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Hello. Um I don't know if you guys can hear us. Um But thank you for joining us this evening um for a session on inflammatory bowel disease. Um So for those of you who are new here tonight, so the six PM series is an international online medical education platform in which we organize a series of premedical lectures aimed towards medical students and junior doctors and your speakers tonight or speaker tonight is Nica. She's 1/5 year medical student at University College London. Um So before we begin, I just wanted to ask you guys to fill out the feedback form before the end of the session. So I'll send that into the chest and I'll hand over Tunica now. Thank you. Thanks, Naima. Um Hi guys. Yeah, I'm Anica. So today I know that there's been kind of a gastro part one session a few weeks ago. So this is gastro part too and we're looking at types of inflammatory bowel disease is um if anything's, you know, ever, if I'm going too fast, if you guys have any questions at any point, just pop them in the chat and we can take it from there. And yeah, Naima said, I hope you guys can hear me thumbs up in the chat if you can. Okay. Awesome. Thanks Ahmed for confirming. Cool. So we'll make a start. So what is crones crones is a type of inflammatory bowel disease? And the thing with crones to know is that it can be present anywhere from the mouth to the anus. So anywhere in the in the gi tract. Well, by that, I mean, like it can be small and large bowel. Um it has a by model incidents. So it can happen, it's usually in kind of younger people, but the kind of the most common is between 15 to 25 years old. And then there's a second peak between 60 and 80 years old. It's also associated with some autoimmune conditions like type one diabetes, mellitus and risk factors for its development include like smoking and nsaids. Um And I've just put, put on the slide there that the exact antibody that causes it. Obviously, that's pretty niche information, but it's helpful to know. And following from that, obviously, a big thing that you do when a patient comes in with an inflammatory bowel disease is that you kind of tend to refer them for a colonoscopy if they have rectal bleeding. So on that colonoscopy, the findings for Crohn's disease will be trans mural inflammation that's really important. So also active colitis, which is the other one is like it's solely mucosil. So it's only on one layer. Whereas transmural means it's through all the layers of the bowel wall. And secondly, you can have skipped lesions. So the inflammation isn't continuous. There are localized sections of inflammation with gaps in between. And it kind of looks quite cobblestone e appearance. That's just what they use in the textbooks. But I, I like to think Crones Cobblestone is a good way to remember it. Um And with regards to like when you look at it on biopsy and stuff, um for Crohn's, you typically take a Duodenal biopsy um or like the Ileo Colic region, you're looking at small bowel, the terminal ileum, that sort of region because I said it happens everywhere, but it's more common in the small bowel. You expect increased goblet cells and noncaseating granulomas. Okay. So that's just a initial intro into crones. And then we'll have a look at like the different ways you can manage, diagnose, treat everything. But hopefully that makes sense to everyone. As I said, any questions, just throw them in the chat and I'll cover them as we go along. So to start with, this is our colonoscopy. Oh, someone said we're intermittently audible. Okay. If anyone's having any issues, let us know slash I will leave it in 90 HMAS safe hands because I'm not sure why it's um I can hear from my side. Um There's just a bit of static but I can hear properly. Can everyone else here? Okay. Static. Okay. Maybe I'll lose this bit of interference. Okay. Um It might increase the volume a little bit. Is it better now? Hopefully it's slightly better? Okay. If it worsens, let me know I've moved my paper. So hopefully that will reduce the interference. Okay. So what is this? Um It's a colonoscopy of the small bell and you're looking at kind of um basically wait one second. So you're looking at basically a, an image of the colon and the kind of fiber it sort of looks a bit like linear and sipping Ghous sort of inflammation pattern is what they call it. Um One second. Okay. Yeah. So linear into pincus ulcerations and there's a fibrosis exudate around it. So that's kind of the whitish area. Um and the area between the white part, I don't know if you can see my pointer. Um If you can, then I'm pointing at just the region in between. You can see that it's kind of lost its normal vascular pattern. So this is kind of your classic picture in um in in currents. This is like another section of bowel, you can still see some of the linear bit, but this was mainly just to show the cobblestoning on the bottom half of the picture and like it should look a bit hyper remick as well by that. I mean, just very red and quite inflamed. Okay. And next, we've got a sign to do with Koreans disease. I don't know if anyone knows it. Um, you do like a, a sort of ct of the small bow, it's called the string sign and it's basically when the terminal ileum. So the, the segment, it looks a little bit like a string going downwards. Um, the terminal ileum is incompletely distant, distended and it's due to there being a stricture present. Um, and it's kind of, it's a really classic, not classic but common finding with Crohn's disease. Um and it's due to sort of the separation of adjacent bowel loops. So they're not kind of altogether, they're quite separate from this one string segment. Um and it's due to like an increase in adjacent mesenteric fat. So it's just something that's good to know that, that, that it's due to like the terminal ileum can't open fully properly. Okay. So things to know about Crohn's, we've talked about where it acts. So think about what your complications would be with Crohn's, you'd classically get absorption problems. So you might get nutritional deficiencies. Um Now these were supposed to kind of be animations, but given that metal only allows me to do PDF upload. Now you can kind of see the answers. But um for the sake of argument, I will ask, I've said that peripheral neuropathy can happen secondary to a nutritional deficiency. Does anyone know which of the nutritional deficiencies causes peripheral neuropathy? Like which vitamin? Yeah. Thanks for being A B 12. Exactly. Um And so if I had a B 12 deficiency and iron deficiency, what would my sort of anaemic picture look like? Would I have microcytic? Would I have macrocytic or would I have like a normocytic sort of picture? What would my hemoglobin level look like normocytic? Exactly. Yeah. So you would get a normocytic anemia because it's mixed nutritional deficiency. But you would get an increased like red cell distribution with. So basically your red blood cells are more varied in their size, but the average size will be normal. Yeah, and hemoglobin would be reduced. Um Other things to note B 12, anyone know where it's absorbed? I think I've pushed have been a bit too hard. She's been doing a lot of the work here. It's the terminal ileum which is why. Oh, I've written on the slide. No one. So yeah. B 12 is absorbed in the terminal ileum. Um Anyone know what kind of anemia is like a another autoimmune anemia that causes B 12 issues due to lack of intrinsic factor pernicious. Yes, exactly. Um That's just a bonus points. Um Other things know about Crohn's so well done. A Lenny's also got it. So other things, no recurrence. Um your, you see kind of perianal symptoms quite often. So peri anal fistulas kind of anal tags are quite common. Erythema nodosa um is commonly associated as well as sometimes pyoderma gangrenosum as well. You're looking at overall inflammatory picture. So you can have uveitis, episcleritis and what kind of an arthritic picture? Even the arthritis is less common, but it's still, it's kind of the same sort of path if it's everything is just getting fired up. So often these patient's will have systemic features. Okay. And then, so say you've got your patient, um they've come in, they, they have several bouts of diarrhea. Um It's not that bloody because Crohn's isn't, actually, it is bloody diarrhea, but all sort of colitis tends to be more, more obviously bloody. Um, the main things you do. So, stool microscopy and, um, kind of culture. What would you want to rule out in a patient with abdominal distention with diarrhea? Say they've been to India recently? What would you want to rule out with your stool sample? And what would you be looking for when you look under the microscope? Any ideas to the diarrhea's bloody? They've been traveling recently. They have similar symptoms in Paris. Yes. Yeah. Some sort of gastroenteritis. Yeah. E coli is a good one. Um, I think Shigella Campylobacter as well. They both cause it. So you might want to ask as well in your history about, have they eaten anything? Is there a trigger? That's often a really easy one to forget. Um, because often these symptoms are quite, they tend to present like, oh, it's been a few months. So then obviously you wouldn't ask. But if it's only a week then you might be inclined to think maybe this is something else. So you're FBC would show anemia as we've discussed. Your ESR is likely to be elevated any longstanding inflammation, raises your ESR. And then CRPS also likely to be elevated risk factors. We've, we've discussed, so we'll move on. So now we know that they've kind of, uh for the record from, from those tests, we don't actually know for sure that this is Crones. We'd have to do the biopsy. Well, we'd have to do first the colonoscopy and then we do the biopsy of the bowel and then we'd be able to confirm crones, but say we've confirmed it and then now we're looking to treat. So main, main method of treatment for like Crohn's, you, you assess the severity, you look at how unwell the patient is in front of you and for the record, we'll go through like an approach to rec rectal bleeding presentation. Um In a second, I have some slides on it and just how you would take it from from first presentation. I just thought we'd put some knowledge in there kind of on, on both of them before we, before I test you guys. But you seem to kind of have a good idea of what's going on, which is really good. So, yeah, treating Crones, you'd go for oral corticosteroids generally. Um And then you'd use azaTHIOprine to kind of maintain remission is a thigh a print your, your ideal to maintain remission or induce it and then if you can't use the azaTHIOprine, then you'd use methotrexate and then you'd kind of go to like, once, once the patient's more settled, then you'd move on to like the amino salicylates, like sulfaSALAzine. MS Alazine. Okay. Um Okay. This is just a picture to demonstrate the different, I mean, we've talked a lot about the colonoscopy findings, so I won't, you know, dwell on it too much. We have some findings listed for ulcerative colitis in a few slides. But yeah, pseudo polyps. Um, and no skip lesion's is kind of a big thing to know about ulcerative colitis. You might also see some pump ticked ulcers in the colonoscopies for you see, it's also a different area. Ulcerative colitis is usually kind of your left lower region within the sigmoid colon and the rectum. Whereas Crohn's is much more small bowel as we mentioned. Okay. And then this is just, yeah, you're kind of list of how to, how to manage Korans. Basically. Um, it can, we've discussed that it can present with a wide array of symptoms. We've mentioned a couple of the investigations. Um, and then yeah, once you know your severity treat as discussed, anyone know any complications of crones, I mean, I've written may get toxic megacolon or toxic dilatations. Sorry, but anyone know anything else you'd be kind of worried about. And the current patient with the bows fischelis. Yeah, fischelis is a good one. Bowel cancer. It is, is a is a risk. Um, yeah, you guys have come up with some really good ones. Um, the one I was going for was kind of like a stricture or some sort of small bowel obstruction, um, due to like recurrent flares, but you guys have come up with some really good ones. Um, this was, anyone knows, spot diagnosis, complication of, I mean, it's not really complication, curren's as such, but obstruction can lead to this toxic megacolon. Yeah, well done. Um And I think if the colonic diameter is greater than six centimeters is when you, when you really worry, the rule is like 36 and nine for, for different parts of the bowel nine is for like the ileocecal junction. I'll double check that though, I'll double check it but well done. Um Sabina forgetting the spot diagnosis. Okay. This is kind of we've covered it about the systemic features of of cones. So now let's do some questions guys, you've clearly proved that you're thinking quite hard. This is quite an intimidating question because it's quite long. So we'll go through it. Okay. Don't get overwhelmed. So you've got a 32 year old man one day history of recurrent episodes of vomiting. Okay. So one day history is pretty short, maybe it's infectious. Maybe someone around him was unwell and he picked something up. But then now we've got he's had 15 episodes of billions, vomiting, okay. Billy is vomiting. If it's green, you're thinking, okay, maybe obstruction because that's classically like it's usually you're thinking small bowel obstruction and something's going wrong. Um, now it's crampy abdominal pain. Okay. That's fine. Doesn't really tell you much, but he hasn't had a bowel movement and hasn't passed latest in ding ding obstruction. Maybe something's wrong. Um, because we've got vomiting, we've got no flatus, no bowel movement. He has no fever or diarrhea. Okay. So, he doesn't have diarrhea fine. He, so he has a history of crone's disease. There we go. Um, which was well controlled good. He had a reception that's important to know he had a resection at birth of some of his Bell and medications he's taking, we discussed the sort of vitamin deficiency that builds. So he's taking a lot of supplements for that. That's fine. He pays uncomfortable. Lips are parched. So he's dehydrated temperature is 37.1 37.1. Worrying. I don't know. What do you guys think? Would you be worried about? The temperature? Might be worried about the heart rate and the BP, but, okay, I'll let you keep reading. Sorry. Uh, went through you guys off. So abdomen is distended. Okay. Tender to palpations, rectal exam is unremarkable finds. He's got a lot of problems here. I'll let you finish reading and I will launch the pole on what you want to do for this guy. Okay. Oh, I think maybe someone's written the answer in the chat. That's gonna be a sorry guys. It was a pool. Um have a think try not to look at the track, the answers in there. It's a pretty hard one so I know it's not, it's just nearly a message. Ok, so Paul started guys. Mm I've only got one total response and if you guys can answer or just are thinking okay too. Well, don't a leather put one in. This is quite hard one So I'm going to give it like a few seconds. Um Okay. Right. So I'll go through it. I'll, I missed you many auto close when I open the next one. But basically the answer is b and the reason is because this patient has had a history of Crohn's and they've had this reception in the past, which means that if you do another reception, which I think is what some people were saying, which is not a bad, like the logic fits. You'd want to remove the part vow that's causing these problems. But because he's a already had one, you don't want him to develop short bowel syndrome where he can't absorb stuff properly and it puts him at further risk of like adhesions and fistulas and all kinds of kind of POSTOP problems. Um So when you're trying to, obviously you're trying to treat his small bowel obstruction, we figured out that that's what he has, but you want to try and do it in a way that's like bowel sparing. You want to keep as much length of the bowel as possible. So that's why it's, it's actually like a stricture plasty, which is when you try to just open, open it up and then keep the bowel kind of somewhat together as opposed to just cutting it out. So, a bit of a complicated one but well done to you guys for answering and dealing with the long intimidating question. I have an easier one coming up next. So I will launch the pole for the next one. I'm not going to go through this one the same way because it's a bit like it's a bit more straightforward. I'll let you guys just think about it and answer, but I have basically two long ones for each condition. So we'll go through them. Someone messaged anyone how many questions so far or anything? They won't clarifying. Oh, someone's gone for e maybe a few people, but I think the majority of you okay. A bit of a mixed bag. Now give it like a couple more seconds. Think the majority of you've responded. Okay. I'll in the interest of time, I'll keep going. So um well done to those of you that said b so it is in fact be um because obviously the differentials in this patient are like he's come in with non bloody diarrhea, crampy abdo pain, the tenesmus, which is when you feel like incompletion, like you haven't passed all the stool that you have to pass. It's just a sensation of, of not having passed completely. Um And the frequency is also quite worrying 4 to 5 times a day is not, um, it's not terrible. We'll go through the classification in a second. Severe is if it's happening more than seven times a day, so 45 would be like moderately, it'd be in the middle. Um, but the weight loss is worrying. So you're differentials or crones of stuff colitis, maybe it's malignancy and the fecal calprotectin is a good answer because it's a screening tool, but it doesn't differentiate between the, the U C and crones. Um Pelvic magnetic resonance imaging. I don't know how much it will tell you. Um fecal occult blood test is actually not done that much. Now, they use um it's called like the fecal immunohistochemical one. The problem with the fob test was that it used to register animal blood as well as human blood, which meant that a lot of people were getting false positives of like, oh, you're having G I bleeding when it was just, they'd eaten something that contained a little bit of animal blood. Um And the abdominal X ray won't tell you enough. So basically go for the most detailed in this instance because they've asked for confirm the diagnosis, not like best initial test, but yeah, so it was b next one is also reasonably straight forward to are launched pole. Um So you got this Junior doctor, three months worsening Abdu Pin. Oh, I think it's launched. Yeah. Um, so junior doctor, three months of worsening abdominal cramping, further questioning, he's had 5 to 8 bowel motions. Okay. I mentioned the severity earlier, deny greater than seven. So this guy is kind of greater than seven um, significant weight loss um, of at least 10 kg, conjunctival pallor, ileocecal junction, which treatment is first line for inducing remission. Um Let me double check. It is in fact, okay, everyone's giving a bit a bit of a mixed bag here. Um But uh yeah, I can, I can understand why people a bit confused. So a lot of people have gone for his thigh, Bryn. But the answer is actually prednisoLONE because you need to use the, the steroid to just get them into remission. And then the azaTHIOprine is an immunosuppressant. You add alongside the oral glucose, cut the oral glucocorticoid in order to help achieve the remission. But you only use the azaTHIOprine if you have more than two exacerbations in the 12 month period. So you and you can't do it like instead of steroid, you have to do steroids and azaTHIOprine and the steroid is kind of more critical in the initial like flare up period like the minute it starts, the infliximab is obviously a biologic agent. So it comes later in your kind of management stage, you have to fail on steroids and fail on responding to the azaTHIOprine before you can then move on to biologics. Um And then what else was that methotrexate? Um It's an immunosuppressant but it's second line two azaTHIOprine for the inducing. So does that make sense? First, you give them the steroid, you just get them into a normal space, then you give a South Iprin. But if you can't give azaTHIOprine because it's contra indicated or something, then you give the methotrexate instead. But the reason it's spread and not is a vibrant is because the is a vibrant kind of needs the steroid to just do the initial job. And then it it kind of boosts it if anyone has any questions on that one, just, just post in the chat and we can, we can go a bit step, you know, I can go through it again, but in the interest of time because the next one is quite chunky question. Um I will open the next poll okay. Messages. Okay. So now again, we've got big long question but it should be reasonably straightforward. I mean, the answer traces are just differentials. So let's see, a 33 year old woman comes in because of four month history of intermittent lower abdominal cramps. Okay. So it's fine for four month history is long term. So gastroenteritis is now not on your differential as much. The woman cramping you might want to just put in your head that maybe there's Gynie differential. They're like, you know, maybe she's having some insane menor Asia or, you know, you might just want to know a little bit about like, um this is just me taking it general, by the way, not keeping it to two G I just to kind of get the thinking in your head. So lower abdominal cramps in a woman who's 33 you might just want to ask about their menstrual history. Um So she's got the diarrhea, bloating nausea, big thing with diarrhea and bloating again, young woman, maybe it could be celiac, you know, is this associated with gluten? Um And if it was I B S, you might want to ask about if they've had constipation and then diarrhea and then constipation and then like I B S has a very mixed picture, but it tends to alternate bell habit. Um It's also associated um with pain. There's also like a pain differential. So with I B S pain, pain is relieved on defecation. But if they had hemorrhoids or something, pain is triggered and is worse with defecation. Okay. So now let's go back to the questions. So she got these symptoms during this period. She has 5 kg weight loss. It's a lot. She feels like she can't empty her bowels, she can't fully empty. That's the tin asthma's we, we saw earlier um oh, two people have already written in. So that's good. They've already answered. So no history of serious illness, high fiber diet. Okay. Father of Ashkenazy Jewish descent. Descent. That's a risk factor. Um, this particular group of people are really prone to this condition. Um, she smoked two packs of cigarettes daily for 15 years. Appears well, okay. So the smoking is a risk factor for one of the conditions we discussed today. Um, her temperature is somewhat normal, right, that he's 36.9 is not too worrying. Um, pulse is a bit high blood pressure's normal ish, lungs are clear, that's fine, cardiac, fine Abdoh, mild tenderness, okay, right. Lower quadrant. Think about the distribution. We we mentioned that left was more common for you see, right in mid were more common for Crohn's. So maybe you're thinking Crohn's a couple of people put U C S and just putting it out there that, you know, think about the differentiation. Um and then bowel sounds are normal. That's good. So, no obstruction in this one previous question had obstruction, right? Tested the school for occult blood is negative. So there's no blood in the stool. Interesting and people have gone for ulcerative colitis with non bloody stool. Um And then the barium enema shows ulceration and narrowing of the colon. Okay. Most likely diagnosis is crones. Yes, well done to 50% of you or the three people that put Curran's. Um, it is, in fact, crones, the reason it's not, you see is because it's right hand sided. She has the smoking risk factor. Um, it, the stool is not actually that bloody Crones is more common in Ashkenazi Jewish populations. Um, yeah, those were the main differentiators. I think if I think of anything else that will come back to it, but those are the main ones. Okay. And I think this is my last Koren's question and we're at the halfway point, guys almost there. I mean, not Koreans but like this sex section, it might, haven't read the actual questions, so it might not be Koreans. Okay. I went through the other one quite a bit. So I'll give you guys a minute to read it. So yeah. Um right sided abdominal pain, diarrhea, weight loss, abdo's tender in the right lower quadrant rectal examination. We talked about perianal disease, show skin tags around the anus and painful fishes and fecal calprotectin is raised. So the condition should be somewhat clear. But which condition, which option would you would you want to go for? Okay. Two people have responded. That's good. One of you is right? Okay. Very mixed bag. One person has got a C D and E er and equal votes at the moment. Hmm I'll give it another like five seconds also. Well done guys. But you know, I realize it's 6 30 on a Tuesday but you're all, you know, responding and taking part, which is really good. Okay. That's over half of you. So I will, I'll kind of call it there but well done to those of you that said Metronidazol may be helpful. Which I know is pretty rogue and, you know, you wouldn't have expected it from this one, but the patient has crones crypt abscess is, aren't associated with Crohn's. They're associated with UC smoking. Improving the symptoms is again, ulcerative colitis, more than half the patient's won't require surgery. It's a bit random. I think a lot of patience with Crones might end up requiring surgery. I don't know the exact proportions, but obviously with exam technique, I don't know if you want to go for that one. It seems a bit random. I mentioned that nsaids were a risk factor for crones. So they don't actually improve the condition. Although you would think maybe anti inflammatories, but it doesn't help. Nsaids aren't kind to the gut or the kidneys. Um And metronidazol may be helpful is actually the correct answer because Metronidazol helps with the perianal disease side of things. So it's just helpful to know. Okay. And on that note, you guys can take a little bit of a breather while we go through ulcerative colitis for a little bit. Okay. So you guys can chill well done. That was a bit intense. So, ulcerative colitis, we've talked through most of the kind of difference is whilst we were discussing crones, um but just to kind of run through it. So we're all clear. We mentioned obviously that it goes through the sigmoid Aasif colitis is more localized to the sigmoid colon and the rectum, it's continuous inflammation limited to the mucosa layer. So it's not transmural. Um It's an inappropriate immune response to the colonic mucosa. It presents with pseudo polyps, punctate ulcers, um and the hyper emmick mucosa on colonoscopy. And then this is like true love and wits criteria. So this is kind of how you determine severity of ulcerative colitis, which is what I mean, I think I said greater than seven, greater than equal to six, I guess is the actual specifics um of how it qualifies as severe. And the way you treat depends on the level of severity. So mild are sort of colitis. You give miss Alazine pr for distal disease. So if it's closer to the rectum or you give P O mesalazine for more extensive disease, you might want to give like topical steroid foams, P R as well like hydrocortisone foam or something. Um or some sort of like retention enema of pre prednisoLONE. So, predominantly with mild, you focus on trying to, trying to manage with the aminosalicylic. It's so the mesalamine and you give everything pr you're working up from the bottom with moderate cases of. You see, you give oral prednisoLONE, so 40 mg a day um and you try to induce remission for about a week. Um and then you can taper down your steroids because obviously, steroids are like a big thing that you can't just stop one day. Really. Suddenly you have to like bring it down slowly just for bonus points because, you know, to make sure you're all awake, anyone know what you have to do when someone falls unwell, if you're taking steroids and suddenly you feel unwell. What do you have to do with your steroids? It's similar to what people do with insulin. What diabetics do with insulin when they're not feeling well? The sick day rules. Yes. Increase the dose. Well done guys. Yeah. Um, for increased cortisol demand. Exactly. So your body's autonomic production or like, yeah, autonomic fits because it's yourself autologous production, autologous production. Of course, result drops when you're taking exogenous steroid, which means that suddenly when your body requires more, it can't actually, it's not used to producing it. So it kind of just it runs on a deficit, which is why it's really important to increase your exogenous dose to account for that. Obviously, when you're doing this, when you're giving these medications, do your F B CS, do you use an needs? Um to kind of make sure that nothing's getting impacted that renal function is normal. Um And when you have severe also typical itis, obviously, you work from IV rehydration, electrolyte replacements IV steroids. Um and you might want to give like thromboembolism prophylaxis in case with all the dehydration and stuff, if your blood is particularly kind of sticky or prone to um to clot. Um But yeah, those are the main things and then obviously, you know, keep an eye on the stool, do a stool chart, um, record how often they're passing bow bowel movements. Um Yeah. So those are the main things anyone have any questions? Okay. I'll keep an eye on the chat if anyone posts anything but we'll keep going. Okay. So these are some of the main symptoms of, um, ulcerative colitis. Good thing to know is that it's associated with primary sclerosing cholangitis. So I like to think of it as like bile conditions. Crones is actually associated with gall stones because it's starting to like bile absorption is typically in that sort of terminal ileum region and oxalate and things like that are absorbed there. So when you, when that region of the bowel is damaged and you're not absorbing those, those kind of things like the vial and the oxygen and stuff properly that predisposes to stone formation, which is why Koreans patient's are more likely to get things like bile stones and issues with the gallbladder. Whereas you see they still do get problems, but their problems are primary sclerosing cholangitis. That's how you think about it if it helps. Um And then again, your list of tests, right? Very similar to the other set. I wouldn't say that there's a huge amount of difference in what you test between ulcerative colitis and Crohns because ultimately the only differentiator is biopsy. So at the biopsy point, then you'd know, okay, this is one or the other. The only reason I've thrown amylase in there is like, if they have some sort of pancreatic issue, it's not common, but that's what amylase tests for. Like a pancreatic problem. Um, what, what else might you want to look for in the LFTs if your patient sort of like dehydrated and I don't know, the fluids and electrolytes are all over the place. What, what might you want to pay attention to? It's a protein that's also a marker of liver function, but it's also important for fluids and things. Big protein. That's a clue. Yes, I'll be in, oh, race DLP is a good one. Um I was, I was, I was going for Albumin because of the dehydration sort of thing. So sometimes these patient's become hypoalbuminemic. Um So that's a good thing to keep an eye on in the LFTs as well. Okay. Right now we've got big, big question. Um, which I think we can do ready. I'll let you guys have a quick head start, but I'll do the same thing as before. Um, so this patient has a six month history, generalized fatigue. He can't work out at the gym fine. So he's, he likes exercising. Um, he has mild cramping, lower abdominal pain, bloody diarrhea for five weeks. So six months, fatigue, five weeks, bloody diarrhea. Okay. Father was diagnosed with colon cancer. Age 65. Ok. That's kind of kind of worrying. It's, I mean, but it's quite old, like if it was a very young diagnosis of colon cancer you might be worried about like Lynch syndrome or does this patient have a genetic predisposition to getting something like that? But 65 it's, it, I mean, it could just be, he just had, it doesn't have to be genetic. He smoked 1.5 cigarettes. Okay. That's not good drinks. Not, not hugely. Um, pulse is a bit high blood pressures, somewhat. Okay. Physical examination shows dry mucous membranes. Okay. So he's dehydrated, um abdomen, soft, nontender, rectal rectal exam shows stool mixed with blood and his hemoglobin is okay, I think, right? What, what do you want to do with this guy? So he's come in with the fatigue with the, the bloody diarrhea for five weeks, history of colon cancer in the family. Which of these I will open poll, sorry, I forgot. Open pool. Yeah. Okay. Yeah, I think most people have got where we're going with this question, which is good. Yes. So, um I think half of you have responded. So I'm gonna go through it. It is in fact, a colonoscopy. So you want to confirm the diagnosis of inflammatory bowel disease because obviously his symptoms sound like it. Um The rest of the tests don't really give you kind of enough information you have to really need to differentiate um, if he was having an acute flare, like if it was really bad um where he's having more than six bloody stools per day, then the colonoscopy would be contraindicated because he's having an acute flare and you wouldn't want to go and disrupt it. But if it's under that amount, then you can still do it and get your kind of diagnosis. Um, anyone know the kind of two week wait referral criteria for colonoscopy, it's quite important. So, when you're counseling, well, first let's go to when you'd refer a patient for colonoscopy and then when you would, how you would talk to them about it. How would you counsel your patient? That's classic Kaskey stations. If, if you guys are, I'm gonna do exam soon. So, referral criteria. Um I'm not sure if anyone knows. So I'll run through it really quickly if you have someone who's 50 and they, if they're above 50 and they have rectal bleeding that's unexplained, then you're quite worried and you would refer for colonoscopy. But if they're over 60 then your threshold for worry is even higher. Does that make sense? So, at 50 they have to have actual unexplained bleeding at 66 weeks of altered bowel habit. Um, maybe, maybe so, I looked at the Macmillan guidelines and they said, um, if they have a positive fit test, but I imagine that the referral for the fit test would be something like having altered bowel habit for several weeks. So, probably so, um, so 60 plus with the fit test positive, 50 plus with unexplained rectal bleeding at any age. If you have a rectal or anal mass of some sorts. Um, no worries, Sabina. Um, so any age rectal or abdomen as, um, and if you're less than 50 so if you're less than 50 and you have rectal bleeding, um, then you need something else. Yeah, you need like an abdo pain altered bowel habit or weight loss in addition to the rectal bleeding to get you the referral because you're so young. If you're, if you're under 50 then, uh you know, to think cancer, you need quite a few symptoms. Um As you said, the more than 5 kg weight loss would make you think cancer in the history anyway, so you'd be more worried about it. Although also with gi you got to bear in mind that when you have all these symptoms, you're intake also drops. So 5 kg weight loss would, would worry you, but it would be important to query. Are they eating? Like if you're not eating, you're losing weight, that's normal. If you're eating and you're still losing weight, that's okay. You have a malignancy or something. Um So just, I mean, you're right, Jessica, that's probably likely, but just keep in mind that intake would be important to gauge. Um and in terms of when to refer for like fit testing. So when you're not thinking colonoscopy, but just, just under that, maybe you just want to check whether there's any blood in the stool, you would do it when they're 50 plus if, and if they have unexplained abdominal pain or weight loss or if they're less than 60 but they have a change in bowel habit or they have iron deficiency anemia or that 60 plus with the anemia. But without the iron deficiency, I'll send this kind of, I'm assuming you guys get the slides if you do the feedback form. So I might uh edited and re sent in Naiman, put those, um, referral criteria in there as well, but I hope that clears things up. Um So we got our next question. I will open pole and you guys can have a read of it and see what you think. Okay, we got one response. It's good. Okay. Right. Well done guys. Um So most of you have gone for, well, it's been a mixed bag. So the same number for eight and d uh a couple of people have gone for see. So 27 year old man presents to his GP with chronic diarrhea, no meds, no past medical history. That's fine. Um Now, which of the following piece of the history would make you think inflammatory more than irritable bowel. So, abdominal bloating, it could be either, right? Both of them kind of have bloating. It's kind of non specific abdominal bloating isn't everything. See, deac irritable bowel inflammatory, um passing mucus with stool. So, yeah, I think that that tends to be slightly more associated with irritable bowel than inflammatory, but I have to double check. So it might be the other way around. Tune Asmus again, maybe you'd think you see. But irritable bowel also has it. It's not that clear abdominal pain relieved by passing stool is usually an eye bs thing. It's very, I B s waking up at night to pass stool. So, nocturnal diarrhea is very worrying. It's, it's more suggestive of like a, a secretary cause of the diarrhea. Like something is actually wrong in the bow, which it's not just irritable. Like there's a problem. Anything where you're waking up at night to do something like nocturia, um, is also like something that's a bit more worrying because your body is actually waking itself up out of sleep to handle it even like pain at night is another one that people tend to worry about. Okay. So waking up at night is actually the correct answer. Okay. Um I might just before we move on to the next one, I'll just go through like an approach to rectal bleeding and then we'll finish with SBA I think because we're a bit pushed for time. So this is like just things to bear in mind when you have a patient who comes in with rectal bleeding or blood in the stool things you need to ask. So how long has it been going on for? When did it start? Was it Frank blood or is it streaks or is it blood on the tissue paper? So that's telling you like Frank blood would make you think it's very much lower gi very close to the anus streaks would make you think. Ok, it could be slightly higher up in the gi tract. If it's Molina, if it's like black tarry stool, then you know that that's an upper gi bleed. Um, if it's like blood on the tissue paper, then you know that it's not necessarily like mixed in with the stool that could be a hemorrhoid. Um Other things to ask. So, trigger, we touched on before. Is it like a gastroenteritis picture? Have they had something? Have they had too much beet root that causes reddening of the stool to not that people would say there's blood in it, but I mean, it's something to think about. Sometimes people think that they're urine looks weird but like medications can turn urine different colors, um and stuff. So it's just good to know. Um, other things to ask, get a, get a picture of how much blood this patient's actually losing. So that is helpful because you can link it to the true love criteria with like the number of emotions and stuff. Is it happening every time they go to the toilet? Are they a bit dizzy? Do they feel like their check? Like their hearts kind of racing a little bit? That will tell you if they're a bit hyperkalemic. Are they getting sort of anemic features? Do they look pale? Do they look dehydrated? These are good things to be aware of. It's important to, as I mentioned earlier, keep track of intake. So with, with everything that's been going on, is your patient's still drinking water? Are they still kind of, you know, eating a little bit at least is important. And then yeah, associated features ask about classic gi stuff. Like are they nauseous? Are they vomiting with vomiting? Is that blood in the vomit? That's really important is the vomit green because those two are like bad obstruction, hemo to missus, which can be like due to esophageal viruses. Um I mean, the esophageal varices the main course, but there are others mallory weiss tear. I think you guys had an upper gi took before this. So maybe link it to that a little bit. Abdo pain is big one. Um Anal itching is like linked to hemorrhoids pain on or relieved by defecation. We talked about before dysuria obviously doesn't really link that much. But when someone comes in and they're talking about bowel habit problems, just throw in a question about like, do they have a UTI is there anything wrong with your other excretory systems, genitourinary tract? Okay. Um Pyrexia is quite important. Um It can tell you a lot. How high is the Pyrex? See if they have one. How long has it been that high? Um They're just quite helpful things to know if it is like a cancer picture. A low grade fever wouldn't be surprising anyone know what you'd want to test for. If colorectal cancer was on your differential in the bloods, there's a tumor marker for colorectal. It's not super specific, but it's just one of the ones. Any ideas, anyone, if I had an old 70 year old man with rectal bleeding and weight loss and fatigue and I was thinking this guy needs to be diagnosed. I mean, I do the colonoscopy all of that, but I would also look at C E A costs, know embryonic antigen. I don't know if that rang any bells, but that's just if it's on your differential, just throw it in. Um What else might you expect with what, what type of anemia if it was colorectal cancer? A chronic disease, normocytic microcytic macrocytic, it's getting towards seven o'clock. I think everyone's getting a little tired. But come on guys. Normal. Yes, somewhat. It's kind of like micro to normal but is, is generally normocytic anemia of chronic disease, well done guys. Um Yeah. And then obviously if you're thinking cancer, then ask about weight last night's words. Um And I think the other like, I mean, they're not classically b symptoms, fever, weight last night sweats are the main ones you might just want to throw in a question about like pain at night and stuff in case they have any Mets or anything, it's quite niche. But if you want to loss of appetite as well, good, nice systemic feature to ask about. And then, yeah, joint pains and stuff. If they have an inflammatory, if you're thinking inflammatory picture rashes, if you want to I D the erythema nodosa, um, and the pyoderma if you want to get like a, an idea if they, if they have skin trouble, um, and I symptoms as well. And then in terms of like clinical examinations before you get to your bloods and stuff, obviously, we've taken, so we've taken the stool sample and the urine sample. And you're thinking at bedside, the pr will be quite helpful because it can tell you a lot about like perianal disease and then you do your referral and we've talked about the two week weight criteria. Um and this was just a list of like good differentials to have in mind. Obviously, it depends, you got to take each patient individually. You've got to look at the age, the demographics. Um If a patient really young diverticulitis is not as likely. Um but it is one of the most common causes of rectal bleeding. So good to good to have in mind. Also, never forget to ask about trauma. I didn't put anal fissure and like trauma to the area as a differential in any of my questions, but it's good to, to think about. Um Yeah. So those are the main questions. So now we'll go back to doing, we'll do one of the hard questions guys, we'll finish on a high. So we'll do this one I'll go through it with you guys because again, it's kind of a long one. So 16 year old boy, remember what I said about demographics, guys. So 16 year old, three week history of loose stool. Fine, 2 to 3 episodes. So 23 episodes is okay. Right. It's not severe. It's, it's kind of kind of manageable, mild maybe. Um, during this period, he also has crampy abdo pain, generalized fatigue and the 2 kg weight loss, okay. Temperatures, okay. Pulse is a little bit high. Maybe it's hard to say. I mean, he's quite young, so maybe a little bit and BP is somewhat fine. Uh Examination shows mild, lower abdominal tenderness, okay. It would have been more helpful if they told us which side but they just said lower. That's fine hemoglobin. Okay. So they've done the test for the stool and they've looked at whether or not there's any bugs and there's none. So gastroenteritis is out. Colonoscopy shows friable inflamed rectal mucosa, okay. That bleeds on contact with the endoscope. So it's bleeding, it's inflamed mucosa and what's the most appropriate therapy? And I've got to open the pool again. So I'm gonna open the pool. Uh That's okay. Hopefully the answers will come in faster because I've kind of talked to you guys through the whole paragraph. If anyone has any questions as well, do put them in the chat, as I said, happy to cover them as we go along or however, ok. Bit of a split bag at the moment, two thirds have gone for a D and, and one third have gone to see if that sways anyone. Um, I'm going to double check the answer now because everyone's getting a bit confused. Yeah. Okay. Okay. Over half of you've answered. So I will, I will go through it. So the answer is, in fact, see, so it's Mesalamine MS, that's catamenia. Um And it's because your patient has less than four stools per day. So it's classified as sort of mild. There's no signs of any systemic condition. They haven't mentioned like rashes or arthritis or eye problems. Um And first line treatment when you have disease that's relatively confined to just like he only has lower abdominal tenderness and he has less than four motions per, per day. So it's kind of you'd start with your amino salicylates as you mentioned. So the mesalamine therapy, now, I can imagine some people a bit confused because earlier, those patient with a bit more and we gave prednisoLONE according to the other question. So I'm just going to double check what the this one to for him it was, yeah, it was this one um because we gave pregnancy learning sort of easy thigpen, right? But that was because yeah, the steroid needed to start before the azaTHIOprine works. So this is just slightly different. Um The U C reason that it's not prednisoLONE is because you start with the Amina salicylates. Whereas with this question, the Koreans question, it wasn't a South Iprin because the President's to work first. Okay. Anyone uncertain on that or it made sense? Okay? If it didn't, as I said, just put something in the chat. So I know. Okay. Um Now that is seven o'clock. So if anyone has to go, um I think we can, we can call it there. Um This is my last kind of question. Whoever does want to stick around, I can open the pole. Um If anyone wants to answer it, but I think you guys do get these questions at the end of um the thing, if you fill out the feedback form, so it should come through, I'll keep the pool open. If people respond, then I'll go through it, but very happy as well because I realize it's like seven o'clock if you guys do have to go and Yaz Naima said do fill out the feedback form before you go. Okay. People are responding to, to the poll so we'll do it really quickly. Uh I think they're responding one. Um No, that's the only question. Okay. I'll just Yeah, someone thanks to whoever opened the poll. Uh Things Naima. Yeah. Um Just if you'd want to. Um But yeah, please do fill out the feedback form if you have to go. Okay. Someone respond. Yeah, fine. We'll go through it. Yeah. So 25 year old woman, bloody diarrhea. It's been going on for a week. So relatively short, you know, maybe, maybe something else. Um She's also been experiencing fevers and malaise has been to India to visit family. Um Okay. So I know earlier, I mentioned that this could be infection G P requests, the colonoscopy where the biopsies are taken, but the biopsies show superficial inflammation of the mucosa. So it's confined to the mucosa and so, oh hang on information. The mucosa and superficial sub, you goes okay. So it's still somewhat that layer. Um Neutrophilic infiltrates were seen with irregular dilated crypt pseudo polyps, pseudopolyps. I I mentioned what that's associated with and lamb inappropriate fibrosis. Okay. So, pseudopolyps and superficial mucosa trouble along with bloody diarrhea as most people have gone forward that you would be thinking are still colitis. So well done guys. Um I think there's maybe like two questions that we didn't go through but um you guys should get the slides so you can go through it then. But for the time being, thank you very much for coming. Um Please do fill out the feedback. Let me know if there's anything I can do a bit better. Um And yeah, if any questions just put them in the chat, I'll stick around for like 34 minutes, but feel free to go. Thanks guys. It's