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Summary

This on-demand teaching session is part of the International Medical Graduates (IMG) series hosted by Minded Leb. Suitable for medical professionals, the lecture focuses on gastroenterology, exploring common topics between surgery and gastroenterology. The session will partly be surgical and partly gastroenterological. Topics to be covered will include acute abdominal pain, upper and lower gastrointestinal bleed, liver failure and more. The session will also look into the practical application of the A to E assessment used in acute patient conditions. Professionals attending the session will benefit from practice scenarios and patient assessment walkthroughs, covering airway check, breathing and circulation assessment, and other topics. The importance of carrying out A to E assessment in an acute situation will also be stressed. Polling questions throughout ensure engagement and encourage participants to apply what they've learned in different patient scenarios.

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Description

Asked to See patient series on gastrointestinal system

Useful for junior doctors during oncall as common scenarios including investigations and management will be discussed.

  1. Hematemesis
  2. Spontaneous Bacterial Peritonitis
  3. Hepatic encephalopathy
  4. Lower GI bleed
  5. Abdominal pain

Learning objectives

  1. By the end of the session, participants will be able to accurately diagnose and differentiate between various types of acute gastroenterological conditions, including surgical cases.
  2. Participants will learn how to conduct a comprehensive patient assessment, starting from airway assessment, breathing, circulation, disability assessment to exposure/environmental control (ABCDE) in an acute setting.
  3. Participants will acquire skills to respond to emergency situations, including ensuring airway patent, providing oxygen, controlling bleeding, providing intravenous access and fluids, and managing neurological symptoms among others.
  4. Participants will be able to identify signs and symptoms of various abdominal conditions by different regions of the abdomen and understand how to treat them accordingly.
  5. Participants will understand the importance of, and practice, determining history of the present illness in patients presenting with acute gastroenterological conditions, and make appropriate referrals where necessary.
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Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hello, everyone. We'll start in a couple of minutes just for everyone to join just a couple of minutes and we'll start. Hello again, everyone. It's lovely to have you all here. Apologies for the session. Uh A week ago, we had some technical difficulties. That's why it had to be rescheduled for today. So welcome everyone on behalf of minded leb to our I MG series. We're doing a series of asks to see a patient now and this one is going to be on gastroenterology. So anything connected to acute gastro conditions, it's gonna be partially surgical and partially um gastroenterology because there is a lot of common topics in between surgery and gastroenterology itself. So we'll just speak a, a bit about uh pure gastroenterology and a bit also about surgical conditions, things like um acute abdominal pain and et cetera as everyone sees lights. Ok. Just let me know in the chat. Ok. So we will look today at abdominal pain, um and abdominal pain divided by different regions of abdomen. We'll also look at upper gastrointestinal bleed, lower gi bleed and some aspects of liver failure when because we are talking about acute conditions when you are assessing a patient. Always remember in acute situation to start start from your A to E assessment. Ok. So let's have a look probably on every webinar as we're doing. Now, ask to see a patient, we will look into um a three assessment. So it's gonna be a good practice for you just to repeat that multiple times and get familiarized with it. So at assessment, I guess everyone knows um starting from a, so that's our airway. We want to make sure that airway is patent. So we can do a few maneuvers in order to make sure we are not or we are on the clear side. Ok. So looking at the patients or inspecting at first anyway, noises, any position of the head that doesn't seem to be a physiological position or it seems to be a position that may have some impacts on airway obstruction, any visible foreign bodies. We can also, if, if the mouth is open, we can have a look around, we can try to open patient's mouth and make sure there's no visible foreign object in there, any fluids or any secretions in patient's mouth, any signs of edema. Ok. So here there are a few interventions that we can do depending on what could be what, what we see in examination, what could be the pathology. So we can try to open mouth, we can try to suction if there are some fluids. If there are secretions, if um uh there is gurgling. So if we uh when assessing a patient, if we um hear, see some signs of gargling, um most of the time suctioning will be very helpful, uh securing the airway and um some oxygen also putting a patient on oxygen. However, if there is air obstruction that we don't clear and put a patient on oxygen, even 100% oxygen won't help because we need to uh open airways first, um be mindful if there is ac spine injury in any cases. So here we are talking about gastroenterology. So unlikely. However, in any other cases, if there is any c spine injury, there are things like um Joe Trust that we can do, but we wouldn't be extending the neck in order to make the airway patent. So our goal is to make the airway patent and now going to be so b that's breathing what we can do. So, looking at the patient initially listening, looking at the, the the movement of the chest, looking at any asymmetry, uh using our stethoscope to listen to chest, uh we can feel the chest if it's expanding on the both sides symmetrically. Um we can already implement uh some observations such as measure respiratory rate measure, saturation of the patient, um check for breathing sound. So that's partially in A and also partially in our B. Um also listen to any added sounds when we're listening to the chest. Um palpate for any signs of subcutaneous emphysema. So, this is when we palpate uh around the neck or chest area and we feel bubbling under our um fingers, that can be a sign of um perforation of trachea. Um As as I mentioned uh earlier, we can also check for symmetry of chest movement. Uh We can also immediately check here for any signs of tracheal deviation. Um and uh things like jugular vein distension. What are the things we can do in order to improve our be on assessment? So, giving patient oxygen, um if there are any signs of pneumothorax, we are treating pneumothorax urgently or emergently rather um with um then inserting a needle just to aspirate that air in the, in the cavity. And we can use some inhalation therapy. We can use nebulizers or we can go for ventilation. And our aim is to provide sufficient oxygenation and ventilation to a patient see which is cardiac. So, in this bit again, we can utilize our observations, checking patient's heart rate, checking their BP, checking things like capillary, refill time on their fingers, uh checking for any signs of bleeding, external bleeding. If this is a patient who uh sustained any sort of injury and looking um inspecting for skin color for any um cyanosis, let's say central cyanosis, for example. Um And here we call, we can also take blood samples while taking blood samples. It's very helpful in many cases to also um take a sample for ABG or VBG depending on the situation and what we are looking for. Remember if you're taking blood in emergency situation, um take a VBG, you will get a mo a, a bit of the results quickly. Um And, and you don't have to wait uh for some time for the bloods to be delivered to the laboratory and uh for the results to be uploaded back. So in here, uh some interventions that we can also do is getting an IV access. So putting a Cannula or Ventolin in um if this is not possible, there's um an alternative using an IO axis. So that's intraosseous axis, controlling bleeding if there is any external bleeding. Um If there is massive hemorrhage, we can call a massive hemorrhage called OK. Um and, and starting things like IV fluids, starting any medications. And again, depends on the situation. As here we are aiming for stabilizing circulation. Uh on our D on the, there are different things we can look into. Very important. Things are things like BM. So this is blood glucose level and Glasgow coma scale. So what's the patient's consciousness level and other things we can do here is we're looking at gastroenterology today. So remember indeed, we can examine abdomen. Um we can also examine neurological system um and do things like toxicological examination, for example. So here our interventions are checking glucose and checking um and, and getting some antidotes if this is, for example, uh a positive uh toxicological case that somebody um overdosed on something too, too many medication. Um And in here, we are focusing a lot on neurological system but also a few other systems like we can examine abdomen like mentioned before. And our e is all the other things like examining the patients from head to toe, checking their temperature, body, temperature, checking for any injuries, any um uh edema around their body, checking their skin, for any signs of scars, any ulcers, any other skin changes. Uh And basically all the other things we can think of, but always remember about this principal ABC, whatever assessment in acute condition you're starting, just go ahead and do your ABC first. Um This list here of what obtained in acutely ill patient is of course not exhaustive. There are a few examples for you of one of the most important things. It's more of if you're assessing a patient for for the first time in acute setting and you're panicking, try to keep this list in your head what to do. So make sure that you do observations. So ask one of the staff members that's around you to take an OP S machine and check the basic things such as saturation, BP, heart rate, do an E CG for those patients as well. Sometimes um it may not seem like um a heart problem, but it will turn out to be a heart problem. Um Remember about axis when you're putting an axis when you're putting cannula or Ventolin in, take lots also and consider taking VBG or ABG depending on the situation. Remember about the blood glucose level as well. Also BM for, for those who haven't encountered this abbreviation at BM. Um it's uh it is an abbreviation used for blood sugar level. Um It's, it's an um old, it's an abbreviation that was used uh in old times um based on the names of strips for measuring the blood glucose level. That's why BM. Uh but this stands for the blood glucose and remember to take a brief history. The patient is able to give you history. Maybe a family member is around. If you don't know this patient at all, it would be very helpful to take breath history uh and things like considered chest x-ray, maybe abdominal x-ray doing urine dipstick. A lot of the times in case of abdominal pain, you may find out that this is a uti instead of any acute abdominal pathology. So keep in mind urine dipsticks as well. And remember there are seniors. So ask for senior help early on if the patient is deteriorating quickly. So we have a, a question here, I'll make a poll in a minute. Uh Let me just read a question for you first and feel free to answer whatever you think is the most likely answer. So there's a 35 year old male patient who presented to ae with a complaint of severe abdominal pain and this pain has been there for the last 24 hours. He describes the pain as constant and localized to the right lower quadrant of his abdomen. Um, he also had nausea and a few episodes of vomiting. The vomiting was nonbloody vomiting. He denies fever. He denies any changes of bowel habit. On examination, there is a tenderness and guarding in the right lower quadrant, bowel sounds are present and there is no rebound tenderness and the rest of the examination is remarkable. So let me, I'll just write a question one instead of copying it up. Ok? And I'll give you just a few options. So the options are gonna be as it appears on the screen. Oh ABC. OK. Let's see. So feel free to answer whatever you feel like is the most appropriate answer. OK. We have the responses already. I'll just give you a minute. Ok. Don't be shy. I can't see answering so you can go ahead and, and answer whatever you feel like is the most appropriate answer and we'll have a look at different options. So the option A is acute appendicitis. Option B is gastroenteritis. Option C is irritable bowel syndrome, option B, diverticulitis and option E cholecystitis. So I can see um almost half of the participants answered just now. Ok. So let's have a look again at the question. So there's severe abdominal pain for the last 24 hours. There is a pain, um which is constant and localized to right lower quadrant. So thank what is in right lower quadrant. Um He has also experienced nausea and some vomiting without blood and no fever. Uh And then no changes of bowel habit. There is some tenderness and guarding in right lower quadrant. So, let's see. So the correct answer in here is a, so 81% of your answer. That's brilliant. Let's see. There were also some answers B and E. So why it's not B and why it's not e gastroenteritis. Um gastroenteritis would most likely be associated with epigastric pain. Um Yes, vomiting. That's right. There is no bloody vomiting in gastroenteritis. But uh there wouldn't be a pain localized to right lower quadrant. This is very specific for acute appendicitis, uh tenderness under the guarding in right lower quadrant. Again, very specific for acute appendicitis. So this is something that's guiding us towards the answer A in this question. Uh So that's a mcburney point. Very specific for acute appendicitis. So that's why I wouldn't go for gastroenteritis because there's no um epigastric pain. And there are signs very specific of acute appendicitis and cholecystitis. Again, that would rather be a right upper quadrant. Ok. And there could be some be vomiting. Uh There's no, um actually there's no details on uh vomiting except of the fact that it's nonbloody, but cholecystitis would rather be right, upper quadrant and would very likely have a fever, the other thing is in this question, it's mentioned that there is no fever, the patient didn't have fever. Uh We would sometimes expect patients with acute appendicitis to have fever. Uh So it was a bit misleading, but I would more of focus on the right lower quadrant pain li right, lower quadrant tenderness and guarding. So that's why it would be an answer. A OK. So let's have a look at that very good tummy picture. So these are some areas of abdomen uh where when you are looking at abdomen, when you're examining abdomen, try to picture where organs are located. Um So just to get familiarized where right, upper quadrant left, upper quadrant is or right um inguinal area or sometimes referred as uh lumbar qua ll right, lower quadrant, sorry. Um which is the lower side of the abdomen on both sides, right and left uh umbilical area in the center and lumbar areas on the sides at the level of umbilical area. So always think where are certain organs located when you're trying to diagnose. It's not al always gonna be true because sometimes pain thirs somewhere and sometimes people feel patients feel pain in other areas and the organ affected. But uh in a lot of the case, you would be able able to diagnose a lot of conditions based on where the pain is localized also in acute appendicitis. Um patients commonly present with central umbilical pain initially that later radiate to right, lower quadrant. So this is also something very specific for acute appendicitis. Um So yes, again, looking at the abdomen and thinking, where is the pain and what are the organs around there? Uh Common things that uh present to common pa patients with common pathologies that present to A&E would be gastroenteritis. Very common patients present commonly with peptic ulcers. Um gor. So that's gastroesophageal reflux reflux disease. Sometimes they, they just present with constipation. And you think, hm, this is acute abdomen. This seems like acute abdominal pathology, but it turns out just to be constipation. Always remember that you need to investigate for more serious diseases, things like IBS diverticular disease and maybe some postoperative adhesions that can lead to bowel obstruction. Those are very common conditions. And don't forget in female patients about obstetric and gynecological conditions, things like ectopic pregnancy, ovarian cysts when you're examining abdomen because they can mask as acute abdominal uh surgical conditions. But this can be actually uh gynecological or obstetric conditions and things like trauma, things like myocardial infarction, things like pneumonia, sickle cell anemia or sickle cell crisis, and DK A can also present with abdominal pain. So that's why um check glucose level because maybe this is DK A. Ok. And a very helpful tool probably most of you encountered already is Socratic. So that's one of the very helpful pneumonics used by most of uh the the the physicians to take a history ta take appropriate history and pain. I think you wouldn't miss anything important if you use Socratic. So every letter stand stands for something. So when you're asking the patient always think at the back of your head, what things I need to ask about? So site where is pain located onset? When did it start? What type of pain it is as in character, where does it go? Where does it radiate? What things is it associated with uh time or duration of the pain? So here, uh two things overlap um things such as onset and time. So in these places, you can ask, um when did it start? And has the pain been there all the time or in some moments it went away and came back? Uh What exacerbates the pain and what's the severity from 1 to 10 things that pain can be associated with are things like dysphagia, dyspepsia patients can experience nausea, vomiting, things like fever, things like change in bowel habit. Any urinary symptoms also to differentiate from uti um any weight loss that they had any shortness of breath, any rashes around your body and ask female patients about gynecological history as well and other things like jaundice and skin itch that would make us think about liver diseases. Don't forget when examining a patient with abdominal pain to do apr exam. Some patients may not report having bowel issues just simply because it can be embarrassing for them. It can be difficult to speak about but doing apr exam can give a lot of answers. Um This can be things like differentiating an acute abdomen from constipation, causing abdominal pain or looking for masses. And in male patients examining a prostate and for patients who already had some abdominal um surgeries in the past, remember to look at their stoma. So what are we looking when we are, what we are looking for when we're looking at the stoma? What is the color of the stool in the stoma? What is the consistency? And if there are many uh any signs of inflammation uh around the stoma um bag that's um attached to the skin, maybe any redness, any erythema, any um warmth of the skin around. Um And um if it is liquid, if the stool in the stomach is liquid, uh then it's likely to be ileostomy and if it's solid, it's likely to be colostomy. So look at where the stomach is located. Um and a very, very helpful resource g kinetics on abdominal pain. So you can scan your cold later on. So this is um to guide you how to examine patients with abdominal pain or how to examine abdomen. Um Also things that I already mentioned to keep in mind is do a urine dip to see if it's likely to be any urinary pathology rather than abdominal pain caused by any intraabdominal pathology. And in female patients, beta H CG. Um So those are for all premenopausal women of reproductive age, uh bloods. So remember taking um basic bloods like FBC S LFD S or any amylase to guide us towards any pancreatic conditions and look at calcium level, look at the glucose. And also if you suspect that this can be of a cardiac origin check cardiac markers, look at clotting and look at lactate that would lactate would help us think about any uh bacterial pathologist, any bacterial infections. If the patient has pex blood cultures would be very helpful too. Um And some investigations such as chest X ray, uh we'll look at some, some of the imaging of it later and uh abdominal x-ray as well in case of abdominal pain, E CG, if you're suspecting it can be cardiac in origin and things like further investigations depending on what you think the pathology may be. So it can be ultrasound can be ct of any sort. Now, we have two chest uh sorry, two x-rays, one chest and one abdomen abdominal x-ray. So the first one chest x-ray shows us perforation. So you can see two domes of diaphragm and there is some free air under it. So normally you wouldn't see um domes of diaphragm so distinctly that you can see their border. Um and it's separating abdomen from chest. Normally, organs would be adjacent to it. Um be careful when looking at ABDO um a chest X ray because sometimes air in stomach can anemic perforation. But if you see it bilaterally like on this, um, chest x-ray, then it's very, very likely to be abdominal perforation, um, such as bowel perforation caused by, uh, for example, peptic ulcer, uh, the second x-ray is abdominal x-ray. So this one shows um, intestinal uh obstruction. So that's small bowel obstruction. And on the next slide, there is gonna be a large bowel obstruction. So abdominal x-ray, the first one on the left of the screen is large bowel obstruction. So let's compare those two, I'll go back. Um, so you can see, uh, for small bowel obstruction, you can see that it's more centrally located. And, um, the vulva lase goes through the all thickness of the bowel. While, well, when we look at large bowel obstruction, this is more likely to be peripherally located here. You can see it all around the abdomen, but on some of the x-rays, if you compare them, um, the large bowel obstruction is more likely to be peripherally located and the whole stress they don't go through all of the thickness of the bowel. They may reach half of the thickness, for example. Um, and it's not necessarily gonna be. So the bowel is not necessarily gonna have a greater diameter if this is large bowel obstruction compared to small bowel obstruction. Because sometimes in small bowel obstruction, the diameter of dilated bowel can be as big as large bowel obstruction. So it's not a tool that would help us differentiate, but things like location of the bowel, it is on the periphery, uh rather than centrally or the opposite that can help us guide us. And things like holster not going through all of this thickness of the bowel would be another thing that could help us differentiate. And the last abdominal x-ray that we see here is sigmoid volvulus. So that's a twisting of a sigmoid again associated with obstruction. And this is a very specific coffee bean appearance. It's also one sort of a large bowel obstruction, but very specific to sigmoid volvulus. So what do we do in different abdominal pathologies? What are the things that we would need to do immediately for those patients? If there is a patient that shows signs of sepsis, of course, go ahead and do your sepsis. Six. So what is sepsis? Six? Remember your sepsis? Six, because your sepsis six helps um increase the rate of survival of your patients. So six things three to take and three to give, give high flow oxygen, give IV antibiotics and give a fluid challenge. So give them IV fluids and three things to take, take blood cultures from your patient. Take lactate level, except of all the other bloods that you would take and measure urine output. So three things to give and three things to take when you have a patient that you suspect may have sepsis. So, sepsis comes from. So some sort of infection. Um we would need to investigate what kind of infection. Is that um, the previous slide? Uh, sorry, sorry. Did you mean, or I think you meant this one? Uh, yeah, we'll, we'll work through it. I just wanted to, to show you the sepsis six. Ok. Um How about peritonitis? Sorry. Sorry. Did you mean um, the one with uh with x-rays or the one with the list of? Just let me know if it's x-rays or is this one that we're on at the moment? Um Now, if you have a patient with peritonitis, as you can see on this list, there's a lot of IV fluids because basically for a lot of them, you would need to um give them IV fluids. Ok. So patients with peritonitis, um patients with peritonitis are very likely to need, need immediate surgery. So those are gonna be patients that are very likely to be admitted under surgical team. Um And peritonitis can be caused by things like um let's say ruptured appendicitis or um ruptured peptic or um associated with perforation. And then let's say peritonitis or some local um perforation later leading to peritonitis. So make sure to keep them nail by mouth. So they should not eat anything just because they will need a surgery at some point and consider antibiotics for them. Um antibiotics you would want to give depending on what's the underlying pathology. But mm, in most of the cases, you would look into your local guidelines and very commonly it would be a a trio of, um, amoxicillin, metroNIDAZOLE and gentamicin. But again, wherever you work, look at the local guidelines because then there can be differences. And then after, um, intestinal obstruction, again, you'd give them IV fluids, you would keep them nil by mouth and know by mouth. Not necessarily because they will need surgery because not all of them will need surgery, but just to give them a bowel rest, um, you would put an NG tube in, uh, remember to put it early in upper bowel obstruction or upper intest, um, upper gi obstruction. Just because you want to decompress the, uh, gastrointestinal tract for small bowel obstructions, uh, they are likely to need surgery if they deteriorate and for large bowel obstruction, there are some, um, criteria to look at this would very likely be a decision of one of the surgeons if they will need surgery at some point, they, they are likely to be admitted under surgical team again. But things to look at is if cum is more than 10 centimeters, uh, in diameter, they are likely to need surgery. Uh, otherwise they're going to be for CT. So this is to look at what's the underlying pathology, what can be causing this obstruction? Some of them will need colonoscopy. Ok. Let's say things like, uh, sigmoid volvulus, these patients who have obstruction because FULV is an, is an obstruction. They would go for a sigmoidoscopy which will help us to decompress the obstruction. Ok. So they will not be treated um surgically naturally. Uh They will just go for um sa sigmoidoscopy to decompress the bowel. Um If this is a tumor intestinal tumor that's causing an obstruction, uh some things that we can do for those patients is colonic stenting. So, inserting a stent in if the tumor is not operative. So if we, we cannot offer this patient surgery, for example, because of their comorbidities and if this is a case of strangulated hernias, so, hernias are one of the things that, that is very common to cause um intestinal bowel obstruction, um then strangulated hernia is for urgent surgery. And now moving to perforation and we would do IV fluids. OK? We'll give them IV fluids. We'll keep them n by mouth because they will need a surgery. Um I will have a look at um, at questions a bit later. OK. And we'll um I can see another question. Uh So we'll walk through them uh when, when I finish the presentation. All right. Um So we would keep them nail by mouth. We would give them I IV antibiotics. Again, looking at our local guidelines. Uh remember about analgesia for all of the patients that are in pain. Um NG tube would be a helpful thing. Um And they may be for CT if this is, for example, a localized perforation, but these patients are likely to need emergency laparotomy uh for acute pancreatitis. Another common condition. Remember to give them plenty of IV fluids. Keep them nil by mouth again for the reason of giving them bowel rest, uh, give them analgesia, then antibiotics questionable. Some surgeons go ahead with antibiotics. Some of them don't and investigations such as M RCP or E RCP later in time. So this is to um, do a focal fo focused investigation for the um, pancreas and biliary ducts. Then acute cholecystitis. Again, we would want to keep them nail by mouth, give them analgesia, treat with antibiotics. This is a strong one for antibiotics. And again, we want to do Mr CPE RCP at some point. Uh So we'll go for M RCP first to visualize if there's any stone that's causing this cholecystitis for acute appendicitis. Again, IV fluids keep them meal by mouth, analgesia IV antibiotics and they will require surgery in most of the cases. Um And for bowel ischemia, again, big one IV fluids, keep them nil by mouth, give them analgesia and treat them with antibiotics and consider anticoagulation because bowel ischemia is caused by an obstruction of the vessel of the blood flow to a certain area of the bowel. Right? So how do we prep our patients um for surgery on the ward? Remember to do an E CG for them, especially those are um patients above the age of 60 or patients who have history of cardiac diseases. Um make sure that they have access. So they ca they have K or Benin um, make sure that they are grouped and saved and have crossmatch just in case that they will need um, bloods to be given a coagulation screen needs to be ready for them as well. Um, regular blood, they, they, and they haven't had them taken, keep them nil by mouth. Um, different recommendation can be around six hours before the surgery, eight hours before the surgery. So just you, you can run that's, um, through your senior and other things to keep in mind um for patients who are at risk. Remember about teds talking. So this is a helpful thing to prevent DVT. Um Make sure to review and discuss medications with them if they are on anticoagulants, antiplatelets. If this is an elective surgery, it can be planned in advance um to make sure we suspend them if this is an emergency surgery, some plan needs to be in place what to do about anticoagulants and antiplatelets for them and things to consider stopping before the surgery as well. Ace inhibitors or a RBS. Um NSAID S and um diabetic drugs such as Metformin SGL two inhibitors and consider putting patients on VR isa variable rate insulin, especially uh type one diabetics and um consider steroids for some cases. This depends on what pathology is that. And if they are on normal steroids, remember to double their steroids regime. Uh I think they grow. Ok. And another question, I will make a pull in a minute. Just let's have a look at the question. First, a 55 year old male with a history of cirrhosis secondary to chronic alcohol abuse presents to the emergency department with me and Melena for the past 12 hours, he reports feeling lightheaded and dizzy on examination. He is pale with a heart rate of 110 BPM. And the BP of 90/60 abdominal examination reveal reveals hepatomegaly and ascitis. Initial resuscitation with intravenous fluids. And BS transfusion is started an emergent. Upper endoscopy is performed revealing large grade three is a fragile viruses with stigmata of hemorrhage. So the question is based on the patient's history, examination, finding and endoscopy results. What is the most likely cause of this patient's upper gi bleeding? And what is the initial management for this condition? So I will create a po for you. So that's gonna be question too. Ok. Let's see what you think is the most likely condition. So answer as peptic ulcer disease and there are some uh suggestions for management. Ok. So just make sure that you read through it. Uh, mallory wise deer is a fragile viruses and what we do about them, gastric cancer and gastroesophageal reflux disease. So I'll give you a few um a, a couple of minutes to answer. Ok, let's see. How many answers do we have? So we have total of nine. Ok. So most of you went for is a vagal viruses. Ok. That's correct. So answer C is a fragile viruses initiate as active drug therapy and aim for endoscopic virus ligation. That's 100% correct. So we have some signs of blood loss. Yes. His heart rate is high. His BP is 90/60. So he's an unstable patient at the moment. Um And there is a history of chronic alcohol abuse. Um and there is water. He, he's symptomatic also of blood loss. Uh He has hepatomegaly and ascitis. That's correct. So that active drugs such as T tally pressing and we want to do endoscopic management of that. Ok. And the other one is a 40 year old. Otherwise healthy male presents to gastroenterology clinic and he complains of bright red blood per rectum and anal discomfort during bowel movements for the past week. He denies any history of abdominal pain changes in bowel habit, weight loss or systemic symptoms. So, otherwise healthy denies all the abdominal pain, history and change of bowel habits. Digital rectal examination reveals external hemorrhoid of mild bleeding upon touch. Endoscopy confirms the presence of grade two hemorrhoids with no active bleeding at the time of examination. Ok. And based on that, what is the most likely cause of this patient's lower gastrointestinal bleeding? And what is the initial management? So what is the cost and what do we want to do about it? Let's see. That's question three, I thought. Oh, ok. We have to pull it in. Ok. So I'm whenever you're ready. So most of you answered. B OK. However, there are some answers A and C. So let's have a look. Um, bright red blood per rectum and anal discomfort during bowel movements. There is no history of abdominal pain, no history of changes in butts, no weight loss and no systematic symptoms. Ok. Um So it's very likely to be hemorrhoids because there is nothing else. So why it wouldn't be seen colorectal cancer just simply because we don't have a weight loss history. So it's unlikely very likely in uh in colorectal cancer patients, they would complain of weight loss. Uh why not diverticulosis? Um because there is no abdominal pain. So he do, he doesn't complain of any abdominal pain, diverticulosis would very likely be associated with left lower quadrant pain. So here it's just some very likely to be simple hemorrhoids. And we want to make sure that we advise the patient of dietary um aspects and modify their lifestyle. Uh We can use some topical treatments, some ointments. Yeah. And um we can consider potential banding of this hemorrhoid at some point. Ok. All right. And let's have a look at some aspects of gi bleed. So for upper gi bleed, um common causes are peptic ulcer, things like variceal bleed or mall wise tear. Um and other things such as upper gi malignancy and esophagitis and sometimes it can be swallowed blood. So the patient is bleeding from um po posteriorly from their nose, for example, can be swallowed blood and then um this turns into upper gi bleed, for example, hematoma. So, vomiting with that, what do we want to do for that? Um Make sure, always to start from A to E um and make sure to look at their obs at their observations. So, are they hemody dynamically stable? Do we want to do anything at the moment about their BP? Is it stable or do we want to act on that? Uh and check urea? That's a very interesting point. So let's have a look uh B UN and creatinine uh ratio. So, blood urea nitrogen and creatinine ratio uh that is greater or equal uh than 36 suggest of upper gastrointestinal bleeding. So, only with blood tests, checking blood urea nitrogen and creatinine ratio, we can um investigate for upper gi bleed. If the ratio is greater than or equal to 36 it's very likely to be upper gi bleed if it is less than 36 it is not helpful in locating the source of bleeding. Ok. Um Important thing to check their coagulopathy because maybe this is their underlying hematological disease or any coagulopathy that may be causing this gi bleed rather than any specific gi pathology. Um And make sure to look at all the other bloods. Just your um regular bloods, keep the meal by mouth. Um and a a gastroscopy for them is a fragile gastroscopy O GD. But this in stable patients. So if they are not stable at the moment, you need to make sure you stabilize them in order to be able to take them for O GD, uh give them IV fluids and query blo blood transfusion if they're unstable, if their hemoglobin is dropping, um consider PPI uh and um especially after endoscopy. OK. Of that is ulcer. And um for varicel, you already, most of you answered that. So, vasopressive medication such as tli pre consider antibiotics. And if this an uncontrolled upper gi bleed for variceal bleed, you can um consider black more tube. This is a measure to stop the bleeding. Uh in case of lower common pathologies that cause lower gi bleed are uh polyps, diverticular disease, things like angiodysplasia anywhere in this. Um in this, the the intestine hemorrhoids, hemorrhoids um are very common cause of lower gi bleed. Uh and other things like again, colon cancer, IBD and, and when assessing, make sure that you start from E to E and um again, have a look if they're hemodynamically stable at the moment, um check their blood, especially looking for hemoglobin for inflammatory markers and do apr per rectum exam. They may also need O GD because the bleeding can be upper gi bleeding but can manifest not with hematemesis for example, but with melena or with fresh blood um down there, if this is a very per perfuse, uh you can do a colonoscopy for them. Uh and lower gi bleeds very likely will settle with conservative approach. So most of the surgeons go for conservative approach. So we're talking about vomiting about Hemas. But remember that vomiting may have different causes. Ok. We'll not look through all of this table, but it's a very helpful table to guide you to think about different causes of nausea and vomiting such as um, neurological causes, um of increased intracranial pressure or things like meningitis, Um, things of gastrointestinal origin. So, bowel obstruction and acute abdominal, um, causes, uh, things like gastroenteritis, but also out of the gi tract labyrinthitis, things like migraine can also present with vomiting, um, or something called plaque induced. Uh, so you have a, uh, of, uh, his and what investigations we look, uh, we are short on time, but you can have a look at that a bit later just to make sure keep this in mind. Um, same for diarrhea. It's not necessarily caused by, by, um, trouble can be caused by, um, most like pathology that's like enteritis, E DBS, um, malabsorption disorder. So, this is not directly connected.