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Hello, everyone. It's great to have you join us today. Um We are gonna be chatting about the acute abdomen, er, and that does look like a painful abdomen that person has. It's a great graphic. Anyway, what we're gonna do is if you can pop your questions in the chat, Erin, we will get round to them at the end of the event er, in an hour's time, there will be a feedback form in your inbox. We want you to complete that feedback form and I will be passing that on once you have completed your feedback form, your attendance certificate will be on your medal account. If you want to see any other um medal er events, we have 100s and thousands of metal events both live and catch up. You can just click on the metal logo and that'll take you to the front page and you can search for any category organization community, anything you like, you can search for that and you can um access it. Most of them are free. Um So the platform is yours to use as you wish. So without any further ado I'm going to hand you over to Thanks too. Right, welcome everyone. Um And thanks for joining me today um talking about the acute abdomen. Um the reason I choose that topic to start my journey with them at all is uh because um I get lots of interest in the, in um teaching about acute abdomen and because also it's a, it's a very common uh problem and I have to say it's the commonest problem that we see um coming to um acute surgical uh assessment. Uh So my name is Besam Amer and I'm a consultant of a giant Bariatric at uh County Darlington Foundation Trust. And those are not from the UK, it's uh in at the uh northeast of England. So I know that you hear a lot about acute abdomen and the classic teaching about acute abdomen is that we go by classifying the areas, abdominal areas, you know, into the nine quadrants and go and uh mention what acute abdomen in each compartment. But that's beyond the, that's probably medical school level and we need to go beyond that. How would you manage an acute abdomen, whether you are in the front line and you are an ed or any um or you are foundational doctor who assist patient on acute surgical assessment or even a GP who see the patient that comes to the clinic with an acute abdomen. So to um talk about acute abdomen, well as the name explained itself, it's uh abdominal pain of a sudden onset short duration, that needs urgent decision. So it's all happens very quickly, abdominal pain, very sharp, very sudden and that needs urgent attention and decision. And as I said, it's the most common uh presentation for uh acute surgical assessment. So what were you gonna talk about? We're gonna talk about how would you manage acute abdomen? Ok. Because that's the most important thing. Ok. And I summarized acute abdomen in this. So you've got four possible management options and for um for clinical presentations. So acute abdomen can present in a four patterns and has got four management options that we're gonna choose from the menu. Ok. So the first management option is surgery now, immediate surgery. So you see the patient in Ed, OK? Where you say, OK, that's a stat or R as the American used to say it's a stat or R means that you need to take that patient to a theater. Sometimes you don't have the time to uh get them changed or anything like that. You just take them on the trolley from Ed and uh rush them to theater and in some cases that you need to drink theater and say, well, actually I've got a patient that needs to come to theater. Now we need to uh stop an elective list, for example. And then you jump on that list with your patients. So it's a kind of life saving uh operation. OK. So that's the first option when you see the patient um the second option. OK. Well, they need an operation but not an immediate surgery. So they need a bit of optimization as you can see from that photo on the right. So that lady or that nurse is going to optimize that poor guy there. Um So what I mean by optimization? So they need a bit of fluid, maybe antibiotics, maybe some pain killers. You've got the time to build them up and to optimize their physiology. So you can maximize the benefits from surgery. OK? You've got the time to run some investigations to get some EC GS for example, or get the anesthetist to see, to see them or you talk to other colleagues and hit you or itu for example, or medical colleagues. So you need to get this patient into the best shape possible to get the maximum benefits from surgery. So you spend that time optimizing them, make them better before you proceed for an operation. The third management option is conservative. So the patient will come in. OK. Well, you know that they don't need surgery at least during this admission. OK. And you treat them conservatively and when we talk about conservative patient, well, people will say, well, what do you mean by conservative? Well, make it really simple. Ok. So the three major things that you need to address when you're talking about conservative treatment, OK? Is a sepsis control, nutrition control and pain control. So sepsis control. Is this patient in sepsis or might develop sepsis? Therefore, they might need antibiotic. And if they're gonna need antibiotic, what sort of antibiotic, what dose? But again, that depends on your local policy or local protocol. Second thing is nutrition because this is the thing that we, well, the majority of us will forget about it. Ok. Well, what nutrition, how are we gonna provide? The nutrition? Are they allowed to have things orally or they need to supplements? Which is IVS or parenteral or? Do, does it need TPN? Does it need nasogastric tube? NG tube? How are we gonna manage that? What's the protocol? Do I need to call a dietician to help me with that? Do I need to get, get in touch with the pharmacist? You know, all these things. So nutrition is really, really important. Ok. And definitely, well, if they got abdominal pain, you need some painkillers, isn't it? And whether they're gonna have it orally or they're gonna have it. I, um IV, and how are we gonna escalate through the analgesic ladder? Ok. On top of that, the other bits and pieces like DVT prophylaxis, anti sickness and things like that. They are, they, they're absolutely fine. But what I'm saying here, the three major big er, cornerstones for any conservative management should be built on, um, sepsis control, nutrition, control and pain control. The last option and it is still an option is, well, this patient, we've seen it, we've taken a history, we examined all the things, but they don't need acute hospital admission. And this is really important decision. Well, this patient doesn't need to come in. I'm happy to see that patient in the clinic or, well, actually they haven't got anything surgical wrong with them. They need to go to other speciality. They might be need to go to Gynae, for example, or the medical assessment units to medical colleagues or even other specialties. So again, when, when you see patients uh with acute abdominal pain, you need to start thinking well, if I see this patient in the clinic, will I admit them to the hospital if the answer is no. So the answer is here is no. So if you don't admit them from the clinic with a similar scenario, OK, you don't them a you don't admit them because they presented to the acute surgical or acute assessment unit. So the four options that we have are the surgery now or surgery later. So you spend some time, a bit of optimization and then get them to the theater or conservative management all the way or even the last option is discharge or referral to other specialities. Good. So in this lecture, we're not gonna talk about how you take history, how we assist patients and examine them because I know that all of you have seen patients with acute abdomen and they know that you are better than me taking a history and examining a patient. Ok. But to summarize the general presentation of acute abdomen, they have four pattern of patterns of presentation. So the patient who either come with uh abdominal pain and shock, ok. They might come with a picture of peritonitis, whether it's a generalized peritonitis all over the abdomen or localized to one of the um quadrants of the abdomen. They might come with intestinal obstruction or they might come with nonsurgical causes and there is no fifth pattern. So these are the only four patterns that happens. So for you to remember, it's four management options and four clinical patterns. Ok. So keep number four in your head. So the first pattern, abdominal pain and choke, I'm not gonna talk about how you identify shock because we know all of you, you, you know the definition of shock. It's all, it's in every single textbook, but simply speaking, ok. Abdominal pain, patient in shock, hypotensive tach cardia, no urine output deterioration and, and the, and the mental status and things like that. And the most common causes of acute abdomen that can present with a shock is rupture AAA or a rupture, abdominal aortic aneurysm and rupture ectopic pregnancy. These are the most common causes for abdominal pain and shock. But luckily, they're not that common. So they're most dramatic, most drastic things, but they're not that common. Ok. So we don't see it, you know, in each single on call that we do and the patient that who present with that picture, you know that ok, which treatment option they will have is yes, is the immediate surgery. So you need to rush them to theater. You need to take them immediately to the theater with all o other precautions like get blood banks, uh alerted, get blood ready for blood transfusion, use the cell saver intraoperative, get everyone involved. And he says, are you all these people? But again, as you're doing that, you wheel the patient to theater without any delay. Second, presentation is peritonitis. And as I said, there is two categories of peritonitis, either generalized or over the abdomen or localized to one quadrant. The causes in surgery that can cause generalized peritonitis is a free proliferation of anything intraperitoneal. So free perforation of an peptic ulcer, free perforation of a colon, colonic perforation, free perforation of appendix with four quadrant peritonitis. OK? Or they can have localized either like cholecystitis, appendicitis, pancreatitis, diverticulitis. You name it as long as long as it's contained within one quadrant of the abdomen. And the reason I'm differentiating between the generalized and uh and localized peritonitis because the treatment is a slightly different, might be there is an overlap in the treatment but slightly different and we'll come back in a second. So here's the picture of generalized peritonitis. Ok. Solid abdomen as we call it uh board like board like rigidity as written in, in the textbooks. OK. Again, tachycardia uh hypertension, dehydration, vomiting, low urine output patient is per genetic. So all these symptoms can be generalized all over the abdomen that you can barely touch the abdomen or can be localized to one compartment of the abdomen. And we talked about the causes in the previous slide. So how would you manage them? Because this is the important, well, you've taken a history if you examined, you identified. Yes, this is the second category. They are in peritonitis. So the two treatment option for this category is either conservative management and you know, now what conservative management means, OK, or a bit of conservative management. But you know that in your head that you're gonna end up in theater or you're gonna call a friend ie interventional radiology. So the patient that will be treated conservatively all the way is someone like pancreatitis, for example, OK. You know that, OK, we're not gonna take a patient with pancreatitis defeat. So they're gonna have just conservative management. But the others, for example, and I know in some places, especially with uh with um uh with cholecystitis, it could be treated conservatively when they present acutely. OK. And then have an interval, cholecystectomy later. So that we'll fall into that category. But now we know that from the evidence and things like that. So we know that the gall bladders can be done if you have the facility. If you have the surgeons, if you have the ability to do it. So it's better to do it. Um, when you have, um, that similar thing, uh, appendicitis in high risk patients, for example, or, you know, uh, are heavily comorbid, there is a strong evidence that you can treat these patients with antibiotics. So they fall into the category of conservative management. But if they have, um, no comorbid it is, um, and they can go to theater. Yes, they need to go to theater, but they don't need to go to theater as immediately as you see them. So they need to go to theater, maybe a bit of time to get them better in terms of physiology, sepsis, control nutrition, pain, medications and things like that and they get better to theater. So when do you use that? Ir interventional radiology. So if there is a localized proliferation, for example of a diverticular disease, yes, they can be treated conservatively. And again, there is a stronger evidence uh behind that or if they've got a Flegmon there, you can put a drain and drain it. Raly, similar thing with the gallbladder. If they got empyema and the patient unfit to have surgery, they can have a cholecystostomy. Ok. So these are the options that can fit in uh in the, in the, in the management into this presentation. So for the presentation of peritonitis, you need to know whether it's the generalized peritonitis and this category of patient will mostly will end up in theater but not now you need a bit of resuscitation, a bit of optimization before you can take an amphitheater or the patient with localized peritonitis. Yes, they can be treated conservatively all the way. So during that admission or they can have a bit of optimization and then proceed to surgery. So the next um pattern of uh acute abdomen when it comes to presentation is intestinal obstruction. OK. And all of you, you they know the symptoms and signs of spinal obstruction. So, the cardinal symptoms and signs of four things. So remember number four that we talked about before. So abdominal pain, distension, vomiting and constipation. So I'm not gonna talk about uh causes of in spinal obstruction and how they present and all the things because the, you know that and that's not the purpose of this lecture, but patient with in stent obstruction, how would you manage them? This is the most important thing. Ok. So the majority of these patients will um will respond to conservative management. So, again, conservative management, you put that in G tube down, you drain the stomach, uh you, you, you um uh decompress the stomach, you give them fluid rehydration, catheter, monitor the kidney blood. Um It's a standard thing. Ok? And they, the majority will respond. Ok? So if they don't respond to the conservative management, ie e they either deteriorate or you've got um a, a reason not to, you know, continue on the conservative management, then use that time you optimize them and then take them to theater and now we're talking about theaters so that can be laparoscopy. So a division of adhesions, for example, can be dealt with uh you know, laparoscopically or you do surgery, for example, to relieve the obstruction, OK? And even now with advances, you know, in ir and an endoscopy, you can put a stent. So if you've got a chronic tumor, for example, um it used to be, you know, an old teaching that used to get, ok, a chronic tumor. Ok. That patient need a bit of resuscitation and then theater tonight or first thing in the morning, but now not every patient with a chronic tumor will go to surgery. You might, you might get a stent, uh especially if there are um uh unwell. Uh and they have got lots of comorbidities. All the tumor is advanced and you just give them a palliative stent. So these are the, are the options to consider when you're dealing with interspinal um uh obstruction. Um So few tips and tricks about dealing with Einstein obstruction. So remember when you see an elderly lady who's uh, has got high BM I and she coming with a small bowel obstruction on a virgin abdomen. So no previous abdominal surgery, um, don't consider it as, yeah, she's constipated or something like that or she's got my, got some congenital adhesions. Please, please please examine the groin. I can't tell you how important is that because you will miss a small femoral hernia if you don't look for it. Ok. And we all been there. We've been all trapped in the ir, ok. You've got a simple obstruction. We'll be fine conservative management. And we wonder why they don't get better. Ok? Because either, you know, patient with a sign obstruction, either you didn't do digital rectal examination or you didn't examine the groin for hernias because this category of patient will have huge pain, left abdomen and you look at it, ok? It's fine. Uh Yeah, put a tube down and things like that, but please do examine the groin and do examine the groin carefully and looking for a small hernia, especially in women, it would be there and there would be femoral hernia. Um, again, when you're dealing with the elderly patients, um, there was nothing called simple small bowel obstruction or simple adhesive, small bowel obstruction. So every elderly patient presented with a small bowel obstruction has got a cecal cancer until proven otherwise. So if you put that in your mind, every time you're seeing a surgical patient coming with a small bowel obstruction, ok? You think he's got a colonic cancer that causing this? You will not miss a colon cancer. Ok? So nothing called ir he's got a simple obstruction. He will get better or put a tube. Yes, he might have. But if you don't rule out a cecal cancer, this patient will present later with a metastatic disease. Ok. So put that in your mind again, when you see patients, so consider a colonic obstruction, especially in the elder cohort of patients when you see them again, not that common, but you see patients coming and going with a bowel obstruction. So they come to the hospital, they've got small bowel obstruction. You give them, um, um, uh, conservative management, you give them fluid, you put a drip down, you put in your tube, they get better, you discharge them, they bounce back two days later with a bowel obstruction or they might get re obstructed in the hospital. And you wonder what were you missing here? You're missing a gallstone ileus. It's because it's not that common. We tend to miss that, um, um, uh, problem, uh, all the medical problem and it get diagnosed, you know, by clinical suspicious. But also if you do a CT scan on these patients, you'll see a aerobia and you'll be able to see the stone in the small bowel. And again, it's something that it's a mechanical obstruction, it's not gonna get better by, um, by itself. So these are the bit holes that I would say. Please remember these when you, next time when you see patients with, um, bowel obstruction. Um, so next, um, presentation. So the three presentation that we talked about is, um, the shock patient who's got ruptured AAA or ectopic pregnancy. The second one who presented with the peritonitis whether it's a generalized peritonitis or localized peritonitis. And the third patient is a uh bowel obstruction patient. The fourth category of patient, the patient that coming with abdominal pain, but due to non surgical causes and there is plenty of nonsurgical causes. But I've just put these three here for you to remember. Inferior MRI can give you or can give you a patient and I GST pain, similar thing with a lower pneu pneumonia will give you right hyp hypochondrial or left hypochondrial pain because um of the position of uh um uh the lung, uh the basis of the lung diabetic uto acidosis, they commonly present with acute abdomen and then they get diagnosed um with DKA. So remember, so not every cause that causes abdominal pain is has to be surgical. Ok. So um keep it widely open and have a wide range of differentials for also for nonmedical um nonsurgical causes or gynecological causes. Um You, you know what I mean? Ok. So we talked about four management options and we talked about four presentations that can um um present to your unit. So you would notice that I haven't talked about history and examination. Uh because as I said, that's beyond the level of taking a history and what to ask for an examination of what to look for. Um, again, with, with investigations, um the classic teaching about labs and radiological. But again, when you order investigation, you need to have a very specific question in mind, uh, or the question that you will go to your uh radiolog colleague and say, well, I've got this patient in my uh department that who I think that it has got bowel obstruction, for example, due to cecal cancer and they need to get a CT. So you give them an impression, not the last. Ok, I need a CT because I've got bowel obstruction, then they have a wide range of different to look for the cause of that bowel obstruction. Does that make sense? Um So when you plan the investigation, you need to know what you're requesting and what, why you're requesting that for? Ok. So when it comes to lab, there is no nothing called. Yes, I need routine labs. OK? Because the more you blood test that you get, you get a false positive results and then you start acting on these results unnecessarily. OK? But simple things like, OK, I need a white cell count and C RP. If they're high, they indicate infection. Ok. Um As simple as that or I need uh hemoglobin to see if the patient is bleeding. Ok. Because you know the acute drop in the hemoglobin is more sensitive than the hematocrit. For example, where the hematocrit can indicate a chronic problem than an rather than an acute problem. FT S for example, they are important in acute cholecystitis or a patient with cholangitis or sometimes it's a patient with pancreatitis. Whether it because they've got stones that causing the pancreatitis or because of pancreatic edema compressing on the bile ducts causing the LFT S um uh to be uh elevated. So again, LFT S is uh of values. OK. Urea and electrolytes. Yes. In patient of becoming obstructed, for example, or becoming bleeding. OK. Have they got prerenal failure that I need to address the kidney? Um Do I need to correct the electrolytes? And this is the thing that you're gonna use your time when we say optimization to correct these uh abnormal uh blood results? OK. Um The again, you can ask for 100s and thousands of blood test, but will they help you to make that final judgment and uh and decision uh for your patient, this is what you need to decide and what I found that the, the minimum blood test that you're gonna get um you can act on it and especially in areas where access to the lab is difficult and it takes longer time to process it for those in the UK if you got a point of access blood test where you get the bloods in 10 seconds. Uh Yeah, that's fine. Get what you want to plan the next step. But where areas are actually the patient will go and pay for the blood test themselves or themselves? OK. Well, you need to be really, really selective. OK? Because that will add to the cost that the patient um will have OK, radiolog, again, acute abdomen, when it comes to radi, I know that some places they don't have CT scan. And remember this talk is not just for the UK based doctors, it's for everyone and it would be, it's gonna be um available uh online afterwards. So anyone can listen and act on it. But you've got chest x ray, abdomen, x-ray, you've got all the ultrasound, you've got the CT scan, you can have MRI you can have whatever you want. But again, you need to be very, very specific in selecting the best modality that will help you to make a diagnosis and um decide a management plan. And if you were pay for that particular test, would you ask for all of these tests? The answer is definitely not, isn't it? So why, why would you ask for all of them? Ok. If one of them can give you the answer? Yes. So again, think that way that will start changing your attitude towards blood tests and investigations. Think if you are the one who's paying for these, if they're coming out of your pocket, would you ask for all these 100 blood tests? Would you ask for all these radiological investigation? If the answer is no. So don't ask for them. All right, good. So um for um chest X ray. So if you're asking for a chest X ray in patient coming with acute abdomen, there should be one thing in your mind. You are looking for a free air another phrag. Ok. I know that we moved away from the chest X ray in, in, in, in our practice in, in, in the UK, in some places. But again, it still, it's a valuable test in other countries and other parts of the world. Ok. Yes, they are. They're not that specific. Ok. And you can miss a perforation. Ok. Um, but becau uh but still you can pick up a perforation in there. Still some places they use it and some places they wouldn't even proceed for a CT scan without chest x-ray. But again, as you can see, the only purpose of a chest X ray in acute abdomen is looking for perforation and how the perforation will present on the on on the chest X ray is air under the diaphragm. Ok. But also you might pick up, you know, other things like um consolidation in cases of pneumonia and things and that might be the reason for the abdominal pain, abdominal X ray. So again, when you ask for abdominal X ray, ok, you need to think why I'm asking for this test. How's that gonna add to my working diagnosis? And then how can I plan my management based on that? So either you're looking for abnormal gas pattern on the abdominal X ray or you're looking for abnormal opacity or nothing at all. Ok. We're not asking for abdominal X ray to confirm the patient has got just obstruction. Ok? Because if you think the patient has got obstruction, probably the abdominal X ray is not gonna add that much. Ok? Then you need to find what's the reason for obstruction. But again, in some places, as I said, you don't have the luxury of getting an immediate ct scan. So these are the things that you might rely on. But again, you need to know why you're requesting this. What's the indication, what you're looking for? Cause if you don't know what you're looking for, there is no point of asking for that test. OK. So abdominal X ray, either you're looking for abnormal gas or opacity or nothing. So abnormal gas, OK? It's a typical picture of small bowel obstruction textbook. OK? You've got the stipulate appearance of a small bowel obstruction on the abdominal X ray, OK? You can get it on a plain film or you get it on a lateral decubitus film but it's there. OK. So you need to get your eyes trained on picking up these signs. So the easy and a free example is radio pia where you look under there and see all the images of the different er presentations. So if you want to see images for abdominal um in inside obstruction, for example, or small bowel obstruction, large bowel obstruction, you can just go there and it's free, have a look, OK? And teach yourself, OK. So this is abnormal gas distribution. Again, abnormal gas could be a sign for colonic obstruction. Ok. Whether it's uh a second, more volvulus or it's a cecal uh vulval, which is less common. Ok. So if you're not trained and you're not a radiologist and that you're not trained your eyes to pick up these signs, you will miss them because you don't know what you're looking for. Ok. Opacity. Yes. Ok. You can see this uh foreign bodies or foreign objects that in different parts of the body. Again, that can be a cause of presentation of an acute abdomen ct scan. Why we're requesting a CT scan? So you're requesting a CT scan because you need to know what you're dealing with. Ok. So if in inside obstruction, for example, you need to know where is the level of obstruction and what causing the obstruction. Ok? Or if you're not sure about your diagnosis, you need to get act scan to um get you into the right diagnosis, but also the scan can give you clues. OK? And to avoid surgery, for example. So if you got, let's say a power colic um collection, for example, secondary to per localized perforation, then you are. Ok. Well, that patient doesn't need surgery. I'm gonna go and speak to my interventional radiology colleagues who might be able to stick a drain and drain that collection. So that can give you an idea about whether this patient can go to theater or doesn't need theater at all. And if the patient needs theater. The CT scan will help you to decide where you're gonna put your incision. Do I need to go upper midline incision? Do I need to go lower midline incision? Do I need to go full laparotomy? Do I need to go uh, laparoscopically, for example? Ok. So that you can plan your surgery. It depends on what you're dealing with and this is the um, beauty of having um, a CT scan. Ok. And you can see some pictures of the CT scan. Again, you need, um, to have a lot of training in picking up the signs on the CT scan. Um So when you ask for a scan, you need to look for either air or look for a fluid and it would be very obvious once you know what you're looking for. Ok. Um, here you can see free air and you can see that usually the free air will be in the area at the top of the skin uh between the f you know, there at the site of the Fancy Form ligament. Um But here also you can see fluid and the fluid will be more dependent. So the fluid be on the side and on, on the back. Ok. Another scan showing a perforation in, in different views. Again, another perforation in different parts of the body. So there is a big uh, air pocket at the front, but also the small pockets, you know, at the sides and things like that, again, few subtle signs. But again, with a bit of training, OK, you go OK, how perforation will look like on a CT scan? And you can see the free perforation or you see the localized perforation. Um And once you see a few scans, you'll be able to tell yourself um if your patient has got a scan without waiting, um you know, for the radiology report to come through. Yes. the radiology report is important to confirm what you're thinking and uh have that piece of medical legal document to say this was confirmed radiologically. But again, as a doctor, you should be able to spot these obvious signs again. So I think we can, we, we came to the end of this presentation. So clearly, we didn't talk about um the history taking and the examination because I know all of you will are able to do that. So whether you have a GP or you have a surgeon or you are uh finally a medical student or your EED doctor, you should be able to take a history and examine your patient. But remember, OK, the four management options that you've got either you take your patient to theater immediately or you discharge them home or send them to another specialties. And between these two wide spectrum, there is two in the middle a patient that will come and need management, conservative management all the way during that admission or the patient that will need a bit of conservative management, a bit of optimization and you know that they're gonna head to theater. OK. Acute abdomen can only present in four ways. There is no fifth way. So either patient will come in shock. But luckily, we don't see that so often. So like AAA and the uh ectopic, they either compare with again, it's generalized or localized. They can come with a bowel obstruction, small or large bowel. And we talked about the, um, pit folds of how we deal with bowel obstruction. And the last thing they can come with a nonsurgical or what we call it a medical cause. We talked about the investigation and when and what to ask for. And we talked about, um, uh, the, um, uh, the, the scans and radiology. So, any questions? Perfect. Thank you. We do have one. hold on, let's pop it up. It's from lie. Uh, it's about gallstones. Um, so for gallstones identified on ultrasound, is it better to operate or wait until it causes issues or pain then operate? Right? Uh That's a good question. Ok. So, thanks Sally for, for the question. So you've seen the stones coming, um, on the ultrasound. So you've got a patient that coming with right upper quadrant pain, they've got stones there. Ok. So the question is, what's the, what do they have? What's your diagnosis? Is it biliary colic or it's cholecystitis? Ok. Because not every abdominal pain. Ok. And you do scans will be attributed to gallstones because the most common presentation of gallstones is silent or incidental. So if the history matches the, the imaging ie if the history is typical of a biliary colic, for example, or the history is typical for cholecystitis, ok, then these patients, yes, especially the cholecystitis, one, they will benefit from having acute cholecystectomy. Only if, if you've got the surgeon, you've got the facility to do that. So if you are a trained surgeon who can do hold gall bladder and that will be biased because that is my speciality, I would say, yeah, go and do it. Ok. Don't wait. Um, late because yes, they might get better and have an elective cholecystectomy, but also they might get worse and develop complications. So they might get perforation of the gallbladder, especially if they are diabetic or immunocompromised. So this category don't wait. Ok. They might get empyema and then you put drains and things like that. So if you have the facility and they have the expertise to do a hard core bladder, yes, please go and do hot gall bladder surgery, don't wait. Especially if they've got cholecystitis. I mean, with the biliary colic is different. Ok, because the biliary colic, they will respond to medical treatment and again, optimize them and get them done in an elective setting rather than crushing in theater, especially if you're practicing in the UK, where you've got a limited access, um, to the emergency theater. So you need to use that wisely, um, rather than crashing, you know, your emergency list for a biliary cholic cholecystectomy type of surgery. Hopefully, that will answer your question. Perfect. We have another question. Perfect. We have another question. Went to use ultrasound for appendicitis in women peds and went to move to CT scan. Well, with women is, um, it is very tricky, isn't it? Ok. So every female in the childbearing period, they are considered to have. If they're coming with abdominal pain, they considered to be pregnant until proven otherwise. So if the presentation is not so typical of abdominal pain, that can be caused by endo scientists, I will go for a scan. So if the patient coming with atypical symptoms, ok, I will go for a scan first. But remember the ultrasound is operator dependent. So you might miss an appendicitis on the scan. If the patient ha this is not ideal for a scan, you might not see the appendix, you might see a trace of fluid, but trace of fluid. Again, it doesn't give you the answer. So you've got here the option, either you do an ultrasound or you just do a diagnostic laparoscopy and then you plus or minus, proceed for appendicectomy. So again, it depends how they present a typical presentation in my practice. I'll just take them to theater for diagnostic laparoscopy. OK. With peds is different with pediatric population is different. OK? With peds in my practice, all the pediatric, um, population, they must get an ultrasound first. Ok. Uh, they get ultrasound and then, uh, we take it from there whether we need to proceed for surgery or not surgery. And again, it depends on the child size, whether they are a suitable size for laparoscopy or the, if you, you know, if you are able to do laparoscopy on pediatric population or you can with a small cut, you do an open appendectomy, the old fashioned way with a CT, again, with a CT in appendicitis, there is longer debate. I know that uh colleagues in the state, they use the CT and they lose low, those um uh a radiation CT scan of the pelvis uh to pick up an er, er appendicitis. But again, it's not that common practice. We rely on the clinical sense and the clinical examination and the history. Um, remember it might be in parts of the world that you don't have immediate access to the CT and you get a CT in 34 days. So that can cause delay. You know. So if you are in a suspicion and you've got um, immediate access to CT. Yes, by all means use it, but please don't use it on young women and young females because they're cancer risk. Hopefully that will answer you a question mot up. Thank you. We have an next question. Is that coming? That one says, how about CT? Is that correct. That's correct. Yep, that's the one. Yeah. So how about ct contrast in case of unstable acute abdomen with high coin 11? What's options in such situation? Again, you need to think in a, in a wider picture. Ok. So if you've got acute abdomen and you've got high creatinine lev er levels, so ie acute renal failure. Ok. The question that you're asking yourself, does this patient need to go to feed him? Now, does this patient need to go to the theater later or does it need to go to the theater at all? Ok. So if the answer that the patient yes, might need to go to the theater later. Ok. That's absolutely fine. I've got that time. Use that time wisely put fluids, put a catheter, monitor your urine output, try to get the kidney functions better to have the contrast. OK. But in the worst case scenario, if you run out of time and you don't have the luxury of that time that you, you, you resuscitate your patient rehydrate them, get the kidney function better? OK. Call a friend. Use your uh nephrology colleague say I've got this patient who's got acute kidney failure. I'm gonna um CT scan them with um with a contrast. Um and the reason I'm saying that because they might say, yeah, absolutely fine. If something happened or the patient deteriorated, yes, we will um do a dialysis for you. OK? But again, you need to explain to the patient, you need to explain. Yes, there is a risk of uh worsening renal failure or contrast nephropathy. OK. And you need to tell them clearly and document that in your notes, that discussion has happened and then, and also discuss with your nephrology colleague and then you can proceed for a scan. OK? But it's not an absolute contraindication because the patient high creatinine level. OK. So in the UK, we use the EGFR and in some places, the EGFR must be above 30 to get a CT scan with the contrast. But as I said, if it's a life saving and you need to get the scan, you need to get a scan as long as you document that you have the proper right discussion with the relevant people. All right. So hopefully that will answer your question. So the next one is, should I ask a surgeon for pancreatic enzymes and cardiac enzyme if I suspect pancreatitis or M I? So I take a job of that you are uh either a GP or a ne doctor when you say ask for a surgeon well, to be able to diagnose pancreatitis, you know, um you need the um the Atlanta criteria for diagnosis of pancreatitis. So if you got a patient who's got a, a typical abdominal pain and raised enzymes and the third one is radiological evidence, then you've got three out of three. But if you're suspecting, especially if they come in, you know, acutely within a couple of hours from the presentation of abdominal pain, the enzymes might not be elevated by then. But to ask you to answer your question, do you need to ring a surgeon to take their permission? I would say no. Ok, because if you ring me and say, well, I've got this 30 odd years old. Who am? I think he has got pancreatitis. He's got a typical history, his symptoms and examination fit with the pancreatitis. Ok. I would, my next question would be, what's his pancreatic enzymes like whether you use like ps or amylase? But to ask for cardiac enzymes without a, you know, good history or a good background of a cardiac comorbidities, it's not routinely done. Ok. So if you're not suspecting it's an mr why would you ask for cardiac enzymes? So remember, you know, when I said, well, if you're thinking about you're paying for that extra test, so you're gonna get cardiac enzymes and it becomes a bit elevated but not diagnostic but slightly elevated. What are you gonna do next? Is it a cardiac event or it's a pancreatitis or acute abdomen event? So again, don't treat the blood test, treat the patient. Yes, the blood test is useful, but it's useful within a context of a story not isolated. Ok. That's why when I have my junior colleagues come in and say, oh, I've seen a patient in emergency department, he's got a white cell count of 20 C RP of this. I said, well, hang on a second. Tell me the story, then tell me about what you've done in terms of the examination general and local. And then tell me about the investigation. Don't jump into the investigation because that needs to be in the context of the story, which is the history. So hopefully that will answer your question, Jeer. Thank you. Uh n next question, Matthew. OK. In peritonitis, we go for surgery or conservative treatment and surgery later according to the general condition, right? Yes. So if it's a Frank peritonitis, ie perforated, you know, free perforation of an ulcer or colonic perforation or appendix or anything that it's got free perforation and you've got four quadrant peritonitis. Yes, you need to go for surgery. OK? But again to this category of patient, they don't know, they don't need to go from eed to theater. They can get admitted to the ward. You put the cannulas in, you put a catheter, you put tubes, you put lines, you give them hydration, you give them antibiotics. You do consenting, you speak to the family, you speak to anesthetist, speak to itu you've got plenty of time. So you don't need to rush them to theater. OK? You need to optimize them, put them in the best possible physical condition to get the best outcome from your surgery. Ok? But again, if the peritonitis is localized peritonitis, ie patient coming with a diverticulitis they didn't need to go to theater. Even if it's localized perforation, they don't need to go to theater. They will respond to the antibiotic treatment. Ok. A patient with appendicitis. Ok. But high risk patient with appendicitis, you don't have to take them to theater. Ok. High risk elderly patients. Ok. The surgery itself is an insult to these patients so you can treat them with antibiotics. Remember during the COVID, I think in the UK, we stopped taking patient with CI Thea theater and they were treated conservatively. OK? And there was lots of paper coming out of that. So again, it depends on the general condition of the patient and the facility that you've got in your hospital. So hopefully, Matthew, that will answer your question. Um Next one is Matthew was our last. Thank you in the chat as well. Um But Matthew was our last question. So that's us done. So please remember the key to success in your management. OK. Operate only when necessary. I know as a surgeon you will be rushing and eager to take your patient to theater. And I used to be one of those that, ok, well, every single patient need to go to the theater regardless. But again, remember, ok, surgery itself, anesthesia itself has got this advantage. Ok? And it's adding more stress, not just the patient to yourself. If things don't go as planned to operate only when necessary and do the minimum, the bare minimum just to save the life or to correct whatever is wrong. Ok. So if you're going for an appendix and you know, ok, it's appendicitis and you went to theater and you took the appendix out. Don't flap around. All right, I'm gonna have a look around and do this and do that. Don't go in, do the operation quickly and come out quickly. Ok? Because the longer the patient is stay on the operation table, the more risks they will get a more complication they will develop. But also don't delay a necessary operation. Oh yeah, this patient can wait till tomorrow. I'm a bit tired. It's 2 a.m. in the morning. If they need to go to theater, now they need to go to theater now. So ring your consultant or even if you're a consultant, take the patient to theater, don't delay it. Ok? Because you will get the best outcome if you make that decision and say, ok, this patient needs to go to theater. Now, go and fight for that particular patient. Don't say, oh, it's better to late. Now, I'm a bit tired. I'm a bit scared of ringing my boss or scared of ringing the anesthetist. Ok. So go and breath. Now, remember they're coming. If they, let's say if they're coming with incarcerated hernia, you won't go to theater and save the bowel, you don't need to do resection or anything. But if you delay them for some time, the next morning and then the morning is all right, the list is full. They get bounced to the afternoon. You lost that window to operate, you lost that piece of bowel. So turning a simple operation for division of adhesion, for example, for an, an a bowel obstruction can turn into a full laparotomy with a bowel, you know, resection, anastomosis that has got its own um complications itself. So don't make it worse, ok? And do the maximum when indicated, ok? You can go and fight for that particular patient. Do everything that you can not just intraoperatively but also outside theater, theater, speak to theater staff, go and get uh you know, everyone on board. We've got a case we need to, we need to get that done. So fight for your patient don't, I wouldn't say lazy but don't get whatever system that you're working in be against you and your patients. Ok. Good. Perfect. Any more questions? Have you got any more questions for me? No, no, just lots and lots of. Thank you in there. Um Just, just a reminder. Please do fill out the feedback form that will be coming to you uh in 10 minutes. 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