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I'm ready. Square apologies, I believe. What? Stop the rain. Um, none of you suggested acute diverticulitis, but I am. When I thought really hard about it, I thought that that was definitely the lecture that I wanted to give next on. The reason for that is that there are lots of kind of interesting similarities between diverticulitis on appendicitis. And I make absolutely no apology for the fact that we're going to use, um, similar slides because I want you to think about their similarities between appendicitis and diverticuli. XYZ because I did not really help you learning. So I'm a colorectal surgeon on the colon is our friend on We love the code on the colon is one of the principal organs of the GI tract, and you can see here in slot in the image A that it is weak. We call the colon. It's the large bowel, and it has found inside the abdominal cavity on it runs away around from the from the right eye, like foster, and that's in. And that's the cecum. It runs all the way up to the hepatic flexure across it in the transverse colon and then turns down was in there, less of a chord in as the splint. It fracture down towards the descending colon on the descending colon continues as the sigmoid colon signaling you s shaped and that's consistent of bends in the left eyelid. Foster in the pelvis and then, that continues, is the rectum, and the anal Canal on the colon has a lot of different functions. The most important functions are for the absorption of water and nutrients for the metabolism, off amino acids for the propulsion of stool on but the storage of stool for expulsion through the rectum. So there's four principal roles of the colon. Um, and you can see here that it's sort of characterized by this big, thick, big floppy tube on that has these very characteristic tenia, which you can just see here. Are these muscular the's sort of muscular parts of the colon on it? Zensa accurate health store folds here, so it's got a kind of characteristic. We'll look to it now. We talked a little bit already. You can have a look here in in the image, be about some of the parts of the colon, but that that those are actually pretty important to have a little bit about, and I think it's kind of hard when you're a medical student to understand, to really visualize things in your mind. But I'd like really like this picture because it not only gives you an idea of some of the link tell Union Mine's I have been kind of things are, but it also shows you something that's really important here. And it shows you here the different wits of the different parts of the coat on. So the cecum is the widest part of the colon. Eight centimeters. And that's kind of interesting, because if you imagine when you're blowing something up in it's Super Wife, and it's wide that when you're blowing up in the walk, it's thinner and thinner and thinner. That is because it's why this is the most likely site for about perforation. So if there's a blockage in the colon, um, meaning that all the air, gas and liquid and stool cont get out all about backtracks along because if you've got obstruction or narrowing here, it's, um, back traps along the colon. On it distends descends distends distends distends on the cecum Compare fur eight. So we're colorectal surgeons always feel in the right arm a foster here because if their patients are very tender there obstructing, they're very tender in the right eye on it. For what? We worry that that is the area where they may have a perforation. Then also here on the left hand side, down in the sigmoid coat on. You can see here the the older has said that this is the narrowest part of the colon than likely slight for obstructions. Absolutely right. And we're going to find that later on in the lecture that actually, when you get inflammation of this part of the signaling, cool and it's this signal competition often cause obstruction, which is a complication of explosives. I kind of put this side in because I know that has medical students are so much a nasty me thrown at you that we all we all kind of gloss over a little bit, and I think that actually may be on your screen is a little bit small, but I think the basket or asked me of the colon is really important to know about just a half home. It's going to be remember that the a nasty of blood supply to the tractors from the celiac axis. The cecum using Terek access on the inferior music Terry access on day thesis. Kapsis has ALS the organs of the Ford up, which is which is more approximately July tract. But the colon is supplied principally by the superior music Terek axis up to the two thirds school Sorry, up to a point about two thirds along the transverse colon on then after that point, the bowel is principally, or the colon is principally. Um ah, it's pretty supplied by the inferior mesenteric artery. Very importantly, there's this marginal Astra of Germans. Can you see that? This is our street, which goes all the way around Just the inferior board of the colon all the way around there. On that connects the superior mesenteric access to the impurities interrogates it's it. Can you see that there's this connection between the two blood supplies on? That is really, really important because that's what helps us do All of our Kalanick operations Onda take wage segments about and join them together. Because you rely on this marginal artery of Drummond to get blood supply to the colon. We take away um, but the colon isn't free of disease on diverticulae. Or this will diverticular a little protrusions or by roads in the code on. Okay, say diverticula or something that I found a little bit difficult to understand as a medical student. But is a little pouch that forms on the side of the bowel on here in image A. You can see these little diverticula a form in the bowel wall at this area here, just where the vas a rectal on the little the blood supply to the colon goes through the smooth muscle and it creates this other area of weakness. And you increased pressure within the colon. Increase pressure, a little pressure within the colon and abnormal motility of the colon. It causes these little pockets these little little little pouches, these little protrusions to form in the colon wall and you can see here on the inside. Said you look on the outside. This is a laparoscopist chur off a piece of colon and you can see on outside dissolve these little bubbles is a little grapes on the side of the colon. You see them all here? He's a little diverticular. This is a little diverticular segment. Probably the signal in colon by the Let's see these little pouches now on the inside of your doing a colonoscopy. This is what you normally see. Seeds look inside the colon, and it's a normal colon, an image we on. You can see that the colon wall is nice and regular. This is probably the transverse colon, actually, not the sigmoid, because it's quite characteristic triangle sex rate in the transverse colon. But I just wanted to show you if you've never seen the inside of a colonoscopy picture before that the colon is normal like flat and, you know, nice and but confused. But then, on the left hand side, here in image D can you see here these disease tiny little by rose these tiny little protrusions or cultures. So those are called on it diverticular. All right, um, on you can imagine that if those of you who those of you who are my lecture from last week you'll remember that the appendix orifice or appendicitis cause by blockage of dependence or positions the little opening and the appendix, and could you see that each one of these little diverticula is like a little opening like the appendix orifice, so you can imagine that diverticulitis and appendicitis have a lot of similarities. Um, Andi, I suppose I have also got this eye pulse. It put this image be in case I wanted to talk through it. And you can see this is just a little diagram off here in the left hand side of the colon, the descending and sigmoid colon you conceived a little outpouchings here on the artist is sort of colored it read to describe diverticulitis. Now there are some really interesting epidemiological nuances to diverticular disease and diverticulitis, and it's always a favorite question in exams and a favorite five. A question cause it really tests whether you're kind of interest in the subject. But diverticular disease is really, really common, and it's becoming war common with time and more common. An associate with a western diet and on a bad diet on you'd be fine diverticula OSIs in about 20% of people at the age of 40 on 60% of people at the age of 60. So for gyn colonoscopies, we found that I particularly is really, really, really, really. Commonly there are lots of different risk factors. Okay? Which are associated with diverticular. Sits being a mayor are being a male sex. Some genetic factors. There are some connective tissue disorders which our associate it with diverticular disease. But importantly, there are a lot of modifiable risk factors. So these mean lifestyle things or things that we do that patients can change to prevent them getting diverticulitis. Well, this is a a thing about, like, right now I'm gonna make this a little bit bigger because it's a bit small. My screen. I'm not sure how big it is on yours. I'm going to make it a little bit bigger so that we could see a little better. Okay, But there are lots of different things here which can cause diverticulitis. Diverticulitis will make it more likely. Peter, get diverticulitis. Now, for those of you are not sure what relative risk means for how to interpret a relative risk. If you have two groups of if you have two groups of patients those with diverticulitis and those without five securitised, if the if a factor is has has equal, it doesn't cause any difference in the two groups. You have a relative risk of one okay. If that factor has a relative risk of higher than one, it means that that factor is associate it with, in this case, diverticulitis. And if that relative risk is lower down one, it means that that factor is associate with less risk of times. Sexual urges. Okay, so we look down this table, you can see here that on a increased fiber in your diet reduces the relative risk. So therefore it it protects against diverticulitis, nuts and popcorn, another kind of high fiber things. They also produce the relative. First you see, See they're nuts is a relative risk of 0.8 on popcorn is a relative. It's a 0.2. A vegetarian diet, similarly, with juice is the risk of diverticulitis that other dietary things like a western dietary pattern on red meat, they increase the relative listen to you. See here it's above ones to the relative vescus 0.55 diet for diet pattern and red meat is 1.5 weight. I don't want you to learn a tall these relative rest. I just wanted to introduce the concept around service to you, but you can see there's different kinds of things in your diet, which which are patients, that which can make their risk of diverticular. It's higher or lower it. So high fiber diet with fiber nuts, pro popcorn vegetarian. That kind of high fiber diet is protective, whereas a relatively unhealthy diet of red meat and things like that that that actually makes upset. That's more likely other lifestyle things like your physical like patients, physical activity there, obesity and smoking. They all affect diverticulitis. So those who are not very active who are overweight on who smoke are much more like to get diverticulitis on. There also is, um, important medications, which make diabetic crisis more, uh, more likely. And it's mostly cortical steroids on down storied old medicine. So those are are some important things to know about. The other kind of interesting things is the, um is the geographical distribution off diverticular disease patterns because diverticulitis says would diverticular disease, and I'm gonna come onto this in a moment. But diverticular disease and diverticula OSIs could have bet any part. The colon. Okay, now, in Europe, on the West, where I practice, 95% of diverticula OSIs is found in the left curl in the left hand side about in the in the sigmoid colon on the descending trail, most commonly in the six point 95% of patients, one was a little high, particularly Asus is found on the left and where we are. But interestingly, in Southeast Asia, particularly in Japan, patients in Southeast Agent they get diverticula cyst on the right hand side. It about on. There are lots of different theories. Why this? Maybe on it's probably something to do with the microbiome and with local lifestyle patterns. Where individuals this. Also, if you move, if patients move from one geographical region to another, they initially take that passenger disease from where they're from on. Then after a while they move it to the pattern off where they where they relocated, too. So the geographical epidemiology off diverticular disease really interesting on. It's a little tip it that examine is and all of us we like to ask you if you know anything about, because it's kind of on an interesting Now, the next side I have put down because I have already made this mistake when I have been talking to you on Everyone makes this mistake. But there are some subtle but really important differences in the terminology off diverticula OSIs dry verticulitis he's on diverticulitis. It's You could consider that these are all it's all very similar or based on the Web diverticul you diverticular, diverticular or whatever. But you can see that these words or have separate meanings. So Diverticula OSIs just means that there are diverticular in the colon. That's all it means you have. There's a patient who has a little pouches in the kernel, but the majority of these patients more than 20 more than 75% of patients will just have diverticular and colon, and they will never have any symptoms from them at all. Nothing, they just have them. That's just the way they are. They don't get any symptoms that it doesn't mean anything. So so if you have a patient who's just found to have diverticul OSIs little pouches, but they don't have any symptoms. They got no abdominal pain, no problems with their bowels. They just got diverticulitis. It's when patients have those little diverticula and they become symptomatic from it, so they may have abdominal pain changes in about habit blow to, um, things like that that is diverticular disease, and that is patients who have long term symptoms from their diverticular. Now, if a segment off diverticula OSIs becomes inflamed in case if there's an area of the colon which becomes inflamed in and up diverticular, that is diverticulitis, which inflammation of the diverticular second. So you can you see that. Actually, people always use these words into changing plea in correctly, but a patient has a symptomatic diverticul OSIs. If they get symptoms from it, they have diverticular disease. If there is inflammation within a segment of the bow, they have diverticulitis, and you'll find that patients use these words interchangeably because they don't understand. The difference is on often one we're talking, you know that Ms Take a swell, but it's an important thing to understand Now. Those of you who saw um, who saw my letter last week will remember the little flow diagram here on the left hand side because it's essentially the same flow diagram that I use for appendicitis. Because diverticula, um diverticulitis, which is what I'm showing here in this. In this flow, diagram is often caused twice by a similar a similar mechanism to Penn decide. It's so you've got the diverticula or office that you remember from that colonoscopy picture just now that diverticula or if it becomes blocked, bacteria multiply within that there is dead. A Dema off the area is schemer. It scheme your inflammation and then eventually perforation. Okay, so diverticulitis has a very similar natural history has has some similarities. And it's not a history to appendicitis is which is why I thought we talked about it today. Now you can see in this CT scan is a little cross sexual image of the CT scan. Not sure how many of these that you've seen. Okay, but you can see in this CT scan for those of you who have interpreted before and no apologies. If this is the first time that you've seen an abdominal CT because you have to get used to it, it just takes practice. You can see here that here is this thing set of gray area in the set in the middle, here to such a sigmoid colon, you can see it's sort of s shaped. Okay, we could see that's within the pelvis, because here's the issue here. Okay. Is the cecum in the back when we're in the pelvis, exceed those extra piece of bowel. And can you see there's a little bubbles Those little gas build bubbles that we saw on the diagrams before? Those are the little diverticular. Okay? Also, you can see some increase it a soft tissue density. Um, it is this grayness that you can see around here. This increased soft tissue density of the fat. That's inflammation. That's fluid within the theme. Soft tissue around the Thea sigmoid colon. So here we've got some soft some inflammation in a diverticular segment. So here is a CT scan of acute diverticulitis, All right? And this is what we would be looking for in normal patients. Now I'm one. So in Trump, there's just a question by how they last filled. Are they not filled with compacted stool? Yeah, great. Thank you very much, Abdullah, I'm glad that you're asking questions, and I would really encourage everybody just to put their questions and they come to their heads. Okay, because I'm really happy to answer them for you whenever they come so well. Your bowel is not filled with people all the time. Abdullah. Your whole colon is not filled with people the time that kind of moves around on. Remember, you've got lots or bacteria up comment. Bacteria within your colon and they produce gas all the time. That's why you close with okay. Say the colon is commonly is commonly filled with gas and stool. But it the colon is know, always felt was still the tour. Actually, it usually has some still within it, but often that the colon is relatively empty because the colon has has some stool. And then you empty about that. Something so usually diverticular your seed. I'll be felt that stool. Sometimes you'll probably see some little I don't know. I can't see any here. But you can see there's this one sort of bearish, isn't there? That doesn't look like it's filled with stool. Yeah, said they're ago. Yeah. Okay. I'm glad you got after. Okay, now, this is pretty small, this picture, But it's really important, because this is the question that everyone always asks because I'm talking today. Not just about diverticulitis, really, but also about diverticular disease. As we said, that symptomatic diverticular on the question that always asked is one of the complications of diabetic. Yeah, disease. So they should have diverticular. But what happens when they happen? Where there are lots of different problems that can occur with diverticular disease off one is diverticulitis. But there are some important other complications of diverticula disease, which I think are really important in this picture really shows it in detail on that is in Prince, mostly as a result, off inflammation around there's this little particular. So the first thing that we've got here on the top is acute diverticulitis. We talked about that that inflammation around the time particular their second one that they've got here is a perforation, and you've seen here on the left how you can get increased Inflammation can cause weakening of the colon wall similar in appendicitis, and it can cause a little hole depopulate defect in the in the bowel, and it can cause a perforation. Here's a little picture off some stool or poop coming out. One of the diverticular you can imagine that's causes peritonitis, or it could have a large amount called a fecal. Parents noticed a large amounts of who entered abdominal cavity. Of course, vehicle peritonitis on small amounts will cause infection on that, because purulent Paris nighters or pass for them. Yeah. Okay. Now, one thing I'm not going to talk about today, but is really important is hemorrhage or bleeding. Now, do you remember that first diagram where one of the first diagrams where I showed you wear the diverticular come in the colon. And I said that they came at where the vas erecta or those the little blood vessels poke through the circular muscle of the colon to feed the mucosa. So you can imagine that those are blood vessels in there sitting on the edge of these diverticular. And because of the way that the diverticular stretch, those blood vessels become liable to damage on so hemorrhage or diverticular bleeding is really common on that can come whether keep diverticulitis point can just come by itself. Okay, it's a hemorrhage. Is a meeting for publication now because of the abnormal motility, which I told you is part of the causing of diverticulitis is what we think is a principal cause of it. The muscles of the cone get very thick and and again the muscle becomes second of the wall of the current because very, very second and it feels really heavy and picking your hands When you hold it, you get must have purchased E. And you can imagine here in this picture that's strange. It really well, that's a muscle gets bigger and bigger patients could get obstruction or narrowing. And that can happen just because I had purchased. Or it can also be due to the acute diverticulitis. Now, the next one they've got here is it was abscess or infection around the colon. On importantly, here, the last one I'm just gonna jump onto it is fistula. So can you imagine that if these diverticular are getting all inflamed all the time, they get all inflamed and they're sticky and they stick on two different organs in the abdominal cavity And as a second other organs, um, a little pathways concomitant between the two organs and those fistula on a colon for cycle fistula or a connection between the colon on the bladder is really common in patients. More complaining off symptoms or passing stool is a cross the wind. I'll get almost beauty eyes, but let's get back to diverticulitis because that's what we want to talk about. And I've already been talking 25 minutes and I want to go there. Lots of things to talk about but keep diverticulitis is characterized by very, very similar symptoms to acute appendicitis, and that's why I've shown the same side. Okay, so you've got a new inflamed organ in the right area or some of the pen to scientists. If you got an inflamed organ in the left earlier fossa on down, you're going to get kind of similar symptoms on you. So I've used the same picture but modify things a little bit. And so patients will typically start by complaining of pain that's been lasting for a few days because, unlike appendicitis, which is an end organ and so of develops pretty quickly, diverticulitis usually developed a little bit more slowly. So patients usually present not on the first day, But they used to say, I haven't been feeling well for a few days. I've had pain in my left hand side. This lady is holding the right hand side, but I've got pain in my left hand side, and I have been feeling well for a few days and say my bowel has been upset, and some patients say they haven't opened their bowels for a few days or others may complain of some diarrhea or loose stool. Patient will have a job set so they'll have anorexia. They would be hungry. They'll have nausea and the vomiting, and they'll also have bloating. Essential. Compare yourself. Been feeling really place it really uncomfortable now with the sepsis comes symptoms of sepsis, so fever and malaise flushed, being flushed those kind of symptoms that they'll complain off with sepsis on. I told you already that you could get bleeding associated with the diverticula of rectal. Bleeding was very common on when they're sick. Mind colon is rubbing against that bladder. Like I was saying, it may not have a history unusual, actually, some of the best, first of all, but but plain sigmoid colon troubling against the visor. Then they can get lots of bladder symptoms as well. So dysuria in urgency and frequency. So lots of symptoms acute diverticulitis. So in a patient presents she's got known diverticula OSIs on. They present with left eye that faucet pain, anorexia and nausea, nausea, a G. I upset with constipation, fever, bloating, got a thing that they might have diverticulitis. So again we do similar investigations suspected with appendicitis. I'm Abdulla saying that sounds a lot like appendicitis. Well, it is similar, isn't it? Because it is inflammation of a G. I organ is located. And I mean in the west, where I practice you get sigmoids diverticulits sigmoid diverticular is so mostly the location is different outdoor, but the symptoms are pretty similar. You don't really get that central to write a letter for some pain that you get with the pincher scientists does that. Do you remember we talked about before? They normally get pain, is localized in the lower abdomen in the lower abdomen on which then comes up to the left. I'll force it, but similar. They present with acute abdomen, the present with abdominal pain. But what you're going to do when you see these patients you're gonna do similar. You gonna do similar investigations? Your first of all, going to do your laboratory studies to look for any change in their in their in their blood count, looking for raised white cell counts, raised inflammatory markers, evidence of an acid base and bounce. That patient has a metabolic acidosis because of because of information on in those patients were very sec as well. You'll see secondary changes in the electrolytes. If they've been vomiting a lot, you may see a message board alkalosis. If they have been very dehydrated for a few days, they may have some real impairment. So you want to do a full set of the board studies to have a look and see how septic there on how much impact that's hard on their other organ systems and then once against managing on, as Abdullah has said. Actually, since you know all these acute abdominal conditions in general surgery present with kind of overlapping symptoms, and so it's not putting all the pieces of the puzzle together. So the first investigations, really you're doing the emergency. Obama's respects write it because they're dead straightforward. You can get kind of instantly, and the reason why we do X rays is not because it diagnose is diverticulitis because you can't see the sigmoid colon properly on an X ray. But we're looking for really serious complications, So the most serious complication is a bit to be honest the most. The most serious complication would be will be septic shock from perforation. So in patients who have a perforation that have a big hole in the coal on loads of bacteria and gas Will escaped out the colon, be inside the abdominal cavity, and they will have peritonitis. Okay on. So you can see that not only will they be extraordinarily tender and they'll be peritonitis. IQ is the word when they are extraordinarily tender in the abdomen, but you'll see some beaches Onley on the x ray. Um, one of the main features that you're going to look for is pneumoperitoneum, which is when you see a runner. The diaphragm new. No air puritanism in the abdominal cavity. So you're looking for pneumoperitoneum on? Actually, um, this is it. Comes is we're looking at his chest X ray. Now, we're not looking at the sigmoid colon because a rises. So if you ask patients stand up, you taken X ray. All that air is gonna be rise is gonna rise. You gonna see are underneath the diaphragm so you can see in this chest X ray. Can you see here the little lines here? That's the diaphragm. Okay, Underneath it is area usually see here in the lungs. You don't see Aaron the abdomen, abdominal cavity. Unless the big problem on this patient has got has got pneumoperitoneum here underneath both hemidiaphragm. So that's the patient is very sick. They have got a perforation somewhere. We don't know where it is, but we know. Sorry, but we know that they have a perforation on that. They need something doing about it. Okay, so that's what chest X ray might show shop, you know, sound strange. Begin read to get a chest X ray when you're looking at something in battle, but it tells you whether they've got perforation are the features of the abdominal. X ray will be kind of non specific, but they may show obstruction. They may show a general area without any bowel gas if there's a big abscess on. So the vet razor kind of useful, but they won't give you the final diagnosis. The final diagnosis is going to come from your abdominal CT on about abdominal CT is going to look a little the entrapped, um, organs. But you're principally looking for the cone on on here again. Here's another transfer. He is not a trial section from a a a CT scan of the abdomen on again. You can see this sort of gray area here. This increased in soft density off the peri colic. Fat on, that's it. Inflames segment off, um, of substance one colony Concede these tiny little these tiny little diverticular coming off besides of them say so. So that would be a CT scan that shows diverticulitis now moving on is always important when, when you're assessing these patients that you're thinking no, only about what what you think it is, but also about what it could be, what else it could be. Because your investigations may not show diverticulitis, it might show something else on. That's, you know, the great mystery in the great art off General surgery emergencies is that there are lots of organs which is very close to each other, which one all give kind of similar symptoms. And so you've got to keep in the back of your mind for other really important general surgery emergencies that this might be and you'll see those on your investigation on. I've just really listed them here and you'll see that a lot of these are similar to appendicitis from last week. Okay, so inflammatory bowel disease, um, in touch about these different kinds of colitis. So not diverticulitis. Spot an ischemic colitis or infectious colitis, for example. Okay, um, irritable bowel syndrome and a patient is not on. Well, he's just got some abdominal pain, which comes and goes a colon cancer can cause obstruction. Similar Teo diverticulitis. What it can cause rectal bleeding. We talked about mesenteric adenitis, which is, um, which is an ad in itis or lymphadenopathy within the knees. Entry matter cause acute abdominal pain is kind of less common in this patient age group. Actually, because he's enteric, adenitis is commonly seen in Children and teenagers. So it's unlikely This is really rare that I've ever seen acute diverticulitis in a teenager, but I definitely seen it in people in their twenties, so I kind of put up that down there. But it's probably low in the differential wrist, Um, and a perforated Judy. Well, so so any sort of Paris. Anything that can cause peritonitis from the judge. African concerned about like diverticulitis. Sometimes Johnny organs are very clear. In the last night, you got less deliveries. What All the girls here but left ovaries as well on, say, a problems with the a problem. A problem with the ovaries or the fluid continues, can cause symptoms that are similar as well. So the same as for appendicitis. A tortoise, a ruptured ovarian cyst. Salpingitis topic. Pregnancy would have to start all of those. The other thing. Other thing is any sort of neurological things, because your sigmoid colon and this diagram of the urine to the lab just sits here over the left ureter. So anything that's upsetting that left ureter, it can also give you a really good, relatively similar symptoms. Too tight, particular. It's just the renal colic on pyelonephritis. Also important things to kind of think about. All right, let's move on super quickly because we don't have very much time. One thing that I do want a very briefly touch on, and I'm aware now it probably only got about five or 10 minutes, and I'm sorry I've gone on a little bit too much. Is is some classifications. It's always good to know constipation with the disease because it helps you to frame some of your ideas. But the hint she classifications something which is really good to know, and you don't need to know a lot about it. You just need to know that we have a CT method for really describing different complications off diverticular it. It's okay. And that's just what the Hinchey classification is on this hip. 123 or four. Essentially him she wanted the least serious and hints before is the most serious on. We judge the hint of classification from we get this teacher constipation from CT scans. That's the most important thing. Him see him. Stage one is just a diverticulitis or just a localized abscess next to the next to decode on. Okay, so that's just a small area of information with small abscess on that can usually be managed with and spoilt. It's okay now, a hint. You to, um, Hinchey to is a more serious. That's when there's a large abscess within the sentry. Okay on Henchy to patients, often a little bit more sick. But you could much have a large abscessed similar to um, similar to appendicitis to a large abscess. We can consider drainage in those patients. Yeah, now, in Hinchey, Stage three, there's a perforation. Okay, so patients are more second hep C three. There's free passes free perforation on that abscess that there's There's Puss And so it's free. Perfect. With Parliament, plus okay on him, she said four. There is also perforation, that perforation. It's worse on. They have actual pooed have a large purpose, actually poop coming out that well. So that's the hint of classifications off diverticulitis on. It's kind of important to know about. All right, just showing you here in image be here's a little obsessed in the pelvis with some gas inside it. Okay, so that's going to be increased aged to on here. See, this is actually higher up in the abdomen. Here is the liver. Okay. And, um, we saw this the X ray for four little gas underneath the diaphragm. You don't know they have gassy or just stop the liver. So here's free air. So although we're not looking at the sigmoid right now, I know this patient's got free perforations somewhere, and I'm going to looking further down inside the abdomen, see where that's coming from. The sigmoid colon. All right. Said in some little drink. Okay. Similarly, um, similarly to appendicitis. Our management is gonna be the same, but directed toward pinsight a director to exactly how sick the patient is. We're going to ask the same questions that we ask before. How sick is the patient? Is there a perforation? Use them in abscess. Is the patient for surgery on more Operation Camry two? Okay, so in the diverticula, see the diverticulitis? We don't manage them all surgically. In fact, we often an issue them conservatively with antibiotics for drainage. And we only really concerned a surgery in those patients who have hinted three, but really hit. She falls in those patients who got fecal in Paris. Nicest. We definitely think about an operation on in. Those were piling Paris. Nice is we'd usually try and get away with it. That's not good. Especially might consider surgery in there. So if they've just got in, if it just infection information, they can usually settle down with ibrance spot. It's alone. If they've got Hinchey to got a big abscess, we can think about draining that. Usually the CT. And if they're not resolving with a hint, she three all they are got him, she full. Then we would consider surgery on that surgery be to and move as an emergency. That same diverticular segment. No office. Now I'm I got here. Actually, an algorithm to depend on the clinical picture. But I think that will skip that because last time he palaeontologist video that I showed on I think of it's kind of nice for you to see some realize surgery on this just tells you you know what you do when but essentially, if they've got diverticulitis alone, antibiotics reduce their diet. If there's an upset, strain it on. If it's worse than that, they're not reserved resolving with birth to the surgeons and consider operation to remove all driver that segment. So here is, um so when we treat diverticuli cyst surgery, a lot of it depends on exactly where the perforation is. And how about the bowel? That's okay. And here is a YouTube video or somebody doing a laparoscopic sigmoid collecting your heartburn's procedure again, a heartless procedure is reception off the sigmoid that extra estate part bowel. Okay, which has the diverticulitis with the net on formation of unending colostomy. All right, so I'm going to show you that here because I didn't really go through it so you can see here. But if this is the inflamed area of this off the signal Come on. That part is resected on. Instead of joining it back together, that one comes out as a colostomy or a stoner where the bowel comes it abdominal wall. So I imagine for those of you who are new or relatively new to meant to mention, or the stool is gonna come out going through the colon. But instead of actually go down to the bottom to pull out, it comes out of the stoma bag on the tummy. Okay on. Then you got a rectum stump. A rectal stump was here, which is not connected. So the patient doesn't pass through every day through here. They still pass tiny little bits amounts because mucus is still produced in here. But all of their poop everything that they eat, you know, their poop in there waist will come out on the, um intervag on the abdominal wall as an end colostomy. So here is a little video, and I think it's kind of really nice to show a video to show you what we see A surgeon. So can you see here and you're looking inside the abdominal cavity. It's a little bit jumpy. This video's in it, but essentially you got the abdominal wall here. Okay. And can he's looking out the plan, Tha okay, and he's gonna hold the colon with this left hand is getting very jumpy. This video and what he's doing is you. This is this is the sigmoid colon. Is this as it's as it's attached to the to the, um uh it is attached the abdominal wall here on his part. Can you see all that? The fat is all kind of lobulated. There's a little bit of blood and bleeding here on what is done here that he's opened up this area on. It's a lot horrible, and he's going to open up in abscess in a minute. Said this patient has Hinchey three. But you know, that's disgusting past. Okay, so you can imagine what he's going to do here is he's going to suction along that plus away, um, within that segment, you know that it's gonna be a perforation within that on. Eventually I wrote show it to you because it takes quite a long time take longer to to do a sigmoid collecting you. Then it takes to do and appendicectomy. Um, he's going to take the blood supply from this area of the colon he's going to write, sent receptor that area, and he's going to bring up in area as a B pilot as a as an end colostomy. But that's essentially what we look at when we are doing a Hartmann's procedure. If we were to do it that way, all right, so once you treated your patient and you got them over the that initial sick period again, the follow up is really important. So what you do well, once they've got better from their diverticulitis is really important that you do a few things, okay, Just like just like an appendicitis, you got to think about what's causing the diverticulitis now. Diverticulitis is, he said. It's usually some who which has got stuck in one. Those diverticular one. There's there's a diverticular, but actually the colon, because it's so inflamed of diverticulitis. Often it's very abnormal on, so once that diverticulitis has settled down and you treat, then it's really important to look inside with an endoscope with either a flexible sigmoidoscopy or colonoscopy to make sure that there isn't a hidden colorectal cancer in there, that, um, that you have been treated okay, so if it's been managed conservatively, just with antibiotics. Remember, you got on the inside afterwards to make sure there isn't a helps. Um, colorectal cancer. Um, uh, someone's asking is an abscess a class two or a class three, and abscess is a larger abscesses of class to a class three is a perforation of parliament with the past. Since I don't know to Justin. Um ah. The second thing that I've said is you got to check histology. Okay, so Thiebaud Colon, when you when you when you do a Kalanick reception, it looks like diverticulitis. It's all inflamed, and it's all horrible, but you can never really talks. It's so thick. It's so hard but really important that you follow up that histology because again, it could be a colorectal cancer within that area that you didn't you didn't know about, and the patient might require some androgen treatment. Some chemotherapy afterwards. One they've got better. If there is need a colorectal cancer on, then they're set. The last thing I just want to say is is that these patients present some patients present with multiple episodes of diverticulitis on. Then quality of life becomes really badly impaired from it on in those patients representing time and time again. Usually those who present elite that sort of three times with diverticulitis is in a short period of time, maybe within two years. It's important to offer them a consult so that they can consider whether they'd like to have that area of signaled Carmen removed. Let's semi electively or two juice. You know when to do it, even when they're not sick to prevent from that diverticular. It is from coming back, so things to think about when they get better. So always remember, do a colon screen check it. There's no correct or transfer. Make sure in your specimen there isn't anything that I don't award and effect on symptoms all the time off for a consult to discuss it. One. Correct me. So there you go a little bit about diverticulitis and diverticular, it sees today. Um, Andi, I hope that you enjoyed that on realize that there are lots of similarities in acute general surgery on, but really, it's all about listening to the history and then my investigations that you can choose exactly what the best treatment is. Your patient. Thank you very much. for your time. Thank you so much dot Uh, we've already got a question that came. And, um, from it's gonna let me. Can you please explain? Sorry if you're happy to just jump. Strange. Yeah. Let you're saying please explain the difference between diverticulitis diverticula OSIs and neck ALS, not Merkel's diverticular. Lenny, I'm delighted you asked that question, but it's also because you weren't here. I think in the beginning, let's because we talked about this because you're right. This is a super important question. Okay, so just say that just said it will go in breaking, so it's really, um, hunted. Diverticula OSIs is just the presence of those little pouches in the colon. Diverticula OSIs gain little pouches in the colon in someone who gets symptoms on those little pouch is we call that the particular disease. Okay. You don't need to have massive inflammation off those diverticular to get symptoms. Some patients on chronic abdominal pain or pain from that second as diverticular disease. Okay, Only about 25% of people who had the little pouches get symptoms from them. Actually, people when people with diverticular disease only about one in 10 get diverticulitis okay. And diverticulitis is inflammation of a diverticular seven. It's about So you've got diverticular. You've got symptoms for them on. You got inflammation of that segment on. That is a difference between diverticula OSIs on diverticulitis. Now, Um, Meckel's diverticulum is a completely different thing. Okay, because actually, the word diverticular just means blind endings. Pouch diverticular is not something that only happens in the colon. The word diverticular is a medical term for a blind, any patch and you get diverticular all around the body commonly and Luminal organs. So you get bladder diverticular, so you get little pouches that form in the bladder. A bladder diverticula. You get diverticula of the small bowel diverticular of the duodenum. I bet you can get diverticular of other organs that are not just rattles I can't think of right now, but a diverticular just means a blind pouch on the meckel's diverticulum is an embryonic remnant. Um, on it is a is an embryonic remnant off the, uh oh, the uric. Oh, not the records that touches umbilicus on my brain is not working on it, isn't it? And it is. It's it formed off the end of the small out like two about 2 ft from the from the Eylea sequel Bowels and it's found in about 2% of pain is a 2% of people. So Meckel's diverticulum is completely different. I heard that kind of on sexual questions. Let's see everyone else's so saying some other things, Thank you very much. I'll find no other questions. Are you absolutely sure that no one has no one? Has anything else understand it yourself? If you have a question, you can also me know. Yes. Oh, there's one more question. I just came in now from here in the child on the you says, If I'm interested general surgery, what would you mind virus me to do in terms of extra work? Is there anything that you wish you need medical stool that would make your journey smoother? I That's a really interesting question. He I would say that when I watch a medical student, I would like to have spent more time exist because I would have liked to have a more. That's why I like to show you videos cause I think it's really important to see what we do. Is surgeons that problem? Weird surgery is that it takes a long time to understand the new one. So what we can see. So it's kind of difficult to introduce for the first time. So I if it was me, I would have spent more time and you could. You don't need to be in surgery. I spend more time like understanding. And that's mean watching videos, spending time with the other surgeons, even spending times in the emergency department, actually, um, to get you know, how we managed patients with the general surgeons sort is is really important for you at this time. That's what I wish I had done when I was when I was a medical student. Is it comes to understanding. Conceptualize exactly what all these different terms men, you know, rather than meeting and picks, it's impossible to learn surgery from a textbook, especially the beginning. Um, l but very Ibrahim has asked, um is one how is how is, um, diverticular OSIs different from Kalanick polyp assists? Well, that's really interesting. Actually, I wonder if I couldn't should show you something instead of that. Uh okay on think. Okay. That Abraham, this is a situation which you need to see a picture. All right, let's have a little work. What we could see here. Okay, So if I have got I'm just looking on the internet here. That's, um that's, um polyps. Okay. He gets right pulling in. So you can you see here, Abraham, some pictures Here. Here is the Okay Here. Right. So this is a colonoscopy on this one. This is a good one. Okay, this is a colonoscopy picture of someone with chronic polyps. Can you see these little growths inside about? This is a good one is Well, can you see here? There's lots of little polyps or lots of little growths inside the colon. These are great scaring in not diverticular going out. Okay. Said contrast that picture to what we saw here. You see that? He's a little sacs coming out off the colon, whereas what we saw before, Can you see that? What? We saw it. What we see here in the polyps is actual little physical rumps in the bowel going in. So it looks completely different on actually someone who's got polyp posttest the outside of the bowel. That's completely normal. Whereas can you see in the diverticular diverticular? See see See here the outside of the bowel has those little patches on, so that's completely different. Does that kind of makes sense? You say anything else and anyone? Not really. Yeah, I suppose it's a good time to say goodbye then, isn't it? With five minutes to spare so that you can relax for five minutes before your next session. But just allow me to say again, what pleasure is to meet you all on? But you have a lovely day. It's really nice weather here in London on Do See you next week because I'll do another lecture next week. But I think it's a one o'clock next Tuesday instead of midday. So seasick you so much for Eitel The best night. I have to thank you so much, but by so I Oh, random I'm sorry. I think we just got 11 last question. That's comment. It's 55 last. And what are the main causes for Dover Diverticul OSIs. Yeah, What The main well is very interesting, actually, as an interesting question, Um, san school thie there is There is not one exact cause of diverticula OSIs. Okay, There are lots of different risk factors okay, they There is a lot of discussion about whether it's something to do the microbiome. But principally, we think that this causes problems with abnormal Kalanick motility, and as that when, as the Copaxone propels, it's propelling in an abnormal way, which causes changes in the structure off the colon. In that segment. So it's essentially abnormal propulsion or motility. Is the cones moving in an abnormal way on that causes muscular hypertrophy me with increasing. You know Moscow had purchased increased pressure when that segment of the colon on that increased pressure causes those little pouches to form at those areas of weakness where those little blood vessels are coming in around the smooth muscle and it causes those areas to become weaker and to start to protrude protrudes. That is what the the the they're sort of main argument is for the cause of diverticula OSIs. But then there are lots of other things as well, and the symptoms of diverticulitis, we think, are due to chronic low level information of those areas. So that's why smoking, obesity, diabetes, all those conditions that we know create low level inflammation, um, get core symptoms in those segments of diverticular diverticular disease. All right. I'll let I'll definitely let you have a two minute to minute break before your next venture. It's really nice to meet all of you again on day. Um, See you in a week. Thank you very much. Feedback. Thinking more, more time going on? Yeah. Like a blow to mention me. Do you have another talking about in that one o'clock in a few minutes. So what I'll do is no end this call in about a minute, and we'll same link. We'll just restart the core and let everyone in once we've set up the next speaker, Um