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Okay. Hello. I'm good evening, everyone. I'm so sorry for the delay. Please. The experiencing severe dig zoom difficulties are usually zoom technicians unfortunately, unable to help us this evening. So we've modeled through on Hopefully we are now good to go. So welcome back to see surgical sessions on day. Thank you for sticking with us through the brief bit of difficulty there. So this evening, we're gonna be talking about jaundice on HPB cancers, which I think is a very big on quite difficult topic on although it seems hyper specialist actually, on the surgical take, you'll see quite a few off these sort of cases coming in. Um, especially you're sort of new diagnosis. Pancreatic cancer is surprisingly common to see, so I think it's a good topic. Is a meat eater OPIC on? Without further ado, let's get stuck in just to remind you about the the course itself, you know, it's designed by train junior trainings, 14 year trainees. It's no nonsense. Just the core clinical info you're gonna need to smash the job as ever will be going through the same general former off the clocking a little bit about the anatomy and pathology that's relevant to the cases on. But we'll talk about specific diseases and the etiology because the presentation this week off a tree be cancers can all be quite similar with then gonna deal with investigations, management and complications sort of all together on we're gonna be tying that up with some cases on some questions. So this is may again. Hello? Those you who were here the first week at Money's been turner of an academic f y too interested in, ah possibility surgery, vascular research and teaching. So this a week of being quite excited talk about actually, Artie Learning points, really, as a junior track training, are going to be understanding the pathology of jaundiced knowing how to investigate it. Most importantly of all, how to bump it off the medics, if appropriate only, Ah, the initial management off patients presenting with jaundice on Ben had applied the skills to some cases. Side we go through. Just bear in mind you're the surgical FBI, one on take when your referred an 81 year old female with Type two diabetes, hypertension and congestive cardiac failure. Yeah, she fills. His skin's been becoming a little bit more yellow over the over the past few days, actually on concede she's glowing up there in the top left corner. She's also been having these intermittent rashes on the legs, arms and chest on. Yes, those are her non jaundiced Harry legs right there. So I just really wondered, What do you guys thought about this? And I'm gonna see if I can see your comments. If you type them in under the video. Livestream. Um, so have a little thing now will open up the floor on. Let me see if I can see your comments. Okay. I'm really sorry. In the in the interest of time, I think we're actually going to move on. But just thinking about some of those key history points that we we talked about before. You know, your key surgical questions of nausea and vomiting and the quality of those any blood, things like that. Your abdominal pain and breaking that down into Socrates. I know no Donald pain here, but it's always wear the mask. It bowel habit is always gonna be really important. Especially in the joint this history. I talk about any blood in there. The quality of the stool. You know Ah needs there to. Really? Whether it's pale, things like that you're drawn. This question is really key here. And what we haven't This knocks that the color of the year and for the skin. And then any constitutional symptoms weight loss, night sweats, etcetera. So you're continuing with all case trying to work through. Our Lady has actually noticed some weight loss in the last three months. That's about 10 kg. It's unintentional weight loss, since that's quite significant. Um, she's also had this persistent feeling of nausea on and off for about a month with occasional vomiting. Urine's very dark stools of pale. She's itchy on stopping her sleeping well, but the bowel habit is otherwise normal. Same regularity, Um on she's got some sort of vague background abdominal pain, so bearing all of that in mind, I'm thinking about hepatobiliary. In general, it's It seems complicated when you look at it from the outside, but it's actually just a remarkably similar a compilation off tubes on Hollywood one's really so obviously you've got your common bile ducts on that is from from the union or assistant that on with common hepatic ducks. Now, if you see up here. I've got the left on the right hepatic darks. You put your whole bladder here and then you've got your pancreatic. That joining the problem ball, but on then got the emperor Bart adjust their opening out into the small intestine. So this diagram is the only thing you're actually dealing with an h b be on. Any pathology is going to be originating around here because one of these things Teo causing difficulty with one of these things. So this is another diagram that slightly more anatomically correct on you can see, actually, that the common bile duct is they're running in the lesser a mental on's you've got your triad off being common bile duct, the inferior vena cava on the on There, a little running back, um, on here again, we can see. Sorry. Know the aorta, the part of artery that was on here. We can see the vascular anatomy, all the parts of your system so that you've got your SEAQ. That's a splitting up there into the left gastric. The splenic on the, uh, major hepatic. All stories on We can read it back just in the intensive last year and at that time. So the way of bilirubin is actually formed is the breakdown off him a global from red blood cells, and that because both in the spleen, on the liver in macrophage, a derivative cells on, they break down the hemoglobin into him. On Belvedere. On the Best informs the unconscious gated bilirubin, which will be transported to the liver. Works taken up by her Paterson lights on It's in conjugated Rome, Insoluble bilirubin into a soluble form of Billy Ruben by uniplate Could run a PSA on back gives you that conjugated been Reuben, that it's important to note that the unconscious, gated bilirubin is insoluble on that the conjugated, the original soluble. Um, we'll deal with that no bit later in one of our cases. Um, so this is just a little bit about the enter. It posits circulation on how, because congregated bilirubin is soluble. It can then be excreted in my pile on. Once the ball makes its way into the gastrointestinal tract, bacteria converts conjugated Billy Rubin in something called Urobilinogen on Stir her violent. Now those two are excreted in the ER, but pigments in both urine on feces. So when we're thinking about jaundiceness. It really comes down to whether the bilirubin is being produced from before the liver, in the liver or after the liver. And we can break this down into our prehepatic plastic in post hepatic causes. Uh, increased levels of unconscious, dedicated bilirubin I eat before the bilirubin has bean concentrated in the liver. Well, they're gonna be of things that increase the breakdown of the blood cells that we were talking about, so that might be hemolysis. And you can get all your random Humira to communion. But it also might be something a bit more subtle, like abdominal wall chemo time. It's that being broken down. And if you've got a significant side, same time that you can actually get quite a quite a big raising have been written because of a plastic causes. That's gonna be effectively any cirrhosis and liver parent final damage. So it could be acute hepatitis. It could be a chronic cause such as alcoholic hepatitis. Four cirrhosis secondary out in surgery because is that we're mainly gonna be looking at all the host about it ones on. That's when there's locket a while outflow, and that will give you a conjugated like a bit of your anemia. I'm so, for example, that could be something like a common bile that's doing but that blocks that outflow from the liver on Lee. It's to a backup of their conjugated bilirubin, and that's the only way you need to think about other. So I just thought with the cause is off post a passive joinus. You know, they're they're in an innumerable number of things that it could be. But if we think about the the tube itself from the common bile duct, then we can really come up with some causes quite easily. This is a useful way of thinking, because it can be applied to pretty much all tubes within. Let's I mean, that's one of the main things that surgery deals with this choose. So if this is our chief here, we can call it the combo. I'll doctorate. Were doing something else you call in March 3 are saying it doesn't really matter. It be a way to break down where the cause is of the structure, not allow the same so you can have it intraluminal obstruction. You can have a numb struck shin that grows from the wall off the cheap itself. And we call that a mural obstruction on. Then you can have an extramural obstruction or something that pushes from the outside on be compressed the cheap that way. So those are broadly our classes off. Well, there are different diagnosis for posthepatic causes. So now going back to our case of our 81 or female, you know, has jaundice, weight loss and rash and a bit of nausea. So you examine her now and find scleral icterus and joined this as we discussed, uh, you don't find a stigmata of chronic liver disease, and you've got score EA shins all over her body. The abdomen is soft and just Murphy sign negative. Important to check the Murphy's sign because off acute coaster slices in association with ruled stones and join the Septra. We're going to be dealing with a gallstone disease in its entirety next week. In fact, but I sign is, is another sign or the cucumber cystitis scapula pain and that was negative, but the cord was a sign is positive, and that was his law is something that says in the presence of jaundice, with a painless, palpable goal blood. Er the cause of the joint. This is unlikely to be benign. So So that's a bit of a clue. I'm I'm really sorry. If I could see you guys answers, I would love to involve you this stage, but I just want need to have a thing about your differential diagnosis, and you see how close were. So the HPV lignin sees that we're going to be dealing with today are pancreatic cancer. Cholangiocarcinoma liver metastases. He's well, so as I was referring to you, they can all presenting what similar ways. We're not gonna focus so much on the presentation. But we're gonna focus on key things for the history of such a risk factors and then in specifics about their presentation for condition. So for pancreatic cancer, 90% of them are going to be a box standing pancreatic adenocarcinoma. Major risk factors for this and type two diabetes smoking obesity on alcohol abuse is well, talk to God. Beats now call a beast. These are both for the same reason, really, is that the diabetes feet is on the alcohol. Both can cause recurrent pancreatic inflammation over time. Now, with any cancer one of the major risk factors is chronic inflammation and said that explains why the notes down here presentation wise one of the presentations. If you block the pancreatic duct, those pancreatic secretions become trapped within the pancreas on the alternative enzymes could begin there the process of bring down memories and that's this continued to an acute on very severe pancreatitis. Another thing got noted. Down here is trust so syndrome, which is also known as thrombophlebitis. My grands on this is not only associated with pancreatic cancer, but it is one of the main cancers that causes it on. This is as the from a bite of my grand suggests. It's a migrate arri inflammation of superficial veins, and that explains our lead from earlier is patchy rash that was appearing on her arms and her legs of the chest. What a typical, uh, locations for a thrombophlebitis to occur. Metastases. Ease your chiefly looking at local invasions within aggressive cancer. Such my breast cancer on local lymph nodes on it could not only you can't you can have a head of pancreas tumor that can obstruct the common bile, but by extramural compression. But you can also have direct invasion into the darks. You can have, um, metastases to report the hepatitis and notes on those Concordes. Question of the ducks higher up on. So it's known as a very aggressive cancer. Uh, gots that. Unfortunately, it doesn't have a very good five year survival. Quite a lot of the ones have been on maintenance is our next one to discuss is cholangiocarcinoma. So this is gonna be a mural. Adenocarcinoma on the chief Risk factors again are are things that cause chronic inflammation of the time. So in the West, alternative Politis, Andi PSC are both associate it with this because but because of the because also, this politeness on PSC are highly linked in their presentation. That explains one of both. Together I'm busy is generally extra pot six sclerosis off, um, ball ducks on. So any inflammation there builds up all the time. You can also get insurer hepatic planted possums on. So for that reason, hepatitis can be a risk factor. Find you a part of them as well as any other cirrhosis. Any other form of our ongoing liver inflammation. Being Southeast Asian is from a Southeast Asian country. Rather is increased risk That plunger constant. And that's because of the association with never flukes and other liver parasites. That is higher prevalence out there, uh, presentation you can easily present with kind on giant cysts and biliary sepsis. On this cancer especially, has a very rapid progression. Average time of survival from diagnosis is six months. Eso, you know, very, very rapid progression on that. Then you've got the same thing with the local invasion. But you also get invasion of the portal being on the liver. And even with surgery, five year survival is still quite cool. Liver metastases. These are actually 20 times more common than any of the liver primaries combined. But weeping for about today on Jemaine one is gonna be corrected. Cancer. And that is because in our diagram on the right here, we can see the drainage off the, uh off the colon on do small intestine, and you can see that they both drain into the portal ban on their four. Any metastases that being shed are likely to go straight to the liver by the portal vein. So your main one is colorectal cancer, but you can There will be metastases, do the never from any organ that is drained by your system, so that includes esophagus on the stomach. Um, on generally you will. If you're diagnosed with corrected cancer, you will have a CT chest up the pelvis and duren that CT. They may discover that there's a synchronous metastasis I won that is existing at the same time as the diagnosis or Correctol cancer. It's about 5% rates of that. There's also 5% rate of metachronous metastases on these are Mets occur within six months of the diagnosis of rectal cancer, so it's an important consideration with this disease. Onda. It's quite good news with this one. Really survival for ah dupes D cancer I distance metastases used to be quoted as 5% on, but with resection of living that up to 25% every five years. But with modern techniques, techniques on be checking for our zero reception. I know cells that microscopic level in the reception, uh, their their survival has improved tol much as 50 to 60% in sun sentence. That's amazing. So while I just thought I talked briefly about gold bladder polyps not that not that it's a malignancy, clearly, but these are really very common when they're diagnosed in the general population. So 30% of population are known to have your stones on. 5% will have a concurrent a gallbladder. Pull it now. These rarely cause any issues because they're normally very small and only ask someone centimeter on. Guidance is terribly changing. But if they are less than one centimeter, they could be left in situ. If they're grace than one sentence up, they really need to kind of suspect me. Uh, these can occasionally cause issues with they can present his biliary colic, income cystitis. Ah, but generally very symptomatic on down rule. Don't need to have anything done about them. So if a panicked if a panic radio before called you or uh or radio just that, you know, you could just bear that in mind Apostle A carcinoma. So most about a cellular carcinoma, as are caused by hepatitis box. Most of roses is caused by alcohol. Now, cirrhosis is the main risk factor, or hepatitis, and so it doesn't really follow. Um, but it's just interesting to note that they're obviously the degree of information that get from hepatitis B and C virus. Uh, has a has a differential. But so on the right, um, diagram. You concede we a very cirrhotic living can see it. It's no Jalyn Fibro's on be in the sort of yellow color there, probably because it's associated with some biologic. You can see a pattern cellular carcinoma so your risk factors the cirrhosis bars is I'll call you on and Copa storage disease is, uh, nonalcoholic steatohepatitis, a nonalcoholic fatty liver disease on talk to diabetes is well, eso these air gonna present large in the same way. But they may present with more of a cirrhotic picture. They may have the signs of chronic liver disease. You might notice a nodular a pattern megaly on examination on you may get more of a hepatic jaundice or not the same predilection for conjugated little movement, and you may have more of a more of a transaminitis more of a rise in your Ailton A S T. I've just noted down here about the Milan criteria. There's, ah, those are the criteria to decide whether or not, uh not sell a car. Cinnamon is operable. Um, you can always look those up in your own time if you like. So as with every week, we'll go through the investigations that you need to order when you're seeing these kind of patients with this similar presentation on the surgical tape on that start with the bedside investigations, then the Bloods and then the radiology. So bedside, uh, they're more or less the same every time. You know everyone needs an admission. HCG not necessarily for us is the surgeons, but because the anus is is going to have to see that before anyone goes to be a tough on. Similarly, anyone who goes a beard to me is there lateral blown that you see are urine dip in this case could be quite interested. We're interesting when you're looking at John this because you're considering conjugated versus unconscious gated bilirubinaemia is so uncomplicated. Billy Rubin, As we said, it is insoluble, and therefore it will not be secreted in the urine. So on your standard urine dipstick, for which you do get a test for bilirubin. If you see that there's a race, Billy, you'll know that this is a conjugated bilirubinaemia on it leads you a bilirubin urea. Sorry on this leads you away from a prediabetic cause and more towards a possible post parts. Of course, I'm a sweet any. Every such mention every means that a urine pregnancy test. So I've got here the panel of over standard blood test that we do for all surgical patients. But on the next page here, I've got specific liver screen months. Now, this is something that lots of surgeons might not know about, but it's quite a good way to you. Distinguish like the cools off your bilirubinaemia on Do rule out any other medical corps causes be they concurrent or the actual courts. So talking about your l A tease rays L. D s is raise a l t. So if you have ah, higher Ailton than a L P. Generally this indicates that it's gonna be some kind. Will have Patterson light problem I. It's a plastic cause of jaundice, whereas if you're looking at the LP on that's distinctly raise, the LP is more in the biliary tree on. Therefore, if that's raise, it indicates a a post hepatic problem. Similarly, you can use the split bilirubin, which is just a fancy way of saying conjugated versus unconscious gated ratio. Um, that gives you vital information on whether it's a prehepatic versus her particle posthepatic course within your liver screen. They should always be a viral screen for hepatitis B C azelas HIV because of its association with both these two viruses. Cytomegalovirus on Epstein Barr virus You want to check the Alpha one antitrypsin levels on Be If you're thinking malignancy, you should always check their the serum AFP on. But we could consider the see a 19 9, so there is. Well, even though it's no, it's not back by nice and more visit. It doesn't have any problems. Sick value. Uh, the serum career plus men. The clotting is an indicator of the synthetic function of the liver, so that so if your blotting function goes off, it means your liver isn't producing the clotting factors. It's a really good indication of the liver health. As his albumin gamma GTE goes with the alkaline phosphatase the LP for indicating more of a biliary tree, uh, pathology than a transit liver pathology On then, or these presentations, you can check the anger and a if nothing else, is coming up positive investigations to consider it. Enjoying this, everyone should have another ultrasound abdomen. Unless you're going straight to something like a CT, abdomen and pelvis on. Really, this is going to depend on how unwell new patient and that age cetera receptor. You're suspecting something like Goldstone's. It's best to wait for the ultrasound abdomen. Or you could go directly to something like a marsupial. Brave, uh, but see, see abdomen, pelvis. If there's a history off weight loss, four abdominal pain or the patient is parasympathetic things like that, then you need to go straight in the rapid investigation because it's very quick. Scan CT of your pelvis done, but it's not quite getting ultrasound done. Um, followup investigations that may need off your CT abdomen, pelvis that has shown a her part of Ilary last. But, well, you're always going to need a sense of chest, abdomen and pelvis to rule out any compartments. Ecstasies. Um, they may well ask for a CT triple base of either the liver or the pancreas, depending on which, which would be malignancy you're talking about. And that's because when you inject the contrast, certainly lesions enhance in typical ways to summarize that. So from the from the radiology, they can tell, more likely what the cancer is without having to do a biopsy on then for gallstone pathology. The ghost town dog Nurses M L C p um I'm for looking directly at more pathology. MRI liver is the best investigation. So after all that what we're really left with our key assessment points we're going through Jordan, Ms are your jaundice history and the pattern of when it's come on any associated symptoms. Then you're going to specifically be looking at your pattern of liver function tests. Um, whether it was a race, a little pea where the heart bilirubinaemia is coming from etcetera, etcetera. On any any liver screen results you get by on, then it it's mostly gonna be your imaging. It tells you the most likely definitive diagnosis. So when when to escalates with jaundice? Well, anyone that's presenting colon genetic I shockers tried and joined this right upper quadrant pain on the, uh, fever. Anyone presented with those symptoms you emergently need Teo escalate to your registrar. Reynolds Penta is just bit refers to hypertension as well as confusion on top of chocolates. Trying on is it's really important with HPB cancers because you get Stasis of bile. This causes a new cumulation of grand negative bacteria in our grand negative bacteria when they get into the bloodstream. Because bacteremia this dramatically drops the BP because of the presence off out the essence so well. So these patients, they can become acutely Um, well, it's stream quickly on. They may well need on a trip it supports to to support the BP. So it's critical that if the patient is spiking, they've got abdominal pain as well that you escalate early to your rent a strong taking it. But I get them to come and see the patient. Is this this person may need virgin ercp urgency Surgery s etcetera, certainly imagine that's part. It's similarly Billary. Peritonitis is ah is a foul and nasty complication surgeries, but can also happen spontaneously with some of these malignancies. So it is critical that if someone is Paris nitpick as ever to escalate your stroke, so going through the pillars of management globally for patients with HPV malignancy, the conservative measures that really these are the key things that you could be doing is the surgical junior on the ward, um, and that is treating the symptoms that can be awful such as nausea, vomiting on just just given some suggestions of what you could use here. Often patients because with things like pancreatic cancer, you can get invasion of the celiac nerve plexus. It can cause intractable nausea and vomiting. So it's important. Teo. It's not a horrible number. Pleasant sentiment. It is important. Teo Maximize Ah, anti emetic cover early on for these patients, just simply for their quality of life uh, similarly for itching could be untrusted will symptom on. You can help with this with your friend of me, which is useful because it's a drowsy antihistamine as well, and so it can help with sleep on. There's also something called calamine lotion. Uh, which is a cooling lotion that consort in the fridge on takes away some of that surface itch pain has ever you know, basic things. Control this with your W H O uh, pain lab. It's done with paracetamol going up something in surgery like Tramadol. If they're getting quite bad pain, that's something you confront rate up on convert into stronger. It gets quite easily weight loss. This is gonna be if you're thinking about weight loss in patients and optimizing them for surgery. You know, that's that's super good stuff on. But, uh, the way to do that, really it is to get a nutrition history involving the dietician for a nutritional support on. Then you can think later down the line, um, Italy. But you can think about, um, enter or parental support for the nutrition on all of these things you're doing. They're really optimizing the patient's quality of life here, medical things that need to be done urgently if there's any indication of sepsis and that would be your two of your service criteria plus minus. Ah, diagnose bacteremia. Um, then you must cover 4 g negative. And normally this will be something like gentle nice in or, um, a case in on. Then you add the an additional gram positive collar cover because your coliforms are like the 3rd and 4th most likely candidates in Bill, um, sepsis. Your main ones are ICO light and plus yellow, um, on with the with treating the sepsis. As we were referring to you earlier, you need to make sure you've got a life. Blood's going. You need to make sure you're supporting that BP, keeping one like about 70 Um, really, I to you, but it is super important for these patients because they can deteriorate so quickly. And I was reading a study today about how those that developed a septic shock. Billy receptionists in a In one case, Siris ah 100% died within 48 hours. So it shows you the severity of developing septic shock in those patients on you don't want it. You don't want it to take that long because, uh, because of the Jonas you conducive eloped problems with clotting on. In order to reverse these, you can give business K 10 mg IV for three days. This is a standard protocol that's done before ercp to minimize bleeding problems when foreman sphincterotomy whilst we're thinking about the patient's bleeding, we also have to think about the risk of clotting Now. We were talking about pancreatic cancer earlier on the association with bromide for bites. It's my grands, which is a effectively movable blood clots that are establishing down the body. Um, in any cancer patient, we really need to think about the risk versus benefit of clotting on, um, I'm bleeding, so this is definitely something to discuss with your Reg would suggest that most people should actually beyond Mama. Let's wait heparin that can be held there before procedure. Um, on your surgical interventions. Now, just it really depends on the HPV be malignancy that you're treating here. But I just thought I'd discuss some of the core principles that we're thinking about when you're forming an intervention for one of these cancers. So surgery while a patient is drawn, this does lead to bad outcomes. Okay, that has been proven in the literature. And it's something that we have to bear in mind. So ideally, we're gonna be reducing or eliminating the jaw on this before operating on patients. Fluid Stasis in any closed system in the body leads to sepsis because you get translocation of bacteria on. They infect the static blew it. So, for example, a pancreatic head tumor that is pressing the common bile duct on causing ball Stasis that is likely to need to sexist. This means it's urgent that we treat, uh, that we treat the reason for the Rockettes as a general principle. If it's blocks, you know, it's simple stuff we're going to try and open it up on. Similarly, if it's in a good spot to take it out. We're going to try and take it out. So those are the main things that we're thinking about when we consider these investigations. So our first quarter cool in acute jaundice with a proven posthepatic course is to try and do e ercp, which stands for endoscopic retrograde, retrograde cholangiopancreatography. So scope goes down the throat, uh, find the, um, find the Emperor Botta perform a sphincterotomy on, then entered out with side camera to try on relieve said obstruction by placing a stent, I can see here that the reason for the structure is a little stone. But comma Baba Um, so that is how you asking people works. And that's gonna be our first port, of course, because it's the easiest option. It's actually the least invasive option on. It's the quickest way to, uh, hopefully rectify the jaundice. If your CP is unsuccessful, then we can consider something cool, uh, continuous transplants. It cholangiography on that and bowls going through the skin. I'm through the liver on placing a stent, usually straight into one of the hepatic guts or both. Now, the advantage of this is that if you got such a tight narrowing that you can't pass stent at Ercp and then you can't drain the obstruction. This is a guaranteed way to drink the flow file on. It's the rep from a liver, and you can see here that it there. Everything is very dilated before the narrowing of the bar. But that's a long segment of stricture there, and everything is very dilated now. PTC can only be done once everything is very dilated, and that means that you've had a little bit of pressure in the system for a while. That's its disadvantage, along with the fact that you can develop hemorrhage hematoma on the stents themselves, come block or fall out. Um, said that is PCC full. Um, small about the cellular carcinoma is on for, uh, isolated colorectal cancer metastases. You can do something called a wedge resection of the liver, which is where you go in with an ultrasound instrument on you. Buzz through the small while back on the small vessels closing them office. You go on. Do you been removed? Your wedge of never. It's a simple is that on? You will analyze the margins of your receptors sample on D and check for your Arciero are one section and finally moving on to the proper surgery here. You've got your Whipple's procedure or pancreas. Kind of do the next minute. Um, on this is going to be four things like your pancreatic head, Juma, that is compressing balled up on D. These can only be done in certain circumstances which we're not going into, but it really is major surgery. And so you can see that they removed the pancreatic head and part of the body. There they remove a section of common bile duct as well as the gold bladder on the parts of the Judean and that the parents cancers likely to have locally in Vegas on. Then you perform a pancreatico judging ostomy, uh, on a coma. Doke. Oh, Judge in Austin, which is the ball. But being asked him anastomosis that judging, um um And then you also perform that's traditional sleep ensure that the stomach has somewhere to drink you. And it's not a blind end of loot. So those are your major interventions complications We're gonna We're going to skim over briefly because there are so many. But, you know, if you're If you're fiddling with anything in surgery, you can have a complication from it. So you're fiddling with the pancreatic ducts. You can have pancreatic duct leaks and pick that fistula from that because of the political enzymes. And he experienced the block stent. Uh, then that could be a real issue with things like a PT See where you don't have many other options. It's after a place, a stent, and you can imagine. Everytime you replace the stent, you can do more and more damage to the liver, which then leads to hemorrhage because the liver is a very fast, let alone and also, when you're doing well, faster that and that's the most he's. Yeah, Then you can have a hemorrhage there ascending her lounge itis if the ducks become blocked again because off, for example, a postoperative stricture. But what cause of came on joints? This hemorrhage again, just important on you can also have by a week from your carbidopa juvenile stomach. So to finish off, we just got a few questions on I. I'm going to struggle to see you guys answers because my my feet for the live video fortunate isn't loading really sorry about that, but I'm going to give you some 30 seconds on each question. Onda are already marked Sears one. I just want me to think based on based on what we've gone through today, what you think would do the most, the most appropriate answers will be. So our first question here is a 52 year old gentleman join this is referred to you want to take, um, he has no background or he has no background. It's all on. You know, Donald Pain. What's the most useful blood test going to be to rule out surgical cause here? Did you get it from the clot thing? Split bilirubin lt LP or the ST? Okay, So that answer here is probably gonna be the split bilirubin. Because if it shows very high levels of unconsciously, it's been a Rubin. Then you know that causes from an excess of red cell breakdown I'm not even going to think about what those might be just noted and not surgery. Um, questions. Which of these is a cause of host parties? Join this. So no narcotics. There's a hepatitis nonalcoholic fatty liver disease habit oitis, uh, alcohol abuse, hemolysis or a common bile duct stone. Okay, so the answer there is gonna be a column ball that stone. Question three, which matter biliary cancer is most commonly associate it with diabetes. So your options are cholangiocarcinoma living metastases have to settle a carcinoma. Pancreatic at no cost. MoMA or gold bladder up. No cost. Can you answer here is going to be high and drastic on my pulse Name One question fall is 54 year old lady presents with D two ugly carcinoma and parents Neil Mets. She develops billary sexists due to compression of the ampulla of Alta from this DDT on my boss Mama unfortunately, Ercp was unable to pass Stent you Teo due to blockage, What is the best intervention to do next? So should we do the the all CP again? Should we do an MRI c p to delineate the anatomy to do Ah pcc a Whipple procedure or or a stink? Trust me. And so the answer here is going to be a PT See on. That's because we've already failed the ercp. So we need to We need to drain that system and we repeating the ercp is unlikely to be successful uh, they will have already performed the sphincter. Awesome with the first time when they were going. Teo, they're going strong and pushing five and 82 year old lady Rx two year old lady earlier with piloted pancreatic out of the cost. Numa she devotes extreme itching and you can't sleep because of that. Help her bilirubin levels above 500 miles. What medical therapies could we give her in order to improve her symptoms So you can choose between the bathroom, cream parlor, mine, hydrocortisone, ranitidine or your family and pick two of these. Okay. And the answers are Columbine relation on Cool Enemy. Um, so this is another shame was plugged for our free weekly surgical webinars. You consign up Teo receiving medication about every week on you. Consign up, Teo, get the get the Facebook links for every week. We're always giving out certificates for attendance. You just need to fill in the be back survey after each session on all of the sessions are available on YouTube on the mind oblique channel as well as that. So I'm gonna actually now handle, but to one of our sponsors for more b m a, um on but he's going to talk to you a little bit about the the BMA on. I will leave the feedback questionnaire. The QR codes the feedback. I'll leave it up on the screen just here so that you guys can stand that means and be back. Session on. Get your certificates Next week will be covering your stones on Thanks very much for bearing with us with the technical difficulties today, Everyone. Thank you so much. Chair my screen. Sorry, This terminal. Um get check some nicks in there. Um, yeah. I can't share my screen while the other participant is sharing. So I've been I stop sharing for you. Thank you. Thank you. Okay. Should I see that now? Eso Yeah, Thanks. Thanks, then thanks. And, uh, yeah, I'm sorry. So have you seen my talk for Please, Please stay. I'll only be I'll be very, very quick, I But there's there's a cure code on screen. I'm I've shared some links that you're gonna be really reposted on on Facebook in the comments s Oh, yes. So basically, um, usually have some free stuff you when we see you in person. So obviously you can't We're not seen you in person the moment seriously, I just It was just a different way of giving you guys something free. Time I billions and see what? Like uh so, yeah, before we start, if you want to get started Free support pack free employment guide like you need the employment guide. Just scan that code. It's something that that we've created here the b m a c a square thing. It's got the employment. A guy for two juniors. I guess some of these unions here on this almost being today it's a scar. Ethics talk. It revealed some revision tips and tricks. I'm looking at yourself in med school on the Q and A with a doctor in Georgia. I really, really good resource is completely free. So it doesn't matter of your A member or no, just completely free, just the way it was giving you something and also means that we we can stay in touch with you. So use that cure code missing the top corner as well. Just while I'm speaking, so do any time you can just to me and so half do it. Is this fine of just little bit about being a membership. I'm sure you remember. We've been members some point. So you know about what we do, what the BMA is, and we shall get a member. So yeah, just a little refresher America. And you may You may have seen my talked before. Mind the sleep, but, you know, you stay to stay and listen. Um, so, yeah, we're the trade unions, doctors or miss units in UK. We actually voice depression. So wraps and you individually, locally and nationally on on the issues to affect you. So we've recently, ah, done a survey of the those the the the agreed pay uplift that Let's face it, none of us agree with s. Oh, yeah. We've done a survey just to clarify that we don't agree of it on will be coming out with the next steps, this toe, what we're going to do where it's and say the word industrial action or whatever it is next. Next steps that we take. You keep an eye on that. Um, yeah, we'll be in touch with you in about what we're gonna we're gonna be doing. We're not We're not indemnity company. So we get sometimes get used and do you and m P s s so we don't deal with patients. Planes were to somebody look after you. Your development. You're working conditions. So So things like pay your contract, your wellbeing. So we negotiate the that all the contracts that union contracts, concern contracts. That's that's sort of where what we do. Um, so yeah, So if your membership we can give you advice is poor and whenever you need it and whatever you need and you got a Sinus or things you encounter in medical school on do also is is a junior s. Oh, yeah, it's all about just giving you advice. We have, um, we have employment advice is based. Every medical school we have a plan advises base that every trust, having dust relationships is based every trust, so so on the ground. So, people, you can see the people that know the staff that they need to know to get things started. So yeah, it comes, come to us. If there's anything you need, everything the sport you need again not just med school, but as as a minute pass pass on and Bubi be enough one and be enough to etcetera eso as a member us to get access to, uh, the BMJ. So if you're finally you get the the BMJ actually come through the post every week. So I asked the actual journal If you're if you already member and you're not getting that, just speak. Sure. You give us a call and just say that I'm my final year now, I would like I would like to get it weekly and then we'll send you. It's no extra money. I'm also you can read every single copy on the BMJ APS if you download the app and again, usually a B M A credentials, you be able to read old and you copies. So yeah, you can You can also opt out if you're on finally year of getting the paper version. I get them every week on Sometimes it's a bit much, I must admit, I don't I don't get a chance to read, um or I'm saying also being a member. Major have access to our clinical noncritical rentals. So you got five access to be M. J learning Ah, over thousands of dollars of modules on there, so very interactive. And he kept up today. Uh, with with practice changes of elements. Ah, sort of simulated environments on different module you do you get sort of pre from learning or sticker it required. You know, when your when your junior so being a library has thousands of 1000 you books and journals. It's not currently open physically. So so so just a little. The books and journalists are lying in a moment we've got in Utah called Clinical Key, so you may have used it before, so so we're now quiet. That's that's not a pipe PM a membership. So essentially Ah, it's it's ah, it's Ah, it's a search engine where you can search conditions, guidelines. I'm going to draw that drug monographs and and the step by step procedure Dios Really, really cool tool. And you can use on your phone or laptop. Great thing to happen. Your pocket. Uh, if you think about your special options already, you may. You may. You may. Maybe you heard this before, but especially explore it always really good. Really good tool for that. So it's an online psychometric. Testing takes about 20 minutes to complete last. You all sorts of work, like balance questions. Then I'll give you detailed report listings on the suit specialties according to the onset of Given. So it's really easy to use on covers all specialties on the reports from injury. Uh huh. So if any time you feel you'd like to speak to someone about your your wellbeing, our services, they're open 24 72 issues and doctors and you have a choice that you speaking to a counselor or a peer support doctor. So this one's a telephone based service on we do a video cause where they give you your B 12 that on. We'll make sure you speak to the same counselor again if it's a wart or doctor. If it's the same, it's more than one called the Service. So these services completely free, confidential, and it doesn't matter if you remember or no, it's it's open separate 1 20. So So if you're not currently a member, there's not because I've been invited along today, Um, if you joined using the link on screen or the Cure Colonel screen, you'll get 10 lb Amazon voucher. So this works for Ah, fine. Drawing is also rejoinders on your free. Absolutely be even join again. Also the rest of this month. It's completely you freeze this Well, so you so you would only start paying from October to get the arms of March and the rest of September free. Um, so, uh, it's free for freshest 3 lbs, 60 mgs, two every 3 lbs. 66 for your groups of other. And then 9 lbs. 75 a month. When you're in F one, but you get taxed actual sounds about 7 lbs. Uh, 20. Yeah, that's it for me. Just one last chance to sign up and receive additional support. Pack using like your coat. The links will. So they're Thank you. Want to keep it quickly? It's possible. Thanks. Thanks for listening. And I hope you use more of this or the B m E tools available to you guys. Thanks. Okay, Perfect. Thank you so much down. That was really useful. And if you guys aren't members bme already, I'm sure that portal of convinced you a should be on bike. Dan said excellent time to join can get 10 lb Amazon voucher on, um massive. Thank you. To bend as well. Who didn't excellent session today. Really, really useful. Um, so just to let you guys know that tomorrow session will be on death verification. And then next week, the surgical session on Monday is gonna be on Goldstone's to make sure you join in and bike. When said, make sure you fill up feedback as well. Any questions? Just see the email us or post it in the comments and someone will check through them. Okay. Thank you. Everyone in good night.