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Ok. Hi, everyone. I'm a, I'm one of the F ones and today I'm here to teach on inflammatory bowel disease. I think there's only the four first right now. Let's just give it another five, you know, two more minutes and see how it's, if it's getting more people, if not, we can start. Do you mind just putting like a which medical school you are from in the chart? Just so that we know which medical schools we're reaching, that would be really, really helpful. Thank you. Mhm. Hi, Hannah. Thank you so much for attending. Let's just give it two more minutes and then make a stop. Ok, let's make a start. So today we're going to learn about inflammatory bowel disease. It's a fairly common thing that affects uh, loads of people. So I think this will be quite good because I'm sure you'll see loads of instances of inflammatory bowel diseases wherever you work. And it's quite good to have a good overview of what it is because often times you can get, um, people with their first presentation turning up in Ed or a GP practice and it will be very well if you can diagnose people successfully with inflammatory bowel disease. It gives them a lot of relief and a lot of, um, help really managing their symptoms because it can be quite difficult to manage for people. Um, especially given the fact that it affects, um, younger people, inflammatory bowels disease, especially Crohn's disease has two peaks once in your teen years and one's in your sixties. So now we just, um, if you see somebody with query inflammatory bowel disease, don't rule that out as a diagnosis in older people because it can happen. So it's always good to have it as a differential in your mind. So, um moving I'm just going to. So I've drawn a couple of things just to help us differentiate between Crohn's disease and ulcerative colitis. So, um on your left hand side, this bit is all about Crohn's disease. And uh on your right hand side, this bit is all about ulcerative colitis. So first, let's talk about where Crohn's and ulcerative colitis affect occurs. So, Crohn's disease is an inflammatory disease that can affect the entire gi tract. So that starts from your mouth all the way to your anus. So, um and ulcerative colitis only affects the large bowel. So, in Crohn's disease, the most common site is the ileocaecum. So that's where your ileum of the large intestine joins the cecum of the small intestine. So oftentimes patients will present with li right, lower quadrant pain and often you'll find that Crohn's can be rectum sparing. So it can affect the entire gi tract but can spare the rectum. So essentially, if anybody presents with right lower quadrant pain, go going on for a couple of days or a couple of weeks with bloody diarrhea. Always think about Crohn's as a differential. But ulcerative colitis only happens in the large bowel. So it always starts in the rectum. So it starts in the bottom end of the bowel and it spreads upwards. So it goes from the rectum to the sigmoid colon to the transverse colon, uh sorry, rectum, sigmoid descending colon, transverse colon, ascending colon. I'm just gonna double check on the chat just in case we've got any questions. No, no questions. If you guys have any questions, just feel free to ping them in the chat and I will get back to you immediately. But is everything clear so far? Um Just put a yes or a no in the chat and we can talk about it further. Is this sort of difficult to gauge if I'm just sort of speaking into the ward because I can only see myself. So if you guys have any issues, just put it on the chat and then I will let, oh, thanks Hannah. That is really, really helpful. Brilliant. OK. Now, let's talk about um microscopically how Crohn's and ulcerative colitis works. So we know that the bowel is made of the mucosa, the submucosa, the muscularis externa and the cirrhosa. So Crohn's is always transmural. So it spreads from the mucosa to the cirrhosa. So you have lots of uh uh MCQ S that will ask you like um a patient has come in with bloody diarrhea, endoscopy shows transmural inflammation. What disease is likely per person to patient is supposed to have? So, if it's transmural spread, it's always Crohn's. But ulcerative colitis only is ex tends to the submucosa. So it's quite superficial, the ulceration. So I guess Crohn's disease is actually kind of worse because it spreads so deeply and it's more difficult to control. So, always remember, Crohn's is transmural inflammation. It affects the entire lumen and up to the cirrhosa and UC is mucosal and submucosal only. So let's talk about the symptoms of Crohn's and ulcerative colitis. So anything with sort of a person who comes in with more of a chronic history. So let's say weeks or months or will automatically makes you think of inflammatory bowel disease. Uh You so long term history of loose stools, malnutrition, generally, general unwellness. You should always think about Crohn inflammatory bowel disease. So let's talk about Crohn's disease. So Crohn's often patients will be malnourished because essentially what happens is the lining of the mucosa is so inflamed and you're not able to absorb anything. So you're not able to absorb um iron. So a lot of Crohn's patients will be iron deficient B12, um folate. So they'll have all these deficiencies because they can't absorb all of that. And the terminal ilium is where most of these things absorbed. So, if you've got terminal ilium inflammation, you most certainly will have malnourished patients. So it's always really important to run a hematinics panel on patients. So b12 iron folate and that can also help you a aid you in the diagnosis. Uh You'll get lots of watery diarrhea because um the H2O the water in your bowels is not being resolved because of the inflammation. So you can get lots of watery diarrhea. Now gallstones is because your patients with Crohn's often are prone to gallstones because what happens is bile acid is also absorbed in the, um, bowels. So, if bile acid isn't absorbed, it's going to collect and form gall gallstones. And, and the other thing is kidney stones, often calcium and oxalate. Basically what kidney stones are made of is not absorbed as well. So you can often get patients having kidney stones, gallstones, watery diarrhea, malnourishment. So those are the main symptoms of Crohn's disease, ulcerative colitis, it's got very characteristic bloody diarrhea. So every time you take a history, it's really important to ask whether the diarrhea is bloody, whether it's loose, how often they're going because of the superficial ulceration. So, like essentially because the alteration is much down below in the large bowel, um, you can get blood mixed in with stool and obviously, you can get dehydration because again, you're not absorbing water, you're peeing all the time. So it's really quite a horrible disease. Um It's quite difficult as every IBD patient I've met really struggles with it. So um it's really important to be thorough with these patients. No complications. So like every single disease, every disease has complications. The main complications of Crohn's are uh there are many complications of Crohn's actually the biggest ones are abscesses. So because of the continuous inflammation, continuous um and basically poo is really dirty. It contains a lot of microorganisms. So things like E coli, so you can get abscess formation because of the ulceration. If Poo is constantly going or digested, food is constantly rubbing up against ulcerated areas. It can, it will become infected, it will become inflamma in inflammatory and you can get lots of abscess formation. So patients uh often patients can present really feverish, really unwell, complaining of pain in the abdomen. Um So it's really important that you think of the complications of C Crohn's like abscesses. The other thing is fistulas. Do you guys know what fistulas are? So a fistula is essentially a skin tract. So it's a tract between one area to the other, for instance, um let's say you've got a pimple. Um So your pimple is full of mucky stuff, isn't it like um pus dead cells, white blood cells. So they all don't wanna stay trapped in the pimple. So they find an area to go to. So they'll create a tract. So an area of infection and they create a tract to an area which is not infected. And hence, that infection will spread. So you can have fistula starting in the bowel and it can go up to the bladder. That's what we call a colovesical fistula. So, vesicle means bladder cola means colon. So, colovesical fistula, you can have another fistula. It's from the large bowel to the small bowel. Um, so that's celal fistula and then you can have skin to large bowel or small bowel fistula. And that's called um colocutaneous fistula. So the cutaneum is the skin. So fistulas are you notoriously difficult to manage in patients because there is really no treatment for fistulas other than antibiotics. And Acetin A C is basically a thread that we insert in the tract of the fistula to keep it open to aid uh things to move, but it usually doesn't really work. So once, if a patient's progressed to fistulated Crohn's, it can be quite um difficult to manage. And it's essentially the only sort of treatment for it is is complete resection. Um The other thing, the other complications of Crohn's are strictures. So basically because this lumen is b the bowel lumen, the gi tract lumen is so inflamma in inflamed, so much of infections going on, often you can get stricturing, which is basically like extra tissue. And thus, once you get stricturing, that's a huge complication because it can cause things like bowel obstruction it can cause, um, lack of, uh, it can cause impacted stool. It can cause constipation. So, strictures are also a big complication of Crohn's. And usually if you get strictures, if you get fistulas, you, it's likely that, um, is very advanced Crohn's and the other complication is cancer. Um, if you just think about it, um, physiologically because of the constant inflammation, it's likely that more cells will mutate. So people with Crohn's disease are a very high risk of both small bowel and colorectal cancer. So oftentimes you'll have, we'll have regular screening programs. Is that all making sense so far? Any questions? One, just one second, you will. Yeah. Um so then the complications of ulcerative colitis. So the first complication is toxic megacolon. That is basically when the colon becomes really inflamed and swells and because the colon is so huge, it's at the risk of perforation. This is a surgical emergency and needs immediate surgical input. The other thing is uh primary sclerosing cholangitis. So, primary sclerosing cholangitis is basically a condition which causes inflammation of the liver. So basically what happens is the bile ducts get really inflamed and when the bile ducts get really inflamed, it causes inflammation of the surrounding liver and your liver can then turn cirrhotic. So, primary sclerosis and chitti occurs really commonly with ulcerative colitis. The other thing is cholangiocarcinomas, uh because of the constant inflammation of the bile duct and the central bile ducts and the other thing is colorectal cancer just like Crohn's disease. So those are uh the complications of ulcerative colitis, extraintestinal manifestations. So this is really important for us to know because this is what the MC Qs get tested on. Ok. So as you can see, um so I'm just going to go over the extraintestinal manifestations. So, Crohn's and UC are systemic diseases. So essentially they affect um not only the bowels, but they can have other um other effects as well on your eyes, on your skin, on your bones. So, common extraintestinal infestations of manifestations of Crohn's and UV is uveitis, which is basically the entire uvea of your eye is really can get really red and inflamed where the sclera of your eye gets really inflamed and then erythema nodosum, which are these very characteristic red, like red lesions, red rashes on your calves. P derma gangrenosum basically is ulceration around the on the leg. And it's a common manifestation of ulcerative colitis. The other extraintestinal manifestation you can get is seronegative spondyloarthropathies. So that is a different. So that is a complicated word to pronounce. But essentially what seronegative spondyloarthropathies are are basically they're serum negative. So when you test for them, you won't really find positive rheumato rheumatoid factor positive ANCA genes, you won't find any sort of positives on the test. But you can, people will present with back pain, bone pain, hip pain, or spine pain. It's basically inflammation of the vertebral column is spondylitis and um inflammation of the ilium. So your pelvic bones, sacroiliitis and these are usually connected to HLA B 27 genes. So, people who are positive for HLA 27 can often happen a lot of a range of autoimmune conditions like spondyloarthropathies, spondylitis, Crohn's disease, UC disease. So, this is really important to know the extra intestinal manifestations of Crohn's and UC. This is an MCQ that comes up quite often. Does that all make sense? So far? Any questions just put in the chat? Right? So, so far, we've spoken about the symptoms of Cro Crohn's. Um the location, it affects uh the complications and the extraintestinal manifestations. So how do we diagnose Crohn's disease? So for initial diagnosis, a full blood count can be really useful. A full blood count and CRP. Do you guys know what a full blood count and CRP is? I'm not really sure which years you're in. So a lot of this, I might just be explaining very basic things. So if you uh do you guys know what a full blood count and a CRP is? OK. Brilliant. So, on the full blood count, you'll see things like low hemoglobin because of poor absorption, high white cells, high CRP. Um A test that you can do is fecal calprotectin, which is basically shows if there's blood in the stool. So um just ask patients to do a stool test and it can fecal calprotectin, we'll show you if there's inflammation in the bowel. The other thing we do is endoscopy, endoscopy is basically the sort of the gold standard for diagnosing Crohn's disease. So let's just go over what you'll see in Crohn's and you've seen on endoscopy. So, in Crohn's disease, the most characteristic thing you'll see is skip lesions. So, can you guys see this lesion here? So this is obviously ulcerated bowel mucosa, then there's healthy lumen and then there's ulcerated bowel mucosa as well. So essentially, it skips as you can see. And the other thing is cobblestone and it basically looks like cobblestones on the bowel mucosa. So those are the endoscopic findings for Crohn's disease and for uh UC disease, it's continuous. So in Crohn's, you can skip skip skip, but UC will be continuous mu mucosal inflammation. So, as you can see here, it's just completely inflamed, it's completely red, it just looks really horrible and friable and you can get ulcerations and friability. And then essentially during endoscopy, sometimes it's really difficult to stay on endoscopy as well if it's Crohn's disease or ulcerative colitis because, you know, you might just have a lesion here but no other lesions. So you might think is that just a patch of uh ulcerative colitis or is that Crohn's disease? So what happens is we take samples during endoscopy and we send them off for uh histological um analysis. Um We'll go over the histological analysis in a bit. The other thing you can do is CT S CT scans and abdominal x-rays. So CT is also really quite good for diagnosing inflammatory bowel disease. But you should, if you're suspecting Crohn's disease is always, it is good to get a CT and toy or an MRI enterography. So basically, that's a CT or MRI of the small bowel as well. And that can show you whether there's any inflammation. The other thing you can see do is abdominal x-rays, those are quite quick, um quick signs. So one sign of uh ulcerative colitis on the abdominal X ray is the lead pipe sign. So as you can see, the hora of the bowel has like flattened out and it makes a red like a lead pipe. So that's quite a good sign of ulcerative colitis as well. So now let's talk about histology. So um nobody is going to give you a histology slide and ask you to identify whether this is Crohn's or UC. But the most important thing to know is sort of the terms. So let's talk about Crohn's disease. So, as you can see over here, this transmural inflammation. So can you see it start on the mucosa and go all the way down to the cirrhosa, the inflammation. The other thing is you can get granulomas ba, which are basically large collections of white cells. So these are big granulomas. Then this shows active Crohn's colitis and patchy involvement. So um just remember the words granuloma transmural inflammations. Um, those are usually indicative of Crohn's disease. You can get that up in MCQ S for ulcerative colitis. The sort of characteristic finding you'll see is crypt abscesses. So, can you see these abscesses were here? Basically, they're collections of white cells and all sorts of macrophages. This is just muck, which is contained. So these are crypt abscesses. And as you can see over here, the inflammation is only limited to the mucosa. So you can see the inflammation stops here in ulcerative colitis. But in Crohn's, the inflammation goes all the way down. So just try and remember these terms. Um So like in ulcerative colitis, you're more likely to see crypt abscesses in, you see granulomas, goblet cells, transmural inflammation. So try and remember these terms because that's what they're gonna ask you MCQ S in. OK. Now let's talk about management. I think from a medical school final perspective, you just need to know sort of the superficial management of these treatment of these diseases. Thank you. Um So we'll just quickly cover the management, but you don't have to sit and learn all the different types of um five A a drug drugs or biologics. So, um if you're talking about any disease, unfortunately, inflammatory bowel disease isn't a disease that you can cure, but you can induce remission in these diseases. And by induced remission, I essentially mean that you can induce periods where these patients are disease free Crohn's and UC are both relapsing diseases. So you're never gonna cure it, but you can give patients medication to stop the disease, actively flaring up. Uh and they can sort of lead a normal life. So if somebody presents with Crohn's or the first thing you want to do is induce remission, which is basically you want to stop them from having such active symptoms. So the first thing we do in Crohn's disease to induce remo remission is glucocorticoids. They're basically steroids. So things like hydrocortisone, prednisoLONE, dexamethasone, uh steroids high, we give high dose steroids to basically suppress all the inflammation and kill all the inflammation and give time, give the gut some time to heal once gluco if Glucocorticoids don't work. So if your steroids don't work, you can move on to five A A drugs. So things like mesalazine. So essentially what they do is they block certain um cell inflammatory pathways and that can help reduce inflammation and hence help heal the gut. And if five A SA drugs such as mesalazine don't work as well. The last thing we rely on is biologics. So, Infliximab and Adalimumab. So essentially these are TNF alpha inhibitors. So they block the TNF alpha and that stops inflammation is a really cellu basic cellular level. So, Infliximab Adalimumab are really good drugs, but they're very, very, very strong drugs and we only use it in rarely advanced Crohn's disease. And because these are biologics, it's really important, we rule out any other infections in the body because they're i they're drugs that we call immunosuppressants. They suppress the immune system by suppressing TNF alpha. So it's really important to rule out any other form of infection in the patient before you give infliximab or Adalimumab. So that's how you induce remission. Now that you've induced remission, you want to maintain the remission, don't you? So what we use to maintain remi remission is azaTHIOprine or metacarpal or if those don't work in maintaining remission, we move on to methotrexate. Again, you don't need to know these in great detail or you don't need to know the mechanisms. You don't just know that this is what we use to maintain remission. Um I'm just uh from a final perspective. Ok. Ulcerative colitis very much like Crohn's disease. We first need to induce remission. So, ulcerative colitis is actually a little more easier to treat because we can do scans and we can figure out where exactly the inflammation is. So sometimes it can affect only the rectum, it can only affect the sigmoid and the rectum or sometimes it affects the large bowel. So depending on where the inflammation is, we give different treatments. So the first thing that we do give is topical aminosalicylates. So we, so those are your five ASA drugs such as mesalazine, sulfaSALAzine. So um these are so we can give like an enema. So if you put an enema in the rectum that releases mesalazine it's really good for proctitis, which is usually only affecting the rectum. Otherwise we can give, um, uh, enemas are quite good for even effect. Uh, even targeting sigmoid, uh, sigmoiditis and proctitis. If you suspect large bowel inflammation or it's not being controlled or proctitis or sigmoid colon inflammation isn't being controlled by the top topical aminosalicylate. The next thing you can use is oral aminosalicylates. So, plus or minus a topical steroid or an oral steroid. So just think about it logically. Um if you've got a big pimple, you're first gonna put some cream on it. If the cream is not working, maybe you can take some antibiotics to get rid of the pimple. So that's how we sort of look at Crohn's. So first we're gonna give an enema or topically. So if the enema is not working topically, let's take some pills orally, which will go into our bloodstream and kill diseases internally. So we go on to oral aminosalicylates. Then if that's not being controlled, we can add a topical corticosteroid. So we can give steroid enema or steroid creams to help reduce the inflammation. Again, if those creams aren't working, we'll move on to oral steroids. Does that, is that making sense? So far? Just checking the chart to see if there's any questions? Ok. No questions so far. Brilliant. Ok. Now, um, so that's the treat. That's how we induce remission in ulcerative colitis and then maintaining remission. It's very sim. It's very much similar to inducing remission. So we can use topical or oral aminosalicylates like enema or if it's, you've got extensive ulcerative colitis, we can give oral aminosalicylates. Um If you're exper if you've experienced more than two flares in the last year, we can give oral azaTHIOprine or oral metacine um to help uh with the long term management of these flares. Again, this isn't really very high yield just as long as, you know, the sort of sequence of medication we use is will, will be good. But um, you don't have to spend ages studying this, right? So now we've covered, um, it said exa what Crohn's is what ulcerative colitis is. How, what the treatments are symptoms, complications? Have you got any questions so far? Ok. Thanks Hannah. You all your s your uh comments have been really helpful. It's nice to know. I'm not sort of speaking into a void. Ok, brilliant. Now, so we've done all the, you know, boring bit where we talk about what the disease is. Now, think of yourself as the doctor or the physician associate assessing a patient who's come in with inflammatory bowel disease. So, should we now talk about how we can assess somebody who's come in with a potential inflammatory bowel disease flare? So what sort of symptoms do you think they'll present with? Just pop some symptoms in the chart? Right? Ok. So can you guys see this? Just put a yes or no? In the chat when you can see it. See that. Yeah, and ongoing stomach pain, blood in stools. Exactly. So, um hopefully you guys can see the presentation. Um So let's talk about assessing a flare. Um So we, we want to ask certain questions. Ok, so in the history, what are we gonna cover? First of all, the number of dia diarrhea? So with diarrhea, we wanna ask the number of episodes they've had, have, have they got blood or mucus in it? The really important question you wanna ask patients who have come in with an IBD flare is about steroids. Have they used steroids in the past? Um in the last year, how many steroids have they used? And are they currently on steroids? Um If a patient using a lot of steroids over the last year, you know that their Crohn's or UC is not controlled very well at all and you might start thinking about uh giving them like biologics like Infliximab or Adalimumab. So it's really important to ask these questions. Ok. Um Then the other important thing is often times a diarrhea can be confused for whether it's an IBD flare or UC flare or if it's infective. So what sort of questions can we ask to rule out infective diarrhea? So, um things like fevers have people had a fever if uh someone's, if somebody's traveled somewhere tropical recently, whether they've eaten anything dodgy, if anybody else in the house is having diarrhea. If they've got any like flu type of symptoms, those are all indications that these are, it's more likely to be infective diarrhea than a flare of diarrhea. That said if some, if somebody with Crohn's or UC has got infective diarrhea, it's really important to keep in to keep a close eye on them because they, an infection infective diarrhea can lead to a pretty severe flare and then you want to find out are they immunosuppressed? So for instance, if patients are on long course of steroids, if they're on um a biologic, it's really important to ask if they've got o other immunosuppressed because then you might need antibiotics. You might suspect atypical infections such as pneumonia, cyclo megaly Epstein barr virus TB. So it's really important to ask whether they're immunosuppressed, whether they've had steroids. Are they using any, if they're undergoing chemotherapy? Because you can get really severe flares, which can lead to death as well. If they are immunosuppressed, you wanna ask about systemic symptoms. So that things like eye irritation, rashes, jaundice, eye irritation because we're talking about uveitis, episcleritis, rashes because we know that erythema nodosum can happen jaundice because ps C cholangiocarcinomas and weight loss because of how high risk patients with Crohn's and UCR and colorectal and um cancers. Um And the other thing you wanna figure out is what's triggering oftentimes you'll find that something triggers flares for patients. The main thing is stress, diet, poor medication compliance they're not taking their aminosalicylate, they're not taking the steroids. So, in your history, it's really important you cover the saline points. So how do we grade um the severity? So, what we use is the t up with scope which is for ulcerative colitis. So, if a patient has got fewer than four stools daily with or without blood, we think it's us with no systemic disturbances and no fevers, no malnutrition. Um and normal CRP S, we, we class them as a mild flare if they're moderate. So if they've got 4 to 6 stools, it may be a fever. They've got moderate flare and severe is when they've got more than six stools a day with blood fever, tachycardia, abdominal tendons, anemia is we, we really worry about them and they need an admission immediately really. So, in terms of their abs, what do you see? So if they've got mild, you see, you might not see anything different. If they've got something moderate to severe, they may be tachycardic. So they've got a high heart rate, they may be hypotensive and if they've got fevers, either they're systemically really unwell or they've got an overlying infection as well examination. So, an abdominal exam is the most important thing you can do for a patient with IBD, you need to rule out if they're peritonitic. If they're guarding, if they are peritinic or guarding, you need to start start thinking about uh perforations or toxic megacolon as we talked about earlier and you should always check the hydration status. So look at the mucous membranes, do a long standing BP. So those are really good things, investigations. So you wanna do a routine blood, so full blood count, you can check for high white cells, um um anemia hematinics. So as we mentioned before, because there's inflammation of the term terminal ilium, there's very poor absorption. So iron b12 folate using these. So electrolyte abnormalities because they're having so much of diarrhea, you can get hypokalemia, hypochloremia, uh hypophosphatemia. So it's really a hyponatremia basically because they're losing electrolytes from the diarrhea. So it's really, really important, you check the electrolytes and you replace them if they are low and then C RP uh usually flares can present with a high CRP. So it's really important to check C RP radiological imaging. So, abdominal x-rays. So when you see patients, it's so so important to rule out toxic megacolon as soon as they've come in. So always get an abdominal X ray to rule out toxic megacolon, chest X ray. So why do we do a chest X ray if we're suspecting an abdominal perforation? Essentially what happens if there's a perforation, there's free air in the peritoneum. And you can see that in a chest X ray. And of of course, you can see if there's any consolidation or anything in immunosuppressed patients and a CT or MRI and tomography can, is really good for visualizing the small bowel. Let's just go through some radiological imaging. So toxic megacolon, as you can see, it's quite simple to spot really, the colon becomes really big. Like the name suggests this is a surgical emergency. So you need to call contact the general surgeons immediately. Um This is comb sign that you can see in Crohn's disease. So you can see like the inflammation in the bowel. It looks like a comb And this is a lead pipe sign in ulcerative colitis, you can see that the hora is lost and it looks like a lead pipe. So these are things you might. So x rays, CT S MRI S are all things you want to be considering management. OK. This is really important for how do you now actually manage your Crohn's flare. The first thing is IV steroids. So this will depend on your trust in my trust. We use hydrocortisone, 100 mg four times daily. And once the patients finish their IV steroids, you're gonna put them down to oral steroids and make sure that the patient has a weaning course of steroids prescribed uh if they're on steroids, um you have to give them omeprazole or pantoprazole or famotidine, whatever like A PPI to stop uh to help with um acid production, um steroids as you know, can cause osteoporosis. So it's really important, we give them Vitamin D replacement whilst they're on steroids. Uh patients who got Crohn's or UC flares are in a prothrombotic state because of uh the inflammation. So it's really important you give them VT prophylaxis. So that'll depend on your trust. I know some people use Clexane and some people use a enoxaparin. So it really depends on your trust, but it's incredibly important that you do give them routine prophylaxis. Um You correct any stool electrolyte abnormalities as we spoke earlier. Um, fluids, fluids is really good. You have to continue their regular IBD medications. So if they're on mesalazine or sulfaSALAzine or azaTHIOprine, it's important you continue them, always send three stool cultures because that will help us rule out any infective cause of diarrhea and get your local gastroenterologist to give them a review to for further management of the Crohn's and ulcerative colitis. Um So that brings us to the end of our session. Any questions at all? Did you guys find that session useful? Ok. So I've sent to you guys a feedback form. We'd be really, really ha ha appreciative if you could uh fill out that feedback form for us and once you filled out the feedback form, we can send you a certificate. Um If you thank you so much, Anna. Um Do you guys have any questions at all? This is my email if you have any further questions and I can send you the slides as well. Ok. I think um no one's got any questions. Thank you so much guys for attending. It was um I'm really glad if you did find it useful. I hope you found it useful. Um If you have any questions, you can email me or put it on the chat. I'll stick around for another 23 minutes. Unfortunately, I've got a night shift, so I need to go now. But thanks so much for coming and hope to see you next week on Wednesday for our next session. Thank you so much guys. Bye. Yeah, brilliant. As I said, we'll post the slides and video on here for review as well. If you guys are wanting any further information, uh please do fill out the feedback form. It helps us improve and it helps us put on better sessions. Thank you very much. Bye-bye.