial in cholangitis. Suppose in the other types of ones. You would just have race and famished markers for the F B C. And it's CRP will show you that. But you'd have a normal bilirubin and LFTs yeah, you don't have a baseline of the peace and bone profile on amylase as well. You'd want to rule out things like pancreatitis, which may not seem completely necessary if you feel like you have the diagnosis. But remember, Goldstone's can travel further down and cause both cholangitis and pancreatitis, a group in saving crossing will be important, especially preoperatively. So the liver screen L p versatility we've talked about, if you could, do you know, in this case, you might not think about being on these things. But just bear in mind. There are lots of other tests. If someone asks you a full liver screen, if you're not quite sure what's going on, you can ask for these different tests, which will, which will do range? Your left is to something so so. The radiological investigations are important to appreciate with, uh, with gallstone disease. We'll start with CT after pelvis because it's often it's. It's not the best test for these sorts of things, but it's often the test that you will get first. Um, either because you're at least trust. I've been working out. People come through the front door, have have an acute abdomen, and they almost automatically get a CT abdomen pelvis before surgical team even kind of got there. Um, if your overnight you know that there's 24 hours, there's a CT in every any department. So it's very easy to get ultramodern, usually working hours, usually 9 to 5 on. You need a, you know, special just ultrastenographer Teo to do it, and they usually don't think they're during the day. And so it's just harder to achieve, even though that a better test for things I could start us. But there are still things that you can go from CT abdomen pelvis is. You can still see that the war might be thickened, which will give you the diagnosis of calluses. Isis. You can also measure how big they see the common bile doctors. If there's a stone in it all the combat duct, which is proximal to I close to the liver, will be dilated because of the blockage, just like if you block the pipe, the pipe behind it. But it's well, sometimes, but rarely you can actually see the stone itself. And of course, the advantage of it is that you can look for things like pancreatitis and other causes of the abdomen if you're not so sure. But the first line investigation for your PSA disease would be ultrasound abdomen. With this, you get a very good look, so it's got a much higher sensitivity and specificity for finding Goldstone's because usually they're made of cholesterol and therefore the gall stones themselves don't show up on the CT abdomen. Pelvis is, but they will. But they'll be echodense, which you can see here by either The sound waves don't go through them so you can see them. You see the shadow behind it here on before they can be seen on alternate plan without stamps, and you can also look at the thickness of the gallbladder, so thick wall would mean that it's angry and inflamed. That's kind of the status as opposed to colic on Do you can also look at things I received the combat doc size on day things about some disadvantages. Um, as we said, time of day. Sometimes I know you're not able to get them right there and then on day also, you know someone is particularly overweight. Sometimes the views are quite bad because the pro pastor shoot sound waves through a lot more tissue. So the MMR CP and the Ercp sound very sound. Very similar can sometimes give you some information, but they are quite different and MRC pee. Look at the first one. The first letter, um, for memory. So that looks that that relies on water having a different properties than the surrounding tissues. And so the ball. The whole biliary tree is full of full of bile, but as of watery substance, so it shows up great very nicely on. But they're a gallstone is you can see that there's if they call filling defects so they'll be an area where there's no water, no bile and that that way. And then you did use that that is a stone, and it's very sensitive to look for, to look for stones in the common bile duct for the arts. And, um, then we mentioned you can see them in the common bile duct, but they're not perfect at at fine. And then So they have. So you need an MRI C P to be 100% sure that they're not in the coming back up, which, as we mentioned before, it's important negative. Taking out the gallbladder you want, make sure that it's not in the cotton ball up, so the MCP you might be able to see their goal. Stones are to see there's information, but you can't have that stage do anything about it. An ercp, however, is an investigation because you you put a device I'll show you a picture later into the biliary tree and you inject dye through it, but the same time at the same time, you can fish out any obstruction that's there. So it's therapeutic, which is a big benefit, but it is invasive, and it has quite a few complications, which will go into in a second. So some of the images of management. So we talked about how the investigations you have bedside bloods and imaging with management. Again, you have conservative medical surgical That should be your structure. When you're writing up your clocking from the patient that we just seen on, it should be your structure. When you talk about it, all skis on when your advice the conservative treat the symptoms. If they have nausea and vomiting, you can give them antiemetics if they have the itching that you can give them some topical, awesome anti histamines. Itching would be because dourness, in this case pain treat the pain basket pounds particularly useful because it's an anti spasmodic, which, as we said earlier, the the cause of the pain for things like colic is because the the gallbladder is spasming behind the obstruction. That's why it's useful to give an anti spasmodic my consultant I had in my hospital last year. It was a huge fan, almost made us prescribe a PR basket pan for everyone that came in with very colic because it was so effective in her. In her opinion, I'm not sure about the if there any acid he has about that. But it did seem to work. Think junction of the others as well. And then conservative things. Weight loss, where we talked about earlier the medical things and for curly cystitis and cholangitis. You're giving antibiotics and you can look at local guidelines because each one has slightly different. So the different advice on deceptive six. We won't go through it. But you know, there's a give three in the take three. And if they're on well, if they're very, um, well, they're shocked and hypertensive you to get really intensive care input from her phylaxis Steve. People are usually I've weight. They're usually they'll be sedentary for that period of time. They will often have other risk factors for clots on. They'll be acutely, Um, well, so considering prophylactic over like, heparin is very important. And if they're overweight, over 100 m. They need to give that twice a day instead of once a day. Be whether, if they're going for surgery imminently, well, if you think they considered remotely, then it might be wise to hold it until they're consultants. He's, um, in the morning, for example, or until decision to be made to operate or not. Then you can you know, um, it it for one or two days is but the definitive medical management for, um, you know, for for so many things, for if there's a blockage would be an ercp, um, and PTC and Drain. We'll talk about in the in a short initial wall, but that's if the ERCP fails. It's the surgical management. You can have open surgery, the cocker's incision then, which is number one there, which you would have seen on patients. I'm sure, on laproscopic, which has better operative outcomes on postoperative outcomes, which will often be accessed by three ports, one of the member like a little bit the Cameron and then two other ports. It's important to note that jaundice leads to bad outcomes. Onda, that's that's well known in veterinary. It prevents effective healing. Onda we mentioned earlier about the hospital. But when adhesions forming and the importance of operating either early or letting excessive sweating after, it's some of the complications of, uh, gallbladder surgery is conflict is a conversion to open. But it's considered the type of complication a bar leak, so that's if that's usually from noticed yxta. So when you have the cystic duct that's clipped on the gallbladder taken out and sometimes that clip either isn't put on perfectly or well, in the case of the Radicals, there are some other tiny little little channels for bile to get into the gallbladder. Usually not by this, is it that, but from the liver directly into the gallbladder tiny ones. So when you take it out, some of those could leak, and that is usually can be treated by doing a stent and letting it heal naturally. So you're sending it so that bile has an obvious tract path of least resistance going straight out so the leak will stop on. Over time, it will heal. The other one is about duct injury. So, for example, if you're doing in a very hostile in environment in there five or something on you accidentally tear off the cystic duct from the common bile duct, you have a gaping hole in the get in the common bile duct. Then that would pose a big problem, and it wouldn't heal by itself. You can't stand too, because of no more of that to me. Isn't there on deaf? We'd have to do better Reconstruction, which they hate should be surgeons will be that that would be one of the things that they be operating on commonly. For those who are interested, you get ruined. Why? Reconstruction on the plum part. The Judean straight into the small intestine. So you get the spare limb on down, you plum. The spelling intto the compound ups proximal toe. Where for there was the big damage bit and the rest you tie off. It's an ercp, essentially a picture. Here it is. So this is the endoscope which is coming through the mouth around the Judean. Um and here you have the pancreatic duct in the common bile duct, joining into the with the stricture or regarding the ampulla of auto where that all comes out on here, the the scope comes away down, you place an instrument into the combat duct on you can inject dye. In this case, you can also fish out the stone with a little net. There are some complications with Ercp, which is very important to know, because part of a job Virginia doctor will be to go review people once they've had their ERCPs. And things were looking out for are abdominal pain, uh, bleeding on. But, uh, after they have lots of sedatives, it might be very nauseous or very, very dangerous, sedated with restoration, things like that. So the complications of your CP bleeding about 1% which rises to one of the heart percent if it's linked or Artemis is performed now. So it draws me is when you make a small cut in this victor of Oddi, which means that any obstruction is less likely to recur. If if there's, you know, stenosis from here, or if there's a reason that thinks can't get through properly, you can cut the side of the sphincter on that that will drain out much better. You have to use a monopolar die for me for that, and therefore it will bleed study anymore. Another thing you can have his Judy with perforation. Um, straight signature. Did, um uh huh. On it can. It can, unfortunately, sometimes perforate, but it's very low incidence. Um, cholangitis because you're instrumenting something into Thorin into the into the into the into the biliary tree. You can actually introduce infection. And also because depicting dye up it, you can introduce information into the pancreas, which is a 1% which isn't. It is, if one of them one of the causes of pancreatitis after alcohol. Ethanol. It's one of those column. So this is the percutaneously transhepatic cholangiogram. Let's say you're doing the ercp um, Andi. Unfortunately, there's a stricture in the Judean, or there is a reason that you can't get to this goal stone, which is lodged there. Despite your best efforts, the consultants, best efforts. You can't do anything. Teo gets out. What do you do? Your options are fairly limited. At that stage. You're not going to just give it another go with someone else because you trust that you know that that go was proper you that there's risk each time you do it, so you don't want to just repeat it. So the thing that they usually do is uh, purchasing. It's transient. Last 100. Um, essentially, if this is coming from the bottom on going up the tree towards a stone, this is coming from the top and going down the tree towards the stone, and it comes percutaneously and through the through the skin, through the liver. Percutane it was transit. Batic on, then into the military, and I'm diagram on. Then from that side, you can put the dye into the trash. So in this instance, you can see this is a tube was going through the skin through the liver, the dyes and injected summer. I'm here and the dye is going all over. It's going down. It's going up the cystic duct into the goal bladder. That was getting down towards where the narrowing is. In this case, it looks like it's probably a stricture. So I just got some water frequently. Yeah. Okay. Okay. Okay. On dots. Why? You can see that they do the PT see, and they often stent it at the same time to then allow it to all stay open and patent. So I said we talked. So there's that we've covered now the main spectrum of biliary disease to be covered. Billy Colic, a syntactical stones, cholecystitis and cholangitis talked about the key principles of investigating them and the key principles of managing each of them. Now we're gonna cover briefly. If the last 10 minutes or so before we have some questions, some other conditions, I'm going to do it in the form of little cases. It's a little little MCQ questions. Don't worry these, that these are the harder ones. So if you've not heard of these things, that's fine. This point of the MS to get them wrong and learn this wouldn't necessarily be. You know what Finals a structured like but maybe example on there might be like this. So question 1 43 old lady with repeated episodes of abdominal pain is admitted with small bowel obstruction. A laparotomy is performed on that surgery. A gallstone I liest is identified. What's the most appropriate course of action? So get the first seconds. Do you think about that and read the answers? And if you don't know Oh, cool setting on it says Great, you're about to that. So a gallstone Eilis is when the you have a gallstone in the gallbladder on you know, in the case of cholangitis and my travel through the cystic duct into the combo doctor cause problems there. But in this 43 old lady's case, what's happened is that because it's been repeated, that's good status or on repeated bouts of colic, The gorse, um, has managed to cause a fistula, so abnormal connection between two surfaces between the goal butter on be closely related duty and remedy inactivated went through the beginning. It's in this case, the goals that has gone from here, straight out through the hole into the Judean and which meant that the girl said, no longer in the go about it. And it's now in the small intestine that within travel a long, long, long, long, long away, down all the way through this one test in intimate will most likely get lodged in one of the narrative. It's the small intestine, the idea sequel valve. So at this point, it will cause a balanced ruction. So you present with bowel obstruction. But the actual causes a gallstone, and that's what's called a gallstone. I'll ius earliest meaning slowing down of the gut. It should really be called a gallstone bowel obstruction, but it's not. It's called a dexa gnarliest. But now you know to treat it, you want to remove the gallstone and you want to do it by approximately cited Interosseous to entrust me Cut, you cut. So during the operation you got a small hole in the small bowel, uh, 20 centimeters proximal to the gallstone because if you do it right here, it won't heal very well because all that tissue is very angry. Inflamed. You do it up here, you then fish out the gallstone suture up the hole that you've made on. Did you leave the gallbladder? Be because it's just like if you do the operation on day five, this area is very hostile on anything. You try and achieve them will probably lead to more damage than good kind, of course, in ideas. So the next kind of sort of uncommon type of English will cover 68. Your A man with type two diabetes is admitted. Hospital unwell. On examination, he has features of septic shock and also write up a quadrant tenderness. And he's not doing this. Imaging shows a normal caliber bile duct and no stones in the ball. Better what's the most likely diagnosis? So the question is kind of leading you along the coast. Isis. But then it is a bit of a curve ball and saying There's no stones in the gallbladder isn't something that we've talked about yet. So we can probably just by, you know, even if we didn't know what these things all meant. That will cover me to send him in a minute. But we've covered cholangitis so we can know it's not that on disease. Acute calculus Coast artist with a stone. It's not that because we could see their in their stones. So just by process of elimination of it exam technique, we can probably just that it's acute. Acalculous cholecystitis. This is when you have inflammation of the gallbladder in the absence of Goldstone's. So here's a nice ultrasound of the gallbladder being a thick walls so usually above above five. Setting around seven millimeters or above of thickness, and that's measured by the ultrasonography is this is in exams. You'll see this if he's the Type two diabetes, no stones and what you think looks like it, it started. It would be a culprit scale. It's itis, but it's also more common. Just when people are generally unwell in hospitals, something else very unwell, they might develop it. Help describe cystitis on disses managed exactly the same way, so there's nothing extra to learn, so you treat it and about IX. This is a risk infection, and you still treat it with the shot because it's text me. Question. Three 41 year old lady is admitted with colicky right up quadrant pain. It's a similar to our our Lady from the first case that we did at the beginning. The session. On examination, she has mild Parexel and clinic. He jaundiced again sooner than we talked about. An ultrasound scan is reported as showing Goldstone's and the patient is taking for theater for an open cholecystectomy to safe are several Operation CalArts Triangle is almost completely impossible to delineate, and we talked about what converts trying. What is this for earlier? What's the most likely explanation? Okay, so if you haven't heard of mercy syndrome good, now you're gonna learn about it. That syndrome is an exception to the rule that Colecystitis does not present with jaundice, and once we explain why it happens, it will be slightly more of this about about why that by the Jordan. This is there. So you have stone impaction to a stone has traveled from Google Bladder on, usually in the cystic duct, and it's causing inflammation of that area. Or sometimes it's just so big. Either way, it's pushing extrinsic lee onto this come about ups. Remember, whenever we talked about obstruction, you could have obstruction from within. I, you know, having like also, honestly intestine obstruction from something within. Or you can have a mural cause or you can have extramural. In this case, it would be an extramural, um, external compression of the common bile duct, which is causing misery Stasis. And it's most common when you have recurrent infections on the question will often tell you about, you know, difficult surgery or impossible to the delineate on Ask me. And that's because everything so, um, flamed, because it only happens with this recurrent infection that it's just very difficult to see what's going on because everything's inflamed and red and everything looks the same on sometimes. Because of that, it's unsafe to do a complete laparoscopic cholecystectomy actually being removal because you wouldn't be able to appreciate the anatomy you might. There's a much higher chance of injuring the combo. Old up on causing bar, leaked or worse, bowel Duct injury. Eso You can do an operative coast cystostomy, which is a hole in the gold bladder. Um, the ostomy is when you make a hole in it on, you could just remove the infections. You could remove the past in the colon that we removed the success on beheld at least for the short love that things settle down. So the principle question 55 year old accountant has a jaundiced in the temperature of 39 degrees. Um, he's known to have call stones, but cultures have shown a gram negative Bassedas imaging shows balled up to measuring 1.2 centimeters in diameter. What's the best treatment option? So that's what we have talked about directly in this talk. So we have shockers try out there. We have jaundice, we have temperature on. We have right quadrant pain, but she doesn't say specifically, but that's right over a courtroom pain as this patient has cholangitis. So we've talked about the different things that so what is the best treatment option already with the question is about treatment so we can get rid of the MCP and ultrasound, which investigations, and we can think about your CP or PTC, which we've explained beforehand on the round, says ERCPs. We're instrumenting. It were fishing out if we can the stone in the common bile duct and were sent here to make sure it stays open, PTC on drain or stent would be if the Ercp fails. The last question is, Ah, 30 year old who is admitted with cholangitis. Bedrooms are how much in eighties or very high and alcohol is through the 48 so very high she becomes progressively more and well on developed abdominal pain. You check her family's, which is elevated at 1080 on the diagnostic threshold. Pancreatitis is above 300 so that's very rates as well. Standard treatment is initiated on Glasko school is three, which is a scoring method for pancreatitis. What's the most appropriate course of action? In this case? You have someone with a pill and Isis, and when we talked about this a little bit earlier, it's to consolidate. That is that the stone contractile further down Onda cause, um, obstruction more distal in the biliary tree and actually clogged up with the pancreatic duct as well. And that's one pancreatic pancreatitis will occur. So the primary issue at that stage is there's a stone in the military which needs to be removed, and we've talked about the ERCP is the best way to do that. Brilliant. So that's the coming to the coming to the end of the session. I just wanted to kind of that's difficult to take in anyway, all of that. But you know, physicians like this, if you could take away a few things, that would be fantastic. Three talked about the spectrum of gallstone seeds, so we can briefly describe that asymmetrical stones biliary colic could start. It's and current itis. Those are the four, which would be important to know for medical, take that surgical take on on board rounds and exams so that that suspension on we've talked about the different investigations and the management techniques you can use to treat all of them on. Then, as as a bracket, it for message, you've been introduced to the less common present presentations. So the course in itis, the merits syndrome on things like that and everything will be. Everything we talked about in the session will be released on the mind a bleep surgical page s so that you can access all this material. The slides themselves will be available on YouTube and through the mind of sleep website. But if you just prefer to read it in a pdf forward to get that information because you can, then we'll be available for you a z well, so I'll just pours down by a few seconds because they'll be, um, potentially some questions which we can talk about. And I wait for my colleagues to let me know if there's anything like that and I'll hang around. But otherwise, thank you very much for listening. There's a feedback slide here on absolutely rely on your feet back. So please, if you can just get your phone out on scan that it takes literally a minute, um, to do it on. But we really that as organizer's, in order to improve for you next week, see what you like to see what works and what doesn't. That's obviously quite hard to make things interactive, but if you have any ideas, that would be great on. Also, we need it for approval is essentially so that would be absolutely great. Thank you very much. I'll see if there any any questions and then otherwise have a fantastic evening. Okay, Right. Just managed to Morgan. It's a bit late, but if surgeon surgeon she for is listening, question was asked, What's the best antibiotic for cholangitis? So it will depend your need. Grand negative cover because E. Coli is a grand negative Bacteria on d, so that definitely be covered. But you also need some broad spectrum because of that stage. You know specifically that it is equal I s O each hospital will have on their own guidelines for mine. For example, the first night before uncomplicated coasts Titus would be Come on up. Um uh, 1.2 g IV, three times a day. If you have cholangitis, then you will add Often sit fox in election agile to get an aerobic covers. Well, but wherever you're working, they'll be a nap or a guideline somewhere. And you will just get back because every bit different. Okay, right. Thank you very much of a role. Have you have a nice evening? QR code Not working. You okay? well post ah linked for the feedback on Put it in the in the chat The video thanks very much.