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thanks. Yeah. So please keep your microphone and camera on mute. Ask any questions interacting in the chat. There will be loads of questions today, and they're very interesting questions to please engage in. Please be respectful in a chat, the session is gonna be recorded on, so any interaction that you guys make will be put into the recording, and the recording is available on metal after the after you feeling the feedback from once you feeling feedback from it's, it will be uploaded on the platform in about one. To do this. The feedback from will not be sent after the session and slides will be sent All those who feeling the feedback from a swell if we have. If you have any questions, please email or squeeze it out. Look dot com or are squeezy at gmail dot com. Um, and we will reply to you and please remove them out of your spam. A junk if you're not receiving Our slides were a free medical society organization, and so we work on helping people out and getting more people into a sessions. And that's what we can fund. Uh uh, our money to go and put it. What's the zoom capacity that be? We put this and so it would be really, really, really be grateful if it Concerta on your social and and do check our spawns us out as well. The platform that you can get the recordings are are on medal. And if your messages before the event we we think we I think we'd be able to give you the feedback thing. But if you messages after, it might be a bit tough Just because we can verify whether you have attended the session, I will hand it over the next two begin recession. These are social. She applies to follow us on the socials. Thanks. You want to show your screen? Yeah. Okay. Okay. So hi, everyone. Can everyone if you can let me just put it? Yes. And the Japanese and you can give Yeah, Welcome. Everyone s like runs. And my name is dish. Uh, very excited to be teaching again. Those of you tuned into our ski series that we did last year hopefully very familiar with me. I have a lot of lectures and I don't enjoy teaching so much on dropping some setting up the platform of the resting guys on Very excited. Teo, start this new Siris that as well. I hope you guys have been enjoying our finals even easy series so far. Uh, the idea of the series is just to give sort of targeted, finally space teaching so sort of focus on SPS, but focus on the important stuff that's gonna come up in your exams and also with this series. We're trying to give a good foundation off knowledge. So a good foundation of clinical knowledge to that. But we start Oscar series as well. In the middle of much, you guys will hopefully be really prepared for that as well. So today, today's the topic I'm gonna be covering is Castor intro. Gee, okay. Very interesting specialty, especially. I'm interested in myself. It's one of the specialties that it just makes sense. A lot of gas and all you will just make sense. If you understand the more of the principles just get into it before he's not just general point about gastroenterologist. Gastroenterology is a very broad medical speciality that covers the entire digestive system. It's a cool medical speciality against one of the cool medical specialties. It's one of the internal medical specialties, and it's highly tested in kind of examinations. Okay, so you know, cardio rest Castro that one of the three big topics that very commonly tested in Canada examinations. So it's very important to have a strong grasp off aspirin. Trollope first and aspirin told you to point a good foundation of anatomy and physiology. Knowledge. Okay, And that's true for most sort of specialty clinic examinations. But Catherine told you in particular, a lot of the clinical principles are underpinned by the inactive by the underlying on aspirin, physiology and also a gastroenterology. When you study in gastroenterology, it's very easy to get bogged down in sort of specialist level knowledge. So I think today I'm gonna try and highlight the important areas that are important. Important areas, too. Learn about as an undergrad should. Okay, so it's gonna be aspirating spn based teaching. So it's not off the question one. And the idea with the sort of the wear structure this session is we're gonna start off by talking about conditions more proximal. It's around the sort of esophagus, and they were gradually going to make move our way down the digestive system and talk about, uh Well, um, conditions. Eso could One of the team got up. The pope is I'll give you guys, but 20 to 25 seconds to have read. Answer. Go under that. Okay, so most of you went for C correct answer here. Actually. Be so equal easier. Okay, so let's break down this SP A It's free test. Here we go. No, just talk through what? The clean your typical. But yet it's trying to represent. And then we'll talk about why the correct answer is rights and why the other answers are incorrect. Okay, So have you got a 65 year old man who's got a woman his history off retrosternal Just pain that's not related to excise anything of drinking. Those reports dysphasia to both solids and liquids is lost. Yeah, he has a history of a weight loss as well on he has seven recent absolute off aspiration pneumonia as well. Nitrates to not reduce symptoms. And there's no history of heartburn. Okay, So if I If I Guys, if I ask you what in this if if you took a history from this patient, what in this patient's history suggests that he's more likely to have a motility problem in the esophagus compared to a structural problem. Well, in this patient's history would suggest a and little itty problem more than a stroke. Structural problem you have left on the job. Yeah. So, solids and liquids from the start. Okay. What if you had a structural problem like you saw for your cancer, for example, which is the most common answer? What would you want to just be, sort, of course off dyskinesia, you'd expect. What do you expect? Yeah, expect progressive. So expect. Think about if you have a musty in the esophagus, expect solid, solid, difficult time passing first, and then liquids as the mass sort of extends into the Lumen of the's office. Okay, so decision to book to solids and liquids initially, that suggests more minute off a motility problem compared to a structural problem. Okay, So, in terms of the motility problems in this FDA, so the two motility problems that are options, there are a little easier. And this story is off your spasm, it really is, is the most correct answer. Because essentially, this is a patient who has who's as history represent of discomfort dysplasia, progressive dysphasia to simultaneously both of sores and liquids. History of weight loss. And a big thing is the episode of Aspiration Pneumonia. Okay, so obviously because they they probably regard stating, and the food's going down into the airways as well. This this presidential be similar for esophageal spasm. What's in this patient? All in this SP a suggest that it's not so. The radio spasm. What's in the spacer? Just that it's not suffered Your spasm? Yeah, and I told you, nitrates don't help if nitrates help the pain that I want to guess more soft your spasm. Okay, very good. Uh, yes, in terms off and in terms of the other options of problem instance, syndrome, classically in SPNS is going to describe. Try it off dysplasia I noticed in junior on Soft your webs. Peptic ulcer disease is it's not really fitting this clinical picture. I've told you there's no sort of heartburn. Okay, he's going futures, like staying best by equal easier. It's in terms of the learning part of this question. I say decision to both daughters and liquids initially would suggest a motility problem. If nitrates relieved pain, this would suggest saw for your spasm. Okay? Just run through some of the chemo, tentatively, sort of we need to know about. So that's a chalasia. Andi, soft your spasm. Okay, so what is the collision? So equation is an inability off the lowest offer to your sphincter to relax. Okay, So you can imagine if you're low and it's off, your sphincter is not able to relax. Food is gonna have a hard time passing into the stomach because of that inability to relax you Lowestoft your sphincter. The tone is too much for filling to pass through. Okay, So that causes Most cases are idiopathic, but some cases can be associated with a particular infection called charges disease. Okay, Very common in cases like Latin America on there's no relationship to alcohol or tobacco. There's a clinical features that we talked about this, that it's dysphasia to both solids or liquids at the same time. Okay, because imagine if you have a tightening of the loss is off your sphincter. You're gonna have difficulty for both solids and liquids to pass regard station, heartburn, weight loss and history, off aspiration pneumonia are all typical things to fight it in a patient with Liza is gonna be This is gonna be a big thing. We're gonna talk about patients over 55 with dysphasia as a rep like symptoms. So it's important in these patients to you and initial and dust be to exclude malignancy again, we'll talk about reflects in terms in detail and gastroenterology. One of the classic findings that will commonly get tested and examinations is the bird beak sign. Okay, so this is what it's basically referring to. So it's referring to this sign that is seen on a barium swallow. Okay, so it looks like a beak. So essentially because off the tightening at the Louis off your sphincter and content, um, difficulties. What's through your having this air fluid level within the distal esophagus again? That's what the bit big Sinus it is useful thing to remember. You know, like people say, like moon face and both Buffalo buffalo hump For Cushing's syndrome, it's just a useful thing to remember for me. Please did. But you know it's useful. Don't be. Don't get confused. Basal is not the most accurate test in a collision the most the test that's going to give you the definitive diagnosis off achalasia is to do softball manometry. Okay, so manometry is going to is essentially you're gonna pass. You're gonna measure the pressures throughout the esophagus, and that's gonna be important in equal. Easier because it's going to show increased tone at the lowest offer. Just finger. Okay, treatment. So treatment mainstays to do a surgical called you my ultimate. Okay, so myotomy is that means you're cutting the muscle. Okay, remember. And when you talk about surgical procedures, Stoney means you're making a whole case. So if you're doing a tricky are stone me, you're making holding the trickier. If you're doing a gastro stony, you're making a hole into the stomach again. But this is my Oh, Tony stopped. Means you're cutting the muscle, Okay. And, uh, stopping pneumatic dilations. That is essentially means, you know, inflating a balloon at the distal distal esophagus to try and open up. Open up the distal esophagus to allow, um, to allow fluid to pasture. Okay, now, this is an important concept. Okay, surely yes. Might be thinking with endoscopy. It's much less non invasive compared to doing sort of a surgical procedure. Why is surgical cardio out to me? a preferred option compared to doing the endoscopic procedure in this condition. Yes. Tell me, why is pneumatic dilation avoided and if possible in he cleans it. Why is it victim just to open a balloon in or patients rupture? It's not exactly okay. So So the magic dilation. The problem is that you actually open the distal esophagus at the sort of sync the level you need to generate a very high pressure. Okay, So the actual balloon need to generate a lot of pressure to actually be able to open these officers to allow food to pass through again that if you when you're doing, you're eating that much pressure is a risk off perforation. Okay, so that's why as a genuine risk with the pneumatic dilation that you need to consider, That's why surgical carry on T is generally the mainstay. Botulinum might be concerned. Might be considered in certain patients, but probably, but botulinum Is that what the effects wear off within six months? Okay. So, generally, it's only used if patients are suitable for any of these two options. Some of your spasms asking of the unity disorder in terms of the kata physiology, slightly different too. Achalasia. It's essentially it's What's happening is you're having impaired inhibitory innovation to use office. Okay, I said it says this if the name is this sore esophagus spasm. But it's not generally limited to the distal esophagus. You can get it through the entirety of your Softwares. But primarily, in fact, this starts off this. So you can imagine if you have impaired inhibitory innovation. What's gonna happen is you're going to get premature Paracelsus. Okay, You're going to get random contractions happening throughout your stuff, Chris, and it's gonna be uncoordinated, okay? And you can, like, if you have uncoordinated personal says that's not gonna help effectively propel food through the esophagus. Okay, So terms of physical features So patient gonna get intimate in chest pain. Okay. With this patient because of the impact of peristalsis. Okay, But the key thing with the actual just being is that the chest pain is usually relieved after taking nitrates. Okay, so nitrates. So hopefully you guys know you know, nitrates is very effective for a stable angina. Okay, The chest pain associated with angina on DS actually is because it's going to help cause scarring, razor violation with districts off your spasm. It's gonna help because it's gonna help a lot. So lot of decent with muscle and help believe a lot of the present spasm pain as well. Okay, this president, if SPS classically, they might say that it's precipitated by drinking cold liquids. Okay, but again, now, I'm not sure. Common, that is It's just something that you find in S p A land. Okay, again. Dysplasia in elderly people, that's a red flag symptoms. So it's important to do the endoscopy. Okay. You know, you see that when someone's going to come in with acute chest pain to the emergency department, it's not. Differential is not gonna be those this patient having to so soft your spasm. That's, uh, let's get him in front of our hospital again. So you're gonna have patients come in with acute chest when you're gonna do the diagnostic work up for they do for the keep chest pain. Okay, so you're gonna do your STD. You gonna do your chest x ray. You're going to do your opponent's. Okay, So, for your spasm is gonna be a general diagnosis. Socks off exclusion with chest pain. Okay, But generally, one of the key findings that you see similar to ecclesial. You get the bird beach and it's off your spasm. You got a Sinus zone. Is he caught yourself? Guess so. Because of that random contractions and uncoordinated peristalsis that you're getting this this could be a typical appearance for soft your spasm. But again, even though their insulin can show this characteristic finding, the most definitive test is to do my knowledge. Three. Okay. And my mom, she's going to show, sort of, uh, very They're burying, um, muscle tone throughout the very impressions throughout the, um, this office okay, hasn't found Baca's on nitrates are used to treat Okay, knish. I think there are a few questions regarding why wants the link with nitrates? Nitrates? Why don't you and nitrates it's It's gonna help Relax the smooth muscle in this office. It's gonna help with the pain, essentially, essentially with acute with just being. If if my trips are relieving pain within sort of 5 to 10 minutes, that suggests that the chest thing is gonna be caused morbilli a cardiac cause. Okay. Like angina. Okay, like a acute coronary syndrome. If it's relieving the pain very suddenly, that suggest more cardiac in nature if the pain is taking if the pain is relieved, but it takes a bit longer. Like around the half an hour mark That was just more off itself. Feels 1000 pain. Essentially let me sense. So it's going to the next session sons are. So if it's a muscle muscular, relax Asian thing, then why doesn't work with it easier, so even easier? The traffic is all these different. Okay, Equal is here. They was actually happening is you're losing the neurons that are responsible for helping that responsible for helping the lowest off your sphincter too. Work properly. So it's nitric. You're not gonna affect that. Be useful in taken easier. You don't have the pope. Yeah, because that Okay, so we got, uh, generally you're a general slip between be on easy. So got spent the teen up a gastro intestinal endoscopy and barium swallow again. So it got down to here. Is he? There's a well known to those of you who said eat. Okay, so if you break down this s p s o. We have a lovely man who is presented with dysplasia. Okay, I stopped features such as regurgitation valve smelling breath. Okay. And it's also evidence of a fracture in mass in the left neck. Okay? And just actually is showing a non capitated infiltrate in the right lower lung field. So can you guys tell me, what is the diagnosis and this patient around your poach? Yeah. So is that Santa's diverticular may have called every year. Sending CS this to the front part of your ankles. I meticulous, so, Yeah. Yes. So, yes. And is that particular? So what in this history suggests, instead of tickle, um, so special Got pee features. Okay, is regards taping undigested food? Got halitosis. Okay. Really bad snowing breath. Okay. And he's also got a mass. So And that suggests that the actual doubt doubt if you tickling is very big. Okay, so his ankles diverticular essentially is an outpouching off the esophagus. It's a typical, you know, you get diverticular and the colon. It's sort of diabetic. It's It's a diverticular that you get at the top of the esophagus. Okay, So the first line, the most diagnostic investigation is gonna be, uh, very swollen again. The first line investigations going to be very swollen issued said What's the problem with doing an endoscopy in them in seconds? Two. Diabetic. Um, Greg, A perforation. Okay, so it's, uh it's a problem. It's a real risk to be aware of with youngest article. Um, so you should clinically assess the patient even though this patient has dysphasia. If you think that this is a fungus diverticular, you should go for the barium swallow as opposed to the industy. Okay. And so the thing you should avoid doing an n g tube is well, because it's risk of perforation. A swell. Okay, so it seems that the Keelan cost of this question so thanks. Diverticula presents with dysplasia, regurgitation and halitosis. Okay, Halitosis. It's just a sort of a fancy way of saying really bad breath. Oh, and another point. So aspirated food usually ends up in the right lower lobe off the lungs, and it really tell me why. Why does aspiration aspiration usually end up in the right lower lobe? Yeah. More vegetable broncos. I just do a quick stomachic diagram. So if we just draw you see, uh, that's against if you got the airway, Here's the main thing. Trachea, right? Main bronchus and the left main bronchus. Any foods generally going to go into the right main bronchus. Okay, this is this is very much a schematic diagram. Okay, so, um, this is just just representing that. The right main bronchus is more verticals are aspirating Food is generally gonna end up in the right lower lobe. Okay, good. This is a summary of all the other esophageal disorders that are important for finals. Okay, I'm not going to go through all of them just for the sake of time, but I thought the highlight. All this sort of stadiums, key points. You need to know about all these conditions for finals time of day and that we have to go through any of this, but we'll keep going on. It's going to next year. Um, there's a question. What is the difference between a capitated and non cavity thing? Long infiltrate. Uh, ask the question. So it's Zumba. You need to appreciate looking at a lot of different chest X rays to appreciate difference between the capitate in a non capitated. Essentially, you. If there's a captain, usually you can see in a pocket off and amidst Asian, you might be able to see a sort of a fluid level. Um, it's delusion. There's a lot of respiratory pathologies that can cause capitated lesions like a TB, for example, outside of the scope of today's session. But that helps. So going up. Okay, so God's 56% going for C on D three. It's ongoing for B. Okay, so So we go down this SP sorry car kinds of his seat, like must have got. So this question is basically are asking, do you know which medications is associated with causing soft practice? Okay, on out of all these options, I'm under a gas. It is the only option that's going to cause, so vaginitis. Okay, 50 learning point. So I'm drawing acid is one of the key causes off medication induced esophagitis. It has to be taken a certain way to reduce the risk. Okay. So I can get you something. One of their different things. You would advise a patient if you're gonna prescribe them alendronic acid. What kind of instructions would you get them if you're gonna prescribe them, I'm joining Acid. Need to be taken with food. Very good. Sorry. Sorry. Not eat. Be checking with you. Need taken with have water is very clear. Clear. Clear water. Lots of water. I take it sitting up like someone said. Very good. Set up. Right. Sit. You should be upright for a good 30 minutes. Take it first thing in the morning. Excellent. Uh, yeah. Take it before from Very good. Yeah, Good. Sometimes of the main side effect. I forgot to take this very well, replied for the session. But in terms of the main medications associated with this object, it's, um, the three I really want you to run, but there's Andronicus ID. There's doxycycline on the potassium chloride. Okay, it's not Ignore this box it. So he's on three ones that are very commonly associated with esophagitis. There's other medications out there, but these are the three that I really want you to remember. Is the Androgel asset medication most commonly used for osteoprosis with this possible it. Okay. And we talked about the different things you need to do if you're prescribed alendronic acid. If you're going to remember one, remember? I have been driving acid. Okay, doctor cycle incident. Uh, going to use antibiotic for patients or penicillin? Allergic on detecting chloride is the oral potassium chlorate might be used to replace someone's potassium. Okay, so now we're going, We're going to re flux again. Then we'll do an STD, some reflux. But that's so that's, um, the key point with Russ reflux. Okay, so court good is a very common condition. Gets assume percentage of the population will have cold. It's very common. So what's happening? Gold is You're getting reflux into the esophagus, and that's going to lead to problems. Okay, risk factors for gold. So be stations more commonly, get it because of pressure. And that's gonna increase the risk of reflux smoking, pregnancy height. So pony is these are all important risk factors. Be aware off, going to talk about the complications off gold on the next SPS. So we'll go through that. Then whole lot of good is gonna be hot button. Okay, that's gonna be the classic symptom. Patients gonna complain off. And SDS don't say that the pain is made worse after meals and often made worse lying down or bending forward. Okay, you'll be surprised about the number of cases, of course, that actually can mimic to corn syndrome. Okay. The number of patients well actually presented mostly department, actually, after doing the full diagnostic work up, actually turn out to have reflux disease. Okay. Without tasting a lot of hoarseness on do cough are all other clinical features that might be seen Now, diagnosis. This is very important to understand. Okay, Cool is a clinical diagnosis. Okay, You make the diagnosis of floored just based on history and physical examination. Okay? Just took listening to patient symptoms. That's where you make the diagnosis off reflux. Okay? And if you're sure that the patient is good and they don't have any red flag symptoms, then you can start treatment. Okay? If they have red flag symptoms, which we'll talk about soon, That's an indication to the end of the hospital. Okay. Up a giant oscopy. Okay, the diagnosis is uncertain. So that's a you you grew up with, like, symptoms. You think the most likely is Gordon. You start treatment, but patients are not responding to treatment. Then you might need to consider it. And you're considering alternative diagnosis. You can consider doing ph margarine on that condition. It Italian vacation actually has good, and in terms of the complications which we will talk about, endoscopy is done to evaluate them. Remember gold? So generally, when you think about treatment and we'll go through this in Austin series as well, you think about three months in terms off conservative management. Medical management on surgical, my friends. So conservative management for gold is the about education. Okay. And change your life. Some weight loss. Very important, because see, being overweight is a risk factor stopping smoking, modified diet. Okay, avoid trick. Avoid food that's going to trigger reflux. Don't eat before sleeping. Okay? Very important. The mainstay of medical therapy is gonna be your PPI is okay. Proton pump inhibitors. So they all say they're gonna work by hitting the proton pumps and reduce the secretion off acid, which is obviously going to help with the symptoms off. Good. And one of the common ones that are prescribed these days is a map result. Peak hours are generally more effective than antacids and hates on tightness. Okay? And remember, you can also get antacid in east winter and haste antagonise over the counter as well. So just be aware of that. For patients who are unable to take medications than in some cases, they might be considered for surgery. Okay, so the surgery procedure is called a nissen fundoplication. So, essentially, what's the surgery? What? This procedure is it just so in the, um you just showing the Lois off your singer? Okay, So and go and reflux, you already have an incompetent think they're so with the surgery, they're just going to. So the top of the stop of the stomach, they found us onto the lowest off your spincter and reduce the amount of acid reflux in. Okay, that's reflux. So this has been going to be talking about some of the complications off court, so I have to go. Yeah, they said it is the trick. ESPN don't be where it's ah, and but it's some important. Any points of that. Okay, because that Okay, so the majority of you went for D, 43% went for the 30%. If you went for a and 20% of you went for B. So good. So majority of you got the correct answer, and that is just off of your stricture. Okay, so this is the squad if you get it, Especially down. So again, we got a patient with dystasia. Can't think I'm loving that this eight, this major question today. But this is a patient who's as the stages swallowing solids or not liquids. Okay, so remember, it's all it's not liquids. That's suggesting of a structural problem. Okay, your past medical history off reflux. Okay, diagnose it bounces off seven months ago on this happens in terms results quite recently. Observations are normal, and the findings on the barium swallow are symmetric. So the conventional narrowing, affecting the distal esophagus. Okay, I think this last time minutes we'll probably gives it away the most. So, complications, of course, is what this question is testing. So strictures are one of the most common, most common complications or reflux. Okay, so if you don't know, stricture basically means narrowing of the esophagus. So if you have, if you have reflux for extended period of time is gonna happen is you're gonna get bruises, a zar healing process in the esophagus, and that's going to lead to narrowing of the esophagus. And that's what a stricture is. Okay, so why is strict in the most appropriate answer here? So he has dysphasia to solids, not liquids. So it's a structural problem which is explained by having a stricture, and that kind of moves out Acne Z as well. Um, his heartburn symptoms resolved to two months ago. Okay, so this is important thing with strictures. Think about it. If you have a narrowing off the If, if your esophagus is like this, and then you develop a stricture and it becomes like But, you know, I say that's gonna be able to reflux is going to reduce again. So that's going to mean that you're at Elson. Tums of heartburn will actually improve if you get a significant stricture. Okay, so if you that that makes sense, that's an important concept. And also, you know, structure is gonna affect this circumferentially in a in a symmetrical manner. Now that's explained by the barium swallow. Okay, tender, the other option. So adenocarcinoma. So if you guys know that's esophagus is a risk factor for adenocarcinoma, Okay, But there's a couple of things in the in this that point away from our new costume. Okay, that point away from a legacy. It was the last normal you did expect. Probably a much longer history of Barrett's esophagus. Okay. Usually takes many years off reflux for patients think I wanted about I patient going together about cancer on. But if they have cancer in the esophagus, you expect asymmetric narrowing, not symmetrical marital. Okay, squamous cell carcinoma is again. You'd expect asymmetric narrowing. And as this office is not a risk factor for squamous cell on this other risk factors for squamous cell, um, and hydrophone year so this patient might have a high. It's okay. Okay, That might explain his reflux, but for the height of hernia, you'd expect you would expect to see some of the folds off the stomach protruding into the esophagus. Okay, Only games for the Okay. So this is why some fuel structure is the most correct answer here. So there's a link. But this question new dysplasia and symmetric narrowing with Gord suggests. And it's offered your stick, their structure a strictures, progress and narrow the esophagus more and more, they can actually reduce the amount of acid refluxing that I can improve the symptoms off Heartburn. Okay, Just about complication of gold. So there's three main complications to think about what gold is erosive. Esophagitis is starting to feel structures on Barrett's esophagus. Okay. Roasted erosive esophagitis is the most common one is just means you're getting information of the esophagus and get started itis and you get problems like also is beating and strictures. Okay, strictures is the one we to talk about in detail. So you get in scarring, scarring and narrowing the off the esophagus, which is going to cause some metrics of circumstance or narrowing because they don't see the I said it's gonna affect land more on the DeSoto. Soft guess It's kind of your most commonly get strictures event in the distal esophagus. And there's a management. Usually they need to do endoscopic, dietician or stenting. Okay, now the most important complication to remember with gold. To be honest, it's probably Paris is off this. Okay, this is what is commonly it comes up exams. Barrett's esophagus is a pre malignant condition. It's gonna predispose patients to developing abnormal or cinnamon. Okay, what's happening in a Barrett's esophagus is that the normal squamous epithelium in the office okay is converted into kilometer dealing, which is going to resemble the everything and that you find in the stomach. Okay, so you're getting conversion off one epithelium into another epithelium, and that is a matter plastic change. Okay, so Barrett's esophagus is a matter plastic change in the soft radio ever being. So go until by soft your cancer. Not so remember about his office is a risk factor. It's it's a premalignant condition to adenocarcinoma. Okay, so when we think about stopping your cancer but generally thinking about it in two ropes, we have no carcinoma and squamous cell carcinoma. Okay, was the two main types of a soft your cancer we talked about no carcinomas, remember, passes off. This is one of the key risk factors as well. A smoking, because it's most common, is is very strongly associated with branches off because it's and about this office is due to crying reflux. It's gonna affect the lower deal of use office primarily. Okay, Squamous cell carcinoma is different again. It's more commonly appears in the opportune. There's a few esophagus, and smoking is the key risk factor. Okay, so smoking can cause both under cost, um, and scream cell carcinoma. But remember, as his office is strongly associated with, I'm no constant okay, and we have some other respected that you can read about it. It's a management for esophageal cancers on This is a principle that can be applied to most solid tissue organs. A solid tissue cancers. Surgeries only indicated if there's no evidence off medicine disease. Okay, this evidence off matter started yourself. Your cancer, then surgery is usually not a not ship into every move, the and cancer. Okay, okay. So before we keep going to access the I wanted to go through a lot of somebody procedures in gastroenterology. Okay? Because I know a lot of people with, you know, Kobe that stuff. They might not be able to go on gastroenterology placements and see a lot of these procedures, but it's important to actually appreciate what what goes on with these procedures and understand these sort of indications what the prep is for these procedures, what the actual procedure will involve and some of the complications that you can get with these procedures. Okay, So not gonna go through everything, but it's under the key points, remember? And Oscar the sigmoidoscopy is, and colonoscopies can be used for diagnosis and treatments. Capsule endoscopy is only a diagnostic thing. Okay, captain and loss busy, it's it's quite a cool procedure, but essentially another endoscopy is only gonna be able to reach up to about the ligaments of traits. Okay, just between the duodenum and judging, um, a colonoscopy. If you do a full index colonoscopy with and you get the patient to have good well preparation, a colonoscopy might be able to reach up to about the level off the ileocecal valve. Okay, so if so, then and also you can reach the ligament of traits where the colonoscopy you can re seeing your cecum valve. But between the ligaments of traits on the ileocecal above, there's about 30 ft off small bowel in between them. Okay, that's a lot of bowel that you might want to visualize. Okay, for example, of you, if you have a patient who's having a G, I bleed and you're not able to visualize the bleeding points on an endoscopy or colonoscopy, and you think that the Aleve might be kept coming from the small intestine, Then you might consider doing a capsule endoscopy. Okay, but again, it's not the most common procedure that you do in gastroenterology. It's, um, the actual preparation. So then don't squeeze. You should stop PPI two weeks before and generally should be no by mouth six hours before. Okay. You should stop the PPI because you don't want it. Might mask and pathology in the stomach on hope. You guys know what colonoscopy. Obviously, he can be a very comfortable seizure for patients. I think a lot of patients actually complained about the preparation that you need to do before the actual procedure. Okay. It's It's a lot of bowel preparation. You need to do sort of clear fluids on. Got a lot of different instructions that they need to follow in order to ensure that the actual procedure is adequate. Okay. Can you tell me in the child why you need to stop? I am at least one week before the colonoscopy. Usually was the relevance off iron in? Why is it important to stop the iron if someone's taking iron supplements? Why should you stopped that before the colonoscopy? Avoiding constipation? Very good. So first off, it makes you constipated. Why else it's always taking high dose first sulfate. What else would you might might you want to and stop it? What? I was gonna soles. Very good. Avoid Miss taking for diabetes cause black stools. Very good. Okay. So I am If you guys know how high those first sulfates can talk in your stools and could resemble Melena? Okay, which we'll talk about. So that's generally why the main thing is the constipation that you don't want your So you don't want patients constipated before colonoscopies, but also the black stools as well as important to be aware of. Okay, so the procedure so the not squeeze, you need to maintain continuous suction. Okay. To prevent the patient aspirating. Okay. And for sigmoidoscopy and colonoscopy is you need to do a digital rectal examination before you proceed and the complications. Generally you get beating and all. And and that's the sigmoidoscopy and colonoscopies. Okay, um, you know that quite rare. It is a possible risk. Okay, so it's important to be aware of. Okay, I could run through some of the key procedures. Let's go into the next next year. So someone's us could be related to be used prior to and dot So ranitidine is I'm pretty sure I've read some other militants no longer license in the UK, and I think it's, uh if the FDA has said they might contain cost in June, so you might need to correct me on that, but I don't think I really studying is anymore. Licensed. I'm not too sure, initial, but I think the hospital that that's closest to us has a shot. Asian? Who needed it? That's all I know. I think I did. I think I read the FDA news out, like, once in a cast on it. Yeah, it is no longer license. One said that as you go up. Yep. Okay. Right there. Oof! This is, uh, has kind. I was hoping that most people get it on this one. Really? Not gonna like, but just to sort of emphasizing really important learning point here. So most of you went for C Correct answer here is actually a look a and lost me within two weeks. Okay, so they had to, uh I wanted to do a bit of teaching on red flags in gastroenterology is which is why I wrote this big scenario. Upped to find emphasize really important. Any points. Okay, so you have a 58 low man who has a new onset epigastric pain, dyspepsia and weight loss. Okay, this is a man over 55 with weight loss and new epigastric pain. Okay, These are and the steps. And these are red flag symptoms. Okay, I don't even need to read ahead, okay? I mean, I can, but the question's asking, what is the most appropriate? Next step is these are red flag symptoms. Need to refer for an Asian doctor. Be in two weeks. Okay. So, again, if I didn't put it in the red flag symptoms, then this is definitely describing a scenario off, Uh, peptic ulcer disease, Probably a gastric ulcer. Probably caused caused by each pill or infection. And if I didn't include any of the events like symptoms and then the at the correct answer would be, um Would be see okay from a test. And and because you have to refer, the patients have endoscopy to do lots malignancy. Okay, that's important point. So let's talk about the key learning about this question. Patients over 55 years old with new onset dyspepsia and weight loss. Need an urgent and osprey. Okay. Very important to recognize red flags. So we're talking about bad flag symptoms like dyspepsia. We generally refer to them as the alarm symptoms. Okay. And I found myself in your monitor to try and remember the key red flag symptoms using the pneumonic along. Okay, So pictures over the fifth patients over the age of 55 with anemia, loss of weight. Iraq's here, recent onsets or progressive symptoms off. Or if the symptoms are not responding to treatment, then and if there's any evidence of masses Melena or most importantly, not forget that is dysplasia on beneficial. These are all red flag symptoms for dyspepsia and a warrant an urgent endoscopy to rule out some malignancy. Okay, so we're gonna talk about gastric disorder, right? We're gonna talk about gastric sodas. Okay. So disorders affecting your stomach again. That's going to lead us to talk about peptic ulcer disease. And I want to break down, sort of introduce the concept of gastric disorder. Sort of because the terminology can be very confusing when you talk about disorders affecting your stomach again. So it was not a gastro. That means that you have damage to the because of the stomach, but no evidence off information. Okay, Jeff, if there is evidence off information, that's when you call it gastritis. Okay, so a lot of things can cause gastritis. Things like alcohol is one of the common causes off cast writers. Okay, it can cause inflammation. But can you tell me in the chart does alcohol cause else is Is alcohol causes peptic ulcers? Yes. I mean, does alcohol Coast checked ago. Says, you know, know that alcohol's not interestingly alcohol. I mean, some of that Excessively. Yes, but generally alcohol is not a solution is not known cause commonly discussed course for peptic ulcers. Okay, you can get erosive gastritis with alcohol, excess alcohol use, but all right, so now, cause not commonly associated with causing ethical says Okay, How bit I say that How What can cause a patient who is quietly alcoholic to developing a project, a bleed where they're current alcoholic patient developed an upper GI. I beat Paris. It's very good. Okay, so I'll call it patient presented opportunity. That mostly just variceal bleeds than peptic. Ulcer is okay, but alcohol is commonly can cause gastritis. Okay. I mean, we talked about gastritis. We talk about acute gastritis. A quarter gastritis that's right is usually autoimmune, or it can be caused by HPV. Laurie, which is more common causes also is technically is just referring. That means that you've lost the entire mucosa layer. Okay? And because you're losing it, the entire ecoza you can erode into blood vessels. And that can lead to be eating because that's one of the problems you get with ulcers. Okay, it does that also as we can, because if I also is into whether by its location okay, if it's located in the stomach, it's a gastric ulcer. If it's located in the duodenum, it's a duodenal ulcer. Duodenum ulcers are generally more common. Have a bullet letting front here? Um, I do. I've drawn a narrowed from chronic gastritis and gastric ulcers to malignancy, and that's because both corn cast right. It's particularly when it's caused by HPV, Laurie and gastric ulcers, particularly when it's caused by HPV. Laurie. They both are having increased risk of patients developing stroke cancer. Okay, that's very important Learning point. And they keep going for here is that I haven't done an hour from doing, you know, says the key point is that duodenum ulcers have no religion of potential. Okay, is the gastric ulcers that can progress to gastric? I have no carcinoma. Okay, so remember doing the answers are not the ones that can progress to malignancy. Gastric ulcers are the ones you worry about. That's for no cost. Okay, So in terms of gonna focus on also is now so peptic Ulcer disease. Very important topic in gastroenterology in terms of the causes, the two main ones to remember our heat Flory and inserts. Okay. Shh. For Laurie infection. Can you guys tell me what is the bacterial structure of his primary? If someone asked in the example, Is the structure off each vial or e? What would you say? Or now, in terms of its microbiology, how would you describe the shape of a challenge? Illich? Oh, Gregor's so like, say like, Oh, for the local bacteria Helicobacter pylori road. Yep. Well, is it grand? Positive gram negative around. Active case of the ground. Negative spiral shape road. Okay, that's probably the way I would describe it in the zone. And it's the most common cause off, Epical says Okay, so innovate. The stomach invented duodenum, most commonly a vein. It'll cause do with, you know, losis. But it's also associated with causing Castro. Go says and hope you guys know crying inside use. This is one of the big things you ever learned in medicine to your wrists and sets? Concourse peptic ulcer is okay, So And said, Hey, that prostaglandin release and can increase risk of ulcers. Okay. And so these are two big risk factors, Okay? On some other ones Teo read about Importantly, alcohol and tobacco. They don't necessarily. They don't generally cause cancers themselves, but they definitely delay the healing of ulcers. Okay, So patients who are being treated for a peptic ulcer and you can follow them up in a couple of weeks, and they might say that it hasn't. The pain has improved. You should get you. It's good practice to ask about alcohol use sense and smoking. Okay. And because that both of these factors can reduce the actual healing off the ulcers. So this is for the most busy slide off today, Okay? Just summarizing everything you need to know about peptic ulcer disease. So let's go through the sort of keep wants. Okay, I wrist back. I am side. It's got a busy slide, but that's good to each fit. So peptic ulcer disease. It's an umbrella term for doing you know, ulcers and gastric ulcer is we said that the most common causes are huge. Pylori infection and and said's important getting points is that even though peptic ulcer disease is the most common cause of opportunities, most patients with ulcers don't actually beat. Okay, most ulcers don't actually bleed, but technically, the most common cause up another job is a bleeding peptic ulcer. Okay, in terms of important clinical and after me to be aware off, most gastric ulcers will develop in the last two coverage of the stomach. And if you guys know, you'll see that drunk enough to me. Let's go to supply to the left Kastigar tree. So yesterday was kind of road. The left Castro guy treating one of the more worrying else is one of the more worrying peptic ulcer. Is that that you see on the posterior? Do it you know, sis. Okay, so the ulcers that developed in the posterior wall of the duodenum, you worry a lot about them because they can erode the gastroduodenal artery and they can cause a significant average. Okay, you have a big opportunity with a posted you're doing, you know, also. Okay, just typical features. So you guys, you guys know this? It's burning at the gastric pain. Respect to your heartburn. Okay, people in s p a line. They might say that. Do you help? The pain improves with meals and gastric ulcer pain worsens with meals instead of the practice. This is an atrophy that useful. Okay, Theo. Only definitive way you can tell what type where the ulcer is is the Julian Oscopy. Okay, this thing about improvement with meals worsen the meals. It's essentially it's a pretty endoscopic approximation of where you think the ulcers Guess so you might just write down in the notes queery bleeding Castroville. So, for example, of other related points. So peptic ulcers, they can bleed. Like we said, they can a room plus blood vessels and lead to upper gi bleeds, which we will talk about rally. They can perforate and need to sign such peritus. Um, and we've talked about this hate. Viloria can increase the risk off Castro cancer. Okay, Particularly abnormal carcinoma. So and that remember, that's for the gastric cancers. Not be doing, you know, ulcers, not the story is for the gastric ulcer is not the duodenum ulcers. So the diagnosis. So we're talking about non bleeding, all sense for now. So the most common cause we said was hateful Laurie and the sort of first line diagnostic test for H. Pylori is the breath test is very, very sensitive test. It's noninvasive as well, and some practices might do a stool antigen with that important notes for doing The breath test is that patients should not take PPI for least two weeks. And they shouldn't not take any antibiotics for these four weeks before the test because they need to for those negatives. Okay, if you're radicalizing the calorie and the breath test can be used for both diagnosis and testing. Okay, Long bleeding ulcers, usually and endoscopy is not usually done. Okay, if it's if it's just the steps. Your heartburn symptoms, usually clinically, you can diagnosed a peptic ulcer and start treatment accordingly. Okay, they hate salary posted. We'll talk about the rather than treatments. Okay if they haven't gastrinoma so. If you have a gastrin producing tumor, which is known as Xolair Ellison syndrome, uh, then you can investigate by doing a fasting gastrin level on a secret instillation test. Okay, so that's for a tumor that's producing excessive gas during the leading to hyper secretion off credit card. I said Richard Lee to multiple peptic ulcer is okay. Yes. I mean, what? Which? Which gym? Which hereditary cancer. Which hereditary syndrome is associated with? Gastrinoma as you guys. It's, uh, tough one. Very good men. One excellent. We'll talk. We'll talk about this more in the endocrinology in a couple of weeks, but multiple endocrine neoplasia took one is associate id with gastrinoma. So Okay, even men. One you could get a pituitary pituitary adenoma was parathyroid. Um, parathyroid have occasional bloomers, and you can also get gas murmurs or incident moments at all. There's a treatment, so obviously for normal, for big thing with also is is to stop any incense. Okay, that's gonna worsen the ulcers. If the heat calorie negative, you could just give the high dose PPI. Okay, if the hates primary post A of you do with the triple eradication therapy, which we'll talk about the next line on for gastric ulcers, I'm gonna keep repeating. And gastric ulcers can lead to malignancy if it's caused by his salary. So for gastric. Oh says if if it's known that they have a gastric ulcer, they need to have a follow up and not being 6 to 8 weeks to check of their developed um, malignancy. Okay, so this is the slide that summarizing the medication therapy for each Valerie. Okay, so it's 321. That's the way you remember it. Three drugs for today for one week. Okay, Dental, that reprint drug sense. You can remember it with the new mark on from so on. A map result. Cl for clarithromycin. I'm for amoxicillin. Okay, so this is the jewel antibiotic therapy with do antibiotic that be with a PPI. Okay, that's the classic one. If the penicillin allergic, you can substitute the amoxicillin for metronidazole expression this question. Talking about allergy eye bleeds. So have ago. You're getting everyone starting. Most people have started to get it. Can't go with that. Okay, so most of you went for a D, and that is definitely the correct answer. So high urea Okay, so this is a patient is presented history of epigastric pain history off Melena on in Texas. Okay, so this is patient is also having an upper gi bleed. Okay, Um, just based on what? What is the history of osteoarthritis? Find to suggest you. Why did I mention osteoarthritis? Yeah, very good. And sets. Okay, um, so some of the other drug night. So alendronate Andranik acid. That's, uh that's what osteo perosises. Okay, this Austin it used in osteoporosis. Osteoarthritis is often managed correctly with pain relief and visual therapy and things like that. And often Asians will be taking in sets a lot. Okay? And I'll see the lack of his living the totally There's no history of liver disease. So that that suggests that the patient not unlikely to be having a virus. Your hemorrhage. Okay, we'll talk about various sees next week with hepatology. Okay, so this is most likely an upper GI bleed secondary to a bleeding peptic ulcer. Okay. And the Lantus findings high urea is one of the key blood test findings. Okay, so when you do your knees, the urea will typically be elevated with upper Japanese because essentially, the high urea is one of the is gonna provide a And so I the blood that's gonna took around the gastrointestinal tract? Yes. For hemoglobin in the blood, it's gonna provide a protein meal for the bacteria and the gut and through sort of metabolic pathways. And as it gets absorbed, it's gonna increase the urea in the blood. Okay, So high area is one of the key blood test findings with upper gi bleeds. Okay, so if you go to somebody the other answer for hyperkalemia hyponatremia, potassium and 17 disorders are not gonna be directly relevant to the upper GI bleed. Okay, That's so you don't have enough information to you Explain why patient would have hyper clean your hyponatremia in this instance. Increase your, um, pneumonia. So what could increase ammonia suggest if you're thinking about, um, up a jab, leads what we're what am I trying to get out with increased pneumonia and get blocked the burgers. Okay, so, yes, if someone's having a virus sealed league on, def, they have at it. And careful opathy. Okay, so they're both signs off liver failure. Okay, so on hepatic encephalopathy, classically, it's most most most commonly thought to be due to liver, failing to metabolize things like ammonia and talk other toxic products, and then it and then accumulating in the brain and causing in capital opathy. I told you, there's no history of liver disease, so there's nothing to suggest that the patient has liver failure or evidence of arson bleeding. Okay. Also, what What is the urea to creatinine ratio of useful for? Why is the area to crap ratio useful in the practice One. Do you use the urea to creatinine ratio? For what? Can the you it Grammy we should tell you so, Yes. So it's useful for determining the likely cause. Often acute kidney injury. Okay, so, um, granulation. Basically, if you have an acute kidney and injury, you'd expect, um, patient that continues to not be able to filter creatinine as well. Okay, on. Based on this patient's BP being low, you'd expect the patients have reduced profusion to the kidneys. And so you'd expect efficient if they did develop an acute kidney and reviewed, expect them to develop a preview. No acute kidney drum. Okay, do to reduce perfusion. And the key thing with the previous kidney injury is that you have a year into creatinine ratio, which is very high. You'd expect you to cram ratio to be well over 52 1 with a pre renal cause of acute kidney injury. The idea is, if you have a pretty renal cause of acute kidney injury you expect the kidneys to still be functioning, and so you'd expect the kidneys to still reabsorb a lot of the urea. And if so, you'd expect your area to be elevated, okay? And also you're getting high urea anyway because of the opportunities as well. So it's like the year to creatinine ratio to be much higher. Okay, so that's, uh, spn up in your belly so quickly up a jab. Leads on. Most common causes are bleeding peptic ulcers. Barris Ear bleeds. You get my wife's there so they'll tears. And the softest on somebody is off it, right? It can also cause some bleeding as well features. Oh, hematemesis is so fresh blood in the bone. It that suggests that it's quite the blood is traveling with quite fast transit. Okay, traveling quickly, too. It's just suggested that the bleeding point, it's been more proximal. Okay, coffee, Ground vomit is probably the one of the most overdiagnosed sign and medicine. Okay, a lot of people say a lot of conditions might say that this patient has coffee ground moment, but in reality, a lot of patients, but I just have the matter just vomited some sort of tea, tea or coffee or something we find looked like coffee ground. Okay, is that it's so Let us true the coffee ground vomit that might suggest that suggests more of a peptic ulcer. That's bleeding. Okay, because the immigrating is getting oxidize and causing that coffee ground color. But in reality, it's a very overdiagnosed sign. Okay, Molina so lean is referring to the black tarry stool that you get up and you're ugly. So really foul smelling stools on and again, that's due to blood getting digested and the hemoglobin get oxidized and causing documentation of the stools with a very offensive order. Okay, getting anemia with bleeding and obviously basic and get him a non avian stable, so shocked as well. Some patients, you get fresh blood. Okay, which might seem weird. But, uh, you know, it's important and important thing to realize in general medicine is that when blood is no in the blood vessels, it's generally quite irritating thing. Okay, so if you have like you have enough, if you have a ruptured ectopic pregnancy, that blood spreads out, you get massive right. Lower quadrant, pain, motion tenderness. You have a subarachnoid hemorrhage, but splits out to get downstage the news. So you get focal neurological signs, irritates the meninges again. Meninges, um, patients who have post e really loose, please. Blood contribute down the back of the fines, and you can get vomiting. Okay, So generally, vote generally, blood is quite an irritating thing to the body. So you haven't opened? Yeah, bleed. Sometimes the blood congest go straight down the entire GI I tracked, and the body doesn't. Doesn't want to handle it, that's all. And that presents as fresh blood. Okay, it's an emergency. So you need to do an 18 assessment high, your ears very common that we talked about and patiently Turban endoscopy. Okay, so this is basically summary of management of upper gi bleeds. Okay, so 80 assessment. We'll try. We'll talk about it in detail. When we start asking teaching as well, you can complete a glass, go back to school. So essentially can tell you if the patient needs to be managed in inpatient setting or on outpatient setting. If it's zero, you can manage them an inpatient in an outpatient setting and some of the definitive therapy. So there's different endoscopic procedures. You could do clippings sclerotherapy thermal coagulation on. If you're giving adrenaline, remember, you can't give a drill in on its own. You have to give it with one of these procedures. And that's what on a PPI can be given after the endoscopy as well. We'll talk about the COPD. It's next week. Okay, Next question. I think I might run over time slightly today. Guys just be just that, you know, Might it might finish around 80 45 50 if that's okay if you want to stick around or everything will be recorded on. But if you have to stick around, please feel free to stick around. Calico that. Okay, so we got a stricture to being be. And Dean guys have got step between colon cancer and T cell lymphoma. Crack down to here is T cell lymphoma. Okay, so can you tell me in the chat? What is he likely diagnosis here? Celiac disease. Very good. Okay, This patient most likely have seen that disease, so let's go through. This is break down this sp it. So you got a young person who's got foul smelling bulky stools history of weight loss on day and most likely has an iron deficiency anemia. Again mild. He's got conjunctiva pallet's. But no, I am slightly has an iron deficiency anemia. Onda is biopsy shows better strategy. Okay, So? Well, the key histological findings and see that disease is Phyllis atrophy. Okay, what about some of the other ones? But this atrophy is one of the key findings. And see that disease and what's happening and see that disease is you're getting, um, disease affecting these proximal small intestine. So And remember, most of your body nutrients are absorbed in the small intestine, so celiac disease is primarily gonna be a mile. Absorption disease is gonna be absorbing a lot of things, So just fats. Okay, so you're absorbing fat you can get when you get steatorrhea. Okay. As well as weight loss against the artery is the bowel smelling both pistols on. Do remember, I I am is primarily absorbed in the do you have enough. So if you have celiac disease, classically patients can commonly present with an iron deficiency anemia. Okay, So if I start with first line blood, the first line investigation is to do I g A on T t t g antibodies. Can anyone suggest why is the anti t tg negative in this patient? Yes. It was something that someone said Yes, i g a anti Very good. So yeah, it's a special day. Might be Is most like the iga deficient? Okay, So certain proportions, certain percentage off the population will be deficient in idea on. In that case, they can have a false negative on the idea. Anti t t do if they so when? So the key linkup point is that you should always chapped the total IgE levels for patients to check their idea deficient. And if they're deficient, you can check I d g. Okay, so that's the GP is most likely. Probably did a GI. And then I was positive and then refer them to have the endoscopy endoscopy. Okay. And see that disease one, the one of the big risks risks complications that patients can get is T seven for my back in the colon. So there's a key Learning point Bill. It's actually is one of the key histological peaches off. See that disease and some patients might have an idea deficiency. This is a pretty much a summary sheet on CNN disease. Okay, so see that disease. It's, uh it's not. It's some people just think it's an It's a gluten allergy. It's not really a gluten allergy. What's happening is that your body is the gluten is triggering. And also, um, you know, reaction in the body, and that's leading to damage the small intestine. Okay, because remember the glutes boots and the gluten protein is absorbed in the small intestine. So you're getting auto immune damage effecting the proximal small intestine. Okay. And that's what's happening in See that disease? It's also associated with a little tuning diseases like type one diabetes. Okay, clever features are all gonna basically you relate to the malabsorption. Okay, so you get diarrhea, you know, absorbing anything fatigue because of low iron and or, you know, other types of anemia as well. But commonly it's I'm steatorrhea, you know, absorbing fat seen gets the artery, uh, on again. All of these features relate to the mile absorption. Okay. On one of their key, don't, um, article findings and see that disease is dermatitis have petty formers. Okay. And this is what the rash looks like. So it's a very itchy, blistering rash that you commonly get over the extensive surfaces, centers over the knees and the back of the elbows. Complications of celiac disease is T cell lymphoma, and you can get some vitamin deficiencies, which we will talk about in a bit. First line investigation for celiac disease is anti T T T T antibodies. Okay on Avandia and teaching and 32 80. Remember, some patients might be iga deficient. Most accurate test is the biopsy. Okay, so you're looking for the histological features off celiac disease. And that's what this that That's what The X three up. It's villus atrophy. Cryptitis pleasure on lymphocyte infiltration. Okay, these other three, it's a logical features off celiac disease. It's a treatment, obviously. You know, general thing. If if someone presents with shoulder pain doing this, then you're going to tell them to stop doing that and see that disease that problems are caused by ingesting gluten. So you're gonna tell patients to just stop eating gluten? Okay, That's gonna be avoiding things like wheat oats, right? Barley. Okay. So they can still eat. They could still eat things like rice and potatoes and things. Can you tell me in the chat? Can they can Patients would see that disease drink vodka and whiskey and things like that. That's a Vincent fact. Yeah. Okay, so remember, unless it's labor, both a lot of the beers, a lot of the beers and whiskeys and things they contain. A lot of derived from sort of weeks. Products of a lotta. So unless it's labeled, generally shouldn't be a station. See, that disease should avoid them. Okay. And in terms of the actual brush, so don't I just had to For most, you can treat that with dapsone. There's a little schematic diagram. Um, a to sort of Explain where what happens and see, you know, disease. So see, that just is primarily affecting the proximal small intestines of duodenum and judges him on things like iron and calcium and folate. They're primarily absorbed in the east of areas and is celiac disease. You get disease affecting this area, so you primarily become competitions, commonly get deficiencies in I am full eights and calcium. Okay. As well as other things that are absorbed here is Well, okay, next question. This is ah, with slowly get everything was yet. But, uh, I've got this question. Yeah, I'm sorry. This session is quite happy. It's quite it's quite difficult to cover the entirety of a specialty in the space of a now and a half. But I hope you guys are enjoying and, uh, useful. Can't go to that. Okay, so pretty much everyone. Very much. So 68% of you gone for be okay. I'll tell you, the correct answer is actually see a case of it'll be three. Okay, So victim and efficiency is that something is probably not talk about often a medical school. But can you guys tell me what is thesaurus syndrome that the patient has developed? What is the disease that's developed because of the It's my division D. Excellent. Okay, so the pill aggressive syndrome. It's a disease that's resulting from nice and efficiency. Okay, Vitamin B three and classically. You can remember the symptoms off Allegra D three ds. Okay. Dementia, diarrhea on and dermatitis. Okay, So dementia. So it's referring to start off. Um, you were what symptoms? Like my memory loss got diarrhea on. He's also got evidence off dermatitis. Well, I've been like I had a pigmented Russia's Well, some patients get course itis, and it's very common in people who've been shrink it. It's a very common not that common, but it occurs in patients to our heavy binge drinkers. Okay? And I've told you this is an alcoholic patient as well on some of the other option. So little. It's a So if you're deficient, it's been a passively will get problems with vision. Okay, get night blindness. I am in deficiency. I am. So I understand why most of you went for that. People often associate diamond efficiency is common in alcoholics because it's common alcoholic. Second, me two things like when he's in couple of the um So this thing, this these features don't quite fit with the kids. When kids you get you guys, tell me, what is the trial of symptoms you get in Bernanke's ophthalmology? Asia ataxia and every box. Very good. Okay, it's a destination. Doesn't have any of that. Okay, um, the six deficiencies of B six deficiency, like we talked about like Sanjay went through on Tuesday. Six deficiency commonly caused by isoniazid use. Okay. Septations taking. I see a nice it for tuberculosis infection. They might get B six deficiency and between the C deficiency is not that common in this country. It's it's can be Teo scurvy, Okay? And it's primarily due to malnutrition. Good. So there's a keen any point this patient's progress you to nice. And efficiency usually occurs in heavy drinkers, so it's stable, basically summarizes vitamin deficiencies. Okay, I'm not gonna go through it. But essentially, remember, you have. That's over Ventolin, which are your A deck vitamins. And you have water soluble vitamins, which I be little lens on. Vitamin C is well have listed the super common causes of deficiency. And I've listed this sort of typical typical features that you developed because off the deficiency as well. Okay, next western. Yeah. Okay, I'll call it there. So if I'm not getting a lot of times, that's a depressing Is just step trying to get through this quickly as I can. Uh, BSO most of you went for D on. That is the correct answer. Okay, so, sprinkly this SP dances a patient to has was in the hospital, has developed watery diarrhea. Okay. He's been treated with antibiotics on has been tested for C diff infection. Okay. And based on his observations, he's has, um, tachycardia is hypertensive, and he has a raised temperature is what's a count is up as well. So this is a patient who has c diff infection, a symptomatic c diff infection that's causing him to have a watery diarrhea. And it's led to him developing human volunteers instability. And he's most likely septic as well. Okay, so this is severe infection. Okay, that's so in terms of the most severe C diff infection, a common reason that's used is IV metronidazole and or vancomycin. Okay, the key learning. But with this question I want you guys to remember is that vancomycin and C diff collectors that has to be given orally. Okay, because it's a really big molecule on. So if you give it intravenously through Canada, it's not gonna be able to reach the Oh, okay. So if you only it won't get absorbed, but it will be able to reach the area off the colitis and we'll be able to act on it. Okay, So vancomycin has to be given or a B and C diff. Okay, there's the other options metronidazole all that tonight. So if you need to give something bit stronger, stronger regime, so you need to get vancomycin with with the intravenous metronidazole houses in, So it has a seven that's a common name spelt used in sepsis. Okay, acute subsistence that it's It's a piperacillin with ti's about them and you got tickets. A very broad spectrum antibiotic, which can cover for Pseudomonas, is, well, problem. It has its own is that it's a broad spectrum penicillin, and it's also associated with causing C diff as well. So it's not the right answer here. Like I said, vancomycin has to be given orally, so this option is wrong. Digoxin myson can be used. It's a very effective drug. And see if it's very expensive, though that's where that's problems. And usually you try the uncle mice in first before you give it back some ice. Um, okay, but the doctor, my sins very effective, and it reduces the risk off recurrence as well. But it is used commonly in patients who have high rates of recurrence. So this is some real C diff. Okay, the key part related to see if see if is a gram positive role. It's a very important hospital acquired infection. It sounds like the company called antibiotics that are associated with seed. If you can remember it with the four seas. So clindamycin simple folks in call amoxiclav. Okay, it's a broad spectrum, antibiotics and careful sports. Okay, in severe infection, you could get a complication known as pseudomembrane is colitis. She gets to be inflammation with the development off the's pseudo mucous membranes, the's yellow mucous, mucous membranes, that that's what they looked like on a almost three, those beaches. You guys know this. Patients develop severe, watery diarrhea. It can be so profuse that they develop hemodynamically on state instability and systemic disease on is also a risk of toxic mega colon as well. Diagnosis. So usually you do a not test so nuclear gas in amplification testing and you can see if some hospitals also use the enzyme. And, you know, I say as well on sigmoidoscopy, if they have student and brain, is collectors taken control? Oh, some pseudo membranes as well, because they're losing a lot of fluid. The mainstay of treatment is strange resuscitation and supported care. Okay, that's gonna be crucial. And c diff on mount a moderate disease. You can either give all metro or you can get a like a mice in Okay, severe disease you could usually go for the oral Banco. If it's full metformin the disease, you usually combine all bank of my son with IV metronidazole. Remember banking. My son has to be given orally for C diff colitis. Okay, Next question again. Then we got maybe three or 443 or four ist is left and then we should be done. Okay, This question has an important learning point, so find out. Work through it, okay? I'll call it there. Okay, So, as expected, there's a bit of a split between C and D. Okay, so majority of you and 40. And that is the correct answer. Don't paradigm. Okay, so let's break down this SP. Can you guys let me go in the chat? What, is he likely diagnosis here? Yeah, Castro Greece is very good. Okay, This patient hae this patient, this is a diabetic patient who has presented with nausea, bloating and sort of early satiety as well. Okay, so I don't know, really satiety. Just general abdominal pain as well on dot So this is diabetic. Gastroparesis is on normally for diabetic gastro process. The first line Asian you give us metoclopramide. So what's happening gas increases you having delayed gastric emptying so metoclopramide can be used because it's a prokinetic and I can increase gastric emptying. You guys let me know. Why is why shouldn't matter. Clipper might be avoided in this patient. Why is my group might should be avoided in this patient? Yeah, extra criminal side. You got it. So it's a space has Parkinson's disease. Okay? Suboxone's disease. If you guys know it's, uh, it's a neurological condition, which is gonna be, which is the symptom of pocket to Parkinson's is due to low dopamine in an area called the substantia nigra on the way. Metoclopramide. It's a dopamine antagonised on. So it's not a good thing to get medical for my patient with positivity's because you're probably you can worsen that parkinsonism by further lowering there took me levels. Okay, now, if I tell you, Don Paradox also works by lowering dopamine levels. But why is it safe to get down Paradorn in Parkinson's disease? Why is it safe? Very good. Domperidone doesn't cross the blood brain barrier, so it acts peripherally to load don't mean level, so it's it's Z anti emetic of choice in Parkinson's disease and can use if Pakistan's patients develop Gastro paresis is okay, So in terms of the key learning point So this patient has gastroparesis diabetic gastroparesis on metoclopramide is a doubling antagonised that should be avoided in patients with parkinsonism. Don't paradigm is a that's alternative in the specific patients. Okay, If there's no evidence of parkinsonism, usually you go for the magical Promide. So this is something a diabetic gastro process. Okay, so you guys know patients with diabetes can get autonomic neuropathy, microvascular complications of diabetes so they can get if again, you're up with the effect in the stomach, you know, And if they're not able to if the news or not able to detect the stretch of the stomach that can lead to delayed gastric emptying because one of the he stimulus for gastric motility is the body being able to detect the distention of the stomach. Okay, so when that's increases, your body's not able to detect the distention of the stomach. So it's not able to stimulate Catherine motility properly. So you got delayed gastric emptying. Okay. Plastic features every society abdominal discomfort, postprandial, but bloating. So the diagnosis, usually you can pick it up clinically but in terms of definitive diagnosis you sent across scintigraphy and late on Do use a technician, labels meal and basically follow the follow the meal and evaluate the gastric Mt. The gastric emptying ability treatment. So generally it's gonna be dietary modification. So telling patients do to up a meal small reduce the actual work load on stomach reduced fat because, um, fat fats are gonna slow down gastric motility. Because if you eat a lot of fats that stimulates CC came release and CCK slows down gastric motility. Is there generally your advice chewed up food on it was a medical therapy. That's a good reminder is most commonly used on a swell A referral. My son as well, because they're both pro can act prokinetic and they will increased motility, gastric cancer, pacing and also help as well. Is there something on antiemetics? Okay, something. I told this just stumbling table on anti emetics that you could have a read when you get sliced. This guy was an expression. I think we have this question and then we'll talk about in front about disease and then we'll talk about correct the cancer and then we'll be done Yeah. Access taking with those of used to it. Uh, you hope you guys have letting it should. We're getting close to the end. Okay. I'll call the the Colon. Okay, so you are split between C and D. Okay, So correct. Answer his d. So this is a patient with Crooms disease who has presented with a recent flare up of the cramps disease. Okay, The flat was nice and high dose steroids, which is often used commonly using Crone's disease to induce remission on D from intravenous steroids. They've been winning toe all steroids. Okay, so keep on when Crohn disease. Is that a zipper else? Sorry. Happened and citramon high censor it. Should, they should say, is the type one is the diaper in Is the first line agent to maintain remission and groans disease. Okay, it's very useful And helping patients that come off steroids a swell. Okay, so, remember, is it type? Urine is the first line agent to maintain remission. Okay, I'll change this when I send the slice, if you might be able to download it. But just remember, this should say, Is that the urine summary on chrome disease? Okay, I'm not gonna go through everything. Just find that some of the key bets, Okay? Growing disease. Is there type of inflammatory bowel disease which can lead to inflammation anywhere in the GI I t. So it can cause information from the mouth to the anus. Usually it's gonna affect a particular location called the terminal Ileum. Okay, so the this will end of the ileum, and that's very clinically relevant. Okay, so the patient, because it's a fact and eternal island. Commonly, when patients get flare ups, patients most commonly will present with right lower quadrant pain. Because if you think about your citizen at me, terminal ileum is located in the right lower quadrant. So if they get terminal ileitis, they'll get right. Little contract pain. Terms of important points. Teo hope you guys aware off groans will typically caused transmural inflammation on. Well, typically, you typically get granulomas. Okay. Noncaseating granuloma us on in terms of the actual inflammation in chrome disease, you get information at different points across the JT. You generally don't get one continuous bit of information like you get with also the contest. You get skip lesions of discontinues, bets off information on smoking worsens chronic disease. Okay, so I'm hopefully none of you put smoking for the previous SBA, but smoking is definitely going to worsen the disease in chromes. Okay, it's a bit different. Ulcercolitis work and improve things, but in Crone's disease switch patients should stop smoking. Okay, features Diarrhea is one the main symptoms. Okay, we talked about the right lower quadrant pain tomorrow absorption disease as well, because it can affect the small intestine. And you get vitamin deficiencies on because they infect the mouth you can get after small focus is on because they contract the anus. You can also get perianal disease as well. Okay, there's a risk of malignancy, but it's less than osteoarthritis when people say risk of malignancy. Lesson also quite is generally technically, the risk is about the same. It's just that crows disease less commonly will affect the, um, colon. So that's why people say there's a lower risk because you don't get that much colon involvement in chrome disease compared to us for colitis. Yeah, but if you have, tell me if you have a patient with Chron's disease who has inflammation affecting the colon and you have a patient with ulcerative ulcerative colitis with information they call on. They both actually have a similar risk of it going on to develop colon rectal cancer. Okay, it's just that cruise disease more commonly will affect the small intestine. Compared to the colon, there's a diagnostic. So Calprotectin is the first line sort of GP test that's done in GP. Okay, they that it's basically a sign off and inflamed colon terms of other features of colonoscopies, the mainstay in diagnostic investigation So mean microscopic finding is the cobblestoning on. If you do a biopsy, you can see noncaseating granuloma as well treatment for chronic disease. So, in terms of from moderate to severe disease, you can use for ms it on the first line you can add on, is it? I've been, um, a captive urine. But remember, when you're adding in these diet urine agents, you should always check the TPMT levels. Okay, you should make sure they're not deficient in TPMT and to maintain remission and crumbs is easier. To tell a patient to stop smoking first line agents is easier than I appear in on surgery is not curative and groans the season, but, uh, patients in chromes these days, they can get complications like strictures and bowel obstruction, and they they can develop a lot of complications that will need surgery. Okay, but surgery alone So removing that bit of inflammation itself. That's generally not going to cure the problems disease, because patients can get Crone's in other locations. Okay, this diagnosis, basically highlighting. We have the terminal ileum here, and you got, like, little strictures forming because it most commonly is going to affect the terminal ileum. Okay, Is there some reflux up for the pathway for investigating Kroger's disease? A solid food? Come protect him and then, if it's positive, you the colonoscopy and then you have microscopic and microscopic findings. Officer Collector's, on the other hand, is the other inflammatory bowel disease. Okay, so you get inflammation in the colon and the rectum. You don't get a transmural inflammation and also a contest. You get superficial information and the mucosa, and so it's only the because of sub mucosal layers are affected. Unlike the skip lesions and crone's disease, you get continuous information. And unlike chrome disease, smoking is usually protective. Okay, as in protective again. It's been shown to help reduce the risk, reduce the rates off recurrence Okay features patient. Bloody diarrhea is a bit more of a predominant feature in Austria collectors compared to Crone's disease because it was commonly affects the colon and rectum left lower quadrant pain is more common, and flare ups on other features are. Some of these features can happen as well. There's a risk of colorectal cancer generally involving Crone's disease, for the reasons we discussed and patients with UC and also get toxic megacolon and perforation as well. Properties investigation, probably similar to Kroger's, is easy to do the calprotectin send them. If it's positive, do the colonoscopy features are a bit different with you. See, you can see everything. But just because you can see also is because superficial information and you can also find pseudopolyps as well. Um, in acute flares of you see, you should generally avoid the doing a colonoscopy. Okay, because the colonoscopy can. Doing a colonoscopy with such friable mucosa can increase the risk of perforation. Okay, so generally avoid it. You can do a CT abdomen to evaluate the flare up in, up in the acute setting. I will talk about minds, but you see now, so the severity of you see, it's a management, but it's in my management of you see, we can we can characterized the severity of the flare up using the true love and it's criteria. So this is what the criteria is. Okay, so I haven't really going to get the slice. Essentially, you can determine if the flare up it's mild, moderate or severe. No, this is this is a summary of the nice guidelines not going to go through it. But essentially, when you think about treatment Austria cholitis you you're thinking about what is the severity on the true love and with school and where is the action and how much of the colon is actually inflamed. Okay, so the so the mainstay of mind in Austria colitis is to use mean it's a list of, you know, salicylates. Okay, like mesalamine. Okay. They usually they're much more commonly used in, you see, compared to Crozes ease. But it can have a read on this slide to try make sense off how the nice guidelines, um, interprets the management off. You see, for acute severe, you see. Okay. So if someone gets acute severe colitis from you, see, generally you're gonna have to admit them. Hospital, you Do you eat the assessment on the first line? You should give a high dose cortico steroids. Okay, If they don't respond to the corticosteroids, then you should consider a rescue therapy with cyclosporine, infliximab and surgery. Okay, so we should really search limp. Input is very important in you. See, it's a table summarizing the key and the key. Pathological differences between Chron's disease and also collected. So everybody get the slice. And this is a table. Summarize. Doing the extra articular manifestations off inflammatory bowel disease. Okay, again, Not gonna go through this, but it's stable is for your use. Our patients with IBD, they can get, um, extra to get my other stations outside of the coma. Okay, so and these manifestations can appear more commonly in severe disease. Some of these again, some of them are not related to disease activity. Okay. And about important ones are Goldstone's and renal stones. Because they're only found in Crone's disease. Okay, You don't get Goldstone's as a manifestation of you. See on you don't get renal stones as a manifestation off, you see? Okay. And oh, explain why? No. So again. If you come back to this diagram, we're wondering why do patients with Chron's disease develop Goldstone's? The reason is in crone's disease, remember, you get terminal ileum disease, you know, able to absorb bile salts. If you're not able to absorb bile salts, then the ratio off bile salts to cholesterol in the bile will decrease. So the actual concentration off cholesterol in the bile will increase. And that can that cholesterol can precipitate and form Goldstone's okay on and really stones it relates to the mall absorption of calcium malabsorption. Calcium right now is Ultram. Yeah, it's calcium. That's not absorbed. Sorry. Because they found my absorption. The fact can hold on to a lot of the calcium on that can lead to increased concentration off oxalate in the ureters. And that can increase risk off calcium oxalate, renal stones. Okay. Okay. This is the last SPF promised. That's who you are definitely close to the end. Now, Um, this is the last S p. A. R. S is on colorectal cancer, so I think what, is he likely diagnosis here? Yeah. Okay. Cool it down. Okay, So most of you went for a and that is the correct answer Link syndrome. Okay, so discussions basically test your knowledge off the hereditary Polyposis syndrome. So Lynch syndrome is the most likely answer here. Does this patient as suspected colorectal cancer okay, he's has a suspicious pre malignant polyp in the ascending column with Lynch syndrome. Classically, you get polyps in the ascending colon. Okay, that's most patients with Lynch syndrome. We'll get. We'll get that. Okay. And then syndromes also associate it with other cancers such as endometrial cancer is on and that suggested by this woman's episodes of postmenopausal beating. Okay, so remember endometrial cancer. One, the sort of rent like symptoms you worry about with endometrial cancer is postmenopausal bleeding. Okay on. So that's what this question is basically trying to get it because that's why the correct answer is lived syndrome. We'll talk about some of these other ones now. It says on the lung 0.9 standard will usually affect the proximal colon. Okay, so this patient has disease as a polyp in the ascending colon is also associated with endometriosis, cancer as well. Colorectal cancer. So quickly. Colorectal cancer. Most cases are sporadic. Okay, So not associated with any hereditary syndromes they developed and what's known as the adenoma cost. The normal sequence here is on the risk factors, so most commonly they'll develop from polyps. Okay, it's sort of new plastic polyps like adenomatous polyps. Uh, it was the presentation, correct, And I was usually faxing left side of the column. But you can get cancer affecting your right side of the column. People tend to say that, right? Tell you cancers was more off. I'm deficiency anemia. Picture left sided cancer is caused more of obstructive picture and can lead to more of a change in bowel habit. Okay. I mean, those the main sort of clinical features to be aware of with, um, colorectal cancer collect has is also the most common cause off large bowel obstruction as well is the sort of referral criteria for colorectal cancers. Have a reading that on, but it's it's a screening for colorectal cancer in the UK The most places all placed in the UK will be using the fecal immunochemical test the Fick test because that's trying to detect detect a coat leading okay, on generally UK defect is offered every two years to all. Many woman age 60 to 74 and something says you also see a flexible sigmoidoscopy. He offered for men over men age 55. On If the if it is abnormal to detect a cult leading, then patients will be invited for a colonoscopy to evaluate the colon. This is some of the manager of colorectal cancer. Okay, this is I'm not gonna go through all this, okay? This is stuff you can revise from. Um, what I will say quickly about colorectal cancer management is that for acute presentations off new rectal cancer, you shouldn't. It's two essential reception immediately. Okay. So if someone, for example, develops bowel obstruction due to a rectal cancer, um, and it's a new diagnosis. Rectal cancer. You should have a receptor immediately. You should you need to stage the rectal cancer before you receptive. Okay? And the reason is, if you respect it before before adequately staging the cancer, the rip there's a risk of these leaving a positive reception margin. And so So basically you leave. It's a cancer hiding hanging behind. So with newly diagnosed rectal cancer, acute rectal cancer, you you have to stage it first before you remove it. Okay? Finals. Lights of heredity Polyposis central says these are some of the genetic syndromes, oldest normal dominant syndrome associated with it, causing colorectal cancer with causing polyps. Okay, so we have f a p familiar adenomatous polyp, posttest leg syndrome and first Vega's FNP. Hopefully, you guys know it's associated causing lows of polyps on down. Basically, the risk of cancer is 100%. So patients need to have a prophylactic colectomy limb syndrome we talked about is, um, associated with various different cancers, and usually the proximal colon will be affected. Okay, 30 ADA syndrome. The main thing in S P is they'll say, is that patients have hyperpigmented macule. Okay, so sort of melanotic lesions affecting the lips and the skin. And they can also have human Thomas polyps as well. Best cancers also more frequently reported in particular syndrome. So is there some conditions which I didn't have time to cover today? So I just included them on the slice like gastric cancer. Gastroenteritis. Guess in fact, um, gastroenteritis. Irritable bowel syndrome on a flat surface. Okay. So you can have a read of all these slides when you get them. That's it from me. Stand surgeon. You in today days I'm sorry that we I was going on. Extended session was a lot of content to get through, but hope you because I'm not useful on duty. Next week, I'll be going through hepatology as well. So cover a lot of the concepts and liver disease. Hopefully, hopefully, and that's actually what run as longer. Try and cut up a bit of a content, but do training for that, I think. Well, I just wanted the feedback from, um least to fill it in. Two Xs thesis lights and the recording The recording give us a few days to posted really slow will have to process it and then screen it and then posted.