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I think this will take the full hour is the first thing to say, I think there's just a few kind of key concepts I really wanted to get across to everyone. Um a little bit of background about how, you know, how I came into this role. So before I did radiology, I was a surgeon for, for a long time. Um and realized when I was a surgeon, I actually really enjoyed looking at the scans and the imaging so much so that I decided actually to to change career and and join radiology instead. So I think in terms of seeing it from both kind of sides, hopefully that, you know, will help me to get these points across because I've really been there from, from both ends of this this spectrum. So not everything is as obvious as this, if it was particular radiology, life would be a lot easier. Um So these are kind of things that you know, aren't necessarily that rare. They do happen. And when they happen, obviously, you know, imaging can really help surgeons plan exactly what's been injured, how to approach obviously provided the patient is stable. So really the role in radiology is to identify and clarify. So the patient gets basically the most targeted approach they can. So these are always the kind of areas that people will talk about your here in clinical practice. You'll hear it when any refer patient or any refers patient's or you'll, you'll see it in clerking as well. Um lots of different areas of the abdomen. But the reason why, you know, it's useful to talk about these is when you use these particular phrases or terminology, it allows whoever you're trying to talk to, to understand exactly what areas of the body you're talking about. One. And if you know what area the body you're talking about that, it means you can actually describe what injuries might happen or what the particular organs. So just to run through them, you know, very briefly, you know, epigastric li you're thinking of, you know, stomach pancreas, duodenum hyper contract, right? Because you think you basically liver gallbladder left up accordingly, thinking many kind of spleen iliac fossa, see, right. You're thinking of, you know, appendix, pathology, hypogastric can be, you know, bladder pathology, iliac fossa, both sides, diverticular disease. So there's lots of kind of common themes that can happen in those particular areas and they're relevant both in kind of non traumatic and traumatic disease. Mhm And in terms of looking at scars, again, things being logical, scars tend to be over the areas where the organ of interest lies. Now that's not always entirely true. Um But 99.9% of the time the scar is going to be over exactly where the organ underneath has been involved. So, you know, midline scars, basically laparotomy mcburney one you can see on the right hand side is it is the classic approach for an appendix decision subcostal, right? Because um that's basically for like an open gallbladder removal, open cholecystectomy or liver operation, something like that. Fantasy and obviously, most common operation for that is a Cesarean section. So again, it all just helps if you can again name these things as well. You know, it's not just a radiologist and clinical practice because everyone then understands exactly what you're talking about. And it's really important in life. One just, you know, but also in medicine specifically to be really specific with your terminology and radiology is obviously, is very important because obviously, everything that we say, all the words that we write have to convey a message. And if we're all speaking the same language that really helps systematic approach, this is for absolutely everything you do and a radiology is no different. So you look at the demographics of the patient, when was it taken time, technical features, you know, is the film sufficient enough for you to actually draw any conclusions? Is it projected, you know, a particular way and old is gold is the thing that I've just written down there. So in radiology, that is absolutely true. If you're looking at any imaging, if you've got something previously to look back to you to compare it with, that can save you a lot of time and also help you make a much more accurate diagnosis very briefly. Just wanted to explain exactly how images are generated. And this is actually the same for X ray or CT just depends on the way it's kind of reformatted. But basically you have um an X ray generator, X rays will be produced by electrons hitting a piece of tungsten target, then then get focused across, they go across a certain distance, they go through a patient and then you have detector at the end. And basically, depending on the level of uh x rays that get received through the patient, you can tell what's going on. It's effectively a measure of density. So going back to a systematic approach A B S C. So airs bones calcifications, soft tissue and this is a normal abdominal radiograph. So gas is really important particularly in surgical radiology. So gas, you really want gas to be in the bowel or in the stomach. I mean end of if gas is outside of those areas are within the wall, you start thinking that you know, there could be problems, doesn't always mean there's a problem. Sometimes it can just be physiological. But the assumption being is gas outside of the bowel is bad, this is normal. So this is normal intraluminal gas. And you can tell by basically the pattern of distribution of it where the gas is and is a normal pattern. So if you see gas within the small bowel, that's great and three centimeters that's really dilated. That's bad. If you see in the large bowel greater than five or cecum, it's nine. So those are the numbers really, whatever stage you're at particular, getting towards exams, um, to have in your, in your head. So 35 and nine, anything greater than those numbers is, is almost usually pathological. And the setting an exam situation, it will be, it won't be normal. So how do you compare the two so small bowel on the left, large bowel on the right. So small bowel has these, these bands that go all the way across the small bowel, this goal, velvety kind of entities and with large bowel, they kind of go, you know, almost across the whole width but not quite, there's a little gap and that's called haus Traore hostile folds and determining on the gas pattern and the distribution, then you can determine whether it's small or large bowel. It may sound really easy. Um, in terms of distinguishing between small and large bowel, if a patient is obstructed or they've got lots of societies or they had operations, it can actually be very, very difficult. And sometimes even with all these rules that I'm just describing here, you still can't quite ascertain it on a plain X ray. Um So then you need to start thinking about things like CT scans in general practice in the real world. Patient's with suspected abdominal injury, abdomina theology will almost certainly end up having a CT scan as opposed to plain film. But plain film is useful nonetheless, as a useful screening tool. And you still see it all the time, but it can be hard to get the full answer from, from a radiograph. Often a CT is what is needed. Again, this just goes through to explain the difference between the two of them. They're so valuable kind of entities and and health will fold. So these are all a bit dilated, you can see and as they dilate, they, they show you these, these fold patterns differently. So this is just something I want to highlight again, just touching what I said right at the beginning. So gas outside is bad. Um This is something called regular sign which you may or may not have heard of and effectively it's gas outside the bowel. And I don't, if you can see my point, I hope hopefully you can um you can see all this area here outside of the stomach. So that's, you know, gas is, is less dense than everything around it. So lots of X rays passed through it, which means it looks black. Um And then you have an interface between that's gas, that's bowel wall, that's gas within the stomach. So that's, that's rigorous sign. So that's gas outside the stomach, gas within the abdomen. So, suggestive of something is perforated. You can't always tell what's perforated, particularly pain, radiographic. I mean, you can have some idea is based on the history of what's going on. Um, but as I said, almost certainly then patient and having a CT scan instead, it's another picture of regla sign just showing the same thing again. So you can see bowel wall there, that rim of gas on top of it and then gas with inside. So it is effectively give me a contrast either side of the bowel walls. So gas wall gas. So this is an erect chest radiograph, all right, chest X ray. Um, the most obvious abnormality on here is obviously this area here. So that's underneath the right hemi diaphragm. That's liver shadow, that's the basic top of liver or the dome of the liver. And this is gas above the live in the diaphragm, pushing the diaphragm up. So this is implying that there is gas, I think that's called pneumoperitoneum. Again, that's a, that's a bad sign. And you're thinking there that that something is, is, uh, is perforated. Now, it doesn't always have to mean pathology. So for example, if the patient's had recent surgery that is normal, um, for a laparoscopic procedure that can persist for a couple of days for an open procedure, it can persist for even longer, you know, after about a week or so. Um If a patient hasn't had any procedures at all, and they have suddenly abdominal pain or they clinically septic and they have that feature there, um That's pointing you towards a perforation. So that can be anything really. And again, this is just showing gas plain film, you can see that it's actually dilated loops, a small bowel, there's also a few things on here as well. So there's this structure here within the pelvis. So that's a kind of dense well rounded structure. So we probably describe as being laminated and then up here on the top, there's gas outside the bowel. So that's gas going on there. That's actually within the biliary tree that's called new mobile eah. So the diagnosis with having small bad obstruction and having an object here and memorabilia um is something called gallstone Eilis. So there's actually a misnomer alias, strictly speaking, is, is what called paretic Eilis is basically where the bowel stops contracting properly. So the bowel is full of nerve fibers and nerve endings called the myenteric plexi for a variety of causes. The patient's are just generally unwell if patient's have neurogenic disease. If patient's have electrolyte imbalance, the bowel can actually stop contracting effectively and that's called alias. Um This strictly speaking, isn't it just, it's just named though it's actually bowel obstruction. It's a mechanical obstruction. So it's nothing to do with the nerves and the bowel, the bowel physically can't contract because it's got something in the way and that's a gallstone. And the most common way that that can end up there is the duodenum lies up the right color here, which is very, very close to the neck of the gallbladder or the body of the gallbladder. And if you've got a big gallstone and you got lots of cholecystitis inflammation, it can get here into the duodenum and can official it directly through the duodenum. The gallstone then will pass all the way through the small bowel. And the narrowest part of the small bowel is distantly towards the ileocecal valve. So towards the elec foster, and that's what we tend to get stuck sometimes rather than fist awaiting through the duodenum going all the way down into there. It can actually fist it directly through to the transverse colon because obviously that's not that far away either. So if you see up here, you can't just because there's no gas in it, but the hepatic flexure is going to be around there. Uh, and then actually sit through into the large colon and then that can go all the way on the large code and actually can get it being stuck down in the rectum as well, particularly diverticular disease. So they can be really problematic. Um And obviously requires an operation to correct this is a picture of just uh interrupt. Uh We can't see your mouth. Uh I think on the bottom left there is a pen. Yes, let me just go back. Yes, there is a pen. Great, thank you. Pen color highlighter. Is it laser color bird? Okay. As it in here to Matic area, there's a point. Uh Can you see it now? You see me getting a red thing? Perfect. Sorry. So dilated loops, a small bound, this thing down here in the pelvis, that's the gallstone that's fish stated through and these little wispy tract here and here that's new mobility. So that's gas within the biliary tree. So that's very indicative, that's actually a rigorous tried. So that is pretty much absolute textbook gallstones just to go back if you couldn't see either as well. Just while on that subject, I was talking about this area here. That's the pneumoperitoneum and Rigler sign, that's gas there. That's bowel wall gas. And then again, this is the gas I was talking about and then that's the stomach wall and that's gas within the stomach. So gas obviously is less dense. Um So it shows up darker, useful and actually, if you're all seeing what I was, what I was saying is I was describing it able just to check just then with the lows acquainted. Good. Right. So this is um a picture of a gallstone. I'll ius it's a very stressful procedure you do is you open the patient up, you, you almost know where it's gonna be before you go and examine them. But this often they'll have a CT scan is all, it will show as accurate it is. And you make a longitudinal incision like this and you milk the gallstone out and then you basically, so it up from here like that, you set up in this direction because if you set up in this direction here, so up to down he calls the stenosis when it heals. So if you, if you do it this way here, it just means that they won't get small bowel structure. That's, that's why the incision is done that way longer to. Um, and then the goal thing, it's taken out, patient gets stitched up and usually recover pretty well. Um, 23 days out of hospital. So it's, it's quite a satisfying procedure to do. The next question someone might ask is what do you do with the gallbladder in that situation? The answer is almost always nothing. Um, because it will often be such a mess that for the chances of you trying to go through and operate and cause about injury or about the ginger quite high. So almost certainly you'll just leave the gallbladder and it's official ated anyway, it's really decompressed itself. So you tend to just leave it be, uh, and that's a picture here just showing you what's early. So that's a, this is a CT scan. This is kind of looking through an actual slice of the patient's if you imagine looking through the end of the bed. So you got the patient's left here. Patient's right here. That's obviously the front, that's the back. And this is the gallstone here, uh, that's causing all the issue. And these are all dilated loops of small bowel with fluid in them. And I said a transition point. So what do I mean by a transition point? A transition point basically means where the bowel goes from being really big to really thin. And at that point there, that's where the blockages. So that's a transition point you'll often see and reported to talk about it, but may not necessary understanding exactly what it means, right? So this is a plain radiograph of, of an abdomen again, continuing the theme uh abnormality here is this. So that's you're descending colon and all the way through all this is quite featureless. I describe it. I mean, it can be normal but basically, can't we see much gas in there? So quite a bit fluid within the abdomen or within the belly itself. Um It can just be a normal variant, but in terms of this here, that is abnormal. Um So that's thickening an inflammation with the descending colon and that's very typical of inflammatory bowel disease, in particular Crone's disease. Um You may have heard that in the books and called lead piping. That's what that is so featureless. All this stuff here. It's really abnormal and actually what that represents is inflammation within, within the bowel wall. That's what that's showing you. So also colitis, obviously inflammatory bowel disease, limited the mucosa the submucosa as opposed to crones, which is where there's all the way through. So trans mural also close is basically just the just the mucosal surface. Mhm. And this is it on CT scan. So you can see again, pretty much exactly the same as the, as the X rays already just that thickening. That's all a Deemer the bow is thick, it's unhappy, you know, that's going to be someone that means a lot of medication therapy, usually with steroids first. But if this keeps happening, um they may well need an operation to resect all of this. This clearly is the pathology. So you can see very, very distended, leeper bowel that line there with the two loops of ballot, kind of joined up with each other. And it's for me like an apex here, this is actually, it looks like an abdominal X ray. It, I suppose it sort of is, it's actually what we call the scout view. So it's actually a CT scan. And when you do a CT scan where the red offers do it, they line up the patient according to where they're gonna actually continue to study. And this is basically like the test film to show you that they've got everything they need to get. Um But it looks like an abdominal X ray because it effectively is, it's just reformatted differently. It's actually a CT scan. Um And you can see this, this is called, this is a volvulus and that's a sigmoid volvulus. So, um I'll show you the CT in a second but effectively the sigmoid colon twists on its blood supply. It's mesentery here. Can you see this kind of twisty swirly Wehrli stuff in the left ileum pasta? And as it twists around, it basically means that stuff can't really get in and stuff can't really get out. So you get obstruction as well. You see this a lot. It's very, very common, particularly elderly patient's who have underlying um new disease or spinal problems. Uh Parkinson's, you see a lot also because the medications they give them predispose you towards it. Uh Most of the time you can get away with just putting a tube up, so some cough latest tube. So you put a colonoscope through into the rectum into the sigmoid colon. You see where the twist is. You untwist everything just with suction to get rid of the pressure and then you can pass, achieve up alongside it just as a effectively act as a valve. Uh if it keeps happening and it's causing significant morbidity or if it twists and the gut becomes a scheme ick, I there's no blood supply to it, then you can receptor all of this as a bowel resection and the patient will often end up with a stoma that doesn't happen too often. Usually you can get away with decompressing it endoscopically, but sometimes you need to do operation all of this, but it's effectively another form of instruction you can also see on this actual ct these fluid air levels. Again, if you're seeing fluid air levels within the bowel, that means obstruction. So that means something's blocked, right, upper quadrant, these little round areas of density almost looked like, um, like coins or little button batteries. Um, they're actually not in this case, but if there's a pediatric patient that they've swallowed battery something, you might think, actually, that's what, what it is. These are actually gallstones. Um So again, very, very common, lots of people have them. Most school stones actually, you do not see on X ray. Um Most of them actually, you see better on ultrasound because x rays just pass through them and that's the reverse to kidney stones. Most kidney stones you see on X ray, most gallstones you do not see in an X ray. That's the difference in kidney stones and gallstones. Again, both common causes of pain. Um Ultrasound is very, very good looking at gallstones and an M R CP test as well as an MRI scan, looking at the liver and the gallbladder is another really useful test. And often patient's before cholecystectomy before a gallbladder section will have these imaging modality for them to, to really try and refine the anatomy. So we can actually tell the surgeons. Thank you. Everything is, um and I mean, there's reduced chance of a surprise in theater. So this is an ultrasound. Um The dark stuff on an ultrasound is fluid. Um so dark on C T X rays, air um but dark on ultrasound is fluid. So different modalities, things look different in terms of the different shades of gray, really these stones here. So these are kind of within the body of the gallbladder. And if you appreciate the transducers coming down, it's picking ultrasound waves across to all of this. They then whiz through the fluid hit the stone, a lot of them, then we'll get absorbed and less of them will come back. And as a result, you get this kind of streak underneath. So that's called posterior acoustic shadowing. So that's absolutely textbook of something solid in the, that's obscuring the way that the sound waves are passing through. This is the common bile duct. And you can see these are stones here within the combo of these are obstructing stones and that's called choledochal mathias iss. So choledochal with isis means stones within billion tree bile dup, colelithiasis just means stones, they can be anywhere. So again, if you see those words, that's what that means. And this is um M R C P. So M R C P stands for Magnetic Resonance cholangiopancreatography. So that's a very relatively quick MRI scan to do. And it shows you can see the anatomy is in credible, you can see all the different kind of subsegmental branches of the biliary tree, all the little ducks. So you can see exactly what's going on. That's where the gallbladder is coming in there. It's just a duck coming through. That's a common hepatic darn shit. Comin bardot as it comes through. And you can see there's a filling defect. So, fluid is bright white on, this is called a fluid sensitive sequence. So fluid is bright white on this type of MRI um, anything which is obscuring that there's gonna be something getting in the way and most commonly that's going to be a gallstone. But if you appreciate you got a tumor there or a stricture or something else, you can also see that really nicely on this scan. Uh And also if patient's have infection or Caroline gi tissue can see information adama. So it's a really, really good test to do if someone's got gallstones or biliary disease, abdominal radiograph a little bit when asked me again because it's quite nice on this film. So these are the, so s muscles here. That's your left. That's what? Right? Nice with the pelvis, there's the eyelid press, that's the pelvic inlet, those your femurs right left. So your hip joints, something here probably shouldn't be there a bit of density at that point. Um quite well described and it's opaque on X ray. So you think it's probably a stone probably calcium in it. So, where is it? Well, it's not up in the right upper quadrant. So not like if you go also, unless it's what we were talking about earlier is a gallstone that slipped across and got off the bowel. But there was a gallstone going to the bed. Expect the other things, right. Defensive about to be dilated, obstruction, all this sort of thing that you can't see. So then it leaves a few other candidates left. So pared structures, you've got one here, you got one here, your kidneys. So I think it's probably a kidney stone renal countless. So that's within the lower pole, left kidney. And we do a test called a C T K U B for that, which is really, really good. And you can also do an ultrasound scan. So this shows you the urata, this shows that you're going through into the collecting system of the kidney. And you can see this kind of like tree like pattern you get uh and that's hydronephrosis and this is the CT KB of uh the same patient. So you can see the stone is right there, that rim of white and you can see it basically is the same color as the bones, the ribs up here left 11 to 12 I like press. So you can see it's pretty much made of the same stuff. When we're looking at C T S, we can actually measure these areas on screen using our imaging software. So you can actually get point values for all of this. Um But I suspect the point value for this will be slightly off bone, very, very similar to bone. It's full of calcium and that's what we're just describing early. So that's hydronephrosis. So you can see left compared to write, this is your left kidney, this is your right kidney. This just looks a bit bigger, bit swollen. You're collecting system is just all, just not as crisp. It's big, it's dilated, you've lost that sharp kind of gray dark brain to face that medullary differentiation that's gone. And also if you look around the kidney here and here, these little kind of wispy bits coming across the back that's called perinephric fat stranding. So that's a sign of inflammation, inflammatory change. You see that you can see it in trauma as well. You can see it non specifically, so much just people just have it. But in the setting with all of this, that's bad. That's quite a logical. And I think that's just actually want to mention just while we're on that subject is lots of things you see in radiology can just be normal or normal variants. And part of our job is putting everything together in clinical context. So the signs have to marry up with the clinical picture arise. You know, you can't just start calling things left right and center if it doesn't really fit. And as I said, lots of patient's, do you have things which are just non specific kind of normal for them? Like you can have perinephric patch standing bilaterally and lots of patient's. You see, and it's just, that's just the way their kidneys are, doesn't mean anything. But in this setting here you have to implant, you have to assume that actually that's bad because this is blocked, there's a stone there. So it's putting everything together to come up with a sensible, uh, sensible conclusion. So things up here we've seen this is probably a bit more subtle. Actually, first glance, you might think I currently see what the problem is. Um I'll just highlight it for you with, with, with the pen. So there's a structure here, it shouldn't be there. There's some clips up there and then it's going down further into here in here. So this is an aneurysm repair. That's an endovascular aortic aneurysm called IV our repair. So this is where you go in through the groins. Usually on this combination between radiologists, um vascular surgeons, you deploy a, a stent through the aneurysm to effectively seal it from the inside out to reduce that risk of rupture or leak. They can still rupture and they can still like um but it's significantly reduces that risk and for lots of people can actually cure them. They're pretty, they're pretty bad. Also aneurysms as a screening program in the UK for now for a number of years now. Um And if you have a ruptured abdominal aorta aneurysm, there's a very, very significant chance that you you will not survive even make it to hospital. So the quote of figures usually is 50% of people having a ruptured triple A will never make it on to into hospital, get help cause they will, they will just die on scene of those 50% and then come through into hospital and then get operated on. Only about half of them will actually survive and go on to, you know, to, to lose a sort of meaningful life. That figure actually slightly slightly better now, because operative techniques have improved, considerably endovascular repair is also now become mainstream. But um it's still, you know, it's still something that you really, I want to take very, very seriously and can cause a lot of problems. So this is um an arterial phase of this is called an arteriogram. So we give contrast to the patient and you time the contrast that lights up the arterial system rather than the bigger system. And this is so this is big uh infrarenal aortic. So below the kidneys, uh the aneurysm and you can see that this is all kind of thrombus within the wall. This is all kind of contrast within the actual lumen of the order it. So if you saw this kind of breaking through into this dark stuff, kind of streaking out into here, that can, that can mean that there's a basically rupturing through the wall or a sign of of an acute complication. But this one just looks like a big aneurysm sac with chronic from this in it. So that will need consideration of repair. So you can do this as an open procedure as well. So you do a laparotomy open up through here, you get the bowel out the way, expose the retroperitoneum. So the back open, the aneurysm sac make an incision, scrape out all the clot and then basically stitch a graft on to see it all up top and bottom. That's another way. There is an open looking. I just like this one because it's just so it's just so horrific that you'll be very unlikely to see this in real life, but you will at some point and if you do, you'll never forget it. So, um, this is gas within the biliary tree. This is gas within the medicine tree. This is gas within the bowel wall. The stomach is just absolutely huge because it's just stopped working. Um, and this is really, really bad mesenteric ischemia. So this is the bowel is effectively dead. It's got gas forming organisms when it's gone. Necrotic. Um, and the gut obviously drains through the mesenteric system into the portal vein. So the gas tracks all the way along small bowel mesentery into the I M V which goes up through the Hispanic vein and across the portal or through into the SMB which shoots straight up and then joins by the neck of the pancreas. And that's really, really really bad. So, you know, my career now it's been a good few years. Um, I've only ever seen someone survive this kind of injury in my entire life once. Um, it's usually what we describe as an anti, more term study. So when this is done, it's usually end game. Um, because it's, it's so significant because effective, this is inoperable because you can't remove the entire small bowel, um, which would be the only real way to treat it, but it's already seeded up everywhere. So this is, this is pretty bad, but this is just burn this image into your mind is an image that you hope you never want to see, but some of you will almost invariably see it. Um This is end stage of mesenteric ischemia. So new mobility gas within the biliary system, bad, bad, bad, bad, bad, you can see it outside of this setting, um only really in one particular setting. And that's if the patient had a biliary stent put in or cancer or they've had a recent ERCP or instrumentation to the biliary system, then you can see and that's allowed. And actually new mobility in the sense of someone having a stent is a good thing because that means that the stent is painted going through from duodenum through into, into businesses. That's a good, actually what you look for. Um But if a patient hasn't had any kind of interventional procedure and has all of this and they're sick. That's a, that's a terrible, terrible sign. Now I put these in through here and I think Anna's gonna set up a pole for these in terms of answers and we can just, we can whizz through these at the end. Um, I apologize in advance if these are a bit too tricky or if they're too easy, it's very hard for me to gauge how to kind of really aim these because it's such a mixed audience. Um So I'll just kind of, you know, I'll just go through it very quickly and then you can come up with your answers. So 24 year old male, modern RTC front passenger went back into the car 40 miles an hour extricated by the ambulance. GSS is 15 and 15 observation initially, okay has some upper abdominal pain when it comes to resource airways. All right, saturation is 90% of rumor. Spiritually, 24 heartbeat 135 is a normal sinus rhythm. BP 85/78 GS CS is 14 and 15 HB is 14. White cell count of 30 kidney functions. All right, Billy up slightly. Um And his lactate is five. He's got a presidential bruising, compare it, emetic, nothing else you've seen on the primary survey. What do we think is the most likely cause for this clinical picture? So you've got traumatic Ballengee music bleeding, you've got renal pole injury with retroperitoneal hemorrhage. You've got traumatic liver injury with a lack. You gotta spin eclac with active hemorrhage. You've got all of the above. I have to think about that. An answer in the pole. All right. Good. Move them. We've got three. So that's the first one. Yeah, maybe we'll come back to that. Um Can we go back, please? I think no one's answers. We might be. No one's answered. Okay. Yeah. Sure. Santa just tell me when people have answered you and then I'll move on unless it's so hard or so easy. They were getting mainly wands. Okay. Cool. Do you want me to go through it now at the end? Oh, can you go through one by one, please? Thank you. Yeah. So we'll do the next one. Yeah. So this is the next case. So we've got an 84 year old may open to feed you with back pain and shortness of breath. Examination is diffusely tender through exam diminished some bruising on both flanks. He's hypertensive. He's smoked most of his life had an M I three years ago with a couple of stents placed, he's on aspirin and a beta blocker as needed his airways. All right. Patent sats 90 for Romir spiritual 24 hydrate 90 sinus rhythm BP 100 over 78 GSS 14 and 15, 83 11 white cell count 16 lactate eight AKI stage one. So it's gone into early renal failure. What is the most likely called renal comic? A slipped lumbar disc prolapse Acs so cute. Christendom. So, repeat heart attack, basically a ruptured abdominal aortic aneurysm or an effective exacerbation of his COPD have a little think about that one. And then whenever you're ready we'll move on to the next one. Okay. We've got some answers. It's good. All right. And then, uh, last question, 65 ft prints STD with abdominal pain and vomiting. She's open about this morning, which was loose. She's waiting, knocks it down to a GP for a current abdominal pain. B M I study five. Past history includes an open hysterectomy 40 years ago, just some bruising in the epigastrium and her abdomen is distended and tender. She's got no of attorney. I soft stolen rectum sats 98 6% on room air. Spiritual 20 for heart 810 sinus rhythm. BP 128. Jesus is 15 hb 13 white cell count 18 Lactaid is for a chi stage two. Billy's 20 for mali deranged LFTs A serum amylase is greater than 1000. What's the most likely cause? Is it acute pancreatitis at huge an obstruction gallstone alias, rupture, triple A obstructive uropathy with sepsis? Uh huh. Okay. You got answers. Perfect. So just go back to the first question, just go through it. So I can't really see, see and just tell me what do people answer this one? Um A lot of people said one said one. Yeah. So I think I think one is not technically it could actually be all of the above. Right. So I think if people are saying that, I don't think that's unreasonable at all because the short answer is you don't really know, it can be anything. So the things to think about with this is you're thinking it's an RTC front passenger, so they're going to the back of the car. So it's two things that come to my mind. So it's a deceleration injuries that are going from very, very quickly to suddenly stopping and also it's blunt trauma. So the steering wheel, um if they're the pass, if they're the drive or the front passion, it's gonna be the kind of the front of the dashboard is they're going to go on into it across their abdomen. So, blunt abdominal trauma, deceleration injury, what I wanted to basically just make sure I am parted with, this is the most likely organs to get injured in that setting. So with blunt abdominal trauma, your number one suspect is your liver, your number two suspect is your spleen and then your number three is basically joint between your small bowel and between your, your kidney. So it can actually be all of these. Um, but most likely this one, it's probably gonna be a liver injury. And the thing that kind of guide you towards it with this one is, is bile's up a little bit and as a LP and as a S T raised, um you can get that because obviously the liver is unhappy and you get a traumatic transaminitis. So that's the kind of the most likely thing. But actually all of the above I think is a reasonable answer result because technically, yeah, you're right. Could be anything. Um, so that's kind of what I wanted to touch on and I've got a picture of it here. So this is how liver lacerations looks. So, when you think of a lacerations, right, you think of a lacerations being, you know, if you cut your skin or, or you know, from something sharp, you know, you're chopping the vegetables for dinner. Something else you think of maceration in radiology, a lacerations is different. So you can see here this is, this is your liver. So this is your left lobe of your liver. This is your right leg with your liver, that's your spleen, that's your stomach. This is just some fluid within your stomach here. Can I show you that line on the outside? So that's the cortex of the liver, that's the world, the liver capsule, sorry. And then just here it gets all bit fluffy and then it reappears again there that bright white light, then surrounding all of it. Here, you got this area of low density, this kind of light gray stuff. And then it got within the actual liver itself. You've got this kind of area hypodensity, you know, so basically less than that's normal living and it's bright this dark stuff here. So what's happened is blunt abdominal trauma. Sometimes you can see a little rib fracture. There may well be this is the wrong window for it. Often a little reboot of cracked that would have just nicked the liver capsule. Here, blood starts spurting out and then gets sealed. Here is a little kind of extra capture the hematoma, something like that. Um Depends on how these are and how the patient is a long time actually can get away with conservative treatment for these. There's different ways of great and liver injury basically based on how big the lacerations and how, what percentage is involved it's involving kind of hilum or vessels, but broadly speaking, lots of different ways to classify it. That's how it looks, that kind of gray area that rim of full on the outside, that's classic for liver lacerations. Um And these patient's need to be seen and assessed by general surgeons to decide whether or not need an operation. So that's a nice little picture of a living like they're so don't forget that one. Uh I just wanted to show you as well. That's ribs here, these kind of intercostal muscles there you just see on this side here, it's just a little bit thicker. So I wouldn't be surprised at the rib fracture with all of this as well. But when we look at rib fractures, we changed the bone windows which graze all this out and makes this much crispy. Um But this is how you look for a liver injury in the first place. Blood gray area here, capsule breakdown. That's a liver lacerations. So this, this one here, uh Eddy back pain, shortness of breath. So there's a few little things here. I mean, I'm digressing from radiology here. Now, I'm just, this is just, you know, just trying to impart some knowledge for whatever you need to use it with clinical practice. So he's hypertensive. So the fact that BP is 100 over 78 you know, that's not quite right. His BP should be a lot higher than that little kind of subtlety. And this is the beta blocker because he's obviously going to be obtunded a bit from that. So you can get funny heart rates and funny blood pressures because actually a heart rate of 90 you think? Oh, that's all right. But actually he's actually shocked and because he's on a beta blocker, he can't mount that tachycardia. So that's a falsely reassuring heart rate. So don't these are classic examination tricks? So just don't be fooled by these hypertensive patient. Always elderly male is almost always going to be a rupture, triple A, whatever the context. And these are just kind of basically saying he's a bit shocked. He's a bit in the, what's the kind of 16? Because that's just a stress response and he's in a chi stage one is lactics eight. So the thing there, which is driving me towards that is, it may have gone through his renal arteries as well. So you may have had a, you know, a super renal or infrarenal aortic aneurysm has gone through one of the renal arteries and, and done that as well. And they just actually bled out, of course, his kidneys to be hyper perfuse and then give a bit renal failure. So all the signs here a pointing to a triple A and this is a, this is absolutely textbook kind of question that we would set the people. Um because it's just, it's got all these little little tip boxes there that, that like to be examined. So, rupture triple A, hopefully that's relatively self explanatory. Obviously, the pictures you've seen before the Tripoli. So we know how them uh the classic thing on that thing as well. I just want to just touch on as well is that it's a, it's a, an mrcs examination station where they'll give you this kind of scenario, the patient will then be examined and they'll put an ultrasound London to measure their bladder volume. They'll say bladder volume looks like 5, 600 mils and the bladder, they'll pass a catheter through thinking it's a big distended bladder and then no urine comes out, you flush the catheter know urine comes out. Um And the answer being is it was it wasn't a bladder. They were scanning, it was a big abdominal aorta aneurysm again unless you've heard of them before? It's quite easy to fall into these traps. So I just wanna make sure that I reduce the chances of people falling with these uh these little scenarios. So, yeah, elderly mail back pain shocked. Don't forget about beta blockers. Look at the history. He's hypertensive, he's a cardio path. He's had an MRI at all. Always, always triple eight. This one's a bit more subtle. There's a couple of things in there which uh which are useful to think about. So the clue in this question here is the current abdominal pain. So she's got a kind of abdominal pain, we're thinking probably biliary colic. So she's awaiting an ultrasound to see whether or not she's got gallstones BMS higher end again, risk factor. She's an open hysterectomy. So she's got abdominal surgery as well bruising their purgation. So um there's an eponymous name for that. So if your blue bruising, we want to be another diagnosis, we'll come back to that in a second. Um distended abdomen which is not stolen there. She's vomiting but open a bowel. So that's telling me distended but not obstructed sacks. The spiritually very take a Codec BP is a bit low. Again, whites account 18 like takes four. So up and her kidney function has gone off and abilities, Molly deranged as well. So it's kind of an obstruction type picture but not quite because she's opened her bells. She's got raised their mind. She's been investigated for gallstones. So you think you just got gallstones. The bruising in the epigastrium is the key for this one is acute pancreatitis. I can see why people might think that these obstruction as well or gallstone alias potentially. Yeah. But the you dig into the question actually, it's is giving subtle hints actually to school safety one. So she's not obstructed. So it will point to was acute pancreatitis. So the bruising in the epigastrium can be from a couple of things. So you can get two methods of bruising and they're effectively a measure of pancreatitis where you've um cause significant inflammation along the retroperitoneum and around the actual pancreas itself. So you have um Cullen sign, which is kind of bruising at the top of the epigastrium or we have great earners where they have kind of bruising along their flanks, left and right. Um Also some people when they have pancreatitis is we'll use hot water bottles on their upper abdomen to kind of help with the pain, which I'll show you in a minute. And this is a picture of a CT scan. So you can see that's right kidney that's left kidney, that's bottom of spleen and view that's liver, that's some bowel, this is your pancreas, it's really fluffy, not critically defined at all. You can't really see where it kind of begins and ends. It's just really, really smudged and this is textbook of acute edematous pancreatitis. So that's how basically this is wet, baggy, inflamed kind of structure here just draped across the back of the retroperitoneum. That's the order that, so remember that one that's acute pancreatitis, fluffy. You've lost the definition of it. Inflame. The fat planes are all gone pancreatitis. Most common cause of pancreatitis as we know in the UK is gallstones and this is what I'm telling you about earlier. So people use a hot water bottle, they put it over their abdomen here to try and help the pain that's called erythema. A big gonna Sure you've heard of that if you have and that's what it is. And again, that's a, that's another kind of nice little thing to examine you might see in, in long cases is clinical examine final. All right, I think we're done. Um, we can answer some questions now. Just come out of this. Do you want to note um, my image of this as well?