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all right? Yeah. Absolutely. Yep. We have you guys mentioned vessel innovation? The struggle somatic. Yep. Um, so to answer fully. So you're right. So basically, you get paramedical gain first because your visual enough just less explaining enough, which is a visible enough which innovates Appendix Get inflamed first. And that supplies the T 10 to 11 Dimotal, which surprised umbilicus. And then a few days later, it migrates to somatic know so and that is localized being s. So you get the right left for something typically, so it's quite good to know why that happens. It's a very it's a favorite surgical question when you go on what grounds, typically after a registration consultant. So it's good to know I'll just go through the the different diagnosis you a CD and eat. Um, because we see patients. Abdominal pain is good to consider those differentials, Um, most often and not you don't always get patients preventing typically currently coping and then right, like for superior to get patients with abdominal pain generally don't know pain, so mesentry of the night is so basically, it's quite commonly seen kids and it typically present with high grade fever and It's typically followed by an episode off and a viral load e, a viral infection, and they usually put them abdominal pain, usually quite unwell and usually have high grade fever. The gel that they tend to be. So she's in a buff. We should consider in your differentials renal colic, Hallion like, in this case, because off the nature of the PT, usually we don't call it. You'll have, um, pain coming in spasms. And if you see a patient renal colic in any, want to see a patient you know college. You remember that patient. The darkness renal colic because the patients don't be quite restless, that the British scream and shout in pain. Um, and you have to give them algesia. Usually morphine. A repellent Fridays. Separate differential. But usually patients present fever, high grade fever, chills and right go on during depo be fully loaded with leukocytes, nitrites and sometimes blood as well. IBSS is kind of red herring in this case. Usually it's a psychological back. Know sees patients presented symptoms alternating between diarrhea and constipation. But it's the first questions, quite a straightforward question. Um, paramedical being followed by right Left was a big cross go over your appendicitis. Um, it's very easy not to miss out on this diagnosis, so we're going to be next question. All right, So the same patient was diagnosed with dependence itis. Instance, You're due for a laparoscopic. An effect on me. You'll be assisting a register on this case. He then proceeds to question you about the anatomy of the pen dicks. What's the most common position to find the appendix? All right, I'll send it there. All right. So Yep. So it's retro cecal most of you guys. All right, So the pendant is retro cecal in san fact addition of the time and usually 25% usually pre a Leo. So but most times a tricycle. So it's quite good to know then, after me, of white, for testicle in particular, during laproscopic and effect to me. Because when you go in with the camera, um, you can be stress appendix, and you have to basically dissect behind the island and behind the cecum. That's where you find the appendix. So you should know the net me quite well. But most guys got the right answer. So going, Teo, the lecture on it and decide. Is the definition wise? Quite straightforward in a kid intermission Appendix. Um, they're different causes. So most commonly due to figure it's a pickle matter. You can get foreign bodies. You can get lymph notes and get tumors. And as you can get parasites and worms tumors, um, you should be quite wary of tumors, especially in patients are really patients presenting with and decide it's like symptoms. So when you do a CT of the abdomen pelvis. So if you don't like the scopic exploration, um, you might find a human appendiceal tumor became excited. So you should be quite wary of that when middle ish or elderly folks present with writing that for 13. Okay, so clinical features like I mentioned earlier, you get paraumbilical pain and then write a letter for Sabine to believe me. But this point, anyone just put in the check where the money's point is okay, right? Someone mentioned one third of the distance. So, if quite common, to get it mixed up 72 distally from the line from right and you're spraying, explain to them because I don't forget to mention the location off the off, which enter spray looks like it's left and right. So, surgeons about specific when they want you, Not to me. So most of you guys will write for a stupid from the right anterior Spiriva, explain to the umbilicus Defend, make money. Fine. Bonus from possibly is. Okay. Um, you can get to get north and vomiting. You can get low grade fever like you mentioned earlier, and you can get you can get apartments. Tons of just roughing sign and so s sign. Um, so rough thing signed, like we mentioned two weeks ago is basically right. Elect for therapy when you park it the left iliac fossa. Basically the mechanism simple. There's a 10 room off and try to me, um, basic by compressing the left leg for PSA, you're compressing. It was right, like for PSA. And if there's an inflamed appendix, that will cause the pain to become worse. So this simple explanation So a sign will explain it later on. So the diagnosis for appendicitis So it's basically a clinical diagnosis based on a good history and upper examination. Um, if you go to hospital Saudi So when you when you come in at four. I want in a fight to. You'll notice that registrars and core training it will just throw feet doing scan straight away your straight. We go for a CT. So the old school medicine of the other medicines being lost nowadays, which I don't agree, but hey, hope that's the way it is. But being good if I want to be in good afraid to I'm sure all of you will take a good history and examine the patient thoroughly before coming to a differential. Okay for treatment. If you're thinking off appendicitis, initiate yourself to Six Street a week. Um, like I mentioned earlier, give three and you take three. So you're give three would be IV antibiotics, IV fluids and give high flow oxygen. Take three. Would be catheterization for urine output. Get elected, eat and get your blood test on you. But cultures done okay. And then you admit the patient and you discussed that your registrar, um, most patients go for surgery. They either go for an open a laparoscope and sector me more center. Saudis do it laparoscopically, but if their concerns is a perfect appendix, then you go for an open approach. Um, there are some surgeons who advocate conservative treatment, which is basically just I went to about six and a fortune weight. But there's no evidence behind it, and most agents still prefer to go find appendicectomy. All right, so so right side. So basically, sweat sign is elicited when you basically do hit extension. The idea is that the panic suspect a cycle and your stress major muscles is in the retro peritoneum. If you extend the hit, you bring the Suess muscles forward. And if that comes in contact, inflamed appendix will be quite painful for the patient. So to relieve the pain, you can ask a patient, the flax, the hip joint and Internet rotate the hip joint. Okay, um, not very sensitive. You can do it. And you know patients that say it's painful. Most of the time you're not sure where the psychological, but it's actually the sound present. But for exams and all skis, mention it four months. Okay, All right. So we'll go for the next light, right? This brings us to the third question. So now you're seeing a 48 year old gentleman who presents with worsening abdominal distention and domino pee, and he has been vomiting for the past three days and be unable to pass stool inflators for the past two days. No fever, no weight loss and lots of appetite. But however you notice that he underwent an open appendicectomy for perfect. And this side is two years ago. Given the likely diagnosis, what would be your initial management? Oh, sorry. Uh huh. Uh huh. Right, So ended there. Right? So most of the right answer. So you're thinking about bowel obstruction? This case, the initial management would be the drip in suck. Basically drippers in giving IV fluids and suck, but putting an n g tube. So not any anti tube in particular. And Anderson's N g tube. So they're large bowl and eat chips and a useful for drainage. And, of course, we keep the patient, you know? Okay, so just move this. You're right. The fourth question So based on the patient's surgical history, indictments is horrible structure in what is the most likely it'll get obstruction. Yeah, All right. So ended there. Right? So almost every day, right? Answer A to the medications. So if you've noticed the previous question, you know, it is a surgical history off going for an appendicitis an effect on me two years ago, so additions might have developed and they're the most common cause off obstruction followed by hernia. Okay, we'll talk a bit about bowel obstruction, so it's an F. I want me to start your general surgery block. You'll see lots of patients with obstruction, and, um, you tend to feel a CT and fully a trip in suck. Okay, so we'll talk a bit of a bowel obstruction. So they're different types there. Small bowel obstruction, large bowel obstruction. And there's something called pseudo obstruction or Gilbert syndrome. They are most commonly seen ugly folk, basically patients. We have electrolyte imbalances that just hypokalemia causing ideas like symptoms, so they have no mechanical obstruction. Percy. It's just that the both not work because of each and also, uh, low potassium was commonly clinical features would be warm eating, um, so vomiting been will be an early feature of small bowel obstruction compared to last for obstruction, and you can get absolute constipation can get in a big puff liters, and you can get an empty rectum on rectal examination. Most of your license and everyone will be doing rectal examinations and you know, for for anything on your surgery be doing, do a rectal examination every patient on define and direct him in a patient presenting remitting. Think about structure fevers. Highly unlikely. Um, unless they have a perforation. If you think that they have a perforation, a fever, speak just seniors immediately and stuff up to six. The cause is like I mentioned earlier, so additions are most commonly the cause full of my hernia melt and see. It's highly unlikely for small bottle but large bowel. That's course. So your colorectal cancer is the chief course of flash. Well structured strictures can cause obstruction as well, especially in IBD like Crone's. Um, you can get things that volvulus into reception and can get a foreign body as well, causing obstruction, which is quite rare, that uses again. It's mostly clinical. A good history terrorism examination. You can do blood tests to guide you diagnosis. So you like to look at your white cell count. You'd like to do a VBG any BG to get your lactate and your CRP, Um, you taking on the skinny, a worsening ball, ischemia and impending perforation. We're going to monitor the lactate the left. It keeps going up. Let the registration, because this patient in to go over go teeter. Okay, you're still getting erect Chest X ray and abdominal x ray. Um, why erections X ray is because to look for any of the diaphragm but taking off a perforation. Okay. And lot. Last but not least, do a CT of the abdomen and pelvis to look at where the transition point is and to guide operative management the patient. We'll talk about the differences off small bowel and large bowel obstruction on extra. And the leader slide management again a 30 80. He's a drip and suck. Give the patient algesia antiemetics get the patient fasted and again in the sense of perforation. Like if the if the abdomen's part in it ic if the vision of being shocked in ships up to six and inform a senior in a jittery All right, so this brings us to small bubble off on your left and last extraction. You're right. There are key differences on how you look at with a small boat. Large bone, X ray. Can anyone give me the features of small bowel obstruction on X ray? Just put it up on the chair over and want to speak up. Yeah. Yeah. Okay. So all right. Includes some. Everyone's mentioning central and belly can even peas. Yeah. So it's basically right. I'll just go back to previous, like, Sorry. All right. So for a small bowel, obstruction is Yep, it's Central. You can see that. Really? Combivent is, which is basically the line extending through the whole length of the bottle. And if it's obstructed, the damages exits tree centimeters. So when you go on computers in hospital, that software compacts and you can use arrows to measure the diameter, If it's more than three centimeters, then you eat a small bowel obstruction. Okay. And you can see fluid levels, usually an obstruction in small bottle. So you can see in the case in you can see every levels. Okay. What about last little obstruction? You have good. So, yeah, you can see Hallstrom so frustrating is are approaching here off the bowel wall and usually painful and for diameter. Yup. It's more than six centimeters. Okay. A quick tip for cecum for the cecum is is she more than nine centimeters. So you can for the tree 69 room if you guys have about it. So three for small bottle, six for large bowl and 94, the cecum. All right, good. All right, we're going to the next question. So sorry. I just have to stop you there. We just have a quick message from Incision UK. Um, just a few minutes to share about global surgery. Um, I do. You just wanna Sure. Yeah. Present. They don't get the honest shake screen if you don't. Yeah, yeah, I can continue. Sure. Uh, let me know if you can see that. That's why you Yeah. Is it only gold scream sometimes? Yeah. Yeah, this year. Okay. Okay. So hello, John. I o m t'adore a and I'm decision president this year. I'm just going to give you a very short of work. You on global surgery and on our work. A decision. Okay, So global surgery is on what disciplinary field Aiming to provide improved and equitable surgical care. Of course, international healthcare systems. And, um, if you are interested in global surgery but don't know where to start insulin in case would be a Great Britain book for a future career. What is interesting? Incision Okay. It is a student and junior doctor led group and we are working to promote access to save surgery for everyone. We currently have a committee or 15 medical students from across the UK and original leads presenting each You gain university our work. So we work with a national international partners to promote a little surgery and we're working three key areas. So we work on education on and we have global surgery workshops, podcast, monthly journal clubs, conferences, events. We do research quite a lot of research, actually. So with the national cooperative projects were originally 10 committee work together and anyone interested also conjoined on we have advocacy focus projects that just like poster presentations or articles or we have online and face face complaints how to find us. So in order to find more detailed information, you convinced our back page. We are also very active on social media, so you can look, have a look on Instagram, Please. Twitter. You can come along to our events to start terrible surgery Journeys of keep an eye on our social media because were advertising them very regularly. And, um, I think we're just sharing the group chat more details on like the links that you can find us. That, and two big upcoming advance would be the global surgery Hackathon, which will be in April, and it has been taking place last year. Response. We can find some information on our webpage, and also we will advertise it in a couple of weeks on social media as well. And we also have the smart protocol where we're recruiting originally are leads, and my colleagues will shampoo will share the The ankles were supporting the project, so thank you very much. It's a very short presentation, but if you have any questions, please drop them in the chart. I'll be around here for a while, just like cancer enquiries and email us. It's incision you, kate at gmail dot com or drop us a message. Or are Social media would very keen to get people involved in group of surgery such an interesting field, which, unfortunately might be like under represented in the medical curriculum. So you want to find out more, have a chat with last time, and you can join this off for our projects. Thank you very much. Thank you. Thank you very much. Yeah, that's all for me. Thank you. Yeah, I think that she just shared in the group that it's well, the the things. Yeah, it's I do. All right, guys. So peace, transition, you keep. All right. So, um, we'll move on to the, uh, the next question. So you have a 30 a weight lifter presenting to the OPD with the lump in the right, in quite a region which produce coughing, and it's easily reducible. He's been diagnosed with a direct inguinal hernia with no signs of incarceration and strangulation examination. You should look for electively knee repair, which wrestle forms the border of the helpful back. Strangle that the opening. That operating surgeon should be cautious off. I'll ended there. Right. All right. So I'm impressed. Most of us that they're right on. So which is C? Try to make it tricky. It's possible body by inserting so many other trees. But you guys got the right answer. So yep. So it's inferior epigastric artery, which forms electoral board off Hassleback strangle can tell me what the medial board and inferior border the triangle. This just when the trap. Yep. Okay, good. Good. Yeah. So yeah. So the medial border is a lateral border off directors of dominance, muscle and your inferior bodies in Going a ligament, which stretches from your yes, I asked the pubic tubercle. Okay, so So so the surgeon should be aware of Hasselbeck strangle simply because we're doing a laparoscope big repair, open repair. There's a big artery which, like you, said, it's inferior. Epigastric artery goes near by the triangle. And, um, there are cases where by surgeons have injured the artery, and that can cause quite a terrible bleed. Um, so you have to be wary of that artery going to the region. So Well, then, guys, so sorry about that went to fast. So the next question you have a 70 old female attendant CD with no, then vomiting. She has been complaining of a long standing lump in her left groin, which has been irreducible for the past two days. According to her, the lump has been painful to touch. She's really nice opening a bowel for the past 24 hours. On examination, the lump is inferior and natural to the pubic cubicle, and it's long pulsatile. It's also a reducible. What is the most likely diagnosis ended there. So most of us got the right answer. The answer is indeed formal hernia. So it's a classic textbook description of a formal hernia, which is inferior and lateral to the pubic. Typical. Okay, Yeah. I mentioned somethings in the question, which is long positive, not passed on its be useful. So you like to keep a wide difference off a lump in the groin area for thinking off. Should be hernia. Could be, um, and 80 malformation could be a fistula. Um, and it could be in a in a demand for mission. So you should think of stuff in America just evil femoral and your femoral aneurysm. So getting off all that renting off about a lump in the groin area? Because, honey. Okay, so a family honey as inferior lateral three people, Typically what about in gynecology is Yep. So it's superomedial tribute cuticle for there being, well, hernias. Okay, so we'll talk about hernias. It's quite a huge topic. Um, so there are many different types of hernia for under the Ask you guys a few questions before that. So I mentioned a few hundreds here. So, in quaternium, known about the two does directing Direct. Can't even tell you what Rick Design. Yes. No, I do. Right. So a rictus hernia is, um Okay, so not quite so a Richardson. Yes, Basically silent hernia. Okay. Doesn't is basically a partial remission of the bowel along the anti Ms centric border. So, basically, you have your Ms centric border and your anti Mr Mason trick border. So Richter's hernia is basically partial. The nation off the bowel wall in particular anti Ms Intrigue border. And they can get strangulated quite easily. Okay. What about little hernia? Yep. Yep. So someone mentioned her needed Macau's diverticulum. We'll talk about Mycelex later on. So that's right. What? What? Pantaloon. Hernia and two minutes? Quite. It's quite interesting. I've seen two. And teacher, um, so pantaloon hernia is basically inguinal hernia sac. You opened the second teacher, and you find a direct any indirect hernia, but in the same place. So it's quite interesting to see that because, you know, the natural be quite distorted, and I'll take a long time to repent a hernia. You should take two or three hours with repairing two different home years. Okay, so that's it will move on to the presentation. Hernias. All right, for type of one year, Like I mentioned earlier in Guanajuato. This 50 to indirect and direct. Yeah, The most common hand is that you'll see on the ward so in any you'll see in directly needs more commonly it and directed. Yes, um, 80% of the time family onions is less common. In reality, you have risk Factors include being elderly females, um, pregnancy and patients with the raised intraabdominal pressure. Um, also the commission each ugly females. For if you've seen the last question, I mentioned all the bublitz 70 old female and the lump in the groin lateral and inferior to the people to tickle. That should ring for Melinda straight away. Okay, Family in years have a higher risk of incarceration and strangulation. Can anyone tell me why? Yep. Yep. Correct. Correct. So the family canal of the family neck, in reality is quite narrow, especially elderly folks. And if you have a portion of the bubbles trapped in there and the neck is quite narrow, you can imagine what will happen next so the bowel wall will get strangulated, and that could lead to a surgical emergency. So you have to operate quite me immediately. So the patient, conventional ear with the family hernia you wouldn't should do an elective repair. Will. Should do an urgent repaired the hernia. Okay, Because they can strangle. And that can cause a perforation. Um, it would be quite a better outcome for the patient. Okay. And lead us any like I mentioned is very rare. Does happen. Uh, but basically any shipping cost of medical. Um, we'll talk about McKell. Seat on. Right. So this is the inguinal canal. So, um, being Guadalcanal is basically about 6 to 10 centimeters in length. It stretches from the deep and final ring, and it goes to a special granule ring. Why should nobody in Guadalcanal? Because off the different after inguinal hernia. So you're indirect inguinal hernia, The bowel go tree, a deep inguinal a ring and will be much to your special and wandering. And it can go down to the scrotum for meal so you can get in Granules, scored a hernia, okay. And for direct can use like you mentioned earlier. You ever Hassleback strangle just the area weakness and that's where the honey can protrude and call directly knees. Because can put your diary. Treat the the wall. Okay, um, I'll just share with you a different presentation because, um, hum, you in particular is quite richer. And that to me, a lot of that to me to be oscal hernia. So this talked to use a little bit about anatomy or 14 years. I'll just stop sharing Mike and everyone Fetus. Yeah, that's that's good. So I'm just trying to enlarge it to the two seconds I am trying. All right, So and then we'll see this. Now, you look so excellent. Presentation given. I gave a few years ago when I had to drink three copay times where I could see actually face is instead of speaking to blank screens. Um, so this culturally, if the abdominal will really quick, I think you should know this. I mean, my heart. I mean, if you're in a general surgery, what? It's a very question to be asked by a consultant. So, um, I'm not gonna ask you to tell me the lady for this portrait really quickly. If your skin you have a Scarpa's Fashir, your it's a little bleak. The internal oblique transit, Dominus Translators. Fresher. You're prepared on the fat in your peritoneum and you're into the cavity. Okay. All right. So use the different types of hernia. Just go to it really quick. Said this is Steve. Part of presentation in the slightest now, right? So dislikes the wanted to ask you guys about is a favorite question among surgeons in MRCS and even in f. R. C s exams. And you'll be surprised to find out that even ready stress get the two teams mixed up, which is the what is the meaning ground point. And what is the midpoint inguinal ligament. So can anyone tell me what? The mid inguinal point issue? What? It's cynical. What's the clinical significance of the meeting with the point. And the next day we printing one ligament. If you don't know the doing, Don't worry about this extending to you. So meaning Wendell Point? Yeah. Correct. Um, eating well, points between your size and your pubic symphysis and your meat point inguinal ligament. Yeah. Okay. It's between sizes and your pubic cuticle. And the significance is your meat point of the inguinal ligament. Okay, um, in between that, you're drawing measuring line like you see here above it is a deep ring. Yeah. Okay. See him? So you mean running wildly? Committing a deep brings that really above it. But I'm eating ground point between your air siphon your pubic symphysis if you go below the light. If you just relying I halfway across it and you put your hand below it. That's why you're feeling you feel a family history in the family pulse. Okay? Going to get access and stuff. Okay, so it's quite easy to get those two times mixed up. Uh, don't worry. I mean, distress getting mixed up. I get it mixed up all the time, but, you know, just before exams, just good to know by heart. What is it? Okay. All right. So all right. So we'll just go true. Um, the differentials. Okay, Like I mentioned earlier for any lumps and bumps in the groin area. Besides the besides, the hernia should think about stuff like a lymph node. The family artery aneurysm. So generous. Um, I think with the bishops cyst like poma saphenum barracks, a source. Obsess, hematoma, lymphoma, Okay. And undescended. Testicle quite rare came, but for exams is good to have a different show. What a lump It's depending on whether region is okay. So this is just a quick, um, rattle to my presentation of this. Stop it, then. Go back to my original slide. Sorry about that. All right. So can you see the sights now? Yeah. So get in true. All right. So, going to the inguinal canal, the complications off in grand 11 years of hernias in general, you can get incarceration, you can get strangulation, and you can get both obstruction and bowel perforation. Okay, so they're different. They're different meanings to incarceration. Strangulations. Incarceration means the hernia is rigid. You can reduce it easily. And because of incarceration, Bobo Dema develops because it's venous congestion on Ben. The world gets strangulated, and that impacts your arterial supply. Okay. And then the arterial supply gets in. Pat, you can get ischemia. Okay. After ischemia. Long time ischemia result in their crosis. And that causes causes, causes weakening of the bottle, and that causes a perforation. Okay, You don't want that to happen, because once a profession starts, can cost peritonitis and eventually that untreated. Okay, so that's how the chain of humans works. Okay, So, definition, it's basically a protrusion of part of full of an organ or tissue to the wall of the cavity that contains it. Diagnosis again. Clinical diagnosis, Tecatara history. Good examination technique. And you can diagnose a hernia. You don't need an ultrasound to look to diagnose and hernia. It's basically how it's really doing a sick examination. Okay, you can do a CT of the abdomen pelvis again. Most register do it anyways, but not just do it to the limit and after me for participating. Okay, Management. You can do an open repair or like this. Copy repair. Um, most centers do laproscopically notice rather than open your best. You only do it openly if there's a perforation. Bilateral hernia. Okay, right. Next question. Um, you have a 66 year old gentleman presents this GP with your history of altered bowel habits and loss of appetite, he has been having trouble opening is bowels and that their blood stains been wiping himself. He's normally fit and well and has no family history of milk and see what would be the most appropriate start to take. I'm sorry, guys. While you're answering this, just make a quick announcement. I'm gonna put a recent a feedback form on the chat. So it's just to get feedback on our collaborative teaching and on these sessions and and our surgical Siris so pleased to fill this out just brightest with information on how we can improve the sessions for the future. So I'm just going to send us now. Just a good form won't take too long to please you. Fill this out on do the feedback form. All the sides will be sent through entries. Well, yes. Think you're right. We'll just send the port is now. Right? So you guys, most of you guys have the right answer, which is C So according to nice guidelines, you do a two week urgent referral for a colonoscopy for indication each 60 years old and above presenting with altered bowel habits. The other criteria is the patient has an active family history of Colorectal Mountain see off any each the present altered ballot habits. It should refer them urgently for two week for cough to be by gastroenterology. So what do you get to the right answer right. The next question the same patient than undergoes a colonoscopy did biopsy which subsequently revealed a poorly differentiated adenocarcinoma in the descending colon. The clerical team then decides to perform staging of the tumor to guide for the management Rich criterias colic really used in staging colorectal carcinoma. Quit Speak for one, I thought. And the pool just now. All right, so most of us in the right. And so So it's c uh, just dukes. So, um, traditionally, people have been using books frightening for colorectal cancer, But nowadays they've been replaced by the TNM Criterias there teaches your size of tumor and for lymph node wolfman and in formats. Okay, but dukes, mister right Answer Going to speak a bit about colorectal cancer definition again Straightforward metal in your present to call on, um, there are certain risk factors. It's always good to divide it into category so modifiable and more modifiable and talk about the epidemiology of colorectal cancer. So modifiable risk factors would be so diet um, smoking, obesity, alcohol no modifiable would be things like your each being meal engender congenital diseases such as lynch syndrome. Okay, trend pcc AP off the millennium animated polyp pulses I median, particularly arthritic colitis, can pretty schools to clerical cancer and over active family history of colorectal cancer okay. So impatient with IBD and patients with active family history off cancer, you should go for routine or regular colonoscopy. Okay, The epidemiology of it. So it's 10% of old cancers in the UK It's the most common cause of cancer, really, the debts. And it's quite common. The Western world, you to the diet. But it's increasing now. This book in Asian countries well, do two people adopting Western diets such a fast food and all that. Okay, so symptoms you can get the colorectal cancer Bondo symptoms such as p R. Beating um, older bowel habits of constipation or diarrhea. Diarrhea as usual for diarrhea. Because of the constipation, you can get symptoms of bowel obstruction, and you can get a perforation if it's severe, can get tenesmus, which is basically straining off, too. Um, and you can get systemic symptoms just weight loss, anemia. John. Different this master deliver investigations. So, first and foremost, a good history. Our examination to erectile exam, um, and also do blood tests. So what, you have to do the full blood count through a lefty's to check for Mets, he Metanx, and you should do a see what your mark a focal, a rectal cancer. You do a baseline chest X ray to look for mets and also for pre op assessment. Um, and you do a colonoscopy or a rigid sigmoidoscopy, we biopsied. That's the gold standard. Okay, um, and you can do a CT, capture the pelvis for staging we do on for patients of control rate colonoscopies. You can do it. What? You can do a CT colonoscopy, break into a truck, not speak. So that's quite a desperately don't know this management wise. Um, for any management off any kinds of cancer always mention MDT approach, because will be a team discussion between the surgeons. The radiologist for the oncology team. You can offer medical treatment first so we can offer new regiment or Edgerrin chemotherapy. The new regiment is chemotherapy before surgery. The idea is to shrink the tumor with chemotherapy and then operate on the patient. Okay, and then surgical management depends on the staging and the patient community me. The approach might be, you know, for penitence reasons, maybe for standing or Mobic. You're it if it if it's an early stage of tumor. So this is this a quick diagram on the different kinds off surgical approaches that we use in a rectal cancer. So, um, I'm sure the size we given to you guys after the presentation, but basically delineates what kind of poetry? It for different kinds of cancer and on different location. So, um, can you tell me what you guys know about Hartmann's about the heartburn's approach. You know what it is and what's useful? Uh huh. Yeah, emergency management. But can tell me what? What do you remove? What do you do? You know Hartmann's? Um Yep. So So, um, it says with the emergency treatment off, usually a perforated carcinoma, diverticulitis, um, and also collections as well. So it's basically a lot people's mentioned left hemicolectomy. So it's partially right is basically a proctosigmoidectomy closure directors stump and the formation off and and colostomy. Okay, because because off the the area is unsafe to do an anastomoses because of collection. And because if there's active cancer, you were You don't want to do an anastomoses. So you bring up an end close to me, okay? And you close the rectal stump, all right? Or gets a quick picture off a large tumor so you can see, it's basically a polyp point mass obstructing this bleeding. And patients, I think the patient presented with the ultimate goal habits looking at this picture. All right, quick diagram on Duke's classification. Um, now this usually is 10 mg, but just couldn't know what Dukes involved. So this is going to A, B, C and D. Um, there's a modified use criterias. Well, that's a B one B to C one c 20. But for this presentation, I mean, this is the normal one is A, B, C and D. Um, I'm not going to read out what a, B, C and D entails, but it's good to know, right, So doesn't want to be next question. Right? So we have a 78 year old gentleman who presented to eat it with Southern left electrodes up being along with fever and north and vomiting. She hasn't mentioned that she has been passing blood stains school for the past one day on examination, chest tenderness and in military, Gadi off the left, left for for blood test imagine was done and she was diagnosed with diverticulitis. What is the strongest risk factor for development of the disease? All right, So we ended there. Okay. So you can see a spit in answer. So the correct answers actually, D is low fiber diet. Um, each is correct, but age is the second highest respect it. So the most common reflective if the lack of dietary fiber. Okay, so I mean, there's evidence behind the people's showing that patients with lack of doctor fiber can present with type two disease in tone in life. Okay, so we'll talk about diabetic a disease quite a bit, and dancing desperate for the night. The definition would be so, uh, diabetes plummeting and normal out pouching of a hollow discuss in the surrounding tissue. And that particular disease can only affect the bowels. It can affect your esophagus, your bladder. So there are four different types of mentioned. She has this McCallister medical, um, Fanjul pouch, bowel diverticulum and off a bladder diverticulum bladder and pharyngeal pouches. Quite rare, But it's quite common to get bowel diverticula. Okay. Like in the case of this, um, for your patient early on. Okay, so we'll talk a bit about McKell. So do you know what McKell was caused by? What's the remnant off? Can even tell me. What's the remnant off? Going back to him. Biology in your list here? Yep. It's a remnant of it. So you'll be telling testicle doctor. Yep, yep, yep. Okay. And do you know what rule that? You use your females room for Michael's? Yeah. Real of juice. Everyone knows it. Okay, so we'll have to. So, basically, he's, um So is doing just long. It's 2 ft from the cecal Balfe. It's 2% of population and 2% asymptomatic. A symptomatic. Correct me if I'm wrong. Um, what about rule of tens when you find a real tense stream? You from stopping, but yeah. Yep, yep. Feel good to know. Good to know if you feel crummy, Saitama. It's real of 10. So just remove for a bit financial poach. So federal pouch of the Western Zenker's diverticulum. So it's basically out pouching off your inferior constrictor muscle of the esophagus. So patients present with financial patches can present with the halitosis dysphagia or dina feature and also good like symptoms. Okay, It's a big run. True, but very good approach. Right? So, talking about a diverticulitis. So symptoms like you mentioned like you mentioned earlier. You can get fever? Um, really. High grade fever, Abdominal pee in particular. Left left. Four. Sir. Why the left that forces? Because the sigmoid colon eventually is usually involved in a good article. I just Okay, um, can get a little achy vomiting, and you can get him to keep you. So hematochezia is basically it, um, for, um, pr bleeding. Okay. You have hematemesis for vomiting up. Blood came up. This is for coughing up blood. Him it. Okay, c is basically PR bleeding. Okay, Don't confuse it. Melena Molina's basically blood mixing. It's too Okay, investigation. So if you're thinking of a patient having diverticulitis commences, sepsis six immediately. Give the patient brought spectrum. Antibiotics is usually IV mg or amoxicillin. Metronidazole on gentamicin conditions are allergic to penicillin. You can get back home icing, so the mg, But again, it depends. Trust guidelines. Okay, do another test. Cultures. F B C d. Elected captain drives for urine output, and you can do a CT of the abdomen and pelvis to look for in collection and to go operative planning. Okay, Treatment. Like I mentioned earlier antibiotics, fluids. You can do operative mention you can do a laparotomy and washing. But again, it depends on the country classification on the country. Constipation. Next light. It's a prosecution for the diverticulitis. Okay. And you can contact the friendly radiologist if the patient is well but has a low class collection, you can contact the radiologist to do to perform a drainage off the abscess collection. All right, so all right. So this is a country complication. If you can see this 11 B 23 and four. So usually cross country one and choose. Usually manage medically with antibiotics, fluids, you know, by mouth three and forth. Manage surgically. So with the protamine washout, want to You can either give, um on Tobi ticks and also do drainage by radiology, but three and forth teacher for pretty management. Okay, so it's good to know that What? The classification And just a quick picture on what you see on colonoscopy. So you have all your diverticuli here, Okay? And it's quite easy for for fecal it off. People made it to get stuck here. And, you know, fecal medical of bacteria gets stuck here. It gets inflamed, and you can get damaged colitis, basic information, diverticulum and like like if you can see here. Well, drink almost to be. It's quite easy to miss. Take this holes as the normal orifice. So it's quite easy to go through that or if it's and eventually cause a perforation. So, um, has happened many times. So and then a patient presented proficient be brought the teeter for management. So is what you see classically. Um, if anyone Yes, triple phobia I don't think will be very easy on you, but he who fighting this is for the night sky. Long session, um, people free to fill out the feedback form. And you have any more questions than just asked me directly, or you can just put it on the trip. I thank you very much for joining. We have a link initial form first, and then we're just going to send the feedback. That's when we really appreciate if you could fill in both forms for us, it shows us how we're doing in this series and whether this sort of collaborative effort actually works. We're trying to assess our own start off. Um, we were there books here. Yeah, So if you feel that yesterday, it would be great if you feel it in today, also because it's transitions. And do you just want to give in the feedback from It's Well, yeah, yeah, we dropped it really, really, really appreciate it. If you fell in both forms, it would be incredibly good for because, as you can imagine, this wasn't easy organizing with everyone. Coordinating is, we don't provide certificates. If you just feeling the feedback from you automatically receiver significant. All right, so it's a just a under some of the questions, I think someone asked about difference between Molina and him.