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Um Hum. Okay. So we'll get started. So just first of all, I work a moment, uh MRI in general and vascular surgery. So I wanted to give you guys a talk along with Mark on kind of how to survive your own calls in general and vascular surgery. Um So we'll do rehab up on how to take a surgical history, how to examine a surgical patient. Um And then we'll think about what common presentations you might come across, how you can investigate and manage those. And then obviously, because we're an anatomical society will talk about how um understanding anatomy properly can really help with getting on well in your calls. We'll think about some surgical procedures as well. So, in terms of how the anatomy relates to your presentation, it's really important to understand which organ has a problem. What is that problem and what's the anatomy of it? And so therefore how can we fix it especially surgically? Um So I've just put some examples of very common presentations that you'll come across if you're on call for general Surgery. Um We're just going to focus on a few of these today. Um And then I've put on the other side of the relevant anatomy that you might want to go away and have just a quick recap of. Um, so that you feel confident and you're on calls. Um, so I'm going to cover the small and large bowel and then Mark is going to have a look at the anatomy of the epigastrium in right upper quadrant. So, um, first things first, whenever you are on call or clerking, inefficient or anything for surgery, you should ask really the same set of questions every time you can moderate it a little bit. But really every single time you need to ask about your presenting complaint, how long has this been going on for? Have they had this problem before? And then you need to ask about surgical symptoms and you should ask this in every patient a matter what the surgical presentation is. So, how is the eating and drinking? Importantly, have they had any nausea or vomiting? Check that that wasn't mhm missus or like coffee ground limit. Um, and that's when they last ate and drink because that's important for anesthesia. I need to ask about the bowel. So, change in bowel habit, is that constipation, diarrhea? Is there any blood in the stool or Melena? Um, and then ask about urinary symptoms, although that's probably more of a neurological thing, which is another specialty in itself and you need to rule out differentials, things like pyelonephritis or kidney stones or even just a uti that can present with abdominal pain. So ask about urinary symptoms and then make sure you ask about abdominal pain and you Socrates for that, that's a really good way of assessing pain. And then you need to ask about what previous surgery they've had. Do they have any complications? And then general questions about things like, have they had any temperatures, weight loss, night sweats, headache, that would suggest something slightly more serious going on in the background. And you've got your questions that are important if you're prepping someone for a surgical procedure. So past medical history, particularly heart problems, if they have an anesthetic or you think they might need one allergies, regular medications, what pain relief have you already tried? Because sometimes they'll say, oh, so much pain and actually they've not really even tried paracetamol or anything. So that can give you an idea of a, the kind of patient and be the severity of the pain. And you need to prepare them surgery just in case because someone more senior than yourselves is going to come along and say, yeah, they do need to go to theater. Have you got them ready? So if they had any anesthesia before, when did they last eat and drink and then obviously finally need to make sure you've covered any concerns that they have, what ideas do they think is going on and a little bit about what's going to happen to them now that they're being admitted, just put this here. Um This probably isn't relevant if you're an F one doctor, but if you're an F Y to going into an S H O role, you'll be expected to things like doctor case, make sure they've got group and save and get the anesthetic team to review the patient. So um if one of my colleagues could just launch pole one for me, please, that would be great. Excellent banks. Just give people a bit of time to respond to that. Okay. Great. So it looks like the majority of use have said six hours, six hours is usually standard. So you don't want a patient to eat and drink um at least six hours before the procedure. If it's an emergency, it's obviously different. Um and some, most places if they're having a procedure at ATM, they just say as a cover all nil by mouth from midnight. Okay. So then then you need to think about your examination. So again, examine exactly the same every time, okay. If you do something repeatedly, you'll get really good, you'll get really sick at it and you'll be able to differentiate the patient's who are actually okay from those who are pretty unwell. So do a general inspection. Are they really overweight or covered in scars or do they look a bit unkempt, um other vomit balls or a capital that could give you an idea what their urine output is? But also things like hematuria, coffee, ground, vomit bleeding, and you need to just superficially palpate abdomens. So have a field and then just warn them that you're going to feel slightly deeper, wherever is tender for them, start the opposite side to that. Otherwise they will lose their trust in you if you put them in even more pain straight away. And then if they have said okay, this is where it's really sore. Your job is to find out the character and severity about pain. So you do need to press on specific areas. So check there's no right upper quadrant tenderness, things like gallbladder, rightly at fossa, appendicitis, epigastric pain, things like also and then just check for any hernias have a quick listen for bowel sounds. That's literally two seconds. Do they have bowel sounds or not? Um, are they high and tinkling to suggest something like obstruction? And then in most patient's really, um, if you are admitting them under general surgery, uh, you should do a pr examination, obviously, depending on the presentation. If you're thinking it's a stomach ulcer that you don't need to do A P R. But it is important and a lot of surgeons expect that's a standard part of the abdominal exam. So OCD, uh, lube is your friend, have some in your pocket for your general surgery on calls. Um, so we've thought about history, we've thought about examinations and now investigations again, I know I sound like a broken record, but do the same investigations every time on every patient you're gonna ask for some obs, every patient you can ask for some basic bloods. Okay. And in your kind of abdo pain work up, you need to make sure you've got full blood count. Using these LFTs. Any female patient, um, of child bearing age also gets HCG. And usually most of the time that the nurses in A and E will add on an amylase and the lipase for you. Um Well, the tests think about okay, it's going to be a while until they get scammed. What can I do to get more information at the bedside? A V B G is really important to look at lactate. That will give you an idea as to whether they're septic. Do they have any ischemia, urine, dip, bladder scam, things like that to rule out infection and differentials. So you've done your base investigations and I need to think about specific investigations. So what are your differentials given all the information you've already gathered from your short consultation? Um That often depends on anatomy. So that's where understanding the anatomy of the abdomen and its contents um comes in really uh really do it. So, so remember we can divide the abdomen into quadrants or the nine named regions and we can also divide it into an intraperitoneal area. So an area that's within the peritoneum um surrounded by it and then the area posterior to the peritoneum which is retroperitoneal. So if one of my colleagues could launch poll number two, please, that would be great. And I'll give you all a minute to, to answer that. Okay. So great. Um I've not made that two basic for everyone, but yeah, the kidneys are are retroperitoneal organ in that poll. So remember intraperitoneal is more anterior structures. So that's most parts of the bowel, stomach gallbladder, appendix, things like that. And then retroperitoneal is your posterior structure. So that's the greater vessels and the kidneys really that are of importance. Okay. And then remember in each of the nine quadrants, for example, and and sometimes I get the most ridiculous referrals. If the patient is tender in the left lower quadrant, don't say that they've got stomach ulcer. Yeah, or that you think they've got a kidney stone or something if it's really tender in the epigastrium and they've got, I don't know huma to missus, you have to think about the patterns but also just think sensibly where is the tenderness and what organs and structures are actually there. So in terms of specific investigations, as I said, that really depends on your anatomy. So where's tender, what organs are there anatomically or what structures are there? And therefore, how can I do specific investigations to assess the function of that anatomical structure. So I just put some examples up here, but again, you've got to go down the, the right route a lot of the time people just kind of scattered and lots of different tests. Um If there's something you will get a result, which you'll then have to act on. So you need to already be kind of thinking what channel you want to go down. And I do think a lot of that comes down to understanding anatomy. Remember, do document everything that's really important. And again, if you do, if you document in the same way, every time you won't miss things. So, um, that's a bit of recap. So now I've just got to short kind of five minute cases for us to work through. So case one, you are called down to E D because you are on the general surgery take. Uh, there's a 56 year old female, she's got worsening abdo pain. It's kind of crampy pain. That's um, ever everywhere she's not open about for five days or passed any wind and she's feeling nauseous, but she came into hospital really because she started being quite violently sick yesterday. She feels tired. She looks quite dehydrated. When you see her, she doesn't really have any past medical history. Apart from unfortunately, when she was on holiday, she ended up having to have her appendix out and it was abroad. So she had an open appendicectomy. But that's 15 years ago when you examine her, you'll use the same steps that we talked about before. Um, you see that the abdomen is distended and it's kind of diffusely just mildly tender, but you don't think she's parroted knittig. She's not jumping off the bed when you examine her, she's slightly tachycardic with a mildly low BP and she's got a normal V B G and normal bloods, which usually panics a lot of doctors because it doesn't really give you any direction. But in this case, hopefully it fits. So this is what our abdomen looks like. Um, so Pole number three, please give me an idea of what you think could be going on with this patient. And I did give you a massive clue at the start of the CeleXA. Okay, great. So everyone's got small bowel obstruction. Um This is a CT scan again. When you're on call, you'll get used to looking at these and, and interpreting report something's is basically just showing fluid level in the small bowel, which indicates that there is a closed section of bowel either mechanically obstructed or twisted. And so when the patient's lying flat that you get third spacing into that part of the bowel and you get a fluid level which is indicative of small bowel obstruction. So, Paul number four, please, um, what is the most common cause of small bowel obstruction? Okay. Excellent. Looks like most people have poor adhesions. So there's lots of different causes of bowel obstruction. Generally, bowel obstruction is small bowel obstruction. If you have a large bowel obstruction, that's really concerning and it's usually due to a quite a large malignancy. Um And yeah, you're all right. So the most common cause is adhesions usually from previous surgery. So, if you've got a patient that's had any previous abdominal or pelvic procedure, think adhesions and that's, you're likely cause um other causes, obviously, things like twisting. So interception allow volvulus or sometimes a hernia can come out of the abdominal wall and that can get cut off or if you've got something blocking the loom. And so a foreign body gallstone or a malignancy postop ileus is slightly different actually, pathologically, but it presents the same. They don't open their bowels, they might feel nauseous, they might be sick. It's basically just when the bowels kind of freezes after surgery. So, presentation wise, you've got absolute constipation. So that's no flatus, not opening the bowels, they might feel nauseous and vomiting, distended, abdomen, colicky pain to investigate it with your blood's, as we said, you need to do a group and save because one option for bowel obstruction is that they might need to go back to the theater. Um, and I'd get a CT scan for these patient's often in E D if they've got abdominal pain. Um, the E D doctors will have ordered that directory for you. It's not really that useful. You're gonna need a CT scan anyway because that helps with surgical planning, but it can give you a pointer in the right direction. Um I can't because there's a bit of a lag. I'm not, I don't want to open questions up, but hopefully, some of you are thinking about why I've put a lactate on the V B G because that's really important in the end of our presentation. Um So management of our smokable obstruction is going to be using basically the drip and suck method, which is essentially, you should always trial 24 to 48 hours of conservative management, obviously from a senior dependent. But you need to basically give them IV fluids, keep them nil by mouth. And you put a Rials tube in which is a wide bore and youtube that essentially decompresses everything that they've been eating that's just been blocking up and filling up the small bowel, then causing them to have fecal vomit. You just decompress that and that's there in that bag. It's quite unpleasant. The red flags and this is why I mentioned the BBg are signs of ischemia. So that's a patient that's vascular pathic because then you might be worried that the bowel is twisted to a point where it's cut off the blood supply and a closed loop obstruction for the same reason because it can keep, keep on expanding. You get third spacing and dehydration and you can end up with a perforated bowel. So to go to the anatomy of the small bowel, I'm not gonna too much detail because I don't think you need to know a lot of detail to understand the kind of surgical end of it. But remember you've got your three parts. So we've got our duodenum um, coming off the stomach judge numb. And I really, um, they're all slightly different histologically, which will look at in a second and this is a typical abdominal X ray showing your small bowel obstruction in the small bowel clearly looks dilated with some enhancing of the wall. So it could be something like an inflammatory reaction response to that obstruction. And remember that Taenia Coli and how straight are in the large bowel and you valve late con inventors, I can never say them properly are in the small bowel and you can see them, they're small bowel centrally located on the Abdo extrate. The large bowel is located around the edge parts of the duodenum. That's important if you're doing upper gi surgery, just remember those four parts. And then in terms of differences between the jejunum and I'll e um, judging, um, is more located in the upper part of the abdomen. So upper left quadrant ish, although it all kind of mulches around inside anyway, um, it's got longer straight arteries going to supply it versus the ileum, which is much lower down. That's obviously just before the cecum, which is a large, large vial. See thinking more lower right quadrant for, um, I'll, um, again, if you're interested in surgery, it's important to understand that the length of the vessels within the mesna tree is different for judging him. And I really, um when we come to think about surgical reception, you can see on the pictures there. Um So I wanted to go over this because I think this is something that people often struggle with um, anatomy of the small bowel mesentery, don't need to know in a lot of detail, but just understanding what mean tree is, is really important. So amazing tree is essentially a piece of tissue or a connection that either connects the abdominal organ to the central part of the abdominal cavity or that can kind of tether and keep the organ in place to the peripheral walls of the abdomen and within the medicine tree, that's where you've got all your blood vessels. So arteries and veins, lymph nodes and some innovation as well to those organs. So if you have medicine tree, so here's the medicine tree in the two different parts of the small bowel. If you have amazing tree, which ends up twisted, so you're nice to see the muse entry there. That's what it should normally look like with the blood supply running from the central greater vessels up towards the bowel. If your mesentery gets twisted, think about what, what the consequence of that might be. And I think we'll look at that in a second. Remember in terms of those large vessels, excuse me, supplying the abdominal organs, you've got your celiac front for, for gut, you've got your S M A for Midgut and your I M A. So inferior Mesenteric artery for hindgut. And again, Mesenteric is literally in the name, it's telling you that those after you've run within the mesentery. So poll uh number five, please, if someone could launch that for me, okay, just give people a chance to answer. Okay. So great. Most of you doing did well on that one. So remember that four got mid gotten hind got is important mainly in terms of blood supply. And that there as an example, the border between midnight and hind but is the distal two thirds of the transverse colon, just a one third. Sorry. So mechanisms of bowel obstruction, we already looked at those. But I think this is a nice image here. So herniation, intussusception where one part of the lumen goes into another volvulus is twisting. Adhesions is the most common that's essentially like scarring in between the parts of bowel and put some pictures on here of um when the bowel gets twisted or what when it's a scheme, it what it looks like. So these are adhesions. This is completely the bowel because it's been twisted. So the blood supply has essentially been completely cut off. So that bit of bowel has then become ischemic necrotic and died. And then this picture here quietly does kind of bowel in different stages. So it's probably been untwist ID. So I suspect this bit was almost completely um going to water necrotic because it's quite a scheme dark. This has had some blood supply kind of regenerated to it. And this bit has always had a good blood supply. So you can tell the difference when you're in surgery in terms of which it's had poor profusion because of twisting. Right. Second case is not as long because it's nearly time for me to hand over to mark. So case to, um, we've got another elderly gentleman who's 67 years old, it presents to E D because you can't get an appointment as a GP practice and it's got three months of the fresh rectal bleeding. So that's blood in the toilet. So if someone has, that says they have blood in the stool, you need to ask more about that. Is it that the stool is really dark? Are they passing clots? Is it fresh blood? Is it just a small amount of fresh blood on wiping? In which case you might think? Ok, it's hemorrhoids or an anal fissure or something like that or is it large amounts? In which case you think? Ok, potentially there's something bleeding in the lower gi tract, um, that needs investigation. He didn't have any pr pain, stinging or mucus. So it's probably not something like I B D but he does wrote a change in his bowel habits. He's also got some weight loss. He doesn't have any systemic symptoms or vomiting. He just really quite tired in terms of his history. He had an M I and he's got COPD, he's a smoker. So then he's in that kind of vasculopathic sort of picture. When you see him, he looks generally unwell. He does look quite pale. He's mildly tachycardic and on P R because he's got some bleeding. So you have to do a PR exam, there's no palpable masses and you can't see any evidence of bleeding when you do PRN but there's also nothing like a hemorrhoid or a fissure to explain that bleeding. Excuse me, he's got a normal lactate on his V B G and his bloods are normal apart from a HB of 72. Hopefully, this is quite a nice obvious one for you. So pole number six, please. Great. Tried to make this as barn door as I could. So, yeah, so this is sounding very much like a colorectal cancer. It's kind of picture. Um So the main thing to know about colorectal cancer, um, if you're going into general surgery because it will be you guys who are ordering the investigations and things is that it usually comes from an ad adenoma, which is just a posh name for a polyp and that's called the adenoma carcinoma sequence. So essentially that normal mucosa for whatever reason that mutates and forms a polyp and then that polyp can then change into an invasive malignancy presents as it did in our case. So change in bowel habit, weight loss and pr bleeding. Um Other nice gardens on two week wait, referral for cancer. Um So you need to do your pr exam. They might have already had a fit test in the community which essentially just looks for blood in the stool. Um And make sure you check the H B because sometimes it can be a need if they've been kind of slowly bleeding from the lower gr track for a while. Um Your consultant will directly to do some more specific investigation then, but they're going to need discussion an MD tea because they will need to see whether they should have, uh, either chemotherapy radiotherapy depending on where the cancer is and whether that's going to be a juvenile or neo a driven. So either after surgery or before surgery to try and drink it and different types of surgical procedures, we'll have a look at in a minute. Um, if your patient is presenting with the obstructive symptoms that we saw in the first case, but also with these symptoms that are quite concerning for a lower gi cancer, um, in the colon, then that is an emergency. So a large bowel obstruction is a surgical emergency. Um, and they usually need to go to theater, excuse me within at the most 24 hours, but usually before that, um, they can also lose quite a lot of blood pr so they might need a transfusion. So make sure you check the HBs, um, in a kind of cereal pattern. So, um in terms of anatomy of the large bowel, we've got, obviously are four parts. So your ascending, transverse and sigmoid uh under sending colon and then at the start, you've got your sick. Um at the end you got the rectum, um an anal canal. Um Remember that some parts of the colon travel retroperitoneal. So some of the ascending and descending colon, essentially, all the rest of it is intraperitoneal. Um And then Paul seven is ago as to what I'm going to talk about quickly. Next. Mhm Great. Okay. Um So remember, I think histologically and anatomically, you've got your division between the rectum and the anal canal, which is sometimes called the pectinate line to be fair. So if you, um if you chose peritoneal line, you're close, but it's a anatomically called a dentate line. And that's more important in terms of rectal and anal skin tags and hemorrhoids and things like that. But again, the level of cancer, if you have a rectal cancer, will it take? What kind of surgery you end up having as well? On the middle picture, you can kind of see the, what we call the para colic gutters. So those are essentially like pots of space within the abdomen where blood or fluid is going to collect if you've got infection or bleeding. So they're called the dependent areas. So things like the pelvis paracolic gutters and then your sub diaphragmatic or subphrenic space um surgical reception, usually it went on block reception. So you take and this is where four got mid foot and hind foot is important. You take the supply vessels to the area of bowel that you're receptive. And therefore with those vessels, you also take the lymph nodes and hopefully any metastases have gone to the lymph nodes. These are all the different surgical procedures you can have for the sake of I'm not going to get into those, but it's not gonna be you deciding what reception the patient's going to have. But it will be important for you to understand what part of their bowel has been respected. And more importantly, what kind of stoma if they've been left with a stoma, do they have? So, um important question is, has the patient had an immediate estima Asus? So they've had a bit of bowel chopped out and the two remaining ends been joined together or they had a stone performed, which is where they have a bit of bowel trapped out. And then they, that are still one end is either closed inside. So you end up with what we call a rectal stump. So they just closed up the rectum and then you would have, for example, an ileostomy or do they have kind of any variation on that? So this patient here has an end colostomy and a mucus picture as well. So I'm just trying to get my mouse back onto the right screen. Um So the mucous fistula is essentially when you bring out a piece of bowel is redundant. It's not attached to anything proximately. So all it's going to do is that tissue is going to produce mucus and that needs to be exposed from the body. I think there was a whole, um, my final poll number eight, please is about stone. This okay. Um I'll give people a chance to answer. So, differences between stone Hmas, um, small bowel soma is always going stopped. It because that has lots of enzymes in it can irritate the skin around the area. Large bowel tends to be flushed the skin. People often say, oh, if it's down below, then it's probably a colostomy, but really any stoma can be placed anywhere in the abdomen. These are all the different surgeries that you can have for a colorectal cancer to maybe go away and just have a quick look at those. If you're someone who's interested in surgery or you think you're gonna see it on letters and referrals and things in replacement. So I've got one minute left, but I am going to hand over to Mark, who's going to talk to you about the anatomy of the right of the Badran. Thank you very much meg. I'm just going to share my screen thing. Hopefully you can all see this. Okay. So my name is Mark. I'm one of the doctors, locum doctors. So S H O Senior House officer F four F three, whatever you wanna call me. I'm pre training. So I've done my foundation years I've done and that to be demonstrating free in Manchester. And now I'm living the locum life, but I'm applying for training this year. Hopefully, get in. So fingers crossed, find out this week. So I've got a case for you. So I wanted to use the chat function as much as possible. It will have a little bit of a lag but I want to use it, ask questions, put differentials, I don't mind. So um we're in E D. First case is a 42 year old female who's coming with abdominal pain, it's severe. You've got nausea, personal history is asthma and all you've got is some observations. So you've got a respiratory of 18 saturation is 97 in room air, the tachycardic 123 and BP is normal temperature is 36.7 and they are alert. So this is the kind of thing you're going to get if you're working in a and a from the triage nurses. So this is all you're gonna get in terms of history. So then you're gonna have to go and see a patient. Um I'd like to hope that you're all going to see a patient in an 80 manner. Okay. So make sure the patient is stable if you get these obs for this patient, you know, the tachycardic. Okay. So they're already starting to flag up. This patient is a little bit sicker than most of the people sitting in the waiting room. Okay. So you're going to do your A T E, you know, you gonna assess the airways patent there, speaking full sentences, you listen to their chest. It's clear they've got no added sounds. You're happy with the chest. Move on to the circulation. So heart sounds one and two and zero is the most common thing you're just going to see. I mean, most people, they can hear a murmur. They will, but I mean most people listen to the heart sounds quite quickly and they're tachycardic, but they've got a regular pulse and they're well perfused peripherally. So, CRT is capillary refill time. G C S is 15 out of 15 for disability. You're gonna make sure you get a glucose on the gas and don't forget the glucose. Then you're going to look at a quick exposure. So you can snow, see no obvious hemorrhage from any of the sites and from the floor. And for more, um you're looking at there's got no catheters, they've got no cannula in and they're clearly in right upper quadrant pain again, this is an 80 is very quick. So this is your initial assessment. You do 80 make sure your patient's stable before you can do a full assessment in full history. Okay. So at this point, you've got tachycardia patient, you've got some dump tummy pain in the right upper quadrant and they're nauseous. So you're differentials thinking, well, you got some shock here. So stage one shock, the tachycardic, they might be a little bit anxious and they might be pain related. So you need to start thinking about all these things. Basic management in this stage. So basic management a and these is kind of a classic thing you're gonna do very quickly before you get either nurse practitioners going to do it or the first optic season is going to do it and then they're going to come back and see them little bit later. So you're gonna give them analgesia because it's in pain. We don't like to have patient's in pain. You're gonna give them an antiemetics, especially if they are about to vomit, you're gonna cannulate them and put some fluids up because you're going to try and treat that tachycardia. Um You're going to do some bedside tests, you're gonna get a urine dip and pregnancy because they are of childbearing age. You're gonna get an E C G also because they're tachycardic blood. So you're going to get a, when you cannulate the patient, you can handily take some blood. So you're gonna get a gas, making sure you get the lactate as meg. So goodly set. Yeah, full blood count you any LFT amylase clotting and a bone and the CRP this is kind of my, like my normal set if I'm going to see in a abdominal pain patient. Okay. Usually sometimes an A and you might get referred someone who hasn't had these done. You can either add them on or you can do them again later, but it's a bit annoying. So it's good to do kind of get the broad set at primary care center first imaging, you're gonna get an erect chest X ray. So why does anyone think we can get it erect check straight? Just have a think about that and an answer later on. Okay. So again, as Meg said history, so we stabilized our patient initially, we're gonna ask the same set of questions every time. And again, it is all the same stuff. Okay? When I make sure we talk to our patient, we get a full Socrates history. Where exactly is the pain? Is this the first presentation? Okay. This can really tell us what type of pathology we're seeing. Okay. This is the first time. Then they usually won't have any imaging on the system. They won't have properly been worked up at all ever since the second or third or they've had lots of times and it's more of a chronic pictures can completely change. We'll be looking at also looking at, when did the last eating drink? Not just because they might be nauseous or vomiting, but also how dehydrated are they? And are they ready for surgery if we need to go immediately? Okay. Look at the vomiting. Look at the frequency, the contents. The color is a coffee ground at all and the coffee ground vomit is obviously gonna change your man, change your differential pathway. If you're an E D going through general surgery or you're gonna go through the medics, okay, looking at upper gi bleeds, um, bowel symptoms, any change in bowel habit. So most people answer this really badly. So you're gonna have to ask specific closed questions for this. So when did you last open your bowels? Any constipation, any diarrhea, how regular leaves and any blood and if there was blood, people are really bad at telling you how much blood there are. Okay. So try and get them to sort of think about norm measurements like a teaspoon, a teacup, a mug full or was it everywhere? Okay. People are really bad at telling you about that but you'll get better with practice. Um Was there any Melena people don't really know what Molina is? So you just gonna say like black sticky, horrible smelling stools. Once people smell Molina, I think they'll never forget it. Ok? You're definitely going to ask you, you're only history. Okay. So the most common reason why you're gonna reject all those be a destructive S H O on surgery is because all of those urology referral is going to come to you as well. Um Not trying to poo poo E D but lots of urinary and medical and neurological stuff will come through the general surgery. S H O on referrals or on the take. And it's good to try and get that history down. So you can exactly find out what's wrong with them early. So, good history was finding out any lower urinary tract symptoms. A dysuria, uh, any frequency, any nocturia, any hematuria at all. And again, do they get recurrent UTIs? Have they had offensive smelling urine, any discharge, looking at urinary stone history as well? Previous surgery really important. So, who did it? What was it? And under who POSTOP complications? Was it a normal surgery? Was there any problems afterwards? There's any collections, was any leaks, etcetera, etcetera? Okay. Ask the same set of questions every time. So we've got a systems review as well. So I would like to, this is my kind of systems reviewed. Like to see all my patient's making sure they've got no chest pain, no palpitation, shortness of breath. So I'm doing a quick, you know, it's just a quick systems check. So make sure I'm not looking at, you know, secret pneumonia or looking at secret Acs that's come up and you do get them okay. So you make sure you try and rule it out with the systems review. So we've got our case three. Here's a 42 year old female, we've gone back with stabilize them. We've got a little bit more of a history. It's not great. But again, we're working with A and E here. It's kind of triage service. So it's a severe abdominal pain. It's in the Robert quadrant. It's been happening for two days. Now. They tell you it's constant. But actually when you talk to them a little bit more it's intimate and it's more colicky. Okay. They're not vomited at all, but they are nauseous and they've had reduced eating and drinking. The past one of history's Aspas, we haven't found that anymore at all. They haven't, they've got a what we call a virgin abdomen. They've had no surgeries on the tummy it yet. Um Again, the, the obs have stabilized a little bit. You brought that tachycardia down with a bag of fluids. You've started your analgesia an antiemetics as well and you're gonna refer this patient. So you need to start thinking about what are you going to refer to general surgery, aunts? Okay. So I'm kind of thinking on the son of flip projection side. It's so what we're going to refer this as and hopefully you've got a little bit of a differential list. You've heard of your surgical sieve before. So, you know your vascular, your infective traumatic autoimmune, metabolic, iatrogenic, neoplasm, congenital, degenerative endocrine environment, functional. So you have to check that cause I'm already bad with my surgical sit, but it's good to have a nice, logical structured way of looking at it. Okay. So how does this all relate? So, we need to know if we've got right upper quadrant pain, how we need to know what we're looking at. Okay, what kind of things pathologic is can come up. So looking at the right upper quadrant, we've got obviously the most obvious organ in the right upper quadrant. We've got the liver, okay. We've also got the ribs important to think about. We've also got the right base of the lung. Um We've also got the hepatic fletcher of the colon. Okay. So again, thinking about outside the box things, pathologies when you get some referred something or you see a patient for the first presentation, need to think outside the box, making sure I rule out all those different potential pathologies before I get onto the bond or. Oh, it's obviously the liver. Oh, it's obviously the gallbladder. Okay. Looking at the retroperitoneal structures as well, need to think about, you know, things like um pilon arthritis of the right kidney, looking at renal stones as well, but also looking at things like um aneurysms, um esophageal problems and also looking at maybe potential clots in the IVC. Okay. This can also very rare but can come up okay. So you just need to think about outside the box structures. So hopefully you've got some differentials. I'm going to write down a few of them. So the bold ones are your red flags ones that you need to make sure you rule early. So this is why I said get it's important to get your E C G. So you can rule out that acs it's important to get your pregnancy test. So you can make sure you rule out that ectopic pregnancy. It's important to get that. I always, I like to get an erect chest X ray. I know it's not very sensitive or specific for pneumoperitoneum, but it is super useful. Just say, all right. Yeah, there's no, I can not see any pneumoperitoneum there. And also I can see there's no basil pneumonias, These things can catch you out and you can be stuck with a patient for a few days before they get accepted and referred to medics. Unfortunately, if you take that patient under you, you have to look after them for a day and I'm not saying it's unfortunate, look after patient's, but you don't want to be stuck with the patient's under the wrong care. It delays everything, okay. So it's important to get these things early. And that's why some people see the general surgery shr is a little bit obstructive, okay. They're not trying to be obstructive, but they're trying to make sure that they're going to the right specialty to stop delays the patient care. So hopefully you thought about some of these differentials. So, pneumonia, biliary, colic cycle, cystitis, viral, hepatitis, all sorts of liver abscesses, etcetera, pancreatitis, pilo, and renal stones, etcetera, etcetera. Make sure you think about rib fractures, well, and potentially colitis and obviously cancers. So malignancy of any and all I've just put on there as Well, so you've got some bedside tests, you've got your HCG pregnancy urine dip, you've got your full blood count, you and LFT amylase TLP and you're at Chester it. So hopefully these things will rule out these things highlighted in yellow here. So they kind of really concerning things. Obviously, we got the triple A on there is the other really concerning thing, but in a 42 year olds very unlikely. And if you really want, you can get an ultrasound machine and have a quick scan if you're trained in that, okay, if you're not training that get someone who is trained in that to do that early. So, and asked me if Robert quadrant, why is it important? So we're going to go through looking at the liver here, so we can see liver spit into the left and the right lobe. We also got the cord eight and the quadrant lobe. So we've got the gall blood on the posterior side. We've got the IVC that runs through. Uh We've got kind of some ligaments here. We can also see. So this is the ligament and Terry's what used to be the umbilical vein. You've got a false a form ligament kind of very easy to spot, landmark, splitting your left and right lobes. And you've got the kind of triangular lim ligaments in the corners as well. And then this structure here is your gallbladder. Okay. I'm going to get on to that shortly. So how's the liver split up? So it's split up into segments. So, like I said, right and left. So we've got the green here is the left lobe and then the orange and the yellow here are are right lobe. But you can see the some other colors here. So this blue one in the center here, this is our core date lobe, the origin or original part of the liver and we've got the quad rate is this purple bit here. Okay. So you can see how this kind of split into different parts by also these hepatic veins here. So you've got the middle hepatic vein, the left and the right hepatic vein and they split up our lobes into segments. So we can call these number these. So we've got number one is the cord eight. Then we go from 2 to 3 is the left lobe, four is the quad rate and then we go 5678 and then 5678, our all of our part of our right lobe of liver. So how does the blood flow through the liver? So to the liver takes up 25% of our cardiac output at all times. Okay. So the hepatic portal vein is the entry point to the liver. It supplies 75% of the blood, all of that nutrients and things you've absorbed from your meals, get absorbed through there. And you've got the hepatic artery proper, which comes up from this um the celiac trunk, which is part of the four gut and that supplies 25% of the blood supply and the option ated blood to the liver. We've got a nice lobule here of liver just trying to remind everyone. So the liver filters all that blood nicely with hepatocytes. The blood comes from that portal triad and travels centrally towards a central vein and then goes up into the I V C bile importantly, is produced by the liver and it will travel the opposite way. So it go down towards these uh bile cuniculus here and then we'll travel down into our right and left. Hepatic ducks down into our common hepatic duct, which joins are cystic duct, which joins the gallbladder, which joins the common bile duct or CBD something you'll hear a lot in general surgery which joins either can join the pancreatic duct or not. It depends on the anti mikel variation, but it will always enter the duodenum at D too, which is part of the four cut at the ampulla of art. And we've got our sphincter of oddi there, which is that muscular thing that allows the contract, the dilated dilation and contraction of uh bile into the small intestine to help you get absorbed. Remembering here, we've got our gallbladder, which is that reservoir of bio. So it contains about 50 mils of bile reservoir. And this is important to know when you're looking at the right upper quadrant pathology. So, we've got some bloods back from our patient. They're still bit tacky, but we've got some raised white cells. We've got a normal, you any, we've got a mildly raised out force and bilirubin amylase is normal, which is good. And we've got a slightly raised a CRP and normal gas, which is good. We've got normal glucose and lactate and our chest X ray was normal, which is good. So, what we're thinking here, okay. We're obviously thinking Curtis cystitis. Okay. So, Curtis cystitis is our inflammation of the gallbladder. 90% of all courtesy cystitis is to do with gallstones and the other 5 to 10% is a calculus which is without stones, uh presents with rubber quadrant pain, which is worse. A deep inspirations. That's when you're examining your patient's and you can feel for Murphy sign, you can feel a deep breath and you're, you're palpating there, right quadrant. You can feel the gallbladder try and go down to touch your fingers and that's Murphy sign positive. They might have a fever, they might not, they will be nauseous and they sometimes vomit but not often and you might get referred pain to the right shoulder tip. Risk factors are your obesity, mainly diabetes, pregnancy, rapid weight loss. If you're on the combined pill, famine history and then more like the a calculus types of colecystitis will come from your major traumas and burns chemotherapy or vasculitis. Initially, you want to get bloods for these patient's going to get V BGS, make sure you know how well they are. But then you want to get some scans. So, imaging will tell you whether you've got cholecystitis or not really, you would find it clinically, but imaging was important. So the abdominal ultrasound is your first line test. Okay. Most people can get an ultra ultrasound quite easily. So either it's the weekend or it's usually the weekend or the night, you have to get to wait till the morning. But in the weekdays you can get an ultrasound. No problem in the morning if you refer with this history. Um, and that will tell you usually if you've got gallstones or not or whether there's any cholecystitis. Um, if you have any problems with CBD, so common bile duct dilatation, you might need to get an M R C P which is a, uh an MRI scan of those ducks. And then if you can't get any of these things, but your patient's really sick overnight, you can get a CT scan. Um, you might get a little bit of fight from radiology, but it's important to make sure you image these patient, especially if they're a bit sick. So what you're gonna do, you're gonna resuscitate the patient and usually these patient's will get antibiotics. Okay. So, settle everything down. You're talking textbooks that Curtis cystitis is treated with a hot Lap Collie. But unfortunately, with the NHS at the moment, we can't do that. We have to conservatively manage all these patient's initially. Make sure the inflammation is settled down. They're not going to get sick from any ascending cholangitis. Make sure you give them antibiotics. It's usually come, ox is some sort of careful sporin early on and then you're gonna give them IV antibiotics. IV fluids. You're gonna give them a low fat diet. You can let them eat and drink as long as they're not gonna have surgery the next day. Well, saying that you shouldn't let them eat and drink if you're gonna get an ultrasound scan up and then the full trying treatment. So, the surgical treatment of this is a laparoscopic cholecystectomy. So you're gonna lap Cody, essentially, you're gonna take the gallbladder out laparoscopically. You might have to convert to open a bit, a bit complicated, but it depends on the anatomy again, if they're sick overnight. So they've got a ascending cholangitis red flag emergency like they really septic with it. Um, then you might need to organize a percutaneous cholecystostomy, which usually is done under your local interventional radiologist is essentially just a drain that goes either can go through the liver or under through the skin and drains the gallbladder because of the obstruction. Usually it's gallstones that causing the obstruction or a cancer. So, your cholangiocarcinoma as well cause it to obstruct and your gallstones will also cause obstruction, obstruction of drawn. This is a big problem because you can get a send, you can ascending bacteria up there and make you very, very ill. And upper gi patient's with FDR sepsis will die quickly. So you need to get those antibiotics. Those sepsis six started. Okay. So it's just a quick very geology looking at. So use the ultrasound scan. You can see the gall bladder here, this dark dark picture here and you can see lots of little gallstones in there. I don't think you're going to get that nicer images when you do it yourself. But um it's quite obvious one there and you can see the liver. It's remembering the skin is up here and this is deeper tissues. If you get a CT scan, you can see there's an actual view. You can see the gall bladder here with your right lobe of liver. And you can see that kind of see like a double edge here. So that's inflammation, that's usually a dumb a. So that will be a cholecystitis picture on this scan. So I've just kind of colored this in here. This is what you want to take. If your gallbladder is inflamed, you want to take it out, you wanna do locally. So you can go in through a laparoscopic approach. You're making sure you visualize what we call Kyllo's triangle. Okay. So the college triangle is formed up of your common hepatic duct, also the inferior border of the liver and then the cystic, this is kind of a triangle used to be just the cystic artery there. But now we look at a bigger picture. We're gonna divide these structures within the less of less of momentum. Divide these structures carefully isolate the cystic artery, then clip this and then make sure we're not touching the right hepatic artery or the big vessel behind the IVC can, that can cause problems. So I've got quick case four again. So we're gonna have happily managed that patient will go on to someone else. We've got another E D referral. 38 year old guy. He's got abdominal pains, very severe nausea and vomiting, got past medical history of depression. There rests are a little bit high, but okay, saturating 91% in air which is not good tachycardic and they're a little bit hypotensive with a normal temperature. So what we're gonna do, we're gonna do an 80. You're gonna stabilize this patient. Okay. So quick check the patent. Speaking to you. How are you speaking in full sentences? Just as fine bit tachycardic looks a bit dry. So obviously, we're gonna cannulate this patient at this point. Get some bloods, get some fluids going to make sure we stabilize them. Get an E C G. They're also nice and alert. They're talking to us that glucose are going to be found on the gas. And again, we do a quick exposure. So there's no hemorrhage sites. They've got no catheters or can you be at that point. And they've got some epigastric tenderness, early differentials. Again, you can see how it's very similar to before looking at stage one shock may be starting to look at stage two shock with a bit of hypertension as well, but they could be a bit anxious and they could be in pain. Okay. So this is, this can cause you to, if these are extreme, they can cause your observations to go off. So we're gonna do oxygen. So first thing you're going to do is stick some oxygen on this patient. Okay. So 91% sat unless they've got COPD are not good. So stick some 15 liters of option. You can always titrate it down afterwards. A rather oxygenated patient than not oxygenated patient. Okay. Get urine algesia, antiemetics, basics in get cannula and IV fluids because it's a narcotic. Get an E C G is the same processes before guys. Okay. Get your blood, get your nice abdominal profile there and then your imaging, you're gonna get erect chest X ray again because you're looking at potential pneumonias, potential perforations. A viscous is all important. Basic stuff that you can do in A and E. So again, same sort of questions every time you see how it's very, it's the same, okay. It's the same as before making sure we're looking at everything and this is what makes you really good F one F two S in this placement. So we've got a little bit more of a history. They've got severe abdominal pain. It's in the epigastric area. It's been a day of it. It's been intermittently worse and it's been constantly there and it's radiating to the back and now got nausea, vomiting. First of all, it was all the food they're eating and now it's some bright yellow color but no blood there actually assaulted by their partner a day or two ago. Um, they've got depression and alcoholic excess history, but we didn't get that at triage. Okay. So again, little delving further interpretations, history will get you more information. Their observations, they've improved on a two liter nasal cannula after some IV fluids there. Also, their heart rate's nice is settled down and they're a bit more normotensive. They've got a really tender epigastrium with distention and their bowel sounds are reduced and we started analogies, antiemetics, an IV fluids. So what we're thinking of this, okay, we'll make sure we look at the anatomy of the epigastric area. So again, think about the ribs, think about the base of the lungs, but also think about the liver, think about the stomach, think about the pancreas, think about the duodenum and the major vessels that sitting in our epigastric area. Okay. So, always think outside the box of these patient's again, looking at the anatomy in more details. So we've got our stomach. You can see here, we've got the greater momentum which reflects down into the transverse colon. We've got a lesser momentum, were touching are lesser surface here onto the liver and we've got a gallbladder there. You can see that's kind of poking up that's not normally poking up. It's nicely tucked under the liver. These are all parts of structures that we can see in the epic ashen. We've got, remember our esophagus there as well. So going back to our history, we're referring this as, remember we look at the red flags, try and rule them out early. Okay. So you've got triple A A C S pneumonia hiatus, hernia, peptic ulcer, potentially perf to do a denials, potentially. Perfect behalf syndrome. Remember that's your esophageal ruptures, visceral perforations, ascending cholangitis. All these history remembers similar. You got to make sure you rule out the red flags first. So what you're gonna do, you're gonna do your bedside, you're gonna do your bloods, you're gonna do imaging. Hopefully you've ruled these out with your, with your basic tests. Uh looking at the anatomy of your stomach again. So we're going through the fund issue body, the pyloric canal and the pylorus down to the duodenum. We've got a lesser and greater curvature there and we've got our blood supply. So remember, this comes from the celiac trunk. It's a four gut structure of the stomach. So we've got a left gastric area along the lesser curvature and then we've got our right gastroepiploic that meets our left gastroepiploic, which comes from our splenic artery on the left and on the right comes from our common hepatic, these meet together kind of in the middle of the greater curvature of the stomach. So kind of quickly again, these these structures all interconnect. So it's important just to think about the blood supply, if you're looking at this structure, especially if they vomit blood at all. Again, looking at the veins. So veins are very similar apart from, they go to slightly different places with the inferior mesenteric vein meeting the splenic before it meets the superior mesenteric to form the portal. Uh We talked briefly about the duodenum before which is good. We've got D one D two which is four gut structures and D three D four which are mid cut structures. And we got this structure here, this dog poo looking structure, okay. So that's the pancreas. Yeah. So we're looking at the head to the neck, the body and the tail and the un connect process sitting within our duodenum and it's important structure to know. Um So we've got our pancreas here again. That's weird, sort of horrible shape. It is you'll see on CT scans. It's not a weird, it's quite a weird shape on there as well. It's fed by both are, it's kind of a mixture between a forgot and a mid gut structure. Okay. So it's fed by both are superior mesenteric and our celiac trunk. And again, the blood supply on the venous drainage side it's supplied by our um it's drained by are superior mesenteric artery, superior mesenteric vein, mainly, but also slightly high inferior mesenteric vein. So, this patient, they've got raised white cell's high creatinine, mildly raised A L T in bilirubin bone profile is normal. The amylase is raised, the CRP is raised and they've got normal gas and like tape. The imaging shows direct chest rate ratio is nothing, which is good. So what we've ruled out, we've ruled out a lot of these. But looking at a high, really high amylase myth structure is going to be pancreatitis. Okay. So inflammation of the pancreas is New York. You pancreatitis definition, I get smashed. You can look up in your own time as the causes and you wanna make sure you look at all of these causes and rule them out. Glasgow emery severity classification. So make sure you're you're when you've got your, these patient's on the take, you get A B G for them, okay. Your seniors will really love you if you have an A B G ready to present in the morning. What's the lactate? What's the glucose? What's the partial pressure of oxygen, etcetera? It's all go about mild, moderate severe classifications. How does this present? So it's epigastric pain, radiates through the back, lots of nausea, lots of vomiting, plus minus fever, plus minus. John is depending on the cause. You're gonna get your amylase and lipase, depending which center you work at, you're gonna get an abdominal ultrasound scan. Okay. So that's your 1st 12 to call the first investigation. If there's, if they're not sick, okay. If they're sick, you want to get a CT scan, but be careful of these because the 1st 40 hours of presentation will not show you an acute pancreatitis properly. So you wanna make sure you think about which investigation you want to do, how you gonna treat this, you're gonna do supportive medication. So you can give them lots of analgesia, lots of oxygen, lots of IV fluids aggressively. If you're gonna give them lots of fluids, make sure you get catheter in them as well, eat and drink as tolerated and observe them because they can get complications and they can get really, really sick. It's important to involve I T U early if they get something like A R D S. So acute respiratory distress distress syndrome or necrosis, necrosing pancreatitis. Okay. So they get necrotizing pancreatitis. You wanna give them IV antibiotics, but usually you can withhold and wait and see how they go on. It's important to do daily blood tests with these patient's as well. Quick again, just looking at the ultrasound. So again, pancreas is a little bit harder to see and it's usually covered by bowel gas. That's why I say abdominal ultrasounds a bit here and miss with pancreatitis. Okay. CT scans are a little bit uh better, especially if they're a little bit delayed presentation. You can see this is a normal uncomplicated, acute pancreatitis and this is uh necrotizing again. I'm not expecting you to read CT scans. Look, you can look at the reports, but it's nice to look at reports of scans and try and report your own scans before they get reported overnight. Especially if you're on the surgical take. So, thank you very much, everyone. We go through the learning outcomes. So we've recapped. I'll take surgical history. We've looked at how to do a surgical clinical examination. We've looked at some common presentations on your scene. You're on calls and you're take, make sure you get their basic investigations and management sorted before you help you get your seniors involved. And we looked at some relevant anatomy to help you understand these presentations and the management. And we've also looked at the some of the help with the anatomy of helping with surgical procedures. So, um this is literally how to survive. So hopefully it's helped you with that. Um Do you guys have any questions?