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Okay. Hello everyone. Welcome to today's session on general surgery and peri operative care. Uh Just really quickly, if you guys can hear me, just pop in the chat if you guys can hear me. Perfect. Thank you, Sue. We'll just give it a few more minutes just to wait for a few people to come in and then we can get cracking. I'm joined here today by Josh. He's the other medical student who's organizing this whole thing with me as well. Um Thank you so much for joining. Um So just quickly running through the overview of this session today, um We've done it the same way before. It's just going through some MCQ questions from past med. We'll be covering some major themes. Um And then I'll be releasing some polls for you to interact with and then you can answer the questions using the polls. There'll be some teaching in between the questions as well on some of the key learning points. Uh If you guys have any questions, you can just drop any questions in the chat and then either me or Josh will answer the questions. All right. It's a nice day outside. Thank you so much for staying in, um, for, for the session. Hopefully you guys managed to get some, some sun right before this. Just give it a few more minutes or a couple of people to come in. All right. So I think I'm just gonna get started. Um, right now. Okay. So today's session is on general surgery and a very common presenting complaint in any general surgery sort of question is abdominal pain. Okay. Um It's very common. So for any, any sort of pain, we would use the Godsend acronym, which is Socrates. Okay. So you ask about site onset character, radiation associated symptoms, timing, assassinating factors and severity. And we pretty much taught this from, from the very start. Okay. Now, for abdominal pain, you know, there's it can affect the multiple regions of the stomach. Okay. And if you guys remember the regions of the stomach, it's this. So you start with right hip contract on the right, upper, right left hypochondriac, the upper left epigastric umbilical, right, left, lumber, right left iliac fossa in the hipaa gastric region. And for general surgery, um a lot of the conditions tend to tend to present pain where it is um which is quite useful. Okay. So I don't want to spend too long on this, but we'll go through some examples of, of um conditions that can present with pain in the specific areas. Can anyone just quickly shout out what sort of pain you might find in something like the right hypochondrium on the upper right side. Yeah. Yeah. So, yeah, you can get biliary colic is a, is a very common one. College cystitis. Um, basically everything involving the biliary tree hepatitis, well done Tunisia. Um, you can even get pneumonia as well in the right, upper right hypochondria, a hypochondriac region. Um, what about the epigastrium? What sort of pain would you expect in the, what sort of conditions would you expect? Presenting with pain in the epigastrium? Yep, gastritis. Basically, most of the ulcers present in the epigastrium. Pancreatitis presents with epigastric pain as well. Radiating to the back guard presents with the burning pain in the epigastrium and ACS acs can present in the epigastrium as well. So, what about the left? Yep. Am I in the epigastrium? Yeah. Correct. So, in the left, it's mainly things to do with the spleen. So it can be splenic abscesses or splenic ruptures, but on the left it's, or, or even pneumonia, you can have pneumonia on, on both sides. Yeah. Well done by. Yes, spleen stuff. Correct. Um, now what about the right flank? What sort of things can present with pain in the right flank? Yep, pyelonephritis, renal colic kidney stones. Yeah. Well done. A lot of the kidney stuff being mainly mainly kidney stuff. Um, urinary tract infections. I think that would more present superpubic. Um, because urinary tract infections tend to involve cystitis, not really pyelonephritis. Um, but yeah. It's all the kidney stuff. Essentially. Polycystic kidney disease can present with pain in there as well. So, now, what about umbilical and sort of diffuse abdominal pain? What would you expect to cost me to cost those? Yes. Very good. Small bowel obstruction, up, gastroenteritis, well done. Um, peritonitis as well. So, if you've got like a preparation and it's affecting your entire peritoneum, then you'll get umbilical pain. Yep, appendicitis. Well done. Um, We'll talk more about appendicitis. Yeah, appendicitis. Early stage. Yeah. Correct. Ischemic bowel presents with refuse pain, obstruction and a ruptured triple A. Don't forget about that. Ruptured triple A can present with umbilical pain as well that radiates to the back. Very good I B S as well. And I B D left flank is the same thing as the right flank. It's all the renal stuff. Um Right iliac fossa, what kind of things can cause pain in the right iliac? Uh, well done ectopic pregnancy. Yep. Very good. Very important thing not to miss what else is in the right iliac fossa, volvulus. Yeah. Yeah. Oh, so was obsessed. That's a rogue one. But yeah, good late stage appendicitis. Correct. Very well done. Um The ovaries are there as well. So don't forget something like, you know, very interscience. Very good George. Yep. Very interaction. Well done. Um So I mentioned renal colic in the right flank. If the stone progresses down into the ureter, sometimes it can present in the right iliac fossa as well. But I think the main things in the right iliac fossa are things like appendicitis, ectopic pregnancy, uh inguinal hernias as well if they're strangulated. Um Chron's can present in the right iliac fossa as well as well as ovarian torsion. Okay. Well done. Now, things in the super pubic region. What causes pain there? Yeah. Ovarian cyst rupture again tends to be more on the right or left iliac fossa. Yep, urinary retention can cause pain in the super pubic region. Well done. Um UTI S as well. Super pubic region. Yep, cystitis. Yeah, family inguinal hernias. Yep. Again, they tend to be right or left um right or left iliac fossa is, but they're not specifically very good. Yep, P I D P I D definitely can cause super pubic pain. Well done. Very good. Um gastroenteritis can actually cause super pubic pain as well. Again, it's quite, it can be quite diffuse gastroenteritis, urinary retention. Yeah. Very good endometriosis. Don't forget that that can prevent, that can present super pubic pain as well. And P I D well done, well done. Um left iliac fossa is mainly the same thing as the right iliac fossa except appendicitis. Uh and you can get diverticulitis and all sort of colitis as well. That's fine. Ok. Again, you'll, you'll have this in the slides when I send it to you, but well done. So this is basically just an overview of all the things you can get in general surgery, uh, and abdo pain. There's a lot to it. There's a mixture of like gastro stuff and general surgery stuff, but I don't think you need to know sort of like any other conditions outside of this. Um, yeah, so let's move on. I'm going to have you as well. Okay. So, does anyone know what the difference is between guarding and rebound tenderness? You know, when you're doing gastro examination, your palpating, they always say, oh, look for guarding and rebound tenderness. But, but what, what, what does that actually mean? So what is guarding? Well, I'm just gonna, I'm just gonna tell you anyway. So guarding is basically there's two types, there's voluntary and involuntary guarding. So, voluntary guarding is when um uh yeah, well done. Sabina. So, voluntary guarding is when patient tenses their abdominal muscles um in preparation for pain when someone is palpating. So that may not be a sign of puritanism in itself. Okay. Um Involuntary guarding is when palpating actually causes the pain and rigidity. And this is what tends to be caused by parietal peritoneum, uh inflammation essentially. Okay. So if there's inflammation of the parietal peritoneum that causes involuntary guarding also called rigidity. So things like preparations that cause abdominal contents to leak into the peritoneum and um irritate, the peritoneum can cause guarding and rigidity. Um like a rupture, appendicitis can cause the same thing as well. So what about rebound tenderness? So, rebound tenderness is basically, when, after you do deep palpations in the pain only comes after you swiftly remove your hand after palpating. So that's rebound tenderness and it points to the same thing as involuntary guarding. Um It's inflammation and irritation of the parietal peritoneum. Okay. Now, I keep saying parietal peritoneum because inflammation of visceral peritoneum will not cause the same thing is only parietal peritoneum that causes this because of the nerve endings. Uh There are more sensitive to pain if you remember, visceral peritoneum tends to be more referred pain or it tends to be more generalized pain and not, not sort of like a very localized pain. So it's parietal peritoneum inflammation that causes the localized pain and that causes guarding rigidity and rebound tenderness. Okay. Uh Yeah. Yeah, we've talked about that. Okay. Now we've gone through all that. Let's start with, let's actually start with the question. So let's start with question one. So this one should be pretty quick. I'll give you guys about 60 seconds. Mhm. All right. 10 more seconds. Just have an answer. Mm. Oh Can you not see the pole? Uh Okay. Well, um let's see. Okay. Never mind, Sabina. If you can't see the second poll in question to just let me know. Okay. I'm just going to stop the pole right now. Um Okay. Um Okay. All right. So well done. Um The answer was a pregnancy test. Okay. So in any patient that presents with abdominal pain, if she's female of child bearing age, always, always do a pregnancy test. And why, why, why, why are we doing a pregnancy test in this case? So what are we ruling out with the pregnancy test? Yeah. So you rule out an ectopic pregnancy with a, with a pregnancy test. So any female presenting with uh any, any female of child bearing age presenting with abdominal pain, even if they don't say they haven't even, even if they deny being sexually active, always just do a pregnancy test because they could be lying. They could, they could have not known, who knows. Like you can't really, you can't really put people's trust, people's words. Nowadays, you always always do a pregnancy test. It's so easy to do is literally just like a urine, like a urine dip and it rules out a very important condition that can be life threatening. So women of childbearing age presenting with abdominal pain just do a pregnancy test. That's it. Um Okay. So she uh so she has clinical evidence of peritonitis as well. And the reason is because it could be a ruptured ectopic, which would be um something like quite life threatening as well. So they would need a Salpingo Oophorectomy for this for this case. Okay. So that's what they'll need. So, always do a pregnancy test and ultrasound abdomen, not a bad shout, but you will always do a pregnancy test first. And the question is specifically asking what you should do next. Okay. Um, what the other possible differentials for this lady that you guys can think of? Well, it can be anything like an ovarian torsion in. Um, it could be, yeah, it could be. Chron's ruptured ovarian cysts. Yeah. Um, renal colic, you see? Yeah. All, all decent differentials. Um. Right. Yeah. Renal colic and also critical like this wouldn't be, wouldn't be very, very high up in your differentials in this case simply because they like the symptoms for it. But yeah, keep point, always do a pregnancy test in a female patient of child bearing age, well done. Right. Question too. So, Sabina, I hope you can see the pulse system. Yeah. Yeah. P I D 100%. You can definitely get P I D as well. No, no worries. All right. 50 seconds. Okay. Five more seconds. Any last answers. All right. So the answer to this one, uh, is a appendicitis. Okay. So, if we go through the history, it's a two day history of lower abdominal pain. Now, they didn't specify where exactly where in the lower abdomen. So that makes it a little tough for us. She complains of nausea and vomiting, which is common in appendicitis and she has not opened her bowels for 24 hours now, just because someone hasn't opened their bowels for 24 hours doesn't mean it's constipation. Okay. Um, because some people just go to the toilet maybe once a day. So 24 hours if they haven't opened the bowels is not necessarily a sign of constipation. She's got mild dysuria okay, which is um, can be possible in appendicitis and it might make you think, ok, she might have a uti but if you go down the question, the urine dipstick is negative. Okay. Urine urinary pregnancy test is negative as well. So that rules out an ectopic as well. So urinary tract infection and topics have been ruled out. Now, what is Middleschmertz? The Middleschmertz is mid ovulation, pain or mid cycle. Pain is pain caused by ovulation and her last menstrual period was 21 days ago. Again, they didn't exactly mention how long her menstrual cycle is, but I guess we can assume that it's a 30 day cycle in which it can't be Middleschmertz because Middleschmertz pain will be caused at 14 days. So if her last menstrual period was 14 days ago, then it could be Middleschmertz diverticulitis. She's a little young to have diverticulitis, which is why this wouldn't really be the best case or the most likely diagnosis. So that leaves us with appendicitis as well. Okay. Uh Yeah, yeah, we've talked about that. Okay. Alright. So appendicitis is basically inflammation of your appendix. Your appendix is basically just this extra piece hanging on your cecum. So your small bowel connects to your large bowel through a part of your large bowel called the cecum. And then there's this appendage called the appendix. So when fecal matter gets stuck in between the lumen of the appendix. It causes gut flora to multiply within the appendix and that causes it to be inflamed. Okay. So that's basically appendicitis. I got this slide from osmosis, which is a very good website. I highly recommend it. Um Right. So, symptoms of appendicitis. Um How does the pain classically present? Can someone tell me in the chat? I've seen it a few times in A and E as well? I didn't think it would be that, that it can present with a lot of ways, but sometimes it can present classically like this. Yeah. Yeah, it's periumbilical and then it moves to the right lower abdomen. Does anyone know why that happens? So if you're, if you're, if you're wondering why that happens is because when the appendix is first sort of inflamed, it's the visceral pleura that's affected. So that's referred pain and that refers painted umbilicus, but as it gets more and more inflamed, it starts affecting the parietal pleura and when it starts affecting the parietal pleura, that's when the pain gets localized and that's why the pain moves the right lower quadrant if that makes sense. So, one of the surgeons told me this and, and it, and it sort of made sense when, when he told me. So. So hopefully, hopefully that makes sense to you guys as well. Okay. So, paraumbilical pain which then migrates to regulate fossa, pain is worse on coughing and movement, nausea and vomiting. Common and you can get mild, a mild fever as well. Okay in appendicitis. Now, there's a specific sign to appendicitis. Can anyone just shout out what it is in the chat? Shout out what, what's the sign and what, what the sign is. Mcburney's. I don't think it's mcburney's. I think you're thinking about mcburney's point. Yeah, mcburney's point is where appendicitis is, which is good. Uh, Albaraka. Um, but I was actually thinking of rough sing sign. So that's where if you press on the left iliac fossa, it elicits pain on the right iliac fossa. It's not mcburney's sign, it's mcburney's point. So mcburney's point is where appendicitis usually is. And I think it's two thirds, two thirds between the oasis and the pubic synthesis. I think, I think, I think that's mcburney's point. It's not mcburney's sign. So it's mcburney's point. Rough Sings sign is what I'm thinking of. Okay. So it's rafting sign where pop it in the light in the left iliac fossa, illicits pain in the right iliac fossa. So, diagnosis of appendicitis is usually clinical okay. You can, you can do some blood tests to look for race inflammatory markers. Um They tend to show high neutral fills as well. Um And always remember to do a pregnancy test and a urine dip to other causes like UTI especially in a woman of childbearing age, you wouldn't get so assigned in this case. I think so. A sign is usually for so as abscesses and that's when, if you stretch your hip or if you extend your hip that elicits the most pain. I don't think you'll get so assigned. In this case you could do, you could do. Um, but I'll double check with you. Okay. Treatment of appendicitis is just an appendicectomy with prophylactic IV antibiotics depending on how sick they are. Um, and yeah, well done. Question three as usual. 60 seconds. All right. 10 seconds. Okay. So let's move on. So we've got quite a split here. There's quite a few people sort of sharing between incarcerated and strangulated femoral hernia. So, uh the answer for this one is in fact, an incarcerated femoral hernia. Okay. So 50 or two year old woman presents to the G P with a new groin swelling and has noticed it for the last two weeks. Masses noted infra lateral to the pubic tubercle. So, if this is the pubic tubercle and it's infra lateral is always a femoral hernia and inguinal hernia is super oh medial. Okay. So it's above the pubic tubercle. If it's below and lateral to the pubic tubercle, it's a family hernia. The difference between an incarcerated hernia and a strangulated hernia is an incarcerated hernia can't be reduced, but it doesn't, there's no ischemia to it. So it doesn't hurt. Whereas a strangulated hernia can't be reduced and there's a ischemic changes. So it will hurt, it will be red, which is not, which is not the case in this question. Okay. So you can see there's no soft tissue swelling or erythema of the overlying skin. So it's just incarcerated, which is why the answer is an incarcerated femoral hernia. Okay. Um Yeah. So I've mentioned all this before. Family hernias are inferior lateral to the pubic tubercle and then incarcerated versus strangulated hernias. Okay. Contents are not reducible in an incarcerated hernia in strangulated contents are not reducible and ischemic do to cut off of blood supply, often presents with pain and everything. Uh and these are the other hernias that, that you might be able to see such as such as umbilical hernias, incisional hernias. Um So, so it's a good, it's a good, it's a good thing to sort of have an idea on what sort of hernias are out there. Okay. So that was a bit on hernias. Here we go. Another one on hernias. Question. Four again, 60 seconds. Good question. What is litters hernia? Um Let me just Google this just to make sure I don't get it wrong for you. So, Tanisha litters hernia is a hernia containing a meckel's diverticulum. And if you're not sure what a Meckel's diverticulum is, it's basically a small outpouching um in the small intestine. So it's like a diverticular, but for the small intestine and it's that outpouching, that's sort of herniating out of the abdominal, out of the abdominal wall, essentially, if that makes sense it really comes out in exams anyway. But it's good to know what literacy hernia is. Um, oh, we're running over time. All right. So I'm just going to stop it there. Um, so the answer is a direct inguinal hernia. So, it was, you, you guys got it right. It was either it was in an inguinal hernia, whether it was direct or indirect is the real question. Okay. Um, so let's go through the inguinal canal really quickly. Okay. So this is why the inguinal canal looks like I got this from geeky medics. They've got a really good page on Inguinal canal. Um And it's where I got a lot of the info from in this slide. I I uh you guys should check it out. It's really good. Um So what is the inguinal canal is basically a passageway that transmits certain structures from the abdomen to the external genitalia? Okay. Um So it's a canal that is boarded by malt. So it's muscles, um muscles, ligaments, tendons and upon neurosis. Okay. So those are the borders of the inguinal canal. Okay. So it goes from your, from your ASIS all the way down to your pubic synthesis and it's, it's available on both sides. So that's where the, that's where the inguinal canal is. Okay. So it starts in the, with the deep inguinal ring and ends at the superficial inguinal. So there's two rings um at both openings of the inguinal canal. Now, you can find a deep ring at the midpoint of the inguinal ligament between your ASIS and your pubic tubercle. Okay. So, from your ACL pubical, from your ACS to your pubic tubercle at the very midpoint, that's your deep ring and your superficial ring is above the pubic tubercle just above the pubic tubercle. So the canal itself is actually not very long. It's kind of sure it's probably about this long, I would say. okay. So what are the contents of the inguinal canal? Okay. This might be good if you, if you guys might have an interest in anatomy. So there's the ilioinguinal nerve, the genital branch of the genitofemoral nerve in females, you'll have the round ligament of the uterus and emails, you'll have the spermatic cord. Now, there are more things in the spermatic cord. If you remember, there's the arteries in the spermatic cord and as well as the, oh, I forgot what else was in the, in the spermatic port. But you guys can look that up yourself. But there's, there's, there's a, there's a whole other other thing in the spermatic cord as well. They basically have the same thing and ilioinguinal nerve as well, gentle branch of the gentle family nerve as well, but they'll have arteries going through there as well as well as the vast difference, I think. Okay. So that's basically what the inguinal canal is now. Um the difference between a direct and indirect inguinal hernia. So a hernia. What is a hernia? A hernia is basically when abdominal contents essentially um protrude through the abdominal wall. So abdominal contents can be things like fat, fatty tissue or even pieces of bowel. So that's, that's essentially what an abdominal hernia is okay. So for bowel contents or abdominal contents to protrude, it has to go through a weak spot in the abdominal wall. So in a direct inguinal hernia. So if you can imagine the inguinal canal on the posterior wall of the inguinal canal, there's a point of weakness called the hassle backs triangle. So that's usually where abdominal contents protrude through and get into the inguinal canal. Okay. So they're the abdominal contents are forced directly through a defect in the posterior wall of the inguinal canal, which is what you call it a direct inguinal hernia. Um It enters the inguinal canal through the defect, which is medial and deep media to the deep ring and further down the canal and exits through the superficial ring. Okay. So that's a direct inguinal hernia. It protrudes through the wall directly of the inguinal canal. Okay. For an indirect, it doesn't protrude through the wall. It enters through the deep ring, travels all the way through the inguinal canal and exits through the superficial ring. So that's an indirect inguinal hernia. Okay. Now, how can you tell the difference clinically in an examination um between a direct and indirect inguinal hernia? So the first thing you do if someone presents me for hernia and you know, it's an inguinal hernia because it's super medial to the pubic tubercle, you ask the patient to lie down flat. Okay. So you ask the patient to lie down flat first and then you try and reduce the hernia by applying pressure on the hernia and then you push it up all the way to the midpoint of the inguinal ligament. So now as you're pushing it up, you're pressing on the deep inguinal ring. Okay. So with the hand, press on the deep inguinal ring. What happens if so, so if it's a direct inguinal hernia, there's still a passage three for the hernia to go through. Okay. So if, if the hernia is, it's not reduced, it means it's a direct inguinal hernia. But if you're pressing on the deep in garnering and the hernia is still reduce, that means it's an indirect because you're closing the deep ring. So the hernia has no way to protrude through. But if you're pressing on the deep ring and the hernia still protrudes, that means there's access through a defect in the posterior wall, which is why it's a direct inguinal hernia. If it protrudes and if it doesn't protrude, then it's an indirect inguinal hernia. I hope that makes sense for you guys. But yeah, anyway, I've got it all written down here. Um Hopefully, that makes sense. But if not, you guys will get the slides after you're feeling the feedback forms and then you can have a read through. But, but that's basically how I, how I, I understood in going hernias. Okay. Right now. Question five, I'll give this 1 45 seconds. Oh, thank you. It takes a while to understand. It. Took me a while to understand that for sure. Right. 15 seconds. Okay. So I'm going to stop that now. So the answer is refer routinely for open repair with mesh. So from the question, we can see that he's a symptomatic, he's got, he's got a hernia that, that reduces and disappears when he's lying down and it doesn't trans illuminate. He's got no abdominal tenderness, no bruising. So why should we treat them well? It's just, it just has to do with the guidelines because if someone has an inguinal hernia, the chances of it becoming incarcerated and strangulated actually increase exponentially. So, if you find an incidental inguinal hernia, that's a symptomatic, you still refer them for treatment and in this case, it will be an open repair with a mesh. Okay. So any inguinal hernia, it doesn't matter at what age. Um, you will always refer for, you always refer routinely for repair. So that's an elective elective surgery, uh for repair of mesh. Okay. Um Yeah, the current guidelines recommend treatment even if patient is asymptomatic for unilateral hernias and elective open repair with mesh is recommended and for bilateral hernias and they use laproscopic approach. Okay. So they use a mesh to make sure that the risk of recurrence is less. So, basically what they do is they push the bowel in, they fix the abdominal wine and they put a mesh there. Um, so there's different types of meshes. Some meshes are absorbable. Some rashes aren't. Um, but they greatly, they greatly reduce the risk of recurrence of inguinal hernias. They always use mesh nowadays. Okay. No question. Six. Okay. 45 seconds from here. Right. 10 seconds. Okay. So there's an equal split here. Quite a few of you went for acute pancreatitis and small bowel obstruction. Uh, sadly, the answer is small bowel obstruction. Now, I understand why you might think this is q pancreatitis. They can present the same way, you know, for meeting central abdominal pain and you do have a raised Emily's. But if you guys remember what the cut off for acute pancreatitis was for the raised Emily's minimum, it had to be three times the upper limit of Emily's. So his amylase is just below what it would be diagnostic for acute pancreatitis. Okay. Another key in the, in the, in the, in the question is that she did not pass any wind or feces in the last 12 hours. Now, I did mention that if they didn't pass feces for up to 24 hours, it can be normal, but in this case, she did not pass any wind. So it's wind and feces, that's when, you know, it's a complete obstruction. Something is obstructing the wind from, from, from, from passing wind. Okay. She's also got a past medical history of a partial small bowel resection and we'll, we'll, we'll discuss this in another question that that sort of involves this. Okay. But basically all this points towards a small bowel obstruction. All right. Um, raised white cell counts, bilirubin is normal that that's basically pointing away from any hepatobiliary cause of the vomiting. Okay. Um, so that's why this is a small bowel obstruction in this case. Um, the key thing as I mentioned before, the wind and the feces, um, within 12 hours. Okay. Um Right. So we've talked about this. You have not passing it for 12 hours. Yeah, emulates has to be three times the upper limit. Um Okay. So how do we differentiate between a large and small bowel obstruction? Can anyone tell me I'll give you guys a few minutes? Yeah, I was going for, yeah, you can do an abdominal X ray. They'll show dilation of different parts of the bowel. Um, but clinically you have bills vomiting. Um And yeah, fecal vomiting indicates large bowel obstruction, but fecal vomiting in large bowel obstruction is an extremely late sign for someone just presenting with abdominal pain very acutely like two days ago. Um, and then already having vomiting is more towards small bowel obstruction. It would take weeks or even months before a large bowel. Well, not months. It'll take like more than a few days for bowel obstruction, large bowel obstruction to actually present with vomiting. If it's a small bowel obstruction, vomiting is, is quite an early sign. Okay. Um, yep. Feels vomiting. Vomiting is common. Yeah, let's sign another part of the, another part of the history is key, but we will discuss it in the next question. Yep. Okay. This is the one, so question seven, this one should be quite quick. So I'll give this about maybe 30 seconds from here. All right, five seconds. So it's a really quick one, no one this session to run to over time. Okay. So let's call it there. Um, I'm very well done. A lot of you got the answer and the answer is adhesions. So from the history, we can see that the patient has not passed through for the past three days. Um, and doesn't recall passing any wind. Uh, so that's a red as like a red flag right there. She's not passing any wind. Um, she's had a laparotomy seven years ago for appendicitis, which means she's had abdominal surgery before. So when you, when someone has had abdominal surgery before it puts them at higher risk or something called adhesions where basically, um, there's like scar tissue within the, within the abdominal wall that sort of sticks together, uh, and causes, uh, sort of like an obstruction for the small bowel. And it's, um, it's one of the main causes is the same thing that happened to the last question, the patient had an operation beforehand and adhesions caused the small bowel obstruction as well. So just remember from this question, adhesions is one of the most, if not the most common cause of small bowel obstructions. If, if that's what I want you to take away from this question. Okay. So just a bit on bowel obstruction, um small bowel obstructions, you get diffuse central abdominal pain, nausea, vomiting, constipation, like flatulence from the extension pink ling bowel sounds on auscultation. Quite classic presentation as well on examination causes main causes adhesions and one of you answered hernias as well, which will not be the case in the previous question. Can adhesions be prevented? I think that depends mainly on the expertise of the surgeon itself. So really good surgeons can sort of lower the chances of adhesions. But I'll quickly have a look if there's any way to prevent adhesions, I don't think there is, but I'll get back to you, Aishah. Um The other most common cause of small bowel obstruction is hernias. Yeah. Right. Quickly. Oh, sorry, Josh, I think, I believe adhesions. If you do it laparoscopically, then you're opening up less of the abdomen. So there's less like air exposure. So I believe that's how you reduce the risk of it. Um as opposed to doing like an open operation. Um But yeah, I think that's my understanding of it, but I might be wrong. All right. Thanks, Josh. Yep. So that makes sense. Doing it laparoscopically means there's just, it's just less invasive. So you mess around less in the abdomen and there's less adhesions. Now, for the large bowel symptoms are roughly the same. Um, but nausea and vomiting is a late sign. Um And then for large bowel obstructions, you will also look for other features like etiology. So, colon cancer is a common cause of large bowel obstruction. So you would look for weight loss and rectal bleeding as well. Um Other things like diverticulitis can also cause large bowel obstruction. So you might, you might be more cautious in someone who's more elderly. Okay. For large bowel obstruction causes include tumor, volvulus and the diverticulitis. Again, it's difficult to clinically differentiate sort of the causes. So, one of the best ways is just through imaging in this case and then you'll, you'll clearly see a volvulus if, if you, if you do imaging on someone with a large bowel obstruction, okay. So hopefully that makes sense. Um So here's a few more tips, things think about when a patient presenting with obstruction. So, consider the clinical context in every situation, okay. So they might be having an obstruction but always considered their age, their past medical history. If they've had surgeries before in the past, are they elderly? Do they smoke that they have a history of bowel cancer? Because the etiology of a bowel obstruction can be so varied. It can be, it can be a hernia, it can be adhesions. It can be a tumor can be a volvulus. So, always consider the clinical context of it okay. Uh, I've said this, yeah. Oh, a serious complication of obstruction is perforation. So they can have symptoms of obstruction, but when you palpate they'll get the garden and the rebound tenderness, that's when your, you worry that the obstruction might have perforated. So you can consider investigations for perforations which we'll get into in the next question's okay. So, hopefully that makes sense on bowel obstructions now. Question. Right. All right. 45 seconds from here. All right. Five seconds. Okay. Very well done. Abdominal CT. Yep. For the patient here. Nausea and vomiting high pitch bowel sounds, tinkling, bowel sounds increasing abdominal pain and she's had abdominal surgery for a ruptured appendix. Classic question, classic symptoms for small bowel obstruction. And with the question is basically asking, what is the definitive diagnostic investigation for any bowel obstruction? Definitive diagnostic investigation is an abdominal ct. However, would, can, okay, never mind. I'll get, I'll get to that. Just, just know that definitive diagnostic investigation is an abdominal ct. Okay. Um, we'll talk a bit more about, about this later on. Let's just go to the next question. First 60 seconds or maybe even less. I hope you guys can see the X ray. It is pretty small. I probably should have made it bigger. All right. Five more seconds. Yep. Well, done well done. The answer is free air in the abdomen. And if you can see right below both diaphragms, um, there's pockets of air and there shouldn't be pockets of air underneath the diaphragm. A raised right hemidiaphragm. I think it is meant to be, I think the right hemidiaphragm is meant to be slightly raised because the liver is there. So the liver actually pushes the diaphragm up. So the right hemidiaphragm is meant to be slightly raised. Um, there is a bit of shadowing in the right lobe of the pneumonia, but, uh, right lobe of the lung, but I don't think there's a pneumonia. There's no signs of any, um, authorized and there's no signs of a scapula fracture. It's basically a pneumo peritoneum going on. You can see the air underneath the thin, the thin diaphragms on both sides and there's like all the air between, between the diaphragms and the actual ab abdomen beneath it. Okay. So this guy has probably got something like a perforation causing air to leak into the, into the abdominal space. That's why he's got a new more peritoneum, okay free and the abdomen. Now, we, we had two questions, uh, sort of on investigations in bowel obstruction. So, despite abdominal ct being definitive sort of diagnostic investigation and abdominal x rays still commonly use first line for both small and large bowel obstruction, you can tell a lot and it can rule out a lot of other stuff so people still do abdominal x rays first and then. Oh, okay. Before that on x rays, what diameters of sections of bowel is a sign of obstruction? So small bowel, for example, small bowel, for example, what diameter would, would you think? Oh, this might be an obstruction. You can usually measure it on an X ray. Yeah, it's more than three cm. So small bowel. More than three cm. What about large bowel? You remember there's 33 areas of the bowel? Yeah. Is that, is that it, it's 10 to 12 is, yeah, it's, it's about, it's about 10 to 12 for the Cecum Sabina instead of nine, more than eight in the ascending and then more than 6.5 in the rectal sigmoid. But again, this is just for, for your, for your knowledge. Okay. Yeah. 369 rule. You can use the 369 before for the, for the large bowel. Okay. Oh, sorry for the small bowel, large bowel and cecum. Sorry, that's what I meant. So 369 rule is small bowel, three large bowel, six cecum nine. Okay. So, yeah, let me show you got that right. Um Definitive investigation is a CT scan. So a CT scan can accurately show the location of the obstruction as well as the etiology. So if it's something like volvulus, you can see clearly if it's something like a tumor, you can see it clearly as well. Okay. Um, so an abdominal X ray or a um or a standing chest that or an upright chest X ray can also identify perforations and free air in the abdomen. So what are the signs of free air in the abdomen that you can see on either a chest X ray or an abdominal X ray if anyone can tell me on the chat. Yeah. Well done. Football sign. Couple a sign. I don't actually have that written down, but those are signs for free air in the abdomen. Well done. Yeah, regular sign. Um So no more peritoneum, regular sign. Um Erin diaphragm is, yeah, Erin Diaphragm is new peritoneum. Um And there's something called a lucent liver sign. Um So lucent liver sign means the liver isn't as opaque as it should be because there's a right in front of the liver essentially. And regular sign is basically when you can see both edges of the bowel. So you on a normal X ray, you only see one edge of the bowel. But if there's a rare is there's free air in the abdomen, you can see both edges of the, of the bowel and you can see both sides of the ball of the small bowel wall in regular sign on the right and then you can see new more peritoneum on the left. Um But well done Tunisia for the football signing, couple assigned. Those are, those are also signs for, for everything, the abdomen. Very good. Now, question 10. Now, I don't have all 20 questions here. Um We've only, we've only got until question 16. So hopefully it won't overrun for too much 45 seconds from here. Okay. Alright. 10 more seconds. Okay. So the answer in this case is any CG? All right. So the patient, yes, he's presenting with epigastric pain. He's got sweating, nausea and breathlessness and the question is asking what is the most appropriate initial investigation? So I know A C S can commonly, you know, you everyone knows how it commonly presents is central crushing, chest pain, radiating to the jaw and the left arm. But ACS can present in a lot of ways, especially with, in someone who may have diabetes in the elderly, in women, they can present very differently. Acs and you should always, always rule it out. So the point of the point of me putting this question in it is to not just focus on general surgery stuff, you still need to do your basics, okay. Um So in this case, he's sweating his nauseous, he's got epigastric pain and he's got a history of hypertension and raise cholesterol. So you've always got sort of heart problems and A C S in the back of your mind and the initial investigation should always be an E C G in this case, okay, because ACS can present with epigastric pain as well. Yeah, he's got risk factors for pcs. Uh sweating, nausea and breathlessness. Also point towards A C S. Now, all the other investigations would be appropriate, but it would not be first line in this case, you would still do an E C G. Okay. All right. Question 11. So Josh has just put in the feedback form in the chat if any of you have to leave by eight. Thank you so much for staying. Uh, I'm sorry, it's overrunning. We've got about five questions left. But if you could fill in the feedback form before you go, we would greatly, greatly appreciate it. Okay, let's say for 30 seconds from here. 10 seconds. Okay. All right. Let's move on. Now. It's been split between barium swallow and a two week wait referral essentially. Um And they're both good, good, good choices. But the answer in this case would be a to wait, wait, referral for an upper gi endoscopy. Now, the thing to remember from this question is any patient presenting for the first time with any sort of dysphagia will always get sent for a two week wait, referral. Okay. They'll always always get sent for a two week wait referral, regardless of what symptoms they have. Be it, fluids or bit liquids or solids or just solids or just liquids. It doesn't matter as long as they've got dysphagia, they always get sent for for an urgent upper gi or an urgent gastroscopy under a two week wait referrals. Okay. This patient also has quite an extensive smoking history. Uh they didn't actually say how the dysphagia has progressed. So that's, that's what they missed in this question. That's something that you kind of have to engage yourself. Um Pain on swallowing is also quite a big clue that it might be something more sinister. Okay. Pain on swallowing or dine aphasia. Um Yeah. So hopefully that makes sense. Any patient with dysphagia um always just urgent reform to wait, urgent to wait reform. Okay. Unless, unless it's something like dysphasia due to stroke or my senior graph is for example, then we know the cause, you know the cause. Okay. Um That's a different story. But if it's, if it's spontaneous dysphasia, then yes, it's a two week referral. Okay. So all patient's presenting with dysphasia, recording upper gi endoscopy, other test should be done. It could very bloods and a barium swallow. But this, this should not delay the endoscopy. Okay. You do do a barium swallow but you should not delay the endoscopy. Other symptoms that meet the two week weight criteria. Patient's with an abdominal mass consistent with stomach cancer patients' age 55 0, 55 over with weight loss and upper abdomen, pain reflux or dyspepsia. Okay. So you'll, I think in G P you'll, you'll see a lot of this. There's a lot of referrals for, for patient's with Dyspepsia especially, right? So hopefully that makes sense. Not question. 12. Oops. Oh, wait, did I, can you guys see the pole for question 12. Okay. Yeah. Okay. 60 seconds. Okay. We've just got five questions from here. I'll try and go slightly quicker. Okay. Mhm. Mhm. Mhm. Okay. 15 seconds. Oh, wait what? Okay. All right. Never mind. I think, I think something's wrong with my, something's been something's wrong with my internet. Okay. Never mind. Ok. So yes, for this one is Eckel Asia. Okay. Um, now the key in this question is presents with three month history of dysphasia, affecting both foods and liquids from the start. So from the start is the key is the key term here along with symptoms of heartburn. Okay. If it's something like Asafa jal cancer or a benign stricture usually start with solids and then slowly progresses to liquids. But in this case, it's both food and liquids from the start. So he's having this, this female patient has been having this aphasia of both food and liquid from the start. So it's not something growing in there. It's something wrong with the motility of the muscles in the esophagus, which is why the answer in this case is echo easy. Okay. So you have to look for these, for these small things that point towards one or the other. So hopefully that makes sense. Uh Next. Yeah. Yeah, we talked about this. Yeah. So Accolate Asia is the failure of relaxation of the lower esophageal sphincter. Okay. Um As I mentioned before, esophageal cancer would typically present with dysphasia that starts with solids and later process it progresses to liquids. Um Pharyngeal pouch would classically have gurgling sounds and bad breath. Okay. Um, esophageal strictures. Um they can present the same as a esophageal cancers. They start with solids and then progress to liquids. Okay. Question 13. Let's see, 30 seconds from here. Why are there symptoms of heartburn? Okay. So, um, so in ankle asia, there's something wrong with the motility of the lower esophageal sphincter. So sometimes it can be difficult to open, which is why you get the dysphasia and sometimes it can be difficult to close, which is why sometimes gastric contents can go up through the sphincter and into your esophagus, which is why you get heartburn symptoms. So it's basically just dysfunction of the lower esophageal sphincter. So it works both ways. So it has difficulty contracting and it has difficulty opening essentially. So you can get symptoms both dysphasia and heartburn or at least that's what I think. But I will reconfirm with you. I think that's, that's what causes the heartburn if that makes sense. Okay. 10 more seconds, get your answers in. Let's okay. All right. Another one divided. So cancer in this case is a sulfa jal cancer. Okay. So the reason it's esophageal cancer, if you see the prompt, it's been getting progressively worse than dysphagia for three and four months and it occurs mostly with foods such as bread and meat and it's associated with some odynophagia. So I mentioned before odynophagia heavily associated with a soft Egil cancer. Okay. And he's got no problems drinking fluids, which you can sort of rule out Eckel Asia with that. Okay. Um, although there's no history of weight loss and anorexia, they did perform a barium swallow and from the barium swallow, you can see that the, the narrowing is an irregular narrowing, which means there's a growth there somewhere. Okay. So, presenting with dysphasia is proficiency, getting worse. Um Ankle asia would typically present with an expanded esophagus, a fluid level and a bird's big appearance. So, on the left here is um a barium swallow of a possible tumor. And on the right is a barium swallow of Eckel Asia. So you can see it's smooth and then it forms this bird's beak appearance because the esophageal sphincter is just closed shut like this. It's not irregular as if there was a growth there. It's just close shut and you can see a fluid level as well at the top. Okay. So that's the difference between um and esophageal cancer, barium swallow on the left and then ankle Asia barium swallow on the right. Okay. So hopefully you can see the difference there. Right now, I've put a list of like the causes of dysphasia and there's neuro muscular causes obstructive causes and motility, dysfunction causes. I'm not going to go through this. You can have a kind of a look at this once, once you get the slides, okay. Um, now we're going to touch a bit about pre operative sort of preparation for patient's before they go into surgery. It won't take long, I promise. So, what are the things you have to consider, um, for the patient before they go into surgery? And when I say things, I mean, like, what, what do you have to, like, prepare or what do you have to, like, think about before they go under the knife if you guys can just pop in the chat? Very good anticoagulants. That's one of them. What else can you think about? Yeah, good. There's a bunch of other meds you need to think about. Yeah, informed consent. Very good. So, when you're going through surgery, let's say it's quite a big surgery. You might not be able to, yeah. Neil by mouth. Very good. You might, let's say you go into surgery and you might not be able to walk for a few days. What might you need to think about? You know, you're gonna be sitting pretty still. Yeah. Vte prophylaxis. Yeah. Yeah. Yeah. Very good co morbidities. Yeah, you do need, and that's called the A S A grade. Okay. So they will need to calculate the A S A grade of the patient, uh, cardiovascular reserve. Yeah. Very good, very good. Um, allergies. Yep. So, the things that I would like to focus on in this session would be DVT prophylaxis. So, VTE you do, everyone goes through A V T risk assessment and then they always get sub cut delta parent or enoxaparin essentially. Okay. Yep. Social care needs very good, very holistic view, infection prevention. So some surgeries require prophylactic antibiotics. So like contaminated surgeries involving open bowels or prosthesis, those will, those will require prophylactic antibiotics. Okay. Near by mouth. Before surgery. I asked, who mentioned it before? The uh Yeah, by I mentioned it before, uh near by mouth before surgeries to prevent aspiration. Very good. Um, di people on diabetes and insulin. That's, that's quite a heavy topic as well that I won't be covering today. But there's a lot of resources out there for diabetes and insulin and then specific medications. So what are some of the important medications we need to think about? Oh, man, I accidentally give you guys the answer, but I was going to ask you guys this, but basically you need to think about anticoagulants, C O C P and long term cortical steroids. Okay. So these are the 33 specific medications you might need to think about. Um, quick question. Why do we need to think about the C O C P? Why is it a bad thing if someone's on C O C P and they're going through surgery? Yeah, Beatty. Right. So you need to stop C O C P before, before surgery because of a V T risk you don't want, you know, it is, it is a slightly increased risk. But we, we we, we should definitely stop it. Okay. All right. Question 14. We've only got three questions from here. It'll be quick. This one will be quick. Right. You've got 25 seconds. All right. Five seconds. Time's up. Time's up. Okay. So it's four weeks. Yeah. So this is, um, this is just the current guidance. Uh, if someone is on C O C P, you should stop their C O C P four weeks prior to the prior to the surgery to prevent clot formation. Okay. Um All right. Question 15. I'll give you guys about 40 seconds for this one. Mhm Okay. 10 seconds. All right. Well done. Um majority of you got this. Um you give hydrocortisone in this case. Okay. So from the prompt, 68 year old woman presenting to the orthopedic surgery for an elective knee replacement. Now, her history she's got, she's been treated for an episode of giant cell are, are try tiss that occurred three months ago with 20 mg of prednisoLONE daily. So she's on long term cortical steroids. Okay. So when she's on long term cortical steroids, what happens is it affects the sensitivity of your hypothalamic pituitary adrenal axis. So, when you're given external steroids all the time, it dampens the sensitivity and the response of the adrenal glands. So, when you're under periods of intense stress like surgery, your adrenals fail to produce the necessary glucocorticoids or the necessary steroids to cope with stress. So that's why you give them IV hydrocortisone during surgery for someone who's on long term steroids. Now, what do you mean by long term steroids? How do you quantify long term steroids? Well, general consensus says it's 30 days of steroids or more. So, if you're on, say 10 mg of prednisoLONE or 20 mg of prednisoLONE once daily for at least 30 days, that's already considered long term steroids. Okay. Um, and then you might want to consider sort of IV hydrocortisone just to make sure they don't go into like an Addisonian crisis during surgery. Okay. Um Yep, we've discussed that. Okay. So this is a general overview of medications preop um sort of when to stop, do X when to stop Warfarin, you can use vitamin K for Warfarin C O C P and you can, you guys can have a read of this once, once, once you get the slides. All right. Last question guys. Last question and then we are done. All right, 25 seconds from here. Okay. Let's call it. The answer is, oh, the answer is wait for two hours. Okay. Um So patient is going in for surgery. A simple, simple lap, laparoscopic cholecystectomy, under general anesthesia. Um, blood tests are normal. She's declared fit for surgery, but just before induction of anesthesia, she tells you she's had a cup of fruit juice without pulp coming to theater. So cup of fruit juice without pulp counts as clear fluids. And if you remember the guidelines is no clear fluids, two hours before surgery and no food or non clear fluids, six hours before surgery. Ok. So in this case, she's had clear fluids. So she actually needs to wait two hours before she can, she can have surgery. Why? Okay. I know. I know. Okay. Okay. So why, why, why do we, why do you, um, did I say that? Okay, never mind. Anyway, why, why would someone be kept near by mouth, uh, during surgery? Why, why, why do we need to keep someone nearby mark during surgery? I think one of you has mentioned it, but we'll, we'll just ask again. Yeah, aspiration risk. Exactly. So, it is quite important to make sure patients are nailed by mouth. Okay. Which is why, for example, when someone comes in with an acute abdomen there in a lot of pain and you might think they need, uh, an emergency surgery, for example, they come into the emergency department, um, then you always keep them nil by mouth from the start. Okay? If you don't keep them nil by mouth and the emergency surgeons come and see you, they'll, they'll give you, they'll give you a stern talking to on why you didn't keep them nil by mouth if you know they're going to need emergency surgery. So if someone comes into the emergency department and they, they, you think they might need emergency surgery, just, just keep them healed by mouth from the start. Okay. That will save you a lot of trouble. Okay. So reduce reflux and aspiration. No clear fluids. Yep. Yep. You can read all this. Um, once uh once you get the slides. So that's the last question. Thank you so much guys. Uh Sorry, it overrun slightly. Um Please please fill in the feedback forms. I really hope that was helpful for all of you. Um If there's any questions you can email either Josh or me regarding this session. Um After you fill in the feedback forms, I'll send the slides out to everyone who filled it in. I'll stay back for a few minutes if you guys have any questions. Um It could be regarding the slides regarding Union General, any other things you just want to ask? Um But yeah, thank you so much for coming again. I'm really sorry. It overran slightly for about 15 minutes. Um But yeah, you're free to go. No worries. Thank you for coming. Thank you so much for attending. Oh, I love to hear that. I'm pretty sure you all will. No problem. No problem. All right. If no one has any questions, I think we're okay to end it here. Okay. If you haven't filled in the fit, you haven't filled in the feedback forms yet, please do. Uh I'm pretty sure they would have sent you an email as well. Um If you, if you register through email, but thank you so much for coming. Do join us this Thursday for another session on neurosurgery. Um We're just going to focus on sort of the important stuff that will come up for exams. Um You know, a lot of the hemorrhages subarachnoid subdural hemorrhage is um and yeah, it should be another good session. Thank you so much for coming guys. Have a good evening.