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cool. So is that Is that live now? I think it's just learning. Okay, now it's live. Um, thank you very much for coming, everyone. Uh, my name is Daniel. I am, uh, the president of the Glasgow Radiology, uh, society. Um, and, uh, grandma got 11 response in the chat. I'm in my first year of med school. Um, gonna treat you tonight, um got, uh got, uh, an alumnus of the University of Glasgow and the Glasgow Radiology Society Doctor Peter Poults in to speak to you about, um, imaging in general surgery. So without further a do, um, if you'd like to take it away, Peter. Yeah. Thanks. Thanks. Daniel. Um, yeah, I'm Peter. I've graduated last year, so I'm an f i one in general surgery just now in the g r. I so in the royal. Uh, okay. Cool. Thanks for, um, popping that in the chat guys. Uh, we've got a nice range here. Um, I've made it quite clinical in terms of the so the chat today. I've worked a couple of months in general surgery now, and I thought I try and give it It's kind of case based. Um, I want to give an idea of what we use different scans for, which is, I think, going to be relevant for all years and what they're good at. Visualizing. And then we'll cover quite a bit of hepatobiliary, um, pathology because, um and and kind of go through cases, um, and that try and cover quite a lot of stuff that comes up in MCQ and all skis, and I'll kind of put some pointers and what's come up in the past, what I found useful. And then for those that are for 50 years, I'll try and give more of a clinical spin in terms of how what you actually do when you start working as well. And what's what's relevant to know, Um, for my my current experience so far. So, um, that's the plan. Uh, I think I'll try and kind of look at the chat if you have any questions and mop up questions at the end as well. Um, yeah, and that's I think, with without further a do we can get started. I'll just try and share my screen. You might ask Daniel to kind of verbally confirm that we can see the right stuff, so we'll see. Uh, just a sec. Right. So is that visible there? Yeah, that's good. Brilliant. OK, so we'll start and we'll go right into it. So, um, first, we're gonna do a lot of so I think my my aim is to all the, um, kind of common biliary. So which has to do with the bile duct, the gallbladder, the pancreas, that's all those conditions. I kind of wanna make them really discreet. And everyone's, uh, everyone's mind because I think they're easy to confuse. Sometimes it's difficult telling one apart from the other in terms of how they present, um, and they're really coming questions. And I've certainly had them come up in all skis, um, and sort of their management and how they differ. So that was my aim. And then we'll touch on a couple of other things, and we'll we'll then kind of have a bit of a summary on the type of mentality is used and stuff. So, um, first of all, um, let's go through some definitions, so you'll you'll hear these phrases banded about quite a lot cholelithiasis less so because people just call them gallstones. But cold basically is, um, bile related. Lift this stone, and so colelithiasis is the presence of of gallstones. Um, um, if it's called DACA with Isis, it means it's in the actual duct. Um, so it's in the biliary ducts, and that's the presence of gallstones in the ducts. And then your itis is usually information. Um, typically, there's infection with it. So call cystitis and Collinge itis, and we'll get onto how they different presentation. Um, and, of course, banker ties. This kind of is also inflammation of the pancreas. Um, and then biliary colic gets, um, kind of it's you can place it. It's essentially just acute, um, pain secondary to having gallstones in the gallbladder. Um, so that's that's how it's usually just called biliary colic, To be honest, um, but that's that's just another term as well. So we'll just go into the first case. Um, let's just say they all present to, um, surgical receiving. So a 45 year old lady presents overnight with quadrant pain. It's radiating to the back. Um, she's had this for a few hours. A bit of nausea and vomiting. Um, she had some food that made it worse. Um, it was quite severe for a few hours, but it's now improved a bit. Um, on examination. She's a bit tender in the right upper quadrant, and John is no fever. But Techie Kartik, I haven't put you know, the whole shebang in terms of, um, history presenting, presenting complaint is presenting complaint past medical history, medical history, social history, family history and all that. Um, that's usually what you put in for clerking as well. Um, but just to kind of keep it succinct, I've just added the key bits from the history. So in in terms of those in 1st and 2nd year, the kind of approach we have with cases is first we take, uh, and that kind of I think you start that quite early in Glasgow in terms of, um, structuring your history taking. So, as I've said, you know, what have you come in with? Get a good history and then you look at their past medical history, your medical history, family history, and then you do a bit of a systemic inquiry and ask about you know, any other symptoms and, uh, systems that might have issues. And then you try and structure your differential diagnosis. What conditions This could be, um, based off of that. You try and differentiate between different conditions by doing investigations. So that's kind of the format. And then once you're pretty sure it's, uh, you know it's a certain condition, then you can make your diagnosis and treat based on that, um, and then assess and look for complications. Or see if your diagnosis changes. Um, so in this case, um, we're kind of looking at the key bits. It's a 45 year old lady. Um, those are kind of relevant. It's right. Upper quadrant pain going to the back, nausea and vomiting. Worse with eating, Not constant. Um, it was there for a couple of hours and now improved a bit, and her obs are actually relatively normal, so there's no jaundice, so that's quite typical biliary colic, and we'll see why. I'll compare it in a couple of slides and, essentially the presence of gallstones and gallbladder. They're often in the Hartmann's pouch or near the neck of the gallbladder. Sometimes they travel up to the cystic duct, and they contract against these, um, and that causes pain. Um, some other differentials. So that's what what else it could be would be cause cystitis, choledocholithiasis, pancreatitis, peptic ulcers. Those things can present with the right upper quadrant pain. Um, peptic ulcers can, depending on where they are, can also present being worse with food. Um, so, uh, those are are differentials. Uh, this is just in terms of actually what happens on the, um, after afterwards. So when you say if you have a ward round and you see a patient and you review them and you decide to get some imaging done, you have to put in a formal request. Um, so you put that on the system, and then usually if it's an urgent scan, maybe less so for ultrasound, sometimes they just they just get done a lot of the time, but definitely for cross sexual imaging, you'll have to call the radiology department in the g. R. I. And so you speak to a radiologist, and then you kind of go through and present your case. Um, so, uh, you you know, you present patient's to, um, to other healthcare professionals all the time, and this is a pretty good example of that. Um, so you can try to summarize the history presenting complaint, Any relevant past medical history or surgical history, you know? Have they had anything, um, done? Previously? Have they had a previous hemicolectomy or, um, anything that you know is relevant to the case into the radiologist. And then you have to actually say what you're looking for on the scan. Um, and examination findings and observations and, um, relevant bloods. Those are all things that they like to hear, um, to see how urgent the scan is, and then what they potentially to look out for? Um, so that's that's kind of good to know, because the more you get into, um, thinking about why you want scans, you know? What is it you're actually looking for? The more likely one. The scan is going to be done. Um, and to that, you also ask for this if you're not sure. And clarify, um, with your seniors at the time of them saying that they want a CT for this patient or an MRI for that patient. That's just a little, um, tip for the future. So, in terms of investigations, um, sofa, biliary colic, um, you know, it tends to be normal bloods. I've put B to a C g negative. That's just a kind of a side note for abdominal pain. The classic stuff that you want to do is your your normal quote unquote routine bloods. Um, fbc you in the LFTs crp. You also want to do an AM Elise, um, usually. And then a beta hcg is done for Most, um, women that, uh, well, particularly reproductive Age of course. Um um, Well, exclusively, you know, But, uh, if they present with abdominal pain, particularly lower abdominal pain, you want to do B to a C G to rule out pregnancy, particularly topic pregnancy. Um, and then an ultrasound in this case would show, um, the following so he can see two discrete stones. Um, you can see acoustic shadowing, which is, um, just sort of below the stones. These, uh, these dark lines, which is very typical. It's a very characteristic sign of gallstones in the gallbladder because the actual ultrasound can penetrate through because the stones are denser. So, um yeah, that's that's what that looks like. But the actual gall gallbladder itself is quite thin. Um, and and we'll compare that to call cystitis, which is, um, looks a bit different. So, uh, management for this usually just analgesia, um, giving worsening advice. You know, if it gets much worse, uh, in terms of developing a fever, jaundice, um, Explaining what? What? This is, um, And then usually, if they have recurrent bouts of biliary colic, then an elective cholecystectomy, um, is often done. And the typical risk factors for these are sort of your four fs um fat fair female 40. That's kind of the typical phrase, but those those are very common risk factors. And also, there's a familial, um, link as well, but those are those are very, um, common risk factors for gallstones. So the second case is a 50 year old lady, uh, 54 year old lady presents with rapper quadrant pain, nausea and vomiting fever. Her pain came on several hours ago, and it's constant. She has not had that before. And on examination, she's got right upper quadrant pain. Murphy's positive. No jaundice. So Murphy sign is when you ask the patient to, um to, uh, breathe in while your hand is pressing against the right upper quadrant and if they have difficult if they, uh, pain on breathing in and sort of catch their breath. That's positive. Murphy sign. Um, and it has to do with, um, sort of capsule inflammation. Um, leading to pain. Um, and, um, it's a sign of, um, cause cystitis it. Not necessarily the, um, sort of the most specific, but it's often mentioned if it's present on exam. Um, so I have kind of given it away, but I think we could tell that it was going to go there anyway, uh, in terms of the working diagnosis, um, And then in terms of investigations, what do you think would be worthwhile doing again? Just have a little think, and we'll go to the next slide. So the way we like to lay this out is well, well, usually in terms of investigations you want to think about, um, bloods. Um, you obviously want to do observations in an exam. And then blood's, um, other, uh, sort of procedural things, maybe an E c g, um, uh, than, uh, imaging. And those kind of tend to be your your common, uh, things to do. Um, in terms of structuring, how you wanna how How you want to look at things. Um then just discussing the results as we go through them. So in this case, with cause cystitis Because, um, there's an inflammatory infective process. You've got an elevated white cell count, which you didn't have, Um, biliary colic. Um, and you also have an obstructive picture because now there's a a gallstone likely in the cystic duct, um, which is causing, uh, Stasis of the the the bile inside the gallbladder. And, um, you've got high CRP. You often tend to do an erect chest X ray for people with quite significant abdominal pain just to exclude pneumoperitoneum. Uh, which is when you've got a rare and the peritoneal cavity from, uh, periphery ation, um, and that you'll see that as a rub of the diaphragm on chest X ray. And, uh So an ultrasound is done, of course, which will show a thickened gallbladder. And there's often fluid around the gallbladder. And when they do it, they'll also put the probe up in the right upper quadrant and press against it and ask and try Murphy sign. And that's called a Sonographic Murphy sign. And so that you can do that like that as well. And that's sometimes commented on in the report. Um, and they sometimes, um, often you actually get CTs. Anyway, um, of people that have cause cystitis. Um, although ultrasound is, uh, the the most sensitive scan for it, um, for gallstones and cause cystitis. Um, and this is what they look like. So here, in this case, if we think back to the previous one where it was biliary colic Here, um, there's this kind of sludgy appearance, the actual capsule, the gallbladder itself. The wall is much thicker, and you can see some gallstones. Um, and then in the other picture again, you can see a really a thickened gallbladder. Uh, there's a calcified stone in there. Um, and that's what it would kind of look like on CT. So, in terms of management, um, what do you What do you think would be done? Just have a quick think. Oh, sorry. Yeah. I'm gonna actually go into, um What? The differences are first, and I've kind of I'll try and highlight this with each case. Um, so they both present with my upper quadrant pain and nausea and vomiting, but causes scientists, um, presents with fever, whereas Billy Creek does not, um uh, biliary colic is more episodic. Uh, so it usually there was a trigger with after kind of spicy food as well. Fatty food. Um, and it lasts for a couple of hours can often be quite severe. But then, um, resolves, whereas cause the status, that pain is constant. And, um, the bloods are and obs aren't quite indicative as well. So obviously for obs, they'll have a fever. Um, it can be tachycardia for both, to be honest because they're in pain. Um, and they'll have raised inflammatory markers, um, and potentially elevated the LP and Billy Ruben in terms of their liver function tests, which is a call static picture. Um, implying that there's some some, uh, pile that isn't going out. It's not draining properly. Um, so the difference is that for biliary colic, uh, the stones are more in the gallbladder, whereas in cost of status, they tend to be more in the cystic duct. Um, they're they're causing an obstruction of bile flow, and and then that stretches. The gallbladder increases pressure. Biles static, and it can get infected. Uh, so with cause cystitis, an 80 you approach is with most, uh, infections. Or if people are unwell. Um, which just means that for those that haven't heard of it yet, it's just airway breathing, circulation, disability, and then kind of everything else. Um, and that just provides you with a really nice, systematic way of assessing the patient and by order of importance. Essentially, um, and treating whatever you see with each step, um, and sepsis. Six. If they're really unwell, which can happen in terms of if the gallbladder perforates um, that can get really severe. Um, And so usually, uh, you usually give these patient's IV antibiotics, uh, which is IV triple and just have a quick think about what constitutes IV triple. Um, and I'm just going to say now, which is just IV marks IV gentamicin and metronidazole metronidazole doesn't need to be, um, IV. If they aren't vomiting, then it can be oral because the absorption is, uh, almost the same. It's very effective orally, uh, and then IV fluids. And in terms of treating this, uh, if they present early, you can consider an emergency, uh, laproscopic call cystectomy. But if they present kind of like a week down the line, then often, um, they are given IV antibiotics managed conservatively, and then they might have a an elective lab colleague down the line once they've kind of recovered. Um, case three. So a 58 year old man presents with upper quadrant pain and draggers. These have developed with the last 12 hours. The pain goes around to the back. There's nausea and vomiting. Um, and this time there's also jaundice. Um, and guarding. So what do we think this is now and again, how would we structure our investigations? What are the important ones? So I've just given the investigations there, but essentially, you'll have a rise Raised. White cell count raised, inflammatory markers. Basically, um um, these are normal. This case, they may be deranged, you know, Uh, that depends on the patient's, um LFTs will show a high bilirubin because this patient is jaundiced. Um, high a LP. They can sometimes show a mild transaminitis. So, um, moderately raised. You know, a l t and A S t um, again, with severe abdominal pain. Um, you would just do a chest X ray as well. An erect chest X ray to exclude a pneumoperitoneum. Um, and then the ultrasound shows a dilated CBD common bile duct, Um, and then gallstones in the bile duct. Um, and in the gallbladder, sometimes ghost. Sometimes this is hard to assess. And then you may go into more cross sectional imaging, uh, which will get to, um, in terms of the management. So these patient's usually are pretty unwell. They are often quite hypertensive, and I'll describe common syndromes that are also just common exam questions. To be honest, um, and just the next slide, the definitive. So first of all, you know, a t e sepsis six, which is to give three and take three. So, um, the important thing here is, um, if you're going through an 80 you know, give oxygen established IV access, give fluids, um, take off a lactate that's usually done with Well, an A B G if they're really unwell, um, or a V B g take a formal lactate, um, and then, uh, take blood cultures. And after you've taken blood cultures, um, start them on IV empirical antibiotics. Um and then you also catheterized them to measure the urine output, See how the kidneys are doing. And that way you can have a really accurate for the balance to see what is going in? It was going out. Um, then the definitive management of, uh this which is cholangitis is ercp along with antibiotics. Of course, because you're removing the cause of the obstruction, which is the stone. So you're trying to decompress the biliary system? Um, now, there's also so ERCPs um uh, uh endoscopic, retrograde cholangiopancreatography. And, um, it kind of makes sense. We'll have a picture. I have a picture in a bit. You can kind of see it here as well. It's an endoscope. Kind of loops loops back on itself, and you're visualizing, uh, the biliary system and the pancreatic sort of ducts. So, uh, it makes sense. And then the p t. C is percutaneous trans hepatic cholangiography That is quite different. It's often done for patient's. It's got different uses. But in this context, um, it may be done in patients that are really significantly co morbid, quite unwell, potentially frail. Um, And if they're not fit for your C P, then they can try and do a PTC to try and decompress. Um, sometimes this is also done. If there's a mass, that is, um you know, uh, is metastatic and, um not receptible. Then sometimes if the patient's are really jaundiced, um uh, or or actually have cholangitis. Then they might try PT. See, um, to try and decompress the system and go in through the skin, um, and then into the biliary ducts, um, through the liver, and then insert a drain and drain it out that way to decompress. Um, but of course, they're not removing the stone or the blockage itself. If it's not a stone, um, so it's, you know it's not a perfect solution. So how does that differ from cause cystitis so naturally? Because there's infection. And most of the time it's, uh, with the coli. Um, but, uh, as a result, there's fever. So that's the same right upper quadrant pain, nausea and vomiting. That's kind of similar for both. Um, however, uh, so cholangitis will have jaundice because there's much more significant, um, obstruction of bio flow because of where the stones tend to be. Or, um, if it's not a stone, then it's a stricture, and it tends to affect the bigger bile ducts. Um, and then Colin Giant is itself is, uh, affects the, um, the bile duct cells themselves. Um, so the cholangitis presents with significant genres, whereas, um, cause the scientists does not, um and often these patient's are really quite unwell. Um, so common presentations or Charcot Charcot's Triad is a It's a very common kind of exam question. It's the triad of my upper quadrant pain, fever and jaundice. And that's very, um, very typical for, uh, any cholangitis. And then Reynolds pen Todd is sharp, this triad and hypertension and a new onset confusion or worsening confusion. And so the causes are if you have, um, in terms of gallstone disease, if you've got gallstones, that then go into the bile ducts, um, and then get stuck there, uh, say in the common bile duct, and then cause cause Stasis, which means that the bile isn't flowing. And then it's, um, it's at risk of just, um, harboring bacteria essentially and getting infected. Um, there's other also other causes. Um, so primary school grossing cholangitis can cause biliary strictures. Chronic pancreatitis can cause strictures. Radio and chemotherapy can compression from elsewhere. Um, anything that basically causes a Stasis in by a flow, and then we'll talk about e ercp. So this is actually good to know about? I think particularly well either way, but from third year onwards, um, it can be a common communication station in Glasgow. In any case, um, we've certainly had it on a colonoscopy, But this is part of that the communication sort of V s stuff. And, um, it does come up in stations, and then obviously, it comes up in life. So this, uh, this comes up all the time in terms of consenting patient's and getting them ready for ercp. So it's really relevant to know, Um, So in terms of consenting the the main risks, uh, or there's always a risk of infection with things. Um, hemorrhage if any biopsies are taking. Not in this context, but, uh, for, uh, ercp can be used for other things. Um, and, uh, perforation. Um importantly, one of the complications of ercp is pancreatitis. Um, and you do see it in in in the ward. So that's something to let patient's know about and and be aware of, as, uh when you kind of look after them post ercp, um they're also given a sedative, and that's another important kind of fact to stress and to let patient's know about often patient's will ask if they can just be fully knocked out. And then, you know you say, Well, actually, that's not the case, and you are just given a sedative. So you'll you're unlikely to remember anything of the the operation, but you won't be fully knocked out. Um, And then, as with anything, if it's unsuccessful, there is a risk of it needing repeated. Um, you typically fast Patient's from midnight, and so that's usually about eight hours. And the procedure itself doesn't actually last very long, But actually getting there and and having it done can sometimes last an hour or two. And then what they do during we'll we'll have a picture in the next couple of slides. But they go in. They you also get a throat an s the anesthetic, uh, to get rid of your gag reflex and then, well, the patient's gag reflex. And then they kind of, um, go down with the scope down the esophagus through the stomach into the Judean. Um um and from there, look at the major pop Judy know papilla. And then they open the sphincter of oddi and go in, and they can inject dye and then I actually kind of deal with the stones. If there there's any there, um and then they they can put in a doctor like a stent as well. Um, and then you need to let patients know that they're likely to be trousers the that they shouldn't drive afterwards. Uh, they shouldn't operate heavy machinery and to give worsening rice to come back. Um, you know, they're febrile or, um, have shortness of breath. And so that's a picture again of what it looks like. Um, I think I think we had an exam question at some point that that just showed an ercp and kind of ask you what that was. Um, so it's just kind of good to know what that looks like. Um, in terms of the fluoroscopy. Um and then that's kind of just so you can visualize where it's going and what they do with the stones. So in this case, you can kind of try and pull it through with the balloon, um, and then m r c p. So don't get confused, even though they sound similar. Um, e ercp is an actual intervention. M R C P is imaging, so it doesn't. You don't actually intervene. You just get a really good image. Um, and this is so m r. MRI s are really good for solved tissues. Um, and they're particularly great for, um, biliary, uh, problems. You can really see the bile ducts Very well. So if you're ever on like there, there have been cases, um, in hospital as well. Where say, there's, um there's bile duct, common bile duct dilatation. But you're unsure if there's actually a stone there. Then MRCB can be quite good. But it's often for those that, um, you know, have, um, call it doe colelithiasis, not cholangitis, because MRI's don't get done as quickly, um, and cholangitis, you know, can be diagnosed based on ultrasound. CT and particularly the clinical presentation is really typical. Um, so you wouldn't kind of wait for an MRI? Um, importantly, with MRI's? Because, uh, the actual machine is like a huge magnet Ferro Magnetics or contra indicated to anyone with implants. Sorry about that. Extra s metal work. Tattoos. Um, uh, that's either they can't go, um, or pacemakers as well. Certain brands or certain implants. Uh, our MRI compatible, but that's always really important. to know and ask your patient's about. Um, yeah, and then those are some of the uses for for M r C p. So case four. A 28 male presents with epigastric abdominal pain for the last 12 hours came on after going out with friends and drinking. It's got some social vomiting. Um, no hematemesis this pain is going around to the back. It's eight out of 10 in severity, not really touched by paracetamol. And then I've given a bit of a social history. Um, on exam is tachycardic hypertensive, tender in the big gastric area. So what do you think this could be and what investigations would we like to do? Just have to kind of think and let's go into the next slide. So in this case, we'll do a V B. G, and it shows, um, following. So, um, that is a very typical picture for people. So patient's that bring up our our vomiting profusely. They tend to have that metabolic arrangement is because they're bringing up a lot of stomach acid, which is mostly hydrochloric acid. Um um and the and the it also contains a lot of potassium. And so the metabolic calculosis. That's both low. And, uh, and the patient is both low and chloride and, um, potassium. So that's quite typical. Um, you do an electric sticks, ray, just to rule out any preparation, and then you look at your bloods, uh, importantly, you, in this case, you would really suspect, you know, look for raised families. Um, which is raised. Um, so and I think you do see, I think, uh, normal is is about up to 100. Um, these patient's can usually are in several hundreds if they have a, uh uh, in terms of the diagnosis. You know this if let's just have a think what this could be. So in this case, it usually would be acute pancreatitis. Um, and then you would do an ultrasound just to see what What the cost could be. Because one of the most common cause is is, um uh is gallstones and we'll go through a pneumonic uh, I think a lot of, uh, you know, uh, those in more senior years or have probably heard of, um uh in terms of how to remember the different causes for pancreatitis and then a CT also shows Q pancreatitis is and cts are really quite good at, uh, imaging the pancreas and trying acute pancreatitis. But that, combined with particularly the clinical picture and then considering the raised analyzes diagnostic and this is an example, So, um, acute pancreatitis. Um, it's got different pathologies. So this is one of those, um, so this is a very edematous and steak looking pancreas. Um, and then there's different scores. Um, and I've I've given it away now, but I kind of wanted to go through it. Um, but there's prognostic scores, and then there are severity scores. So the first one, the Glasgow Emery score, was developed here. Um, and that's a prognostic score. So if you score, um three or more, um, as And if those factors are qualified, um, three or more is has a worse prognosis. Um, if, um, CRP is its own independent kind of prognostic factor as well. So if that's elevated, then it's more likely to become necrotic. Um, And then you've got the revised Atlantic classification, which is there to kind of set a standard for how severe? Um, it could be, um and so those are these kind of get banded about a lot. These these scores. So it's good to know them. And an easy way to memorize the memory scores just through the pneumonic pancreas. Uh, where it's po to age. Neutrophilia. Um, hi. Polka calcemia, high urea. Um, drainage enzymes, particular ldh, um, albumin being loved and then high sugars. Um, so, yeah, that didn't work the way I wanted it to In terms of treatment. The important bit is that no, you don't typically give antibiotics for pancreatitis unless there's a concurrent infection or they seem incredibly septic. Um, um, so the the mainstay is really fluid resuscitation because they tend to be very hyperkalemic, and we'll go through kind of why. But essentially release a bunch of vasodilators as the pancreatic gland, um, releases these digestive enzymes, uh, and all to digest itself as the sort of presumed mechanism. Uh, this cause inflammation and damage. You release series of dilators. You get third spacing. So, um, you get really leaky capillaries. Your circulatory volume, uh, reduces because it goes into your tissues. Um, so it doesn't really stay inside your blood vessels, and as a result, you get very fluid deplete, um, and so they need significance amount, significant amounts of fluid and and then those in the more clinical years. So the way you judge how much fluids you give is based on, um, factors like the heart rate, the mean arterial arterial pressure, which gives an idea of, uh, profusion pressure and how well your and organs are perfused. And you want this to be between 65 85. Um, if this isn't high enough, uh, then well, the way you can tell that is deranged, like decreased consciousness and confusion. Um, poor renal function, things like that. Um, and then you also want to monitor urine output. Um, so flu bounce is really, really important because you give these patient's a lot of fluid, um and, um, analgesia as needed. And then complications are really quite important to know, um, for a couple of reasons. So, one, I mean, in terms of medical school, it's these are common questions, um, and common exam questions and then two in terms of the timescale, um, you when you're asking for a scan as well, um, you kind of wanna if you know, if you're senior says, try and expedite the scan, you the radiographer will off. The radiologist will often ask you, you know, what are you looking for? What do you What? What does your senior think The complication is, You know, um and then that's when it's actually really relevant to to understand. Okay, What am I looking for? What is realistic? Uh, say what is an acute complication that we're looking for? You could Could there be a hemorrhage? Could there be a suspected thrombosis? Um, um and then in terms of, um, systemic ones, you often get, um, an A. K. I, uh, these patient's are are often quite shocked, as I've described. Uh, and, um, you can get plural effusions. Um, and then, you know, if it's really severe, then multiple organ failure in terms of the pancreas itself. Um, there's kind of two ways it can go. 80 80 85%. You of cases have interstitial pancreatitis, which is less severe. You first get a peripancreatic collection that then develops into a pseudocyst, um, and then the minority of cases for for Ms Acute necrotic collection, um, which then becomes this own Waldorf necrosis. And these patient's do a lot worse. There's a much higher risk of it getting infected because it's a neck roast area. Um, and they may need it sort of debrided or, um, excised, And they often end up in I t. U and and with a really prolonged admission. Um, and this is kind of what we've talked about as well. There's a risk of, uh, fist elations occurring and, um, a really common exam question as well as to define a fistula, which is a non epithelialized tract between two epithelialized surfaces. Um, and then, um yeah, chronic pancreatitis. Chronic pancreatitis is, of course, with recurrent pancreatitis is a complication. The way that usually goes is, um you kind of have this chronic abdominal pain. And then you you have to think about you know, the key functions of the pancreas, which are endocrine and excedrin in terms of, um, exocrine. So those are the, uh, secretary functions into a duct. Um, and that means that your pancreatic digestive enzymes don't really end up where they should be, or you don't have sufficient amounts. And so these patient's are often on digestive enzyme replacements like Korean, and they have to take them with every meal, Um and, um, in terms of um, endocrine functions, which is creating into into, uh, circulation. Um, they often have pancreatic diabetes, so they may be insulin dependent and then going through a quick summary of pancreatitis. So I get smashed. Is the key pneumonic here? Um, or, uh, like, in particular get smashed. And the key to, well, the key three, but particularly two key causes here. Um uh, the west of Scotland are gallstones and alcohol excess, and then other important ones are And in terms of medication, steroids can cause pancreatitis. Um, is that, uh, is a thioprine and mercaptopurine can cause it thigh asides to a degree as well e ercp as we've mentioned, um, as well. And then the key things you're looking for really is Emily's or lipase amylase. Um, well, the difference kind of is that, like pays, um, stays elevated for a bit longer. If they present a bit later, it's quite useful, But amylase is more commonly done. Um, I think because, like pays maybe a more expensive test. Um and yeah, the mainstay is supportive treatment of these patient's. This is, uh, on the left. This is like a kalg. This is by this website called Calgary Review or something like that. They did a really good, um, kind of pathophysiology flow charts. And that's that's kind of what I tried to describe in terms of you've got this big inflammatory process. Um, enzyme release causing damage. Um, and then 85% are create this edematous pancreatitis, and the rest is, and then the closing type. You often get a systemic inflammatory response. Um, yeah. And then just that's just to kind of differentiate between the two different types in terms of, um, kind of more edematous interstitial versus, um, necrotic. That kind of gives gives us a similar idea. So this is the last case. Uh, this is 70 year old, 71 year old male presenting with sudden onset central abdo pain and collapse. They were out with the family on a walk, collapsed on the street, brought in by ambulance background of smoking hypertension. Type two diabetes has ongoing abdominal pain rating to do the back and feels faint. Um, on examination, the patient's hypertensive, pale, um, you know, as a reduced GCS distended abdomen, palpable masses present. So what do you think this patient could have? Um so for this one um, this is very suspicious of ruptured Tripoli abdominal aortic aneurysm. The risk factors here is that he's an elderly male. Um, and, uh, he's a vascular path. So smoking, hypertension, taxi, diabetes. The history is pretty, um, very stereotypical of of a ruptured one where it's, uh, presents with collapse abdominal pain rating to the back. Um, and then he's also quite, um, he seems very hypovolemic. Um, and typically for, uh, Triple A, um you see, uh, pulsatile palpable central abdominal mass. That's expansive as well. Um, so for this one, you kind of just do an a t e approach. To be honest, um, if it's if it's symptomatic, this is, um, a very severe diagnosis. Um, So you would do a major hemorrhage protocol, which is essentially calling double two, double two. And then you state that you want a major homage protocol, and you often get O negative blood. Um, and you get a Porcher and you get potentially access to a hematologist. Um, that's kind of it. So you often have to put out, um, say a pair of arrest call or or, uh, you know, depending on how the patient is an actual arrest call. Um, if they have something else going on as well and to get more personnel. Uh, that's kind of, uh, sort of the classic statement that, um, that recess officer is always say that just a major hemorrhage protocol doesn't get you much personality. Just gets you the blood, to be honest, um, and then this will require an urgent vascular referral. Uh, for probably an emergency IV. Are the two options for, um, triple A surgery or treatment? Um, endovascular repair, which is IV are endovascular aortic repair or it's open, uh, open repair. Um, but it's kind of it depends on age and fitness. So if the patient is, um, is younger, sort of, uh, below 70 usually, um, and quite fit. Then they may qualify for open repair. This is more kind of often more electively. Um um, whereas if they're older and more frail, they often tend to benefit from IV. Are a bit more because the recovery is much, much faster. Um, and the benefits are pretty equivalent for them. And this is just kind of a quick history on it. Um, so the risk factors are elderly male. Um uh vasculopathic connective tissue disease as well. Uh, females. Although having a lower prevalence in terms of who has it, is there a higher risk of rupture? Um, and the presentation is usually asymptomatic. They just get found, incidentally, or with screening. But if it's, uh, symptomatic they present in and similar to this case, um, and then the best imaging is a CT angiogram, because you can properly see the actual hole aneurysm. Um, and it also helps with planning safer and IV are because you can, um, you can really see where the aneurysm is. Um, and you can measure distances really well and and plan the procedure. Um, And then there's a screening program as well, which we'll get onto. So this is a little summary I made of the screening programs. This is pretty good to know. Um, often you get a communication station in on skis that either want you to talk about a screening program or, um, bring someone in that was positive in the screening program and then discuss the next steps. Or it's, uh, an MCQ question with a patient. And then they're like, um, you know what is the next step for the screening program or when is your next, Um, when are the next to you or something? It's good to know, Um, so the relevant bits is cervical screening has recently changed where it's first checking for HPV, and if that qualifies as positive, then they check for dyskaryosis, which is a cytology test. Um, and the for Triple A. It's good to know that below three. So that's just a one off ultrasound, and they get discharged from the screening service. If it's below three centimeters, Um, and they get regularly followed up. If it's over three and then depending on how big it is, it's either an annual or three monthly scan. And if it's 5.5 or above, then they referred within two weeks, and, um, we'll likely receive treatment for it. This is a bit of a summary of all the different conditions we've kind of talked, most of them that we've talked talked about so far. So again, if a patient presents with John, this is it's most likely something. Um, well, in the right upper quadrant, pain and jaundice, it's often with, uh, biliary disease and often with the bile sort of a gallstone in the bile duct. Um, so it's either choledocholithiasis ISS or if they have a fever, which means that there's likely an infection there. Then it's Collinge itis. If they have right upper quadrant pain and fever, then you can suspect cause cystitis for college itis. The key differentiating future. There it would be the jaundice, which is, um, typical of college itis. Um, and biliary colleague will have right upper quadrant pain, but otherwise, not that much going for itself. You don't really have as deranged obs and your blood sent to be fine. Uh, and pancreatitis has, um epigastric pain. Sometimes because of the complications which we talked about kind of hemorrhage, you can get retroperitoneal preperitoneal bleeding, and you've got classic signs called Great Turner's, which is flying, bruising, um, and a periumbilical bruising as well. Um, and those are really sort of, um, classic exam questions as well. Um, and that's Collins signed, by the way, for periumbilical, um, and then, in terms of going through different imaging types and what they tend to be used for and kind of other bits of advice, um, for the abdomen, you often use ultrasound for gallstones. It's the best mentality to check, um, particularly the patient. That's quite thin. Um, cause the scientists and you can also assess for CBD derotation. I've put appendicitis in there because it's, um, not always the clearest. But if you've got a young patient, particularly if they're female, you try and prevent, um, CT or you try and minimize radiation. So, um, as a result, they often just do a kind of abdominal ultrasound. If you think they might have appendicitis, or they combine it with a pelvic ultrasound as well and rule out any, um, Ginn pathology. The key things is that for the abdomen you want to. If you particularly for bility pathologies, you want to have them fasted because then the gallbladder is still full. If they've just eaten, it's contracted down and you won't really see as much. Uh, the benefit of fasting is it will also minimize bowel gas. For Reno, it's good for checking for hydronephrosis, which can be good to check for post renal causes of AKI. For instance, if there's a renal stone that's causing an obstruction, um, and then X ray or sort of plain film, um, you often, um, do chest X rays for consolidation. So a pneumonia, um, to check for pneumothorax or hemothorax? Um, checking for pleural effusions. Checking for fluid overload. Pulmonary edema. Um, it's in terms of the abdomen, as we've sort of said multiple times. Pneumoperitoneum is really, um, good for an erect chest X ray. Um, to think it's a it's a, um, quite sensitive for it. And then also checking if the equipment is in the right place, like an n g tube, Um, and then in terms of the, um, uh, abdominal test through, they're they're used less often, to be honest, Um, because we've got CTS that our cross sectional give you more information. And actually, abdominal X rays have a lot of ready. It's a big radiation dose, um, with sometimes limited information, but they're often still used for contrast studies. They, um they can be useful for checking for, um obstruction. Um, and also for monitoring renal calculi that are radiopaque and kind of monitoring, sort of, um, doing one every couple of months and then ct good for cause Cystitis. CBD derotation pancreatitis in terms of the pass A biliary stuff. They're really, um of course great for visualizing any masses any obstruction? Um, showing colitis, abscesses, um, and then c d k u b So that one does not have any contrast? Because the, um, renal stones that are radiopaque, um will kind of light up. And so you'll just dilute that if you put contrast down. Um, so, yeah, these are some of my sources. So BMJ best practices a really good one, particularly if you're looking into conditions. Not with some textbooks can be quite useful for, um, just being, you know, on the wards. Sometimes I'm just double checking something quickly, as most is a great thing. It's great for PBL stuff. Um, just taking some stuff from previous notes from Glasgow RSD Scotland Public Health, Scotland. They have good information for screening information. Um, easy med learnings where I got the diagrams from in terms of the biliary tract. Um, surgical talk is a pretty good, um, almost conversational textbook on surgical conditions. It's pretty good, very readable. Um, radio pedia is a good resource. I got stuff from as well, um gives you good, uh, sort of imaging cases. And, um, you can scroll through cts through and stuff and see different pathologies. And that is it? Sorry, actually tucked for a bit longer there, but I hope it was useful. Try and stop sharing my screen. Um, yeah. So if if anyone had any questions and, uh, yeah, just let me know if you can pop it in the chat, Um, or just shout out if you can. I'm not sure if that's an option on at all, but probably I have a question about you mentioned that, uh, some people who have, if they have tattoos that that could prevent them having an MRI scan, Have you ever, ever come across someone who's had a tattoo in an MRI scanner or has been told they can't because they have a tattoo? No. Um, I don't think I've met that yet, to be honest, but there is so relevant, there is just a mental pigment in certain tattoos. Um, interestingly, though with tattoos, it's good to know that they're also quite a risk factor for hepatitis. Um, uh, there have been cases where people have had tattoos recently and then were diagnosed with, like, full minute um, hep B. So, um, just got to be aware of tattoos. Sometimes to be honest and ask about it as well. When you're doing like a hepatic like a liver disease screen to, you know, go through like S T I s And, um, foreign travel and whatnot and risk factors like, uh, you know, um, like being a sex worker sharing needles, but then also asking about tattoos because, uh, that that there have been some cases where that actually has has led to hepatitis, but anyway, but it hasn't hasn't come up come up yet, but they always ask, um, when you're requesting an MRI scan, the there's almost like a questionnaire that you kind of go through like that. You need to ask the patient. Have they had metal work? Have they have previous implants? Have they got any tattoos? Are they pregnant? That's kind of just for any investigation, even though, you know it doesn't actually have radiation for MRI. Um oh, yeah. In terms of the slides. Yeah, well, I'll share them with with Daniel, we'll distribute them. So that's no issue. I mean, it depends. What we could do is, um, if you're willing to have this lecture made available on catch up, um, that's one way around that, um because what we can do? This this, uh, session sort of auto recorded, Um, And what I can do after the second click a button that will allow you to watch this lecture back, um, on catch up. But it'll also allow. If you have any friends who want to watch this lecture, they can then watch that and get a certificate of attendance. Um, if they watch 80% of the video, um, so if you're happy with that Peter, then we'll just sort of make it available to catch up. Uh, and you can just go back through the lecture yourselves. Well, if there's no more questions, um, and I'll say thank you very much, Peter. Uh, that was an excellent tutorial. Um, uh, I just like to know if there's any first or second years at Glasgow, um, or elsewhere. Um, the Glasgow University Reality Society is running, um, to revision events. One first year, one second years in November, police on the 29th, and and, um, first of November of thirst of, uh, of December. You can find that on medal. Um, you can find on our Facebook page as well. Um, What? I'll also ask you guys to do is, um you'll get an email. Um, from the email that users signed up this event that will, uh, forward you to a feedback form. And if you fill that out, then you'll be able to get certificate for having attended. Um, and yet you should get that in an email. But just to be certain, I'm just gonna I'm gonna find that and put a link to that in the chat just now, Uh, if possible. Mm. Okay. Right. I've got a link now. Sorry. There we go. So that's the That's the link there. Um, not only I was getting so good, but thank you so much for coming. Everyone. Yeah. Hope it was useful trying to do it to the best of my knowledge, but yeah, if you have any questions and let us know conflict through the slides and check out the resources I've listed. Great