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Hi, everyone. Um I think we're live now, so hopefully you can hear us all. Um, welcome. It's good to good to have so many people here again. Um If this is your first time joining then, welcome. My name is Sam. Um I helped to lead the seven foundation cases teaching platform this year along with Boris, who if you were here on Tuesday you would have met. Um And today I'm very lucky to be joined by Mr James Thornton, um who is uh a surgical, who's been working at South Me this year. Um And yeah, he's gonna be leading us through some teaching on general surgery on calls, um, just a little bit of housekeeping. So, uh there is a chat function on this. Um and we will be monitoring that I'll be keeping an eye on it throughout. So if you have any questions, um if there's anything you're unsure about just pop a message in that chat, um and we will get to that um as soon as we can and then otherwise, yeah, I think, I think that's probably it. Um And at the end I'll open the little tab for you to submit some feedback, which we would really appreciate. Um And if you do the feedback, then you'll get sent a certificate out um for you to log on your portfolio. Um And also this is something that you can log on your Horus as a non core teaching hour. So make sure you do that at the end as well. And I'll remind you that towards the end. But um without further ado, I will hand over to James, um, who's gonna teach us? Um All right, thanks a lot for that, Sam. Appreciate it. Um, evening everyone. Thanks for joining in. Um So I'm just gonna be running a few uh a few useful things for starting on call in general surgery. Uh Obviously it's pretty difficult to cover one of the broadest specialties uh in medicine in a, a short time period, but I'll just be going through a few sort of key presentations. Um And then having a bit of discussion around that to give the bit of a broader idea about the things you might be seeing and things you need to think about when you're doing on call with Gen Search. Uh One thing, there's a couple of polls and um, quizzes in, integrated into this. So if you just have your phones handy, you can scan the QR codes. Um And hopefully that will work smoothly with Sam's assistance. Uh I feel pretty fancy because I've got him skipping the slides for me. So I get to bark next slide at, at points as well. So I'll enjoy that. Um Yeah, pop some questions in the uh in the boxes and you know, do you get involved? Um uh try and get, well, I know you can't speak but write on the boxes. Um That would be great. So, thanks everyone. All right. So, uh if we get to the next slide, please, Sam, and we'll just um get going. So, gs obviously my specialty, the best specialty. It's one of the most uh broad specialties in medicine and it's not all just about the cutting, although we all it um the favorite bit for most of us, it's also because of the nature of the special. You got so many other elements. There's uh frail patients, uh patients with cancer malignancy, uh young patients, everything really um covered and as well as people with surgical problems, they also have medical problems as well. So whether you want to be a surgeon or not, you're gonna get a lot from the specialty. So definitely something to look forward to in terms of the general on call roles for the house officer. Um In the daytime, the main role will be managing the take and the caring of all of the patients that get admitted via the various routes either by a GP A&E most trusts will have a hot clinic type arrangement, um which if you're not familiar with is a sort of extension of a ward usually um within a an ambulatory area where you can see patients referred in by Ed GP um uh and sometimes directly from uh ed receptions sort of walk in which can bring same challenges because not all of them are as ambulatory as they first appear. On top of that, you'll also be getting referrals from uh other inpatient specialties, uh the medics, other surgical specialties, things like that. Although in most trusts, the referral goes by the reg or the sho that's something to be aware of. The good thing about the specialty is that although it is very busy and you see a large number of patients, the majority of surgical patients will tend to be not too comorbid. So unlike working in Jerry's, when you're clocking patients in, and there's three drug charts involved, usually patients with acute surgical pathology, not always, obviously, it can be very complicated, but the ma vast majority will not have loads of other medical problems to clark in and sort out at the same time. So, although it'll be busy, hopefully there's a um sort of element of being able to sort of rattle through it. The main thing about being a house officer in a surgical firm though is that obviously it is a specialty and you're not expected to come in and know everything about general surgery and about abdominal pathology. It's very much a specialty where every patient you see will be seen by someone more senior to you fairly early on and it, you know, escalating appropriately is um absolutely crucial in this role. All right. So that's just a bit of an infection if we pop to the next slide kind of brushed over this already. Um Essentially saying it's a, it's a cradle to grave specialty. Um Depending on the trust that you work in, obviously, as well as that there are some subspecialty interests within each trust, depending on your work. For example, uh H PB in some areas or even more niche things like bariatrics. Again, things you're not expected to know loads about, but some interesting stuff that you can be exposed to major trauma center is obviously something that uh will come into the role. And that's something that people often find um really interesting and it's something to that you can take forward in your career no matter the specialty. Um And like I've already said all of these patients when they're on the ward, when you see them will have medical problems as well. So, you know, as we always say, a good surgeon is a good medic as well, but can also do the cutting. So you'll learn that element of uh acute patient care as well. All right. So just to sort of get you thinking, we get to the next slide. Um I've got a sort of word cloud thing. So if you scan that QR code, hopefully that'll work. I will share my screen and then I just want you to start thinking about some of the things you might have seen when you've done your surgical firms before. Um, and what sort of the main presentations might be either as a sort of symptom, uh group or spec specific diagnoses and hopefully you can see that sliding thing and things will pop up and let me know if that's visible on the screen. Yeah, that's great. Thank you, mate. Ok. Yep. Some gray itis is coming up already. Some of the two sort of key um presentations, appendicitis, pancreatitis, see some more people typing some more great itis cholecystitis, SCE canis, diverticulitis, great bowel obstruction, nonspecific abdo pain. Yup. Unfortunately, the most common presentation to surgical ambulatory click. But one that can hide many things. Am I still typing? Yeah, that's great that all um no deal. Um something that no one's mentioned as yet there is uh the, you know, these are all the, the general things that you expect on your uh from your abdominal causes of pain. But there's also this sort of curve balls you might see that come under general surgery. So, um penetrating trauma, for example, um pelvic trauma, uh ruptured spleen liver lacerations, splenic, lacerations, rib fractures. Unfortunately, something that comes under general surgery, uh pneumothorax, hemothorax. So we do cover a large spread of diagnoses. And that's before we even talk about all the uh malignancy uh presentations. So, bowel cancer, pancreatic cancer. All of these are things that will come in the uh acute surgical take. So yeah, hugely varies, especially, but obviously the most common is abdominal pain and then you go from there. So that's great that screen and we'll go back to the presentation. Cool. So obviously there is, we've gone through loads of presentations there and loads of diagnoses. If we were to go through all of those presentation presentation, we'd be here for quite a while. So we will think about the sort of common patient's picture you are in surgical hot clinic or on Sau. And these are the sort of things that are coming through the door. Fortunately, you got a whole team with you most of the time. So the nurses uh will often do the, the obs blood test and all that sort of stuff for you. Ed might have already done some things. So you're already, usually by the time you're seeing them have a little bit of information. Um So, and then we'll have a little think about the broader other things to think about. So this is the first one, a 19 year old fit and well, female patient presenting with uh two days of nausea, anorexia, right? That fos pain and she's now pyrexia, she's a bit tachycardic and she's got a sort of low grade fever there. Importantly, negative pregnancy test. So you can see on her blood, she's got raised CRP and raised white cells. I get, you know, you're thinking appendicitis. Hopefully, I've said it there, you suspect appendicitis, but she is stable. What is your next step? So that's going back to our, uh, presentation and we can be with me, use my hand and I'll share the screen again just while you're working on that. Hopefully, that will be active now. Great. So that has been working. Can you see that on the screen? Yeah, it looks like it looks like we've so far. All got a bit of a split coming on. Cool. So all of these options I've put here uh with a patient with that presentation are all potentially reasonable things to do. So, nothing that you've put on, there would be an absolute curve ball uh or a no, no, but I see uh there's a um a couple of people have gone for arranging ac T abdomen pelvis. We love a CT in general surgery. Obviously, that's our, our bread and butter. But on a 19 year old female patient, we might want to just maybe hold that one in reserve. Um If we need to might wanna get a bit more information first, obviously, because that's um I think radiation has potential implications in such a young patient, especially a female patient, but there are many consultants and many registers who would do that, especially in a patient who you know, sounds potentially unwell and we wanna get a definitive diagnosis. So ct scan possibility, I probably wanna hold off first and then it looks like we've got a good split there between admit and start IV broad-spectrum and arrange ultrasound abdomen and pelvis. Both of these are reasonable things to do. However, the conventional teaching with potential appendicitis in a patient who is stable is to confirm the diagnosis either by involving in, you know, bear in mind is from the position of an F one confirming the diagnosis by getting your senior to review the patient seeing what they think they're confident and they think the patient is for theater for appendicectomy. Then at that point, we would start an IV antibiotics. Usually we wouldn't start it until we're confident that the patient is for theater because it can muddy the waters. Say you give one day of antibiotics. Patient gets so better you think, oh, maybe it wasn't appends after we'll send them home, they would then get worse at home. So what I would say is the next best step in a young patient like this would be to as many of you have voted, arrange an ultrasound abdomen and pelvis. Um which is an excellent thing to do. That's ca you have to consent the patient for that in a way, verbally consent them because it is usually a transabdominal scan, but also a transvaginal ultrasound as well. Um which can surprise the patient if you haven't mentioned that to them before. And the reason we do that is because that gives the uh best possible views of the reproductive organs have a little think uh about that and post on the chat if you can, what other things might we be thinking of? Um, apart from appendicitis because an ultrasound is not very good at diagnosing appendicitis. In fact, mean, if you put on your request, ultrasound to look for appendicitis, many radiographers will reject that scan because an ultrasound is not a good way of diagnosing appendicitis. Not very good at, at seeing a, a blind, small blind ending tube in amongst all the other loops of the small bowel ovarian torsion. Yeah. Really good. Anything else anyone to think of bear in mind? She's, uh, Pyrex as well. Yeah, atopic pregnancy always gotta think about it. And you, unfortunately, if you haven't, if on a patient like this and you haven't done a pregnancy test when you present this to your senior, you might, er, get your ear chewed off a bit there. So she has got a negative pregnancy test but you know, nothing's 100% reliable. In fact, there was an incident at one of the trusts I worked in where the um, all the pregnancy tests weren't working so that the whole batch was, wasn't working. So you still gotta think you mind, you can't have 100% confidence in everything. If the story is more like an ectopic pregnancy, you've got to think down that route. So, really good. Um, and yeah, like I said if you haven't, um, even done the pregnancy test, you might be in trouble. Ut I, exactly. Yeah. So the abdomen is a really complicated area. There's, there's a whole load of organs there. Obviously, the small bowel, large bowel appendix things we're thinking about general surgeons, but the, in the female, especially reproductive organs and in both males and females, obviously, the urinary tract as well. So, um, pyelonephritis, urinary tract infections. absolutely gotta think about that too. Um And even the sexually trans infections as well, or pelvic inflammatory disease typically can cause similar pain. Um really good spread of things that only one that's maybe I would uh think might be useful to put on there too. Uh would be a a cheap ovarian abscess, especially with that um sort of defined right pain and uh pyrexia with the ray crp got think about an infective process there. And the 20 and AB is um quite common present, very similar to a um appendicitis. So, yeah, really good work. Let's stop sharing that screen and see if that goes back to the presentation. Seems like you have great. So, yeah, this is just a um I mean, the one on the right, obviously, abdominal anatomy just to keep in mind there's other organs in that other than the appendix and not just um go down that bottle neck. This other thing on the left is the Alvarado score, which you might have heard of a partially helpful score. Um Essentially, I you used to find it useful as it, you know, reminds you of the key questions to ask and the key things to think about when you're taking history from a patient with who's been referred in as query appendicitis. The score cutoffs, I would say less useful. The initial, the pre the paper that reported it claimed that if you had a score of 7 to 10, the patient goes directly to theater, think might be a little bit confident of someone here uh to base it entirely on the clinical score, but it's something to keep in mind. And if you want to um impress when you're presenting, if you give them the Alvarado score as well, um People find that um quite impressive. So that's uh that's great. Any questions at all about so are seeing a patient with right fossa pain and potential appendicitis presentation just while anyone's typing. The um other thing to mention, the last option on there, which no one voted for, which I was pleased about was book and consent. The patient for theater thing that would be getting a bit ahead of yourself. Um If you were the sort of first month f one on call, um maybe leave that to the um uh sho or reg to um make that call because sometimes if you book someone on the theater list, they'll just end up there and never who's booked this patient. So always discuss it with the senior before you book a patient on the uh operating list, which I'm sure you all would. All right, no questions there. So we'll move on to the next presentation. So this time we've got a 52 year old male who's coming to your imaginary surgical hot clinic with vomiting and severe epigastric slash riper quadrant pain with a sort of low grade fever, but significantly raised CRP and white cells and are kind of borderline raised lactate though. So let's get on to our. Thank you again. Hopefully you can uh vote on that. So this one's a word cloud. So have a little think about when you see this chat. What sort of things might you wanna ask further? This is just your line from Ed. What blood tests are you gonna want to to add on? So, Ed have done the basics, but you might want something, some other stuff I think about that and comment on the, I'll share the screen straight. Yeah, straight in there with the Amla. Perfect and the LFTs. Absolutely need to know that in this chat. Yeah, lipase slash amla. The sort of age age debate really uh different trusts use different ones. Um South Me, for example, uses lipase claim it's uh um more sensitive, less specific amylase does have its use um serum amylase. It works the same as lipase. A more useful thing that you might not have encountered is um urinary amylase sort of specialist test because that has a longer half life the lipase, you'd be surprised if you, even two days after the initial start of pain, the Amyl, the lipase might be normal. So that's sometimes if you're really confident clinically urinary, um, uh, Amy can be useful to help back up your diagnosis. H pylori. Yeah. Thinking about, um, duodenal ulcers, gastric ulcers. Yeah. So bit, little bit tricky to arrange, uh, in hot clinic. Um, more of something that you do on, um, OGD or a stool test. But definitely something that you see, if you see someone, see you're confident it's a reflux slash ulcer. Give them a H pylori stool test and then get them to start on some omeprazole history. Yeah. Fever, swinging fevers, things like that would be useful to know hot and sweaty overnight. Know gallstones. Absolutely. Lot. You'd be surprised a lot of people have had ultrasounds in the past or lots of scans in the past that have incidental gallstones that they know about. Definitely worth asking. Yeah. Arranging an ultrasound this admission. Absolutely. The right thing to do. If they've come into Hot Clinic with these symptoms, you need to get a, uh, up, uh, ultrasound upper abdomen. So, looking at the biliary tree and the pancreas, uh, looking for gallstones or gallstone complications. Yeah. Absolutely. Yeah. So you're all, you've all gone down the right route. So we're going down the, go back to the, uh, slides Yeah, we'll just go to the next slide. So, yeah, this presentation is all about all about the biliary tree. So there's a whole spectrum of biliary pathology that it's your sort of job to work out from the history in your early sort of initial investigations. What, what point of the biliary problem that patients at? So if we go from sort of least severe or potentially life-threatening to or most severe start down at biliary colic. So, looking at our biliary diagram, that's when gallstones are just in the gallbladder, just chilling in the gallbladder, not causing any blockage. But when a patient has a fatty meal, for example, the gallbladder contracts to deliver that bile to help digest and emulsify those fats as it does, which is, it's great job, but it thinks it's trying to empty the gallbladder and it contracts hard against those hard stones that are in there uh causing the patient, um severe colicky pain, but they wouldn't have any systemic features. So, you know, they wouldn't be pex and unwell, the LFTs would be normal. Sometimes they have a mildly raised uh transaminases, but usually not much. And they're not definitely not jaundiced. Those patients analgesia, tell them to avoid a fatty diet, send them on the way if you've got, you know, reassuring blood tests, good ultrasound. Next step along the sort of ladder of severity we've got uh cholecystitis. So in this case, normally cause people, some people believe in acalculous cholecystitis. But usually that just means small stones rather than large ones. Usually. What happens in this case is that where we can see on the cystic duct or at the neck of the gallbladder, the stone is impacted and obstructed there, meaning that the, uh, gallbladder is unable to drain which point it becomes distended. It's often colonized with, uh, anaerobic bacteria. Usually e coli and you can end up with a cholecystitis and eventually that can become uh an empyema or gallbladder abscess. Um And don't underestimate how unwell those patients can be. Although it's a common presentation, people do die of cholecystitis, especially if they're a bit more frail, especially if they're immunosuppressed. So, those patients usually, if they're in the state of this trap where their CRP is, is up or their pyrexia will need to be admitted for IV antibiotics and potentially consider further management just for your interest. That would usually be between. If it's a young fit patient, you'd consider a hot and they weren't improving with antibiotics. Consider a hot cholecystectomy. So, uh an inpatient urgent laparoscopic cholecystectomy or in an older frailer patient or someone that you don't want to do a risky operation. You uh could do a cholecystostomy. So that is a interventional radiology. Pop a drain in percutaneously through the skin into the gallbladder abscess and drain all that pass out and it gets some out of trouble for now. But eventually they will usually need a definitive problem if they are fit for it in due course. So think about our next step along this sort of matter of severity. If I were to say, um Raynaud's pen tab or Charcot Triad, what diagnosis are we thinking of there? And what other features if anyone could pop those in the, in the chat? Nobody fancy it. Oh, there we go. Yep, there we go. We've got, um we've got shar triad there, the, the right quadrant pain and Y jaundice. So that's what's changed from cole cystitis. And what, what um diagnosis is that and if anyone wants to chuck in the other T four Reyna's Penta sending cais. Yeah, hypertension confusion. Perfect. Yeah. Really good. So, Ris really dangerous condition and unfortunately, people do die from this fairly frequently. So we need to get on it pretty quickly. But yes, in this case, the stone or blockage is beyond the cystic duct and it's into the common bile duct. And it's meaning as you all know, bile is unable to drain from the liver. So that's causing that jaundice and on top of that, they're infected and it is, it is ascending which is less important, but essentially they've got an infection of the biliary tree that is unable to drain the management for. This is m multifactorial. Obviously, all of these patients will require an element of supportive sepsis management IV fluids or antibiotics, all that business, but they will need something to unblock their biliary tree. Usually an er CP uh if that's indicated from, from imaging to unblock the drain, um unblock the blockage, let them drink their bile, hopefully let them improve, get on top of their sepsis. And then lastly sort of move down to our blockage. Bit further down is, you know, when we're talking about biliary blockage at the level of the pancreatic duct or the ampulla can cause a whole any of the spectrum of pathology, but can now involve the pancreas and that would be uh pancreatitis caused by gallstone. So gallstone pancreatitis, which is one of the topics that we wanted to talk about in this lecture, pancreatitis. You could do a whole series of lectures on it really interesting condition. The main thing that you guys need to take away from it and when you're seeing patients in the general surgical take is that most pancreatitis in the UK, it's caused either by gallstones or alcohol. Those are the two main causes. I I'm sure you'll know uh all your usual niche causes your scorpion stints and all that. That's great. But in the UK, first things first, you gotta think about gallstones, you gotta make sure they've had an ultrasound scan. We've definitely shown, you know, even if it's a banned or alcoholic pancreatitis, you need to get an ultrasound because you'd be surprised how many people have actually do have gallstone pancreatitis and that's something that can be managed very differently. To alcoholic pancreatitis. So that's the one first thing I want you to think about with pancreatitis. The second thing when you're seeing a pancreatitis patient is that these patients get on well really quickly and they require a lot more intensive management than you think. The modified Glasgow score, the um Apache score, all these things, there's loads of tools that you can use out there to calculate patients risk on almost all clacking documents in general surgery. You'll find that there'll be a pancreatitis element to help you go through that. So you don't, you know, don't feel like you need to rot, learn all of the elements of that or if you don't have that, just google it on the day, but make sure all of those boxes are ticked when you're seeing a pancreatitis patient. But the main thing is don't just leave them be in hope that they'll, you know, sort of do. All right. They need fluids, fluids, fluids, you know, don't worry about overloading them in the first instance, smash them with IV fluids. That is what they need. It's a hugely, uh, fluid losing pathology and they do get un unwell really quick and once you've starting to fallen behind with the fluid recess, it's can be really tricky to catch up with that patients heading for it before you know, it. The other thing is if you're seeing them in hot clinic and they've got pancreatitis with a raised lipase and and they seem sort of all right, the rob are all right. Don't really be tempted to send that patient home even if they look absolutely fine without speaking to someone, most pancreatitis patients, even if it's mild on the presentation will be admitted for at least a, a period of monitoring because it can evolve so quickly. Um And this picture that we've got here is just things I'm sure you're aware of, but it's things to think about the complications of pancreatitis, which usually are divided into local i pancreatic pancreatic or systemic. So these are why these patients get multi organ failure and end up on itu and unfortunately, commonly die. 10% of all patients who present with pancreatitis to hospital will die. So, you know, it's not a condition to be taken lightly, it's serious and escalate and manage appropriately. All right, these local things all managed with by subspecialty involvement like er CP endoscopic drainage of cysts. All this kind of thing didn't need to worry too much about that, but just be aware that there are complications just before we move on. The last thing to mention is the one other cause of um obstruction that might catch you out. And that's Merisi syndrome, which you might remember from med school. Uh and sort of glossing over it essentially, if we look at our little diagram within the gallbladder, there's an area called Hartman's pouch, which is the sort of an outpouching at the bottom near the cystic duct stone. A large stone can sometimes become lodged in there and cause external compression on the common bile duct and cause that ascending cholangitis picture. So that's me syndrome don't need to say too much about it. But impressive if you pick it up or think of it in your differentials, so that's fine. So I've talked about that for a little while, but pancreatitis is one of the key things. So any questions about that and sorry that I've rattled through it a bit. It was just, just while anyone's typing, I think there was a question earlier and I, you've already, you've slightly addressed this already, but it was just about lipase and amylase. Somebody just said for pancreatitis further to checking serum amylase. Could you also ask for lipase in the same blood sample? Yeah, that's a good question. So you wouldn't normally do a serum i blood lipase and amylase in the same admission won't add too much. But as I mentioned, if you've got a amylase that's not raised or a lipase that's not raised. But the uh history is uh very convincing for pancreatitis. In that case, I would consider a urinary amylase to see if that's raised and you've just missed the, the, the peak of the lipase. Um which kind of leads on to my um further thing I forgot to mention is pancreatitis diagnosis. There is one of the sort of controversial things, but it's sort of widely regarded that there are three factors that you think about when you're diagnosing pancreatitis and that is clinical diagnosis. So, epigastric pain radiating through to the back, right? Radiological findings. So, CT are ultrasound findings consistent with pancreatitis. So, CT can be very sensitive at detecting peripancreatic stranding on the scan and pancreatitis. Uh and then lastly um raised biochemical marker amylase or lipase. And you need two out of those three to make a diagnosis of pancreatitis. Often we get referred a li a raised lipase by IUD as pancreatitis. But with neither of those are the two features and that would not be diagnostic. Raised lipase is nonspecific. You can get it very commonly actually in uh basal pneumonias will cause a raised amylase or lipase. And ob and ob confusing me with that can also cause right upper quadrant pain, but that's something to think about. Um As obviously, they shouldn't be on the surgical ward. It's a medical problem. Um best managed by our learned medical colleagues. Hopefully, that's answered that. I haven't seen any other questions there. So we'll move on to our third presentation. How am I doing a good time? Yeah, we're doing all right. There's only four presentations. So don't worry. Um This one a little, a little bit different as uh older, older female patients. Uh 86 year old has turned up to our uh surgical assessment unit Clinic. Uh Ward assessment unit depends on which trust you, you work at, they'll have a different name but often where the GP referrals come to. So she's been getting worsening, abdominal distension and vomiting after every meal. She tells you that she's opening her bowels. But when you question her it's mucus only. And then in terms of past medical history, she has a f on Apixaban and she's had an appendicectomy sometime in the distant past. So, first of all, let's, I run out of, uh, um, quite the same. Just have to do this old school way. First of all, what sort of things people are thinking about for a differential diagnosis, pop them, pop them on the chat this time, rather than on the, um, quiz. I'm afraid mesenteric ischemia. Very nice. That certainly. Oh my God, pa ischemia, bowel obstruction. No great. And anybody wanna take a punt on narrowing it down on what type of bowel obstruction, small versus large. Obviously, you might not have quite enough information to be confident, but yeah, small bowel obstruction and then come up with ischemia. So, yeah, that, that, that's really good. So obviously you haven't got quite enough, uh, information here to make your full diagnosis but worsening extension, abdominal pain. We're worried that this lady's got bowel obstruction and now with pain got to worry about. Did you, have I mentioned the, I can't remember if I did either that or not, uh, no abdominal distension but not pain. Uh, so I don tension without pain obstruction. Once they start to develop pain, like you've all said, you gotta start worrying about ischemia. The reason they get ischemia is, uh, usually microvascular uh, distension of the, of the small bowel, unable to perfuse itself. Once you get an area of ischemia, you then get an area of necrosis, ultimately ending in perforation and in a patient like this perforation, uh, of the small bowel would be very life-threatening. Yeah. And now he's seen someone start to think about initial management gastric decompression. Absolutely. If you present, found this patient and then you present it to, to me after and you know, you saw her three hours ago and she hasn't got a NG tube in, I'd be, um, no, I'd be disappointed that I would educate you that gastric decompression is absolutely vital in a patient presenting with features of bowel obstruction. Either, you know, either small, if you're not sure whether it's small bowel obstruction, large bowel obstruction, you know, large bowel obstruction, NG tubes, unlikely to be that helpful. Just, just put the NG tube in either way. Cause if it's large bowel obstruction with an incompetent valve, you can ma you can manage it like small bowel obstruction to a degree. But the number of times I've seen patients who haven't had an NG tube because, oh, no one was available to do it or whatever and they've sort of forgotten about and they vomit aspirate and die. You know, it's extremely presentable. So, putting an NG tube in getting your IV fluids in the usual d drip and suck. Absolutely. And, yeah, I see Freddie there summed it up. ND tube IV. Antibiotics. Potentially. Often we were, we haven't got our blood if our cop was through the roof. Definitely because they can get bacterial translocation when the bowels stretched, uh, and peritonitis from that with or without perforation. No, by mouth. Absolutely. IV. Fluids. Yeah, drip and suck and the ct abdomen and pelvis. This is the time where we love a, uh ac t of the pelvis and an older patient with bowel obstruction. We really wanna know what we're dealing with and I see someone's gone to a etiology here. Fati fatima, um, adhesions due to surgery. Yeah, we've mentioned that she had an appendectomy in the past. That's absolutely, um, in most patients in the UK adhesions. So, stop whether or not due to surgery is the most common cause of small bowel obstruction. Can anyone pop a few more things? And there are some other common causes of or not common causes of small bowel obstruction. Have a think cancer. Yup, hernia. Yeah. I'm glad someone said it absolutely. In a patient like this, you've got do a thorough abdominal examination and hernia examination. These patients, a six year old female will be absolute barn door for a femoral hernia. So make sure you've checked, uh, for a femoral hernia in the groins. You'd be surprised how often people have them and they're not complaining of groin pain or anything like that. But you, you know, if you find that hernia and, you know, if you're able to have a go at reducing or if someone can reduce it, then you've really got them out of trouble. If not, if you've uh not examined them and they go through AC T scan and the CT diagnoses hernia, it's a bit embarrassing. Should be able to see that on examination. Obviously, a small hernia or in an uh obese patient, you might not be able to in a slight patient. Um, you need to at least have examine for, for hernia. So any patient with obstruction features, you definitely need to check for um hernia. You know, people say, oh, if you, you know, haven't done ad re haven't put your finger in it, you put your foot in it. That's true. And that relates to cancer typically in a large bowel obstruction, if you've not checked for a low rectal cancer. Um And the patient goes to the CT scanner, the CT scan doesn't uh see low rectal cancers very well. You're actually more likely to find it with a clinical examination. So if you haven't done that, yeah, you're in trouble. But more so than that in these patients. If you haven't checked for a hernia, then uh you need more trouble because that's the, the first thing you've, you've gotta exclude whilst we got that. Yeah. Can, so, it's definitely a cause of large bowel obstruction. More the most common cause of large bowel obstruction would be a bowel cancer rather than adhesions. Small bowel obstruction. Tumors are more unlikely you can get, uh, lymphoid tumors of the small bowel that cause obstruction or, um, rarely gastric gastric outlet obstruction caused by gastric tumors. Um, and even more, rarely massively, uh, uh, enlarged pancreatic tumors calling duodenal level obstruction. But, but yeah, definitely something to think about. The other things to think about are more, uh, niche, but, um, things like gallstone ileus. So it's a misnomer. It's not, is, it's a mechanical obstruction caused by a gallstone eroding through the gallbladder wall and into the duodenum where it then works its way down, usually blocking at the most narrow point of the small bowel, which is the, um, ileocecal valve and then causing small bowel obstruction. It's actually fairly common. 10% of small bowel obstruction will be caused by, uh, um, course like this. So, yeah, definitely something to think about and you'll see that on imaging. So it's, you know, always a good x-ray or CT scan. One thing to mention is with these, typically, obviously, the historical teaching is an abnormal x-ray nowadays that, you know, that's a needy sort of thing when you're in general surgery, do an abdominal CT scan, it will give you a lot more information and it'll help you guide, uh, surgical planning. So that's the, the right S scan to do for this patient rather than serial x-rays. So I've Whitted on about that one for a little while. Apologies. Do you just write any questions that you've, um, you've got in there whilst I'm talking and I'll, I'll come to them afterwards. Terms of management, this sort of patient would give them a good 48 hours, 72 hours of conservative management. If they're not improving after that, then most likely we'd have to then have our sort of pre op considerations or chat, whether this patient is suitable for a uh emergency surgery, most likely a laparotomy and possible small bowel resection depending on what it is or for palliation because that's sort of the way we go. There's a couple of intervening steps, you know, during the NGG, we try things like Gastrografin, um which basically is a, has a high osmotic load and reduces edema in the wall of the small bowel, um and can resolve obstruction. Um So that one's something that we'll try, but you'll, you'll see that on, on the ward, right? Any questions about small bowel obstruction? Can we get to the next slide? Uh Sam. Yeah, that's just the subtyping. I'm just talking about the, the abdominal film. Um And those dances kind of now updated. Thanks to the um CT scan. The one other thing I did want to mention was the, before I forget was this, she said that she still was opening her bowels. That is something that catches a lot of people out. If you've got a quite proximal small bowel obstruction, obviously, the small bowel still makes large amounts of mucus by itself. So patients will still open their bowels, but it will be mostly mucus. So the trap to fall into there is when you take in history, you say, are you still opening your bowels? And they say, yes, you go. Ok. Well, it's not bowel obstruction. Uh something else move on, you know, dis either discharge them or think, you know, start thinking about uh down other lines. They will still open their bowels. But we be basically you could say, keep that in mind. All right. And we got to our fourth presentation time. You all right. So yeah, last one, sorry, I've spoken a lot 91 year old again in our hot her neck with pr bleeding dementia patient who is in the care home. And when you examine him jumps off the bed, when you touch him in his left eye fossa and his para and tachycardia list of his uh medical problems though. He's got a few. What would you be thinking about in terms of your differential diagnoses? Yep. Straight in there with the, with the two headline ones which is great diverticulitis or c you know, a left-sided colonic tumor of some kind. Sigmoid rectal tumor. Yeah. Perfect. Perfect diverticulitis. Yeah. Diverticulitis. Y all good stuff. Um Yeah. Absolutely. So, pr bleeding is one of those sort of nightmare, uh, things that we see on the surgical tape because just painless pr bleeding alone, we do very little for, we reverse their anticoagulation. If appropriate, we basically keep an eye on them. Sometimes we just give them some broad perspective. Antibiotics for the sake. It's one of those sort of unsatisfying things, but very rarely do. We do much else. But with pain that makes us think about either in this age group, most commonly diverticulitis or depending on, you know, how they had bowel cancer, screening all these things you might get from their history. Could this be a first presentation of a, uh, either locally eroding cataracts or cancer, um, or a perforated tumor? Um, absolutely. Things to think about. So, yeah, when you start thinking about that, what sort of, uh, you can take ischemia? Yeah. So that's, that's a, that's a good one. And I'm glad you said, um, mesenteric ischemia rather than, um, some of the other stuff we think about. So, I like that gives a good point of distinction. Sorry, mesenteric ischemia versus ischemic colitis. So, mesenteric ischemia, they have a clot in the mesenteric vessel, supplying the, um, bowel, that area of bowel becomes hypoperfused, sloughs off its wall and need becomes necrotic and dies, presents with pr bleeding. That is a surgical problem managed in a number of ways either by interventional radiology, if possible, sometimes with, uh, localized colonic resections. But yes, ischemic colitis also causes uh lower G I bleeding. And again, it's from a similar pathology, but it's microvascular this time rather than macrovascular, the small vessels usually due to hypoperfusion diabetes. Things like this. The uh bowel, the mutation becomes hypoperfused, sloughs off bleeds. That is a medical problem managed by improving their overall medical state. So, improving their hypoperfusion, improving their diabetes, whatever things like that, something to think about when you're referred pr bleeding, um, it can sometimes be a medical problem that needs to be managed in a different way rather than by ourselves. So, that's great. Um, yeah, so with this chat, what, what, what investigations would you like to do? Um, common on and it's one of our, it's one of our favorites on general surgery alongside all our usual blood tests, sepsis. Disc. Yeah. Absolutely. He's tachy Pyrex. He's, he's frail. He needs to get on top of this early doors. Absolutely. Anyone else? What about imaging wise? CTAP. Yeah. Absolutely. As long, you know, e early doors we're getting, we're treating this guy, we're getting some bloods, we're getting some clotting to see if he's, uh, you know, got low platelets or something that's driving this bleeding. Um, you know, is there any red herring? Sometimes it's worth examining the rest of him. Chest x-ray, examine the rest of his abdomen. Could we just be missing this? Could he just have hemorrhoids? Definitely need to examine this trap? Definitely need to do a digital rectal exam even if it's tricky cause if he's just got bleeding hemorrhoids and a pneumonia, we don't wanna go down the wrong line. Yeah, CT of the pelvis cause we're thinking about diverticulitis. And then I put colonoscopy here. Um It difficult to ask in this format but essentially to say an acute colonoscopy would, is not helpful in uh acute rectal bleeding. First of all, uh un, unlike with an upper G I bleed, you can't get to what the bleeding point is. And with an acute infected colitis, if that's the case or a tumor, you risk making things worse and perforating the large bowel by doing a colonoscopy um as well as not helping them. So we don't do that, but we would do that six weeks or so down the line. If this is diverticulitis after the episode is settled to make sure that there isn't a um colonic cancer causing this or a younger patient, a um inflammatory bowel disease, that's great. And if we go on to the next slide, yeah. So this just talks about the Hinch classification of diverticulitis, which I wouldn't expect you to know about this kind of an MS S thing. But it's just something to uh keep in mind this is a sort of ct classification of diverticulitis ranging, this is a modified one but ranging from 1 to 4, essentially, it's become a bit ID. Hence why it's modified almost all of these patients will be managed with IV antibiotics. In the first instance, some units do trial oral antibiotics. But again, depends on the patient. This one would definitely, I antics and then if they have a collection, either IR drainage or if they're not even fit enough for that prolonged IV antibiotics. And then if they have perforation and they're well enough for surgery, then they will have a Hartman's procedure which is a um acute resection of the uh colitis and a formation of an end colostomy. So I I, you know, if you don't form the colostomy, then it's just an, it's an anterior section in this patient. You're not gonna be doing a joint because of the, all the various risks that we can get into another day, but infected uh ischemic bowel, you do not join. So you bring our Stover. Hence why you do a Hartman's procedure. But that's obviously something that will be being, decision, being made by uh someone above your grade at this point. Bye. We'll just go to the last slide. It sort of relates to what I wanted to say there before that anyone got any questions about diverticulitis, pr bleeding or any of the things that you've wanted to ask about. There's one question James about, would a CT angio be helpful in acute bleeding? Yeah, great question. So, in this patient with, with where we think of diverticulitis probably wouldn't be your first book call. But if someone's absolutely, if someone's presented with torrential uh pr bleeding, usually painless ct angio. Absolutely, the right thing to do. Colonoscopy won't give you any information at all. But CT angio will also usually, if you have interventional radiology in your trust allow them to do the therapeutic at the same time. So they can uh embolize a bleeding vessel, um which can cause problems down the line. So usually a branch of the inferior mesenteric artery, which then causes rectal ischemia down the line and ya ya ya da, but it will stop the um to bleeding. So, yeah, great question. Ct Angio absolutely helpful in in ent bleeding, right? And you know, I've said surgery not helpful if CT Angio can't find a bleeding point or there's diffuse bleeding. The last part of call is um laparotomy and colonic resection for bleeding. It's very rare. Usually with nowadays, with how good irr they are able to sort it before we need it. All right. No other questions there. Thanks for flagging that sa So just some top tips for general day to day um on when you're on the ward with the general surgery before you're on call or um when you've got your on calls coming up is learn how to request our specialist in in investigation. So, colonoscopy, sigmoidoscopy, OGD. Um and when you're requesting them or being asked to request some an endoscopy, think about why we're doing that test versus another one. loads of trust it in different ways, paper request sometimes which is a nightmare or uh online on ice and then mrcp and er CP again, very specialist things. Um and not the sort of thing that you, you should just request Willy nilly because all of those requests will be vetted by a consultant. So you need to put a good amount of information on there and it needs to be a convincing reason. All of these will be discussed with your consultant. So if on the ward and the consultant says, oh yeah, I get an, er CP for this guy that's the time to stop and be like, oh, just to clarify, what do I need to say on the request? Because, you know, it's a lifesaving procedure but it's also a high risk procedure. 1% of uh there is a 1% mortality associated with, er, CP. So 1% of all patients who have, er, CP will die. Therefore, you don't just request it willy nilly. And as a result, the radiologists are pretty hot on um who requests it and who, who does it right? And it's either radiologists or gastro drugs depending on your trust or, or HPV seven. Um, yeah, learning how to book patients on the emergency list is a useful thing to be able to do. You know, I've already said don't be doing it on yourself, but it will help your sho will be grateful if you know, how to do it as well and they can talk you through that. Um When the consultant says, book this person for a lap care, book, this person for lack appendix, so on and so forth. I said, don't forget the basics, obviously easy enough to say um harder to do in practice. But what I mean by that is when you see a patient in hot clinic, you know, they've got abdominal pain. Don't be the guy who's like, oh yeah, this guy needs a spy glass for his uh fulminant obstructive, blah, blah, blah. You need to do the pregnancy tests, do the examination check for hernias, do the dres, all the things that are expected from a good thorough clocking is the stuff that will give you the information and make sure you're not missing things. You'll find that the consultants and the registers work at speed and they will take your word for it with things. So if you're, you're the person who's spending the most amount of time with that patient. So really crucial part of the of the team to get all that information at that point. So you don't get the basics escalate early, either for patients that you've seen during the admission or patients you're seeing on the ward or overnight, particularly post-op patients, general surgery patients can get unwell really, really quickly. So one of those specialties um with a really high acuity and a sort of fast turnover, you know, you'll, you'll see it yourselves. Patients with perforation. That's why we rush the theater and that's why consultant general surgeons continue to have a bad life is because these patients do need to be operated on overnight in comparison to some other surgical specialties. So yeah, escalate early get people involved. People want to know, especially about um any worries at all about POSTOP patients and yeah, get involved. It's a really, really broad specialty, really fun. There's something for everyone really, whether you want to be a surgeon or not. What I mean by getting involved is um I think almost every uh f one who's ever worked with me on call. Um I've got them to do it at least an abscess or something in theater and you get a, you know, it's a real opportunity to get a taste for what it means. Like to be a surgeon, what it means like to control that operating list and hold the knife. Um And all those things are, you know, are really rewarding and most general surgeons are enthusiastic about their specialty because you have to be all right, because it's uh it can be quite, quite challenging as well as rewarding, but it's a life saving specialty and it's something that hopefully all of you will enjoy. So I think that's everything. Thanks so much for coming. I think I've finished up ba on time. Um If there's any questions at all or anything, please do just, just put them on there. I hope you all look forward to your general surgery placements and, and do you think about it as a career? I didn't want to be a general surgeon when I left medical school. Um, but I really enjoyed my f one job in it actually. Um, and from there developed more of an interest taste weeks and these sorts of things. So, keep an open mind. Say I'm really great specialty. Oh, yeah, I do do the feedback. That would be really helpful. Thanks so much James. Um that is so helpful. Um And I think having done a general surgical rotation this year, I feel like that, but I wish I'd had all of that at the start of it because that is all so relevant. So, thanks so much, mate. Um Thank you so much, everyone for coming. Um The link to giving feedback is in the chat now. So if you could fill that out, we would really appreciate it and you will also get a certificate so you can then log that on your portfolios. Don't forget to go on your learning log and add an extra hour of non core teaching. Um I know that it seems a little bit like you're going to just sail through getting 60 hours at this point in the year, but you will very likely sort of be looking around for some extra hours to log when it comes to your a RCP later. So definitely log that now. Um and the link to the next session which is on next Tuesday, which is looking at some general on call stuff, um not specific to any particular specialty, but looking at sugar management. Um and then looking at some sort of like dolls and dealing with agitated patients death verification, um some general tips and tricks that's next Tuesday. So the links there to sign up um and Freddie, if you're not a member of one of the trusts in the first question. Uh, no, don't worry about it. I don't know if you have to provide a link. Um Just put, I'm just, I'm just looking at the form myself. Um, don't worry about it if you can just put a random one, if not, but um, if you don't have to put anything that was fine. Um But yes, say that again just at North Bristol's where I put North Bristol. Um Yeah, that's great. Thank you everyone for coming and hopefully see you next Tuesday. All right. Thanks everyone. Yeah.