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No. Yes, got it. Um, good afternoon. Good evening. Good morning. Wherever you are. Um, I'm from Wales. Uh, my name is Doctor Mister. We call it in, in, uh, in this country UK. Uh, because I'm a surgeon. Uh, let's start it because we're already 10 minutes late. Uh, ie si think we are looking for a word, the best word for, uh, intestinal obstruction. So, IES is not exactly the right word. I think that came in 1706 twisted bowel, revolving bowel, uh, turn squeeze, et cetera. English. The muscles does not work and that's really paralytic Eylea. So, uh, um, I'm not sure what is the best word, but, uh, we have two words which is intestinal obstruction, right? In some languages. You may have, uh, one word. I think the contents does not pass through the gut in the normal manner. So I think if you can find one word in your language, uh, it will be nice. Ok, because you have a complete obstruction, you incomplete obstruction in like, uh, if you have a gallstone ele, uh, uh trio and uh, phyto bso uh sterol it whatever, uh, or it's only kind of partial obstruction because you may have a diarrhea. Yeah, like, almost like gastroenteritis, richters, hernia. Uh, obstruction is not, it's a, it's an obstruction but, uh, uh, the, the, uh, is not complete. So, anyway, we'll, uh, by the end of the lecture, hopefully, uh, uh, we can, uh, come to a conclusion. It's a significant surgical problems, especially in our hospital. We have got at least 34 admissions per week and some are fairly seriously obstructed, um sometimes perforated. So, the morbidity and mortality PSIS with each passing hour. So uh earlier you get on with it before the bowel get strangulated. It's important. What are, what are the, because the mortality is fairly high and what we need to know is the site, the onset uh pathology duration and whether the uh whether it's any strangulating obstruction or simple obstruction. So, uh uh mostly the causes are adhesions. Uh We'll see a pie chart soon. Uh One in three post laparotomy, you get adhesion form and sometimes when you see the patient admitted with distended abdomen and a battle scarred abdomen, multiple uh multiple scars from various operation. In the past, of course, in the laparoscopic era, it is becoming much less if it was one in three post laparotomy. You had a, you had multiple adhesions and laparoscopic surgery because we don't touch bowel. The bowel doesn't get dehydrated, uh not exposed to air. Uh uh no one handles it. So it is much less and the addition formation is less because the talc powder, which is the deadly uh cause for additions uh does not happen. So it is uh whenever a patient is admitted, you, you have a serious decision to make. So are you going to um operate immediately or that's the decision you have to take or, or try and manage it conservatively, especially somebody who has had multiple conditions in the past and add these obstructions in the past. So it's very, it is not an easy decision for even for uh senior surgeons. So we need to determine the cause it, uh whether it is adhesions, whether there's history for addition, previous surgery, previous inflammation, previous appendicitis or is it a non ahe new problem? So, uh the other thing is, you know, we're there to manage it conservatively and, and what is the best time to do it? Uh And so that's why it is important to go through the observations, we'll be discussing that later on. So there are track and trigger teams um in the on the ward itself. And there is a critical out care outreach team, especially in our hospital here. Uh in Tebu, uh we have a team which goes around the world and uh go through the charts and see whether this is going to be a strangulating obstruction in that case, resuscitate, optimize the patient and take the patient to theater in the right time. Um The uh folk this is so often repeated examinations are important. Uh There are the age like chest x-ray and the plain film, Supine Pai, plain film abdomen. I keep repeating that because we, as I described to you last time, we hardly ever do AAA rec abdominal x-ray. Although most countries do that still uh we think it is unnecessary. We have, we stopped doing it almost in the 19 seventies. So uh what we need to find out uh I is it strangulated hernia where you need to operate on the patient or uh uh or not? So, uh so it is uh multiple episodes in some patient and it's a real therapeutic challenge to cut. Uh and it can go and divide additions because you come back with if you uh we say normally if you divide one, you get two addition, but there are ways of not um minimizing that. OK. Now, when uh you are asking the exam across the table, uh all you, you all seem to be uh struggling a bit, you know, you may say, well, it's a dynamic obstruction, a dynamic obstruction which is paralytic ileus dynamic that the patient. Yeah, the, the uh obstruct you, the gut is working against an obstruction. Uh But I would say that uh better to do a kind of a pipe chart and never start from the lo when it's inside. So I always tell this to the medical student because you tell the most rarest things don't say uncommon things to the examiner first as it annoys the examiner, I put that here and it, because you may come out with a uh with uh with uh Goldstone E which is not that common. But what you, what you have to say is the, is the commonest thing. So uh I say that you walk from outside the bowel and go inside. So if you, if you say what are the outside lesions which cause problems? Hernias and adhesions, you have answered the question more than uh uh 60%. Uh you have already got the right answer. So they, because they are the common things, hernias and adhesions. And of course, uh uh uh then of course, you uh uh go to the intraluminal problems, the strictures, the tumors, et cetera. And then last you go to all these Bizos which are not common. Um Trichobezoar uh phytobezoar or worm, worm infestations. Um gallstone ideas, they are not very common. So walk from outside inwards. So that's important because sometimes, you know, you may have seen a rare thing, you know, now in this x-ray, you, you see uh AAA filling defect uh and there was a mushroom. So if you say a mushroom to the examiner, um he will chase you out. So don't say are rare things. This uh this can um well, I have never seen anything like this. Uh uh So uh don't say rare things that's very, very important. And the um suddenly, uh if you say this, then of course, you uh you get into more trouble. We will ask you, where would the mushrooms get stuck? I, I'm afraid to talk about this mushroom because you may go and tell some examiner about intestinal obstruction in a mushroom. It never happens. I would say so where would get, where, where was the, where is the narrowest point of the small bowel? Remember this for the rest of your life. Narrowest point of the small bubble is not ial valve. It is the first narrowest point is where the vital or intestinal duct gets stuck. And that is where the my diverticulum be. And that is the narrowest point where things get stuck uh like gallstone ele. So uh you should know that and of course, if that passes, that then may get stuck in the ileocecal valve. So uh so don't say rare things. I especially did this. Uh And uh sometimes they uh you should know where it gets stuck. Uh Again, if you want to, you can go into details about congenital problems, uh neoplastic problems, inflammatory like Crohn's uh strictures. Um Then of course, uh me diverticulum, uh various tumors can cause intussusception. Um very rarely, of course, uh in the in the developing countries, you may get tuberculosis, actinomycosis and diverticular problemss. Uh These are the intraluminal lesion. These are the ones I just said that uh it's very, very rare. Um And the only thing here that you must really to, uh, to, you must know about gallstones gallstone is, and never take a patient to theater unless you have corrected the metabolic, the metabolic problems, especially hypokalemia. You have to correct all these. And as I said, you should never send the patient to theater. You know, uh, it has to be normal glycemic and, uh, everything has to be normal. So, uh, so, uh, otherwise the anesthetist will scold you because he has to do all that in the, in the induction room. Uh make sure they are not on various medication which cause uh is. So, um and uh the uh the common cause for large bowel obs uh obstruction is colon cancer is the largest uh uh group. And then of course, diverticular disease, ulus uh and pseudo obstructions and uh occasionally ischemic ischemic strictures especially at the splenic fracture. And you know why that I described to you the other day, the where the, where the mostly the ischemia as you get old as well is comes in the splenic flexure area because the it is the uh watershed area of mid gut and hind gut supply. So, uh so you need to remember that because the, the marginal artery may be incomplete right there. So that is the same reason we don't divide the blood vessels close to that angle because sometimes you have bypass structures, uh various uh various uh known arteries which will bypass that splenic flexure. Uh Again, the, depending on the age group, I'm not going to go into detail because we have very little time uh Children intussusception because diverticulum uh uh and uh various groin hernias. Then of course, the adult group comes the uh colonic tumors and is a colon, get the problems, Bulus, pseudo obstruction. So common cause for small bowel obstruction. This is what I did for my B BS. Um II, I drew a pie chart. I still maintain that everybody can just uh take a paper and do a pie chart in the exam. And of course, uh maximum number are the adhesions. Uh and then comes the hernias uh then various miscellaneous things. And uh of course, the 60% have now reduced to less than 40% because of the laparoscopic surgery uh as I described uh a minute ago. OK. And we, what are the addition, there are bread and butter adhesions you may have seen if you had to take a patient to theater. Couple of days, 234 days later, they are the bread and butter addition. You can almost use your finger finger fracture technique. You can separate those without even using the uh using the um using the uh uh knife uh 00 the scissors. So uh so the bread and butter add add but as time goes by uh fibrosis takes place and they eventually get vascularized um and get ahe to inflame focus. Uh and uh So that's why we, now we don't use TALC powder containing glove, although it may be inside the glo and not from outside, they do leak out. You, you, you can see it at the end of the operation, they have come out. So, uh, uh, TALC, uh, TALC GLO uh, should not be used, right. So the large bowel, of course, the majority are the, uh, the carcinoma, nearly 65%. And then, of course, diverticular masses, we discussed that the other day, volvulus and uh various pseudo obstruction. The most uh important pseudo obstruction is the OVI A syndrome. It is an uh acute colonic pseudo obstruction, it is painful as well. So it is definitely acute ogilvy syndrome and make sure you have done APR examination uh in every case. And uh I have seen the, the registrar getting the junior surgeons to lift the leg up and trying to do apr why you can't find the tumor inside the abdomen. Never get into that scenario. It is shameful to do that and possibly uh any studies will get very, very annoyed as well. You nobody has in the team done apr examination. So as we said that as the Baleen la, the famous book says that if you don't put your finger, you will put your foot in the trouble. OK. So uh so foot in it, that's what he said. OK. So that is very, very important uh because it could be just a pseudo obstruction. You could have just put in a uh flexible stigma scope and suck everything out. So, and check the uh uh electrolytes, uh especially potassium and uh you may make a fool of yourself by opening into these patients. So, Ogilvy syndromes, look it, look it up uh in the book and uh it is a, it is an acute pseudo uh colonic pseudo obstruction, right? So, uh the when does the um uh so you need to know whether this happened post-operatively or not. So, you need to know when does the bowel sounds come back? Somebody did a research paper about 30 40 years ago when I was a medical student. And the uh uh he, he uh uh he, he got an award for that. He just listen to the bowel sounds in your own word and uh and uh listen to it and found out when did it come back. So, so it is a, it's a thing that you can uh you can see. So the, when there is a pathophysiology, when there is a, an obstruction, the bowel will work against it. And then of course, the uh uh with the peristalsis to overcome the obstruction. And then of course, retrograde peristalsis and vomiting occurs and the uh the uh higher, higher, the higher the level, of course, it was almost uncontrolled, almost projectile, you know what happens in pyloric stenosis. Yeah. So higher the level it may stop early. But uh patient will vomit and vomit and uncontrollably. So, uh, but after a horse is tired, he has flaccid paralysis. It start getting distended and initially there is gas accumulating. Uh So, uh, again, if you do, uh, looking for air fluid levels, you may only find air. So 68% of this air is swallowed air. So, uh, so that is why we, we tell the, uh, nurses to put an NG tube. Uh, and then they will say nothing comes out, doesn't matter. You have sprayed the gas because you need to decompress this bowel before it perforates. So it's very important to management of NG tube. Um There, there should be a protocol in your hospital or that you should be told what to do. Uh, initially you uh uh put on free drainage, you get an NG tube, I hope you know how to put that in. And uh, if you are not sure, you know, you have a way to do it with the syringe and listen to the epigastric area or uh you can get an x-ray done if you think it is curled up somewhere in the esophagus. So, uh uh but you make sure you don't introduce anything through it. So you, you have aspira, you must aspirate regardless of what comes out uh every two hours and then of course, keep it on free drainage. So after that, if it is less than 100 you, you can determine, uh, your own protocol um in our hospital, if it is less than 100 we go on to four hourly aspiration and free drainage. And then of course, if it is uh absorbing and it's going down, of course, uh we uh we uh we will uh stop the free drainage and spigot it and re aspirate every four hours and that it is still less than 100. Uh uh then of course, you can start feeding the patient. You cannot, you, you must not pull the ND tube out because nothing comes out. You must test that correctly. You must have a protocol. Uh I think about 20 years ago, we had a patient died after taking the ND tube out by a junior doctor because nothing come out. The nurse come and tell you nothing comes out. Why do you keep it? This patient doesn't like it and pulled it out without any, any, any, any uh any protocol, follow following any protocol and put, and the patient had a gastric dilatation patient aspirated and actually die. So the Welsh Parliament sent me as a clinical director to uh look into this and make a protocol. So that's why we, when we did that, you think ND tube is because er, er, for conservative management, you must kneel oral ND aspiration, the way I just described, they may ask you how to manage the ND tube IV fluids, correct electrolytes. So, optimize the patient uh and resuscitate the patient if the patient is dehydrated. Of course gas at night could be and most of the physiological gas get absorbed initially carbon dioxide and, and oxygen. And then of course, what what will remain is the nitrogen, hydrogen sulfide, the indo cattle, all these things. And the um uh then eventually the absorption will uh will get reduced because of the obstruction. And there, there will be more secretions into the gut third space accumulation of fluid. And uh uh so, uh about the uh uh if about the obstruction, there are maybe 8 to 9 liters of fluid, all that will be lost. So you have to make sure um I hope you know the levels of uh uh I can't really go through all that. Now, uh dehydration, we have to correct the dehydration because the uh uh uh mild dehy hydration, moderate and of course, severe dehydration when there is sunken ice and et cetera. So, uh you need to know out of 42 liters how much uh the patient lost 5%. And then you calculate your uh thing that uh the amount of fluid that you have resuscitate the patient. So, uh dehydration due to vomiting and sequestration and the uh so, so all this time, the distal peristalsis will continue at least three hours or so. And you may tell the patient that of course you are obstructed, but the patient will say I just opened my bowels. So, because the distal part works normally absorption is also normal. So therefore, there could be a couple of bowel actions even after the patient admitted with uh admitted with uh obstruction. So, so that absolute constipation that means nothing night, the flatus, no feces comes out, uh does not happen immediately after the obstruction. So, so those cardinal four features, pain, vomiting, distension, uh uh uh distention and absolute constipation, the, the classic uh uh tetra or uh uh caught, caught it. Uh It does not happen immediate. So because uh uh don't be fooled by the distal peristalsis, right? Ok. So, electrolyte, depletion, bowel distention, we talked about that. So you, you and you have to decide. So, correct all the electrolytes, I'm uh going through. So all, so if this is obstruction, I just drew this this morning. Uh uh uh So all this fluid is saliva, gastric fluid and the biles with about uh 900 CCS. Uh And what is coming from the pancreas, et cetera, all this will have will be vomited away. So, therefore you need to, you ne you definitely need to replace all that and correct the electrolytes. Ok. Um Anyway, it is the same thing. So, uh you know, this from physiology, I'm not going to go through that. So, history is important whether there was abdominal surgery, uh whether aioli is done already, uh or or previous admissions due to ad obstruction. Uh look for hernias, whether past history of hernias, especially, you don't miss a femoral hernia which will be very dangerous, uh malignancy. Although the patient had malignancy, it doesn't really say there is recurrence. So you treat the patient, uh, uh, in the same way as an intestinal obstruction because that patient uh cannot tolerate and strangulated bowel. Uh And of course, uh uh uh large bowel obstruction change of bowel habits may be there because of, uh, o pr bleeding could be there. Uh And, uh, it could be a volvulus quite sudden onset. Um, uh, but most of the large bowel ones are slow onset. So these are the, uh, the classic, uh, uh, features, uh, we call it the classic, uh, quartet. Uh, and the, uh, it is pain and vomiting, uh, distention and constipation. Remember I told you that, uh, uh, the, the absolute constipation does not start immediately and the there will be no, uh, no obstruction as such in a Richters hernia. I hope you all know about Richters hernia. It is a knuckle of a bowel, get caught in a, especially in the femoral hernia. And if you push it back, obviously, it will perforate in 48 hours and you will be in trouble, the patient will be in trouble. So, rectal, yeah, doesn't not totally obstruct vascular olu, there will be diarrhea from the patient, you know, and there may be abscess in the pelvis causing kind of an obstruction and spurious diarrhea. So, uh, so constipation, uh, may be absent again. Gallstone elis is another one, um various pain pattern. It is colicky, severe colicky pain. And unlike the gallbladder disease where it comes to a plateau and remains for a couple of hours then goes away. So it's not like a biliary colic. It comes and goes, comes and goes. And uh you can see you can from a distance patient is uh is uh is rotating with pain and you should watch this patient suffering, you know. So uh that could be strang uh close to strangulation. Ok. Uh Oh yeah, this one is important, right? So, uh one of the question that we will be asking you what is fecal and what is fecal and vomiting? The horrible fecal like vomiting? This is not fey. So remember that this is not fecal vomiting. This is fecal and fecal like because uh um I think 80% of the medical student get this wrong fecal and vomiting is uh is uh a fecal like vomiting. It, it doesn't mean that the small bowel get connected with the large bowel. So don't get that wrong because fecal and means the broth, the the horrible stuff uh which secreted into the bacterial activity and the uh digested and undigested put together and the hydrogen sulfide and nitrogen and all that uh make that horrible broth. And that is what is fecal and vomiting. And when that happens, there will be translocation of bacteria because the bowel wall desquamate the epithelium, the um that is why the cells get destroyed in the bowel because of the distention. And that is why it is important to do uh lactic dehydrogenase and DH is goes up as well. Uh So fecal and means uh it is uh it is obstructed and pa and possibly now the bowel is strangulating and the uh uh and the patient uh is uh uh I is in trouble with, with the strangulating obstruction. Uh there will be translocation of bacteria. So, uh uh you know, this, I'm not going to go through that. So, uh inspection uh uh so you can see scars in the abdomen. And you know that there are three positions that you, you see the abdomen, you add the foot of the bed first. And if I don't do that, I will get very annoyed. And then you go to the side of the bed and kneel down and have a look at the abdomen, the movement of the abdomen. And then of course, uh uh you go right onto the abdomen and, and then see the abdomen. So three positions to see the abdomen. So um before you palpate we uh in our hospital, we say that you have to do auscultation uh because the uh uh once you disturb it uh by palpation, patient is in pain. Uh and the uh the bo the, the auscultation may not be the same. Again, bowel sounds may change. So, uh so what are the bowel sounds, you hear normal bowel sounds that you and me can hear, uh, in the resting position, hyperactive bowel sounds when we call it sluggish too. And then hyperactive, more frequent bowel sound as if you had just drunk a glass of water. Uh, that means they are maybe already working against an obstruction. Then high pitch is totally distended. Bowel almost like playing a guitar. And once you heard this, you will never forget that. So four types of bowel sounds or none. That is a grave situation sometimes. Uh if you hear the lub dub of heart sounds through the abdomen and nothing else, that means that bowel is strangulated. So remember that, so palpation should be done afterwards. Uh They don't unnecessarily do if there is guarding, you don't need to do rebound because it is violation of human rights. Uh Unless you think that the patient is uh purposely doing that. Uh It's very difficult to find out. And then uh then of course, you will look at the hernial orifices if you miss, I think I normally start with the examination of the hernial orifices with there to see whether it's intact. It's not always easy to palpate a a uh AAA uh femoral hernia. Uh Of course, uh in the exam, you will not be allowed to do pr examination. And you just have to say at this stage, I would like to do apr examination. You have to say that word. Uh I would like to de do apr examination. Right. So, uh, the, well, I'm going to go through that. I mentioned that at the beginning. Ok, because we have got only 20 minutes left. Um, right. So all these tests need to be done with, you routinely should be done before you start. So any time you put the cannula, you take blood for examination. So, whatever this field you are in, uh, whether it's obstetrics, gynecology, um, physi or, or surgery or, or medicine, uh, you put a cannula, take blood for investigations. And sometimes if you think this patient is going to theater, maybe get, get the patients, uh, cross match. So that is important. Always, you have to do amylase in adult. So, so, uh, uh, uh, otherwise, uh, uh, you may occasionally miss operate on a patient quite unnecessarily because they may have an acute abdomen, uh, with, uh, pancreatic, severe pancreatitis, um, which I had a couple of years ago, uh, and the CRP. And if there was inflammatory bowel problems, I'll do sr as well. L should always be done. And, uh, uh, in our hospital, if you say E left is they do MLS as well. So, uh, we don't have to tell the, the, uh, the department to do MLS. But in your case, um, I know in Lanka they don't do MLS unless you ask. So, uh, it is important. Try the first x-ray, we'll try and go through some x-rays, uh, we are not going to talk about. And so looking at an x-ray, you uh tell find the patient's name and the time. So names and times important, why you, why is the times important? Because it may have taken in the afternoon and you may be seen the morning x-ray after the afternoon x-ray. So we don't know what happened. So make sure that you, you, you look at the even if you learn how to look at x-rays. So, and then you ask, what is the x-ray? So this is actually a supine abdominal x-ray, as we said, we do not do erect abdominal x-rays unless the diagnosis is not clear. Uh So uh so we look at this x-ray, it is not adequate because this uh I think it is probably my mistake then the radiologist mistake uh I did not include this in my, in my picture. So uh it has to be, you should, you should see that pro peritoneal line, the translucent line on either side. So pro peritoneal line, look it up. That is your uh uh preperitoneal uh a layer which has got some fat and it it is translucent. So that line should be there uh to be adequate. And also uh the uh uh the uh the uh uh pubic rami both has to be there and of course, diaphragm has to be there as well. So uh so uh uh this one we go through anyway. So you, you then you look at the calcific densities in the x-ray and there is some ra uh I we found out that this patient, uh I can remember the, even the name of this patient uh uh had some barium study done into one of the barium in, in the uh CALC studies. And there is something there, I think when the radiologist missed this one, I think there is something there. And so, so you look at the, all the calcified density. So all the lines first, then calcified densities, look at the bones, whether there are any collapsed bones, any metastatic deposits, uh is important then, so bones uh calci, then you go for gases and the masses. So gasses. So what gasses, we see when you do that, you first see the central part, there are a lot of bowel in the central part and there are lines from one end to the other. We'll be asking you this, what are they? They are valvula Cortis. Ok. So this, this uh sometimes they se but it, and that is small bowel. So there are a lot of gasses with valvula convenes all over. So centrally placed. Uh So that is definitely uh distended loops of bowel. It should be only about 2.5 centimeters. Now, this is nearly five centimeters. That is distended, loops of centrally placed uh bowel. So that is la that is small bowel with valvular convenes. So it's a small bowel obstruction. So but we have not finished seeing the, uh, so you go from every quadrant to every quadrant. Uh, uh So, uh, area I can't see some, uh, I can see some uh gas because somebody has done apr examination and the, uh, but there are no large bowels to be seen here. This is the stomach in the left upper quadrant. And what is that? So that is a hollow structure. Uh, it normally, uh looks like to uh uh in this area. What is the, what is the tubular structure? That is the common bile duct? So there is gas in it. So it is pneumo mobilia. So pneum mobilia, intestinal obstruction and the calcific shadow in the sacroiliac area, it could be on this side as well. So look at both sacroiliac areas and that is known as Rigler Stride wr ID, DLDRSR Triad. I added another one to this rig triad change of liver function test. I wrote the paper on that as well. Uh So uh I don't put my name on that, but it is important to have that because 80% of the patients had change of liver function test. Uh and the uh uh so uh and diagnosis made of gallstone elis. So uh uh this happened on the Millennium Day and everybody, I annoyed everybody by taking this patient to theater at 11 p.m. because you are not supposed to operate on anybody after 12 in our hospital. And that is the uh port uh uh protocol. We don't take anyone to theater e only in daytime hours. But I thought if I did not take this patient to theater patient could die because uh already uh there is bac bacterial translocation patient having pyrexia and I thought is perforated. So you have to take a supine abdomen and a erect chest x-ray on these patients. So why, why do the examiner will ask you, why do you have to take an erect chest x-ray? It is to see gas under the two hemidiaphragm. So, uh so that is very important to do that. So, so before you think about CT scans and all that, the big stuff, you must as a medical student get a direct chest x-ray and uh uh and a supine film abdomen. So this are Goldstone e we took this patient to theater and we no time we located the uh uh located the uh gallstone and that was it. Uh I I we put that in the x-ray department. So uh so before 12 midnight, we went to, we went to the party in 1999. So uh I love to say her name also, but it's not ethical to do that. So, uh so this is an old x-ray ni taken in 1965 in our hospital. And uh so uh so you know the, the, when you have the cardinal four vomiting pain distention and absolute constipation, you know that it is an obstruction. What you need to know is the level of obstruction if you go to that x-ray, uh, initially, uh, uh, sorry, we have a level of obstruction because it's only small bowel. So the level of obstruction is distal, small bowel. So, getting that level, the site of obstruction, as I said in the, my 1st, 1st thing is the most important one. So gallstone es, uh, you probably know how the gallstone got to the gut. It comes from the uh uh comes from the gall gallbladder. The whole thing migrate and uh fistula formation due to pressure and then get into bowel. So you milk the gallstone out to the normal area and then take it out uh with the longitudinal incision and, and, and, and uh suture it transversely to widen the lumen. So, uh, and then look for a daughter, daughter stones if you don't look for that because there could be another stone er, behind it. Otherwise you'll have to go back to theater. So make sure you look for that daughter of stone. So, um, so th this is the, um, a fluid levels, the classical x-ray, we don't do that anymore. And this is, this is a, a large, there's a, there are lines, there's one line here, one line there, the three lines in the x-ray with the hugely distended bowel and uh uh they are featureless because they are so distended. The hare folds are not seen So, if you're looking for large bowel, it is the hare folds. If you're looking for the small bowel, it is, well, conven uh this is just uh and usually, um, the uh right. So, uh so, so I didn't say that this is the uh sigmoid volvulus. It normally twist uh uh anticlockwise. If you have a, a scal volvulus, it twist the other way. So, uh uh and the uh this one usually that is the mesentery. So it was it is mesenteric coaxial rotation, mesenteric coaxial rotation. So the bowel can rotate on its own mesentery or organo axial rotation, like the stomach may roll on its own uh around the organ. So, so there are two types of volvulus. One is mesenteric or axial rotation. Uh the other one organo axial rotation. Uh So this is scal ulus. Um We are not going to go through that. And this is why you need to get the uh get the um uh pubic rami included because this, the whole thing is in the scrotum. And there are are vais I know the original original x-ray. I can see that in the x-ray I put here. So uh it is important to do uh have this uh pubic rami included. Otherwise, you have to say this is an inadequate x-ray. So uh the even if I can tell you about a strangulated hernia, the strangulating hernia, you have to operate fairly smartly. And uh we asked this question from everyone. Um uh uh If you have a strangulated hernia, how do you know that it is strangulated? So it's painful, obviously, tender, so painful, tender, tense. Uh The whole hernia is very tense and irreducible, so painful, tender, tense, irreducible lump. So that tells you it is AAA strangulated hernia and the um no expansile impulse. So you have to use the middle word expands side because if you say, well, I can, I, I can feel an impulse. It could be just the patient coughs and it hits your finger, hit, you hit your palm or the three fingers. So, but it's not expanding. So, but if your fingers are expanding, that is an expand i impulse, cough, impulse. Ok. And the patient always tell you it increases in size la last week or this morning. So it recent increase in size, size and of course red in ted skin if uh if um uh uh if it is strangulated, uh and it's too late. Ok. So, um, uh when you, uh so if you have a, uh, if you, um, I think I'll have to go through this quickly. If you have a uh nons obstruction, you treat it conservatively before we go any further. You do not give antibiotics, then he has nothing to observe. If you give antibiotics, you can't observe anything. Your white cell counts will not go up, er, CRP will not go up. PSR will not go up. Why? So, uh temperature will not come. And so, uh uh, you, you manage it conservatively with nil oral, uh IV, fluids correctly, electrolytes, observe, observe and observe. Uh, the, the, I put that picture, of course, you can't observe forever, er, because there should be a time limit, uh, because you can't go so 72 hours, uh, is the one that, uh, we think you should, after that, you can get a small, uh, uh gastrograph in study and find out where the obstruction is. Now, if you do a CT you see the pathology as well. If you do a barium follow through, which is a bit dangerous to do in a obstructed situation, you have to make sure there is no strangulation here. The patient is not getting better. So you need to know what's happening. So you do this kind of uh ba uh gastrograph in follow through. And this is another one I think I showed you this x-ray. Uh this is a closed loop obstruction. That is the obstruction. Nothing beyond that. This is the beauty of doing the supine abdominal x-ray. You do it like that and the gasses will go to places where it can go to only, not beyond. So that's why you know the level and is massively is the scum. And we saw that in the, in the, in the CT scan as well and this should, you should not wait. This is the message that I want to tell you if you see a closed loop obstruction, you must not wait till the strangulating signs comes which is high temperature, tachycardia, lo BP, no bowel sounds. Uh sometimes pr bleeding, you don't wait for that because if you see a, a closed loop obstruction and we took this patient uh to theater before we see anything. Even by that time, the, the, the, the tia has toned but luckily, no perforation, uh we had to do a extended right hemicolectomy because we don't do anastomosis in the splenic fracture. For the reason I told you uh because it is a watershed area, uh marginal artery is incomplete there. So we go for extended, right hemicolectomy. There is nothing called transverse colectomy. If somebody does that, it will leak, it will never hold. So uh this is another x-ray, the tumor is somewhere there. Uh And uh there is bowels obstructed. Uh uh That is a CT scan done again. This uh the, the, the important that is in the scrotum ha hugely dilated sliding hernia uh caused the obstruction here. Yeah. So what x-rays, you know, what is the name of the x-ray? Even if you learn this one, that's enough for me today, the time is up. Uh uh uh uh uh So it is important to uh uh get the right exposure, appropriate adequate x-ray, including all those lines and the uh and the uh uh and the uh pubic rema, et cetera. And then you look for lines and bones, the diaphragma line line, sometimes you can see when the blood outline calcification masses and the gasses. So, uh the I don't think I have valvular co test. So not going to go through that today. So this is uh actually Pembrokeshire Beach here. Uh And uh this is the Baleen love name. Never let the sun rise or fall on a patient with bowel obstruction, but they are talking about just 48 hours. But I say 72 hours is the established time. Even without nons strangulating signs, you must not wait for more than 72 hours because uh it could be a closed loop obstruction as well. So you should go and I will finish with the slides. This is an important one. So you have the cardinal signs, pain, vomiting, distension, and constipation. Uh I did this this morning as well. So the the proximal gut, you normally small bowel pain and vomiting large bowel. You get distension and constipation and distension. When it becomes acute, it goes to this side. So from this side, the large bowel start from this side, the small uh small bowel start. So you divide that into acute strangulating obstruction, you must operate immediately. Uh Yeah. After resuscitation and optimization of the patient, non-stable subacute obstruction, do not give antibiotics unless you think the time is up up, we need to operate on the patient. Then of course, you can give antibiotic. So until you decide to take the patient to theater. I normally tell my staff to get the consent for laparotomy before you uh start the antibiotics. And of course, chronic nonangle obstruction, you have some time to do a little sigmoidoscopy and take a biopsy and wait and carry on with the uh the thing. So um fluid resuscitation, so, operate or not to operate. So uh we have uh one of these uh uh you may be able to see that later uh uh charts in order to for the outreach team to come and see whether this patient needs to be transferred to ICU to uh optimize the patient resuscitate the patient and take the patient to theater. So, um I think I'll have to stop there. Uh uh Thank you for listening. And uh do you have any questions? I know it is a bit late. Uh You can ask the question still.