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Gastroenterology Lecture

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Summary

This on-demand teaching session, suitable for medical professionals, explores numerous gastrointestinal concerns. Beginning with esophageal issues and red flag symptoms, the teaching shifts focus to intestinal issues, ending on abdominal x-rays. Information is offered through an interactive process, including single best answer questions and case-based discussions to enhance understanding and participation. Topics include conditions such as gastroesophageal reflux disease, esophageal cancer, upper GI bleeds, and inflammatory bowel diseases like Crohn's and Ulcerative Colitis, with comprehensive analysis and advice on diagnosis and treatment options for each condition. This session will enhance your ability to recognize and handle these common GI issues.

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Learning objectives

  1. By the end of the session, participants will be able to identify and differentiate between a variety of common esophageal and intestinal issues, such as gastroesophageal reflux disease, esophageal cancer, upper gastrointestinal bleeding, and various inflammatory bowel diseases.
  2. Participants will be able to discuss and correctly apply a range of appropriate diagnostic tools, such as single best answer questions, abdominal x-rays and existing clinical signs and symptoms, in the evaluation of patients with digestive system problems.
  3. Participants will be able to identify red flag symptoms of gastrointestinal disorders that would necessitate immediate or more comprehensive medical intervention.
  4. Participants will be knowledgeable on the standard treatment options for conditions such as gastroesophageal reflux disease and inflammatory bowel diseases, and be able to select the most appropriate strategy according to individual patient profiles, including allergy history and disease severity.
  5. Participants will be capable of understanding and applying scoring systems like the Glasgow-Blatchford bleeding score, and the Rockall score for assessing the severity and risk associated with upper gastrointestinal bleeding in patients.
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Computer generated transcript

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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Bye, bye. Wonderful. So we're just gonna go over a couple of single best answer questions, some esophageal issues, uh a couple of red flag symptoms and moving on to intestinal issues and finally ended up with a couple of abdominal x-rays. So in the interest of trying to make this as interactive as possible, if anyone would like to join in a couple of single best sta questions, there is a, er, code. Um There's only a couple, don't worry, I'm as entirely anonymous just to get a little bit of interactivity going on. Um And obviously you can also put any questions or anything you have in the cha. So I'll just go into the first question here. Um And it is a 59 year old man who has a one month history of a burning sensation in his chest, particularly when lying down and after heavy meals, he has not lost any weight, uh but has noticed an unpleasant odor in the morning. Uh He is also having some difficulty swallowing as well. Um So would anyone like to give that a vote? I'll just move on here. So, yes, I, I'm very sorry. I started off with a horrible one. Um, so this person is giving off off, um, a symptoms of gastro cycle reflux disease and usually that can be caused by achalasia, but it's more commonly associated with hiatus hernia. Uh, I know, I, horrible. Um, so the hiatus hernia, the sliding hernia, uh, of the, uh, esophagus coming out of where it, um, ends through the diaphragm is more commonly associated with the bad odor swell in the morning, um, than um, the stereotypical other ones as well. Um So this is the same patient. Um, keep particularly in mind the symptoms that they're having, uh that you're worried about uh for this one. So what would be the most, um uh appropriate next step? Ok. So, yep. So we've got 53% getting the right sort of gassy. Um Usually you would, if there wasn't any signs of any difficulty swallowing, you probably would just treat this patient with uh PPI uh but however, since they have the dysphasia being their red flag, you would be quite worried about that. So, gastroesophageal reflux disease, it has many, many triggers and it is one of the most commonly uh diagnosed um gi issues in the community. Um And several things make it worse, stress, smoking, obesity, uh coffee, greasy foods or lying down. Um, they usually present with this epia or heartburn. Uh Some will describe a burning sensation after meals in the epigastric region. Others will describe it slightly differently. But that's the classic one. Um No, uh others can get a hoarse voice or some nocturnal cough as well. Um, so management, uh you want to change anything you can change, get them to stop smoking, uh, lose a bit of weight if they are suffering from obesity and the medication. Uh PPI is the main one used. It's the gold standard. Um And if for whatever reason that is not working, there is a surgical option, uh not overly uh common because PPI usually solves it quite well. You would have to warn this patient though, on um the complications of if they do not get ill treated. So they include um inflammation of the esophagus, some strictures and Barrett's esophagus. Um So barretts, esophagus is a change from the squamous epithelium to P epithelium in the um lower part of the esophagus and it's um premalignant and can turn into a adenocarcinoma at the end. So, the red flag symptoms that you really want to be looking out for in an aspect of gi um is summed up by neuronic alarms. So, if they've got new and recent anemia, uh a loss of weight, anorexia or persistent vomiting, uh recent onset of dyspepsia resistant to treatment. So, if you treat them with a PPI and it's not helping at all, then that will be a red flag. Um Melina. So if any of you have been unlucky enough to experience that, you know, the smell will never leave you. Um Melina is that it the digested uh blood um going through the gi tract to come out. Um um uh Still, so it's black and Tarry. Um and epigastric mass, um you'll be very concerned then and dysphasia, any difficulty swallowing that again is another two week um red flag. Um So what you're worried about is the esophageal cancer and in those cases, so, uh adenocarcinoma is adenocarcinoma, sorry, is one of the more common is the more common one. And it is in the lower third of the esophagus. Um So, as I mentioned earlier, Barrett's esophagus is a very high risk factor for that. Uh Smoking and alcohol are other risk factors as well. Um Squamous cell carcinoma is uh on the upper two thirds of the esophagus. Uh And as you can see, there, there's a lot of other risk factors as well, but smoking is the main one for that type. Um So this one doesn't have a um single best answer. This is just a scenario. So you're one of the f ones on nights. Um And you've just been called to urgently review this uh patient who's a 54 year old admitted with an aspiration pneumonia. Uh And the nurse states that they have started vomiting large amounts of blood. So they have a history of alcohol excess and hypertension and their observations. Uh You'd be giving a score probably around 11. Um There are a high respiratory rate of 28 their oxygen saturations are low and the BP is very low and they've slight tachycardia. Um So this would be an upper gi believe um several causes of this. Um the most common cause there would be a mallory wise tear. Um due to persistent um straining and vomiting, small tears open up in the esophagus, giving a little amount of blood. This wouldn't usually cause a massive hemorrhage. Um The esophageal viruses which are linked to uh liver cirrhosis and portal hypertension causing swelling um of the um the venous system within the esophagus. Um So venous wall is very thin, these are very likely to rupture and lead. Um They would cause more of the catastrophic hemorrhage that you'd be very, very worried about. Um So presentation hematemesis, that's the one, as I said, you're concerned about coffee ground vomit is more of the ones that the um GP could comment on. Uh and Melina as well as I said earlier is digested blood going through the um intestines. Um So the management, the main thing is don't panic if you panic, the patient panics. Um So I know you, you haven't overly gone through how to assess a critically unwell patient yet. Um So I've just put it in there. Uh You assess their airway, the breathing and their circulation and try to fix what you can. So this patient will need oxygen on a lot of fluids and bloods. Um and um the patient will need an endoscopy. Um depending on the cause, will um change the treatment of this, of the endoscopic part. Um So, urea is always raised in an upper gi bleed. So, if you're considering whether this is an upper gi or a lower gi bleed, the urea is always raised in an upper gi bleed. So if it's a uh esophageal viral bleed, um before they go to their scope, they get um tele pre which um will have shown to improve mortality outcomes afterwards and broad spectrum antibiotics. So they get surgery and they get a band ligation if it's in the esophagus and scar therapy is more for if it's in the gastric region. Um Afterwards, these patients will be on propranolol to try and bring down um the risk of a reoccurrence if the peptic ulcer, um they're gonna go clipping plus or minus adrenaline and depending on where it is, they might also do a scar therapy as well. Um But if it's a peptic ulcer, they get IVP P after the endoscopy really just depends on what the cause of the bleeding is. Um So there are two main scoring systems and they like to ask questions about these. Um The first one is the Glasgow um ad bleeding score and that is um before endoscopy, considering whether this patient can be discharged and done as an outpatient one, how worried are you about them deteriorating? Um If they've gone through their endoscopy. Uh there is the Rockall score which is to see what is the risk of rebleeding and mortality afterwards. So, um the Glasgow er Bachar score is before and Rockall is after um another quick case here. This one does have uh a little bit of an interactive aspect to it. Um, so 57 year old female um intermittent epigastric pain after having diagnosed by a, with a judine ulcer, the urea breath test has come back positive and she's had an anaphylactic reaction to flucloxacillin last year. What is the most appropriate management for this patient? Mhm. And, yep, I, all of you got correct. I didn't catch any, anyone out. Um, yes. So, uh, metroNIDAZOLE, Cycin and omeprazole for seven days because they had a previous anaphylactic reaction to um, flucloxacillin. So, h pleura, um, you treat it with three drugs, uh, either amoxicillin or metroNIDAZOLE depending on their allergy. Thein and, uh, omeprazole, uh, twice a day, uh, for one week and you can test after that one week to see if it has, um, succeeded or not, the treatment wise. Um, this one is not interactive because I only gives you a couple for free. So I'll just go through it then. Um, a 21 year old, um, has, uh, ongoing diarrhea, right sided abdominal pain or recent weight loss and there is no blood and diarrhea, but they have noticed ulcers in their mouth and no past medical history. What would the likely diagnosis be um for this one, this uh would be Crohn's disease. Uh And we're gonna go through all the inflammatory bowel diseases now. So the main two, the two are ulcerative colitis and Crohn's disease. Um They're very common in northern Ireland. Um You'll see a lot of patients in the hospital with them. Um So here is, I know it's a lot on one slide. Uh This is, is a summary comparison between the two. Um I've tried to highlight the main things in bold here. So, ulcerative colitis will give bloody diarrhea, but it will only go through the submucosa and give widespread ulceration in the colon only. So it won't pass um beyond um the colon into the um ilium um or sorry into the small intestine. Um and it can give a drain pipe colon, uh appearance on X ray um in extreme circumstances. And Crohn's on the other hand, is non bloody diarrhea, but it is from mouth to anus and it gives skip lesions. Uh it also gives full thickness inflammation. So because of this full thickness, er Crohn's patients are more likely to get um fistulas or other types of complications because there is a full thick thickness compared to saris, which is only on the inner aspect, this goes all the way through. So it's more likely to cause a hole or a fistula um either to the outside world or uh within the body itself. Um So you can use and want a close up to remember. Um some of the um key points about ulcerative colitis. So, continuing continuous inflammation, it doesn't have the skip lesions that Crohn's does it limited the colon only the superficial mucosa. Um Smoking is protective against ulcerative colitis. One of the few conditions that smoking actually continuing to smoke, um not necessarily is recommended. But if someone is having a flare, sometimes they can flare because they stop smoking. Um, they usually excrete blood and mucus and the treatment that you can use uh immuno uh salicylates and is also heavily linked with primarily disclosing cholangitis. And we'll cover a bit more about that condition in a minute. So if it is mild to moderate, um ulcerative colitis, you can treat it with the uh aminosalicylates. Um, you can use rectal first and then move on to oral depending on how severe it is. Um, as well as corticosteroids, usually, um oral or rectal predniSONE. Um And if it's severe, um, you give them IV uh hydrocortisone. If that hasn't worked in 72 hours, you can give them the, um, the labs and the surgery as well. Um, but you give those 72 hours in the hospital without your hydrocortisone to try and calm down all this inflammation going on. Um, once you get them into remission, you want to keep them into remission. Uh, and there's a list of medications they give, they usually just have the um, oral, um, aminosalicylates. Uh, but they can give a few other ones depending on a couple of criteria met there. Um, a bit of an easier way to think it through. Are you trying to adju remission, maintain remission or does this person so severe that they need surgery? Uh, and depending on how you want, where the disease is when you're in just in remission, whether it is just in the, um, rectum or has it moved on to the left sided or is it extensive? Depends on what, um, would you give oral or will you give topical, um, a sa, um, so deciding whether someone is mild, moderate or severe ulcerative colitis, IU use the true live and wits criteria. Um, m majority of it is the amount of bowel movements they have. It's usually what they will give you in questions. Um, so if someone is having more than six bowel movements a day, um, they would be classed as severe. Um, you don't need all of these to be classed as severe. It's a bit like the asthma guidelines. If you have one in severe and the rest are in moderate, you're still in severe and you will be treated as such. Um, so they, if in severe they'll be getting IV steroids, Crohn's disease. Um, you can use the mnemonic, uh, nes nests for this. Sorry. Um, so they don't have any blood on mucus. It's the entirety of the g, uh, gastrointestinal tract from mice to in uh they give skipped lesions, uh usually in the terminal uh ilium uh will be uh the focus of a lot of the disease and smoking is a risk factor for current. Um So to induce remission, um kind of similar, um you'd still use the steroids and the uh aminosalicylates. But they have a uh because it's the entire gastrointestinal tract for Crohn's disease, they will need some extra feeding. Um whether that be through um IV um TPM because a lot of the information might actually be in the small bile where a lot of the um absorption actually takes place. Um once they are in remission, a lot of the time, it's the same picture as uh with ulcerative colitis to try and keep them in remission. However, they do use meth methotrexate um and they can do surgery. Usually the surgery they do in Crohn's disease is to remove the terminal allium and the cecum er where a lot of the um inflammation and disease focus will be. However, that leads someone more likely to develop um anemia due to that's where I think it is um B12 is taken up. So, um primary sclerosing cholangitis that I mentioned earlier. Um So this is a disease where inflammation occurs in the intra and extrahepatic bile ducts and this causes an obstructive uh bile pattern. Um So the risks are if you're between 3040 male, if you've got ulcerative colitis or if there's a family history. Um, so if someone presents in a question and they have diagnosed, uh, ulcerative colitis and are coming in with an obstructive, um, bilary pe, um, this, um, is the most likely cause and once you've ruled out like gallstones and stuff like that, um, so the inflammation that occurs in the hepatic, uh, bile ducts causes strictures, which then is the thing that causes the obstructive jaundice, um, which then leads up to um the sclerosing of the bile ducts themselves and the stiffening and the thickening of them. So, investigations wise, you want to check their LFT S which will give you an obstructive picture. Um And there are some antibodies. Um but these for this particular condition are not as sensitive or specific. Um So I'll just put them in there because a lot of, but a lot of the time they're not really that helpful. Um Imaging wise, you're gonna do an MCP and management is an ERCP. If there's um structures obstructing the bile ducts, you need to find them and then you need to get rid of them. And that should hopefully help um the obstructive bile picture. Now, the main uh point for this disease is it's highly linked to uh cholangiocarcinoma. So, um if someone with ulcerative colitis suddenly develops destructive jaundice and um they are a much higher risk of developing um the cancer of the gallbladder compared to um anyone who doesn't have ulcerative colitis so that nonspecific insensitive. Um So a similar condition is uh primary bilary um cholangitis. It used to be called primary bili uh bilary uh cirrhosis. Um And it is an autoimmune condition um, of the small bile ducts within the liver, um which was also gives an obstructive jaundice picture. Now, it's only autoimmune, the other one was genetic and environmental. Um So investigation wise, the antibody antibodies play a much greater role in investigations this time. Um AMA is the antimitochondrial antibodies and A N A is anti nuclear antibodies of those two AMA. So, the antimitochondrial antibodies are more, are used more often than they're more specific. Um and I GM uh will also be raised in this condition. Um Treatment. I'm going to butcher that if I try to say it. Um bye doxy cholic acid. Um So it is a secondary bile acid to help. Um but just by um bacteria, I believe in in the small intestines. Um and it helps to treat this condition and that doesn't need an M RCP or an E RCP. That's the only treatment for it. Um However, it slows progression um because the main complication of this is liver cirrhosis, these people could end up waiting for a liver um replacement. Um A couple of the um and uh polyposis syndromes. So I'll just put all the information out here. Um You've got familial adenomatosis. Um So this is where thousands of polyps are within the uh colon, much greater risk of having cancer in, in this patient. Um And if anyone's ever seen uh someone with it when they're doing scopes, it is literally full. Um a bag of marbles. I think it was a, what a one doctor said it about it once um when I was with them. Um but Lynch syndrome is the very, very um hereditary based. So, autosomal dominant inheritance um always involves at least the proximal colon, er can involve other bits as well, but it's always pri uh primarily the proximal colon. Um And it's not only um uh the colon that can be infected as well, it can also have um a greater risk of endometrial ovarian and different types of skin cancer. Um So, they will all because of that, they will have a greater um suspicion of people who have Lynch Syndrome to uh red flag them off for any changes. Um The last one, very rare condition, it's more that they give um numerous hematomas and there's very pigmented uh maculos all around the face and the mouth. Um and it is also autosomal dominant, not a greater, not as great a risk of cancer in this one, but um it still can come up in a couple of questions every now and then. Um So, celiac disease, um as everyone knows, it is um inflammation due to gluten in the intestines. So these uh people usually present with a failure to thrive um, so young Children usually, um, not able to do, not gaining as much weight as to what they should. Um, they can also have diarrhea, vomiting, fatigue, weight loss, and also some mouth ulcers. Um, so diagnosis and they have to keep eating gluten for six weeks before either serology or um endoscopic biopsy. Um, because if they don't eat gluten these, um, the antibodies and um, what you're looking for on the biopsy aren't going to be present. So, on serology, you're looking for the anti ttg antibody. Um and the gold standard is still the biopsy which will show um as I've written there atrophy uh crypt hyperplasia and increased lymphocytes, er intra. Um So the management for these uh patients is um lifelong gluten free. Um So they're allowed rice, potatoes and corn, but uh everything else, everything with gluten, um they're not gonna be allowed. Um They're also offered the pneumococcal vaccine and the booster every five years. Um And there are a couple of um the main complication of this is malnutrition. If someone is constantly vomiting or having diarrhea because of gluten, that's, they're losing a lot of um fluid and losing a lot of irons, um then they can also get quite bad anemia as well and osteoporosis. Um So everyone's favorite infection c diff um a lot uh very common, especially in the hospital setting because all its link with um antibiotics. Um So if someone also, if someone's on a long term proton pump inhibitor. Um they are at increased risk of developing C diff as well. Um So see if they will have a raised white cell count and if it's severe enough, it will become a toxic mito and they are extremely unwell. Then most patients um with ac diff infection are um medically well, but they need to be isolated in the side room. And because of the way C diff is alcohol gel is useless. So everyone needs contact precautions and needs to properly wash their hands after dealing with this um with the patient infected with C diff. Um So they need a CD um toxin um sample sent and if that comes back positive, then um they usually begin treatment. So first line treatment is uh oral vancomycin. If someone has been on Vancomycin before recently, within the past week or two, they move on to the second line. Um uh famcin. Um But if someone is, if that hasn't worked either or someone is severe, severe has got, they've got toxic and colon, their BP is really low. Um They are just as dry as a stick because of the amount of diarrhea. Uh you give both oral vancomycin and IV metroNIDAZOLE for those patients is um so, um we're gonna just go over a little bit of the abdominal x rays. Um just uh to cover the main things what they would ask in. Uh for example, on Os, if they or if they gave it during um uh one of the MC Qs. Um So it's always, you want to check um details. Um You want to make sure that, that the projection um and the, the, the, the X ray has actually gone through is OK. And the exposure and make sure that you can actually see um from the diaphragm to the hip and you can see everything from the sides as well. Um I know um I think the most important there is to check the patient's details for osteo purposes because they could give you um one of someone who you could show a seminar sounding name. Um and then what you want to look at is the bile, the bones and any calcifications or artifacts. Uh BBC would be the Pneumonic. Um So when you're looking at the bile, there is the 369 room. So the small bile should be less than three centimeters in diameter. The large bile should be less than six centimeters in diameter and the cecum er in the right iliac fossa should be less than nine centimeters. Um So if you see in this patient, um this is a large bile obstruction. Um So you can see it's peripherally located mostly um very, very wide, so far more than six centimeters here. And you can see the um he er which only go halfway um of the diameter of not even in some cases diameter of um the, er, large bile. So that's how, you know, that this particular is a large bile obstruction. So, large bowel obstructions are less common than the small bowel obstruction and are more commonly linked to malignancy. Um, and if someone has complete constipation, so they haven't passed a bowel motion or any flatus or any gas. Um, that is a complete, um, obstruction then, and that is the most concerning, um, they could require a surgery depending on the cause and, um, or if they're not fit, they can have a flatus tube inserted. Um, it's not comfortable for anyone that one. but it can relieve some of the pressure going on in the large, um, large bottle. Um, and here we have a small bile obstruction. Um, you can see it's more centrally located. Um, and they've got the, uh, valet conven, which are the lines that go all across the diameter of the small bar. Um, so it doesn't usually include feces in the small b. Um, and 80% of the causes roughly are mechanical. Um, 20% are roughly caused by the, um, a large bile obstruction. Um, so, uh, the mechanical, one of the most common causes would be a POSTOP ileus, which is a paralytic ileus. So there's no movement, um, of the peristalsis of the small bowel. Um, so that leads to an obstruction. So these people usually have nausea and vomiting and if they are vomiting, this can lead to a loss of potassium. Um So you treat these patients with um they would say drip and suck. So IV fluid replacement with the potassium because they're losing so much of it and insertion of a large NG tube called a coum sump. So it's just an NG tube that's very, very wide. Um And that allows uh suction to be applied to try and bring some of this obstruction back up. And um especially in POSTOP surgical patients, this will hopefully stimulate um the small bottle enough to um get moving again. Um This one is a little bit of a harder one zoom in here. Um This is the double lumen sign or regular sign. Um So as you can see here, you're not, if I go back to you, actually, you don't really see a crisp outline of the uh small bowel here. Um But it's very crisp in this one and there's two limits. Um So this would be a sign of pneumoperitonitis so that there is air caused by um if there has been a leakage such as a diverticulitis, um leakage, we do. Um You can also see this if you get a chest X ray and you would see air on the di uh diaphragms, um key bit being erect because air rises. Um um Another one they can also ask for is this one here, this is thumb printing sign, which effectively is just because it looks like a child has gone around and placed her thumb in ink or on certain bits. Um So this is a sign of edema uh within the bile wall itself, um which is a sign of uh colitis. So if someone has come in and you're not sure exactly what's on, it could be ulcerative colitis or Crohn's disease could have caused this picture. Uh So once you've looked at, oh, you want to look at everything else, you can see, this is the outline of the clear on this side as well. This would be the pole of the left kidney and the liver up here. And that would be the gastric bubble uh of air within the stomach in the large vial, um possibly some fecal loading down at the bottom as well. Um And once you've looked at the bile and other organs, now you're gonna look at the bones. So you just want to check around the spine, uh both sides of the hip, you can see here uh that both heads, a femur and a couple of ribs, just checking for any obvious abnormalities, anything broken, anything lighting up any um li like lesions which could keep in mind with like a um uh metastasize to uh the birth of um a cancer. And then finally, you want to check for any calcifications or artifacts. Um So this one is a ureteric stent that has been put in. So um just keep in mind that there could be if they had a staghorn um, obstruction in the kidneys, uh you could sometimes see them um, other stones as well. Um, um, any stents or anything that has already been put in place before. And you can also see. Um, but yes, that is my very short overview of um gi completed there. If anyone has any questions, please don't hesitate to say. Great. Thank you very much, Connor Flat. Um And yeah, if anyone has any questions, you can either fire it into the chat or you can unmute yourself. And I'm sending in the feedback form here. So that's into the chart there. And as I said, start in the lecture. If you fill that in, then you're able to access the slides. Um I would love to give you 10 you have. Um But yes, thank you very much for that. That Connor is very good for you. OK. So, um then the next old questionnaire there was a question. Um Why is your high and upper gi pla but not lower gi um Do you remember this one? I actually don't know where that is. Thank you. I can't remember from memory. Um But I think it has got something to do with um the protein metabolized by the S um Not too sure I will find out. Um Yeah, if you have any, a lot of questions you can find. Um So next we're gonna have who's going to do um her on uh Hepatology. Thank you so much, Connor. That was fantastic. I also do not know the answer to that question. So mm um let me just share what I think that that all good. Yeah, that's yeah, perfect. Um So my talks can be really quick too. I am not fond like Connor. Um I don't have any interaction. I figured you guys would probably want to have your dinner and watch me talk about the liver, which is the best organ ever. Um But I have that in my email and if you guys have any questions do send on and, and I will get to you as quickly as I can. Um I had a very quick look. I know you guys are just set the UK MA very soon, especially final years. So I had a very quick look um at their mind map and I do recommend sort of guiding your revision with that. Um And I've kind of highlighted the hepatology ones and we do cover most if not all of those. Um But have a quick look at that um just to help you with revision. So we're gonna go quickly over liver function and liver function tests. Um That is a very like high yield topic, both for your M CS and for your patients. And honestly, I think it is a point where people do quite um get, get quite confused. Um We'll go over some jaundice hepatitis serology specifically and one just your liver diseases and cirrhosis and Connor is very, very nicely gone over your PBC and PSC. So, um I will get those and you can just have a look at my blood if you want to look at them. Um ok, so your liver in a wonderful organ, it does many, many things. Um and the way that I look at it is if you know what the functions of the liver or any organ are, you're able to sort of figure out what the side effects the um complications and then also what treatments um can be used for the liver. So um major ones to sort of think of um in the context of diseases that happen with the liver are your um protein synthesis pretty big, your production of your bile um and your immune system, your metabolism. Well, all of them, but these are quite important in terms of the effect um of liver cirrhosis when the liver stops working. Um They're also quite great when we are doing our liver function test. So these are again, I have a lot of slides. So I, you can, whenever you have a look, um there'll be a lot more information. But the main thing to remember is that your liver function tests are divided in some of your LTs, which are your A FDA LT alt and GGT and then your synthetic function. Um And then you can go on to have a full liver screen. Which include various different investigations. Um, these are sort of the main ones that you will be looking at and I think this pain really, really nicely highlight exactly what you're looking at and what might have caused an abnormality in that, um, specific, uh, liver function test. And so just as sort of, um, a basis, your at and your alt are transaminases and may cause hepatocellular damage, which is also known as a transaminitis. Um And then your ALP specifically and your GP are your obstructive picture with your bilirubin. Um Bilirubin can be high or impaired in both the allergy obstructive. So that is not always the best indicator of dividing between the two. And then your synthetic function lets you have a bit of an idea on how far um the liver damage has progressed. Um So the way that I like to think about it in terms of, if I have investigations up in front of me, if you wanna have a look first at your classic liver function test, then you'll have a look at your synthetic function and you have a bit more of an idea of what is going on. Um At which point you can do a liver screen and usually you do do the full liver screen, but it does help you um rule out a bunch of um potential diagnoses. Um So yes, like I said before, your AST and your alt will indicate um hepatocellular. So this is if they are wildly deranged. Um And it's not usually a very small derangement. It is usually like in the 100s or even the thousands and your cholestatic pictures usually work. Um, it is important to remember that there are a few sort of things to keep in mind if your ast to alt ratio is higher than 2 to 1. Um, you are considering alcohol, liver disease. Now, this of course, is in conjunction with your history with um other information that you've gotten and commonly it might also be with a elevated gamma GT. Um And the other thing to keep in mind is that alcohol also um rises in bone disease. So that might be one of your differentials whether it's whether it's deficiency of Vitamin D or B meds if they have um either bone pain or any A is cancer. Um And then when it comes to synthetic function, the, the way I like to think about it is like the four main functions that you are assessing is your coagulation and elimination of bilirubin, your synthesis of the albumin, your clotting factors and then your gluconeogenesis. And then that will go on to be measured through your serum bilirubin, your serum albumin, your prothrombin time and your um blood glucose. So, the main ones that we do end up looking at are your bilirubin albumin and your um inr or your prothrombin time. Um The, what they help us sort of identify is whether or not the liver disease is acute or chronic. So, your abdomen is usually quite low in chronic um liver disease and um your prothrombin time is usually also commonly affected in your um liver disease with bilirubin. However, um especially when it comes to sort of guiding you in terms of what type of jaundice someone might be presenting with whether it's prehepatic, intrahepatic or post hepatic. And we'll go into sort of the differentials for each in just a minute. But um um I think the table on the right here, no, on the left, um is very helpful in terms of understanding what the process of that breakdown of hemoglobin um is and how it affects each um of your different types of presentations. So, in terms of your prehepatic, it is usually due to heat thrombolysis. Um And that was when you have um increased uh um unconjugated bilirubin in the blood um in the intrahepatic. It's sort of usually a mixed picture. Um And your post hepatic is the increased conjugated bilirubin and that is due to the um obstruction. Um And another key thing to sort of remember is that with your posthepatic, you often get your dark urine and your pale stools. Um So again, this is a really nice picture of what sort of your different causes of the pre intrahepatic and posthepatic might be. I will go over them in a minute later on. I just wanted to talk to you a little bit about the liver screen. So, um, when someone, when someone on the Hepatology board is getting a liver screen, they will be assessed when various different things and far more than one is on here. Um, but I think just in terms of whether you're doing your a, um, and you're just sort of meant to be asking questions or even if you're a counseling, a patient on, um, liver disease, one of the few things you really need to know is um alcohol intake and family history medications. People forget um how and uh just intense paracetamol overdose can be. Um and people are very sort of um quick to take paracetamol and just accidentally overdose as well. Um, so paracetamol is one of those big things that you need to keep an eye out for. And then there is a huge list of hepatotoxic drugs out there. I will not begin to name all of them. The BMF has a wonderful chart that you can have a look at. Um And then of course, all of your Hepatitis risks which include um sexual activity, drug use, tattoos, transfusions, any of those uh vertical transmission, any of those sort of high risk um hepatitis and issues and also a very good travel history. Um And then you also will do your different tests for G bears, you will feel some disease, hematosis, any viral infections, um and then your autoimmune stuff as well. Um It can be a little daunting to have a look at, but most trusts usually have a very good outline and this is for when you are actually practicing. So, don't worry too much. Um And I think this is a very good summary table. So just to sort of keep in mind um increased bilirubin in terms of prehepatic on this is usually with hemolysis. Um and if it's not, it's probably Gilbert syndrome, which is quite high yield, I do have some notes at the very end for it. So I do have a quick look over it, but don't spend too much time learning what it is. I mean, all the physiology behind it, um your gamma GT, if that's the only um elevated um liver function test, you are very, very, very highly thinking of alcohol and abuse, sorry. And um an alcoholic liver, whether or not an alcohol hepatitis or um further cirrhosis in terms of synthetic function. And if you have done tests in the GP or if you have a patient who um has present to the GP with the range synthe synthetic function, um it is quite important to get them to the hospital because they will continue to deteriorate. One of the things with the liver is, but it is very good in maintaining um its function while still having injury. Um but once it reaches a certain point, it is completely decompensated and will only worsen um your post picture and it is just very important that if the person has any signs of malignancy that you get that referred to. Um And, and for your hepatic picture, like caught are very um nicely talked about. You could go down your um issues with the bile duct, so your, your E RCP, your M RCP required and then you could go down managing the obstructive picture that way. Um So very quickly on jaundice and I just wanted to point out you're pre hepatic, posthepatic and he intrahepatic um causes of jaundice. I think it's very nice to have it outlined this way. Um Because if you're in an OS station, someone asks you what the causes of jaundice are, you can very quickly list a few. Um So, um Gilbert's um can also say the most common prehepatic um in terms of hepatic, it's usually viral if not alcoholic or an autoimmune. Um drug induced is quite common in um And then your extra hepatic is usually gallstones. Um And um either PBC or PC and as well as malignancy. Um um Yeah, another thing to keep in mind with jaundice is um different people with different skin tones um show the yellowing of their skin or their a lot differently. So, um as you can see, as likely highlighted in the um little baby picture as the varying skin change or the in the skin increases, the jaundice looks really different and it's just very good to get um used to seeing jaundice in various different skin. So do take that opportunity to see um Jaundice on the Hepatology ward. I do believe pediatrics will be going over neonatal jaundice. Um And so it's a very key thing. Um And if you have any questions about it, I'm happy to answer, but they will probably do a for a better job than I will. Um OK, so Hepatitis, this is where I think everybody sort of, um, feels just a little bit scared about. Um, but I'll try to break it down as much as I can. So in terms of what can cause hepatitis and hepatitis is really just inflammation of the liver. You can have your viral causes which are all notifiable. Um, you're autoimmune, you're alcoholic and you're drug induced. Um, I won't go over autoimmune. It is quite high yield, but really all that you need to know about autoimmune is that there's a set of bloods that you need to get set up in terms of the, um, autoantibodies, immune immunoglobulins that are associated with autoimmune hepatitis and then alcohol, he will go over in a bit. Um, and drug indued usually just involves a very thorough understanding of the medications that a patient is on. Um, so for viral, this can be a very possible a patient. I think we had like one or two in the past three years just in our year. Um, but the main thing to remember is that uh is firstly the transmission and the vaccination. So, um the only virus that is a DNA virus is HEP B. Um The transmission goes along the lines of fecal, oral, bodily fluids and blood, blood ver vertical transmission which is just bump to baby. Um And the important thing to remember with the DNE ones are, first of all, D only occurs in conjunction with hepatitis BB. Um And E is oral and it is quite uncommon. Um in terms of your vaccinations, B is given in your six and one quite regularly to most people who um have grown up here and outside. Um A is only really given to those at risk. Um And, and do not have um uh vaccinations available or vaccinations that have proven to be beneficial. Um in terms of management, majority of it is supportive and it is a lot about complication, management, making sure that they steer away from um paracetamol and alcohol misuse because that can further their liver um damage and also keeping an eye out for any high risks of um contracting either further infections such as your Hepatitis B if you're healthy or um ac as well to be fair. And then also ensuring that you are keeping an eye on um routine cancer testing if required. Um And then you just have your Hepatitis B is treated with your directing antivirals and your regulated interferon for your um hepatitis B. So your hep A B and C are quite important in terms of serology. Um Someone once said this to me and I haven't been able to get it out of my head. But um for hep A, you're kind of looking at the immunoglobulin. So your um ID and your I DM, um and, or immediate, um which means that it is an um infection G is for going on for a while, which means it is previous. So if you have both, it might be an active infection that has been there for a long time. If you have just your um IgM, it's just an active acute infection and then your IgG um it can either be immunity from a previous vaccination or a HEP A infection. Um And, and I got the bottom bit here from the clinical summaries, which I just wanna highlight, highlight are very, very good in terms of giving you the guidelines um of how you would go about getting the serology and how you would go about management as well, not just for hepatology, but various other conditions. So do give that a look if you haven't already. Um OK, now HEP bi think this is the one that really, really messes with people. And I think to understand that you really have to understand why we're looking at what we're looking at. So in the HEP B serology, you're looking at the antigens and you're looking at the antibodies um and just to sort of wrap your mind, mind around and going back to basics your antigens. So what are already on the B molecule that is entering your body, your antibodies are what your body um creates. So just in terms of thinking about it, your surface antigen means it's a very surface level um interaction that you've had with the virus, your e antigen is further inside and your core antigen is quite important in terms of um how much of the interaction has happened, how long for um and your antibodies subsequently are, what kind of reaction you had to um the virus itself. And I think that this is a very good table just because it helps you figure out what you must do in the um uh case of whether or not there is an immunity, there is infection. Um But I will just move on because there's this table that I think is far more helpful. So um just keep in mind your um alt of course, will be elevated and you might have increased IgM. But these through these eyes that you are looking at kind of at the top are the ones that will really help you figure out what exactly is going on. So, in an acute infection, the most important thing that you'll be looking at are these guys here. Um And then in terms of um immunity just with vaccination of your um anti stairs body, which is right there. Um And then moving on to your chronic or um, chronic inactive, um, can be quite different. Um, so just to be sure you're active and inactive is dictated usually with this test right here. Um, and I know it's a lot to think about, but, um, I would really recommend putting time in to learn, um, at least the basics behind why this happens and, and how to have a look at the test and also figure out exactly where in their infection, a person might be. Um And if this table is a little bit too complicated, I would recommend just having a quick look at this one because it, it uses just those three your two surface antigen and antibodies and then your core antibody to help you figure out exactly where they are on that. Um I hope that makes sense if that doesn't, I'm really happy to go over it again. Um And you can send me many, many questions about serology. I don't mind. Um In terms of HEP C, the screening test is the on the RNA testing, but the RNA testing is usually done um to confirm the diagnosis and it really does help calculate viral load and monitor the disease as it progresses. Um HEP C is the one that is usually treated with your direct acting antivirals that doesn't mean that you won't give the patient supportive treatment, you will be um doing both of those things. Um And it is usually quite successful Um ok, so your um liver disease, in terms of fatty liver and alcoholic liver, um they both may present either incidentally or in a similar fashion. And the main sort of um indicators between which is, which is sort of your history, your examination and all those other um and key facts that you can gather outside of just the blood test. Um So in terms of your non alcoholic liver disease, it really is just um the excess fat that accumulates onto the surface of your liver. Um and it is commonly associated in um obesity, insulin resistance and metabolic syndrome. And when I say metabolic syndrome, I mean, people who have hypertension or um lym or um uh hypertriglyceridemia. Um So these are risk factors that just increase um their likelihood of developing nonalcoholic fatty liver disease. Um The o the other ones would be poor diet and smoking, smoking just for all things. Um And I think one of the other things that people struggle with is figuring out the different acronym for um fatty liver disease. So, um NFA L is when you just have steatosis, which is just mild accumulation in the liver and it may not affect your function of the liver yet. So your synthetic function might be quite well as well as your t um nash is the presence of inflammation in the. So we can quite clearly see um that there is some impact there. It is usually reversible as is um NFA L whereas with fibrosis is when there has been long term injury to the liver, um, that results in scarring and cirrhosis and eventually, um, just generalized scarring that has worsened over time. And that was when you get to that irreversible stage. Um, and the liver decompensates. Um I hope that makes sense. And so this is quite a big list of investigations. The only thing that I want you to pick up is that you will always do an ultrasound of liver and you will always arrange a biopsy, which is a gold standard for your liver disease. There are various other things that you can do. Um, one of the few things that I think would be quite good is to identify your risk factors such as, um, getting your HB A1C, getting your patient weight measured. Um And then of course, doing your whole liver spin that we talked about, which includes the majority of the other things on, on this list. Um, have included pictures. I don't think Queens would be made enough to show you ultrasounds of the liver or CT scans of the liver in, but in terms of your CT scans, the liver is quite easy to identify. And also it's quite easy to see the, um, just the areas of um, fatty tissue or scarring on the liver. The um, ultrasounds are a lot harder. Um It's usually the brighter spots that would be the fatty tissue. Um but I really don't expect, um, them to ask you about that. That would be quite mean. Um, and then in terms of your management, so, absolutely, it would be a lot of conservative management in and preventative management is to prevent them from getting to that fibrosis and cirrhosis stage. Um, and a lot of it is just diet and exercise. Um, and then a lot of it is also, um, managing an, any symptoms that they may have already um of liver disease. A few people may end up getting bariatric surgery. Um And then of course, liver transplant is reserved for those who have decompensated livers. Um and are in endstage liver disease and also qualify for a liver transplant. There's a huge list of um requirements and criteria for being able to qualify for a liver transplant. Um And the demand is quite high, as you can imagine with both fatty liver disease and alcohol liver disease. Um So just keep that in mind. Um And like I said, your complications are of course to decompensated liver disease, but also hepatocellular carcinoma. A lot of patients with fatty liver disease will be put on to regular surveillance um as well as sepsis as you can imagine in terms of any scarring, um or any inflammation just makes it more prone to infection. Um And just because it is such a um disease that is affected by other risk factors, um it can further cause or worsen those um conditions as well. So that for high BP, your um cholesterol and your um glucose, so your diabetes, um and it can also create sort of um issues in your coronary arteries or um cardiovascular disease with quite a common cause of death in patients with fatty liver disease. Um in terms of alcohol, liver disease, now, this is really common. I would be really surprised if you get through year three years replacement without seeing someone with this. These patients are usually really jaundiced. Um They have wildness, very catic um and, and their history is very, very indicative of alcohol liver disease. Um in terms of identifying it in, in comparison to your fatty liver disease that really does rely on your LTs. Um And then of course, your um liver scans. Um So, one of the few things to keep in mind is that um the pathway that sort of fatty liver disease goes through in terms of whether or not it's reversible alcohol liver disease does the same. So um it is also injury to the liver, um either fat accumulation or just it being overworked and inflammation. Um and cirrhosis can develop when it is really severe and that means it's irreversible. Um with alcohol liver disease, there's a lot going on in terms of malnutrition, dehydration. So your um electrolytes are going to be deranged, your blood N is also going to be deranged, especially in patients who um have more nutrition. Um you may also see coagulopathy and patients who may have alcohol, liver disease may be prone to fall into hitting their heads. So it's very important to get um a very thorough history of what's brought, brought them in what events have um taken place. Um And then just in terms of covering your other risks, you really do wanna get your hepatitis three, especially for those acute viruses down. Um And as I mentioned in your LFT S, the classic picture would be a very, very elevated gamma GT and then your ratio of a therapy is high too. Um The other thing to keep in mind is in patients who have as I go over it in a bit, but um you might have to do a diagnostic and that is just to the um to um ratio um and it is also to exclude any um infection as well as culture, the the sample um in patients who have um throw up to the more they will be screened to see if they require an OGD to look for varices if they have very severe disease. And um and they will get regularly followed up for that as well. Um ok, so, and the important thing to keep in mind is that if someone's come in with a really bad tachycardia deranged LTs, um bad necys and a sort of mild fever and we've ruled out all of your sort of viral um causes you are going to think alcohol, liver disease, um especially if the patient has um come in to Ed. Um So your black alcoholic Hepatitis score really helps you figure out where they would lie on that prognosis scale um is also quite used. But again, that's a very um specialty specific um so efficient. Um in terms of alcohol abstinence, I'm sure you all know less than 14 units per week is you are going to um more than six units is a binge. And just sort of, so you have a picture, a point to two units um which I only recently learned and blow my mind. Um But um the key thing to do is get alcohol liason and sort of identify where on that sort of habit breaking cycle. The patient might be um for your ascites, you might be either using um well, you're gonna do your monitoring and you're gonna do your low sodium diet. You might have to put them on spiral. Um And then they might require it. Um It is quite important to um re nourish these patients and just keep in mind of refeeding syndrome and nourishing too fast with your feed. Um And that can lead to um arranged on, I can't remember, but it needs to, to an imbalance in your you need and that can um predispose you to further complications um or your transplant. So you need to go through a very thorough investigation to see. Firstly, if you are um, um, a candidate for a transplant and it is commonly a scar, I'll show you a picture. It's quite good for your oscopies just to have an idea of what it might look like in case the patient has it or they show you a picture with it. Um, but it is a, a, um, very big scar. Um, just for your alcohol dependence. If you happen to have a oscopy patient, I do think it might be um quite good to have a quick understanding of what the cage tool is. I know people use the audit screening to tool as well, but I think cages are a lot simpler. Um And that's just sort of ascertaining whether or not they have tried to cut down when they're annoyed when people are criticizing their drinking, how guilty they feel if at all. Um And then asking me about eye openers and if drinks are the first thing that they think about in the morning. Um So just have a look through that. Um And it really helps you sort of counseling patients or even take a quick history when it comes to alcohol dependence. Um And as I mentioned, there are quite a few um scores to be used to measure severity. I don't mention that you would have to know how to use them and what is used them. I have included the scores. But um just in terms of, if you know, I think you guys should be fine for both u um your demo. So this, you might see quite commonly an e this is for patients who come in after an alcohol binge or um just high volume of alcohol, you are going through withdrawal. Um A lot of time you can see sort of different things and things that you might present, whether it's just nausea and sweating, whether they're having visual hallucinations, whether they're having tremors. Um And according to sort of where they score on this, they may get some sy. Um OK. Yeah, so I just sort of very quickly mentioned that but if someone is in withdrawal, you wanna get them, their th I mean, just to replace their vitamins, keep them nourished. Um And then you will give your benzos. Um according to your GMO score, you might also have to give laxatives for patients who may be enallax like. Um And then, of course, for your, as I've mentioned, the other thing to just keep in mind is um with your um ascites, you wanna have a quick look at the neutrophil count which helps you just sort of gauge just how high the risk is for your spon spontaneous bacterial peritonitis. Um And then according to that, you would have to get a range of um antibiotics and albumin solution if their abdomen is low. And OK. So cirrhosis, this is our last little section. Um So this is essentially when your liver is so far scarred that it, it um irreversible, right, irreversibly affected. Um And it is completely decompensated and this is usually only um diagnosed through um either clinical findings or a fibrous scan. Um which really just assesses the elasticity of the um liver and we've gone away the majority of the common causes. Some other ones just keep in mind are um hematosis, Wilson's disease and um all those other low yield but beautiful um conditions. Um So, decompensation is when you have those um symptoms that we were just talking about. Um And these are furthermore, so just to keep in mind, you have your jaundice, you have your um cachexia or your loss of muscle, you have coagulopathy, you have your ascites. Um and oftentimes people present with um physical features such as medusa, which is sort of the um uh upturning of the vessels around your um umbilical area just because of the pressure of the ascites. Um And masia is also quite common. The other thing to keep in common is that you can get hepatomegaly, but often with cirrhosis, the liver ends up shrinking in size. So that might not be an indicator of liver disease. Um or cirrhosis specifically, I think it's good to have a very quick understanding just five that you can name off in terms of signs of cirrhosis. Um And I think you'd be quite good for whether you're being out in the ward or even in the R. Um So, yeah, these are just very quick signs and symptoms and I wanna just take you back to thinking about the functions of the liver. So you're gonna have your jaundice because of your bilirubin, your signs because of your albumin and, and the liver just not working. Your co coagulopathy can um your Vitamin K will be disrupted and your prothrombin time is disrupted, esophageal varices for a similar reason. Your hepatic en cephalops has to do more with your um gi system and your gut and your inability to get rid of pneumonia. Um and then your complications sort of affect those functions as well. And I think this is a really good example or sorry, this picture is a really good example of um the various different um conditions or functions that are affected. So if you are in a counseling station, just go through the functions of the liver and then in reverse, talk about how um they can be affected and will stop working. Um So that is just a quick rundown. Um And I think I've gone over most of those if not all. Um the other thing to keep in mind, this is a very common score that you'll see on the wards, especially in patients with cirrhosis is your child's score and that really helps you assess severity and prognosis for patients who have cirrhosis. Um It is really just looking at encephalopathy, your ascites your better than your element and your perform in time. Um And I don't think you'd be known to know how to score this score, but I do think it's quite good to know how it's used and what it's called. Um And also keep in mind that for cirrhosis, your liver biopsy is your gold standard. So it helps you firstly differentiate whether or not cirrhosis is present and whether or not it is acute or chronic. Um And it is very good at um differentiating difference between fibrosis and cirrhosis where we talked about that fibrosis is more sort of localized to where cirrhosis is a lot more generalized scarring of that tissue. Um And your other tests can be quite helpful, but your liver biopsy is in uh by far what is most commonly used. Um An ultrasound is more common just um in terms of like acute um conditions and symptoms that someone might present with. Um So, like I mentioned in terms of managing the studies, it is usually just getting a very quick understanding of um how much fluid is there. And one of the things that you might be asked to do is assess shifting dullness, which is a lot more simple than people make it seem. But it's really just to see whether there's any change in um sort of the resonance um of your abdomen. And if there is you just get the patient to lie on their side where you and keep your hand where you've noticed the change and then tap again to see, um if it has changed either from dull to re or re to dull. Um And that helps you understand whether or not the dullness that you're hearing is liquid or whether it's um solid. So whether it's organometal or whether it's a, um, so as I mentioned with he hepatic encephalopathy, this is when you have your patients who are um sort of confused, agitated on the ward. Um And this can worsen very, very quickly, especially with infection when delirium is also added on. So essentially what happens is you have this accumulation of ammonia which enters your blood brain barrier. And these sort of two main lines of management are ensuring that patients are um maintaining regular bowel motions. So you would give them regular lactulose just to ensure that they aren't um sort of retaining that ammonia in their gi system to be absorbed. Um And then your treatments would also be um antibiotics which help ensure that the bacteria in your gi which are your normal healthy bacteria um produce less pneumonia. And and that is sort of the extent of it. Um There is always um a constant uh capacity monitoring with patients with hepatic encephalopathy, they can be confused and still have capacity while some may be in may confused and have no capacity. So it really is a varying spectrum there. Um The other thing to keep in mind for cirrhosis patients is that you will be monitoring, as I mentioned earlier, your esophageal therapies and that is because you do not want an acute bleed, especially um as Connor was talking about today, it can be quite scary and it can be quite, quite complex. Um So they will either be given propranolol as mentioned or um they will have either medical um emergency management or an endoscopic management. Um and often patients who um have shown up to the ed with various um um episodes of uh upper gi bleed due to varices might require a tint procedure which is quite good for people with um oral hypertension and cirrhosis. The other thing to keep in mind is that hepatocellular carcinoma is common um especially in patients with cirrhosis and other um viral infections related to the liver. So, um they will get a six monthly surveillance of the ultrasound as well as your alkyl protein. Um Connor has very nicely gone over these. Um I just had a break pictures because I'm a bit of a visual learner. Um But you can go over those in your own time. The only thing I kind of wanted to, these are extra bits, feel free to go over them in your own time. Um I'm not gonna bore you anymore with it. I just wanted to show you a few the examination fine. So this is your acidic abdomen. It is quite distended, but it can also be um a lot less sort of obvious and that's when shift and I really helps it easier on the, um, these, your toas that kept me when I was talking about the to, um, vessels. This is your Mercedes Benz sign. So, um, it is, like I said, quite a big sign and, and I think it would be an easily, um, examinable either station or an Q question. Um, that's very Cania and again, that can be something that is either white, prominent, invisible or, or very, very sort of hard to pick up is very severe. Yeah, most commonly you'll see in um, cirrhotic or um, patients with liver disease, you'll see it in their arms and their legs um because their abdomen will be so swollen that um it would look normal to a person on general observations or do make a show of having a look at their um musculature. And then the other thing just to keep in mind, something, I always forget what I'm doing. A hepatic exam is check for liver flap. So, um when you're doing their tremor, just have them and their risks back and um just assess to see if there's a liver flap. And if you do get to see a patient who has severe alcohol, liver disease or even just fatty liver disease, their liver flaps are quite prominent. So it would be quite good to get that. Um, just that opportunity to have a look at what it looks like if you haven't already. Um And that is all and well for hematology. Um I hope that was helpful. It was a very quick um one stop sort of understanding of the liver. Do send me any questions you have. Um And um I do think you guys get slides, so have a look through those other um wonderful nitty gritty conditions. Thanks guys. Perfect. Thank you so, so much. That was very good for you. Love your slides. Um So yes, um yes, you get the slides in if you fill in that feedback form, which I sent into the chat and then the R code will bring you to the feedback form as well. Um So that, so thank you so so much and, and um Connor who are both very good actors and thanks to everyone who joined. Um So our next lecture is on Thursday and it's on ophthalmology, that's at 7 p.m. again. So um that it what?