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The eye conditions, take it away. All right. Thank you so much, Flo. Uh So hello everyone. Uh My name is I'm 1/4 year medical student at New Plan and today it will be my pleasure to kind of talk about some lower um L I sorry, lower gi conditions. So just I'm gonna see if I can switch the slides. Ok? So typically when you're seeing patients with lower gi symptoms, um I'm just gonna open up the floor. What sort of questions would you ask uh those patients? And what sort of signs would you expect to see? So if you guys could put some in the chart, are you able to see the chat or do you want me to read them out? Sure you could read them out. Perfect. So everybody, let's put what we think in the chat. That would be amazing. All right. No worries. I can answer those questions as well. So you would basically ask them questions around if they, they have any pain. And from there, you can ask them where it is located when it started. How does it feel like? Does it travel anywhere, any symptoms that might be with it. So, like rashes or maybe they might have experienced, uh, some upper respiratory tract infection, uh, that they might have had recently, um, maybe some fever, some night sweats, some weight loss, uh, maybe a change in their bowel habit, uh, change in their appetite. Ok. In terms of the signs that you could notice, maybe they look pale, uh, they might have a distended abdomen or just, they're in pain, so they might be holding their tummy. Um And in terms of the bedside investigations, you could think about, ok, maybe checking for their temperature, um doing ad R examination, doing a, an abdo examination, maybe uh seeing if we can do some bloods, um and doing some urine dipstick test as well. So you can see three images here. Now, it'd be really nice if people could interact as well, put something in the chat. Um What do you think I'm trying to do towards when I'm showing you these three images? What do you think is going on? Is there anything in the chart flow? All right, no problem. So, what I'm trying to get here is constipation. Ok. So constipation is basically um passage of less than uh three stools uh per week. Uh basically passage of hard lumpy stools. Ok. Which can cause in, in the middle we have, it can cause uh hemorrhoids and it can also cause anal fissure. So I'll be introducing those topics in a bit. So what are hemorrhoids. So, hemorrhoids are basically abnormal swellings or enlargements of the anal vascular cushions. Ok. Um And they're found at the anal word. So they're found in the three o'clock position, seven o'clock position and 11 o'clock position. Ok. They're commonly found in uh age groups, 45 to 65. It can, it can occur at any point but mainly pre prevalence is around age 45 to 65 years and the risk factors that are associated with patients with hemorrhoids um is constipation, mainly chronic constipation, increasing age dehydration and increase or raise intraabdominal pressure. So that could be due to pregnancy due to cough or ascites. Ok. So in terms of the presentation, so typically these patients would present to a GP and they would talk about a lumpy sensation that they would feel um often that lump would be painless and can come with a bright rectal bleed, bright red rectal bleed. Ok. Post defecation, it can be a bit itchy and that could be due to uh the fact that they might also notice a bit of a mucus discharge with it and a bit of irritation. And they would also say that they would feel like there's a sensation of fullness uh in the rectum. OK. Now, uh in the images, you can see uh those are the different types of classifications. So first degree would be basically within the rectum. Second degree would be a bit of a prolapse of that lump that we could see after defecation, but that can be reduced spontaneously. And third degree would be. Now the lump, uh, it has prolapsed through the anus on defecation but would require someone to push it in. So require you to reduction. And fourth degree is basically, no matter what you do, it remains prolapsed. Ok? And with, with that, it can be large, it can be thrombosed and it can be painful for those patients. So it would be very difficult for them to basically sit as well on that in terms of the investigations you could do for hemorrhoids. So basically you would do with the bedside, which would be quick. So you would do a digital rectal exam. And like I've mentioned, you would find uh this hemorrhoid at a 37 or 11 o'clock position by the anal verge, ok? If it's large, it's gonna be appearing large, blue and purple, edematous, tense and tender. And then Gold standard investigation for hemorrhoids is to use a proctoscope, uh to confirm it. Uh You could also do colonoscopy in the case if it was complicated hemorrhoids. Ok? Or if you think about if you want to rule out any other pathology as well, in terms of management, you would, then depending on the uh whether it's first degree, second degree, uh or if there's any complications associated with it, whether it's asymptomatic or symptomatic, you would go for a lifestyle approach. Uh So you'd ask them in usually like, ok, if it's first degree, you know what, just increase your fiber and fluid intake and try to avoid constipation if possible. Uh, if necessary, give them laxatives as well. And that can help with, um, the constipation aspect of things. Um, so anything that pro uh, prevents putting strain on the rectal region? Ok. Um, now if they ha if they're symptomatic, if it's painful for them, you can give them topical analgesia as well. And, um, if you know, you wanna prevent the worsening of the constipation, so you can avoid oral opioids as well. Ok. So, in terms of, you know, your, um, surgical treatments, then you can think about uh ligating the uh artery of the hemorrhoid if there's a lot of bleed and then you can also think about removing the hemorrhoid itself. So, in the 3rd and 4th degree hemorrhoid, you could do what we call he a hemorrhoidectomy. Ok. Um, you could also do what we call banding. So, rubber band band ligation. So that's done in theater. So that's most likely 1st and 2nd degree hemorrhoids. Ok. Um If that doesn't work, then you like it. Um, if that doesn't work, then you remove it. Ok. So, the main complications that can occur with hemorrhoids is the recurrence of them. You can get strictures and you can get incontinence. Ok? All right. So the next one we're gonna talk about is anal fissures. So, anal fissures are basically, um, basically a tear in your mucosal lining of the anal canal. And that's most commonly due to inflammation of the anal canal or trauma due to constipation or hardened stool. Ok. So you would um think about risk factors. So, constipation is one of them. You think about dehydration. You can think about uh inflammatory bowel disease as well. That can also cause uh fissure to develop um and diarrhea as well. In terms of classification of anal fissures, it depends on whether it's acute or chronic. So acute would be present for less than six weeks and chronic would be present for more than six weeks. Now, what sort of presentation would it have? So you have this patient coming in with intense pain or they will tell you they experience intense pain, post defecation, which will last for several hours. Ok. And along with that, when they're wiping themselves, they would notice a bright red bleed. Ok. Uh, so basically fresh bleed or a sort of an itch they would feel after defecating. Ok. So those are sort of the keywords that you'd find in questions, uh, that would kind of point you towards the direction. Ok. This is more like an anal fission and not a hemorrhoid. So what sort of investigations you would go for? Well, you would, again, uh, quick bedside, you would do a digital rectal examination. Now, this one would be under anesthesia. Ok. And when you're examining, you would notice that the fissures would be visible or palpable. Uh they'll be very painful as well for the patient. Um And then in terms of its location, because location is important, they'll be more likely in the posterior midline. Ok? 90% of the cases and they can be on the anterior side as well if they are in females. Ok. In terms of uh gold standard uh investigation, again, you're gonna use a proctoscope and that will help us locate the fissure within the anal canal. In terms of managing uh anal fissure, we have to think about. Again, medical management and surgical management. In most cases, you do not require surgery. So we'll go for medical management like hemorrhoids. We're gonna talk to them about reducing the risk factors. So making sure you have a healthy lifestyle, make sure you have plenty of fluids, plenty of fiber. If they need stool, stool softeners, they can use that as well. If they're in pain, then you can give them pain relief, topical, uh or as a cream. So you can give them um short term course of lidocaine uh for symptom relief, you can give them uh dilTIAZem cream if they're still symp uh symptomatic and they wanna apply the cream in terms of surgical management. So, if they are having f chronic fissures and medical management is not working for them, uh it's been more than eight weeks, then we can think about giving them injections. So, Botox injection within the internal anal sphincter to help relax the sphincter and promote the healing of the fissure. We can also think about uh spin uh sphincterotomy basically. So the vision of the internal um anal sphincter muscle. So those are some of the things that you can do and just to let you know that the fissures can reoccur. Uh but there's a small percentage of that. So 4 to 5% would reoccur. Ok. Now we're gonna touch upon inflammatory bowel disease. And then I'm gonna also talk about later about um colorectal cancer. So we'll talk about inflammatory bowel disease first and then we'll go into the next one. So in terms of inflammatory bowel disease, as we are aware, there are two kinds. So we have ulcer colitis and Crohn's disease. Um Can you guys tell me which one? So I'll just go back. Um, which one has skipped lesions and which one is more, uh more towards the, the rectum and the sigmoid colon? Absolutely. So skip lesions would be Crohn's. That's right. OK. And then the rectum and sigmoid and onwards, like if you want to move towards proximately, then that would be ulcer colitis. Absolutely. It will be continuous. That's right. Absolutely. So, um I'll touch upon ulcer colitis. So, like uh one of the participants mentioned, uh it's a continuous inflammation of your bowel. So of your large bowel. Ok. So ulcer colitis is mainly restricted towards the large bowel, whereas Crohn's disease is more extensive, it can go from the mouth all the way down to the anus. So I'll touch upon ulcer colitis first. So it's basically described as a diffuse continuous mucosal inflammation of the large bowel. Ok. It starts from the rectum and then spreads proximately. It's more commonly seen in two major age brackets. So it has a peak age onset between 15 to 40 years old. And then it's also seen in, um, the age group 60 above. And surprisingly, when we talk about risk factors or, or, or something, smoking actually is a protective factor. Whereas in Crohn's disease, it's a risk factor. So what would be the presentation of the patient that comes in with ulcer colitis? So this person will come in saying that they have noticed an increased frequency and urgency in their stool. They will have a sensation that they, um, have not emptied out their bowels or tenesmus. Um, and when they have emptied out, they would notice blood in their stool. Ok. So they will notice a bloody stool or bloody diarrhea, uh, if it's severe. Ok. And they will also notice that there's some discharge also from the rectum. Um, in severe cases, they would also say that they have severe abdominal pain. Um, and if they mention that, then that's a sign that perhaps that this is an acute, severe flare up or perhaps it's a proliferation. So we need to do investigations to see what that is OK. When you look at the patient, you will also notice that um they seem very anorexic, they seeming very malaise and they might also say that oh I think I might have a bit of a fever as well. When you look at the, the body, the skin. So you ask them to expose their legs, you might notice that they have uh what we call erythema nodosum. So there'll be large bumpy uh bumps, um red bumps on the shins. Ok. So that's erythema nodosum. And then you might also notice some ulcers. So that might be pyoderma gangrenosum. OK. When you look at their eyes, you'll notice um redness. So episcleritis might be there, anterior uveitis might be there. Um And in terms of their um M SK, they might say they might have arthritis as well. So they're more likely to have enteropathic arthritis uh or maybe they might have osteoporosis as well. Ok. So in terms of assessing the severity, um we use this criteria and it's called True Love and wits criteria to assess the severity of ulcer colitis. So you can have mild, moderate and severe. So, remember I said the main presentation, they will say like, oh, they've noticed an increased frequency and urgency in their stools. So you'd ask them if you, if you were taking a history from them, you can ask them. Ok. Um If you were to kind of uh say how much or how many times do you go to the toilet? You pass that stool? So, what would you say? So, they say if it's less than four it's mild, uh, between 4 to 6 times it's, it's about moderate and if it's more than six it's severe. And along with that, if they say, oh, I've noticed a lot of blood in it. So you would classify that it's severe as well. Ok. Um, you'll do, also, you'll check their pulse, you'll take their temperature, you'll even ask them for their weight. So, pulse, if it's, uh, uh, more than 90 it would be severe. That's something to notice in terms of the bleeding. Like I mentioned, if it's la large amounts and that's also under severe. Ok, weight loss. If they have, uh, more than 10, I believe this is, I'm gonna double check what it is, but more than 10%. Ok, then that would be severe, uh, in terms of their temperature. If they have a temperature over, uh, 38.8 °C. Ok. Or more than two of the four days that they ha, uh, having symptoms, then you would classify that as severe as well. The reason why I'm kind of spending a bit more time on this is because exam questions love to check, uh, whether you can or you can understand from the question, then if it's moderate or severe, uh, and based on that the management comes about. Ok. So that's why it's it's good to know this uh, criteria so that you can think about the management later. Ok. Just gonna check. Yeah. Ok. Now we're moving on to Crohn's Disease and someone had mentioned Crohn's disease and I had mentioned earlier as well. It's, it's something that it's the inflammation uh, of your, it starts all the way from the mouth can be anywhere from the mouth to the anus and it's the inflammation anywhere throughout. So you'll notice skip lesions, ok, might be present in here and, uh, the age group that it commonly affects or uh, there's a peak incidence of that is between age group 15 to 30 years. And then again, it's seen between 6080 years. Ok. So, in terms of the presentation of this disease, well, the patients will say, um I'm having chronic diarrhea. Ok? And along with that, I'm noticing blood as well and I have this, uh, you know, colicky abdominal pain that comes about as well when I'm going to the toilet to pass stool, uh, when you check for their mouth, you might notice that they might have ulcers as well. Exactly. So the manifestations are similar. It's just that when you do the investigations and when you, um, basically, um, basically assess the patient, you'll notice a little bit of differences. So, uh, you might notice ulcers in the mouth of the patient with Crohn's disease. Whereas in ulcer colitis, that might not be the case in Crohn's disease, you'll see more of the, the bleeding uh, compared to no, sorry, in ulcer colitis, you'll see more of the fresh red bleed in comparison to Crohn's disease. So in terms of extraintestinal manifestations, it, they will be similar. Ok. Um Right. I'm just gonna make sure I've covered everything in terms of that. So, yeah, so it's gonna be similar in, in both cases. It's just, you'll notice the ulcers in the mouth. Um We'll come to histology and colonoscopy a little bit. OK. So, uh in terms of investigations for both of them, OK. So you will do some blood tests, you'll check for um, basically the hemoglobin levels because they're bleeding, they can bleed. So you're gonna check if they have low hemoglobin. Yes. Uh I'll check with flo if we can get, get you access to the lights after this presentation. Um And also you'll check for inflammation because this is an inflammatory disease. You're gonna check for CRP S. OK. So raise CRP S and white blood cells. Now, the key marker that you want to look for in terms of your investigations is fecal calprotectin test. OK. So that is very sensitive to IBD. And if that is positive, then that indicates that you need to follow this up with a colonoscopy. Ok? Um You can also do a stool sample test, ok? And the reason why we want to do a stool sample test is so that we can exclude any infective causes cause you know anyone can present with abdominal pain, can have uh blood and this could be due to other reasons as well. So it's good to always exclude other causes. So, taking uh a stool sample on the bedside, doing the blood test, um checking for temperature, examining the patients, those are some of the things that you do early on. Ok. And then if you know like I'd mentioned fecal calprotectin comes positive, then we'll follow it up with uh colonoscopy. So your gold standard is your colonoscopy with your colonoscopy. You're gonna take some biopsies. OK? And that can help us distinguish whether this is Crohn's disease or ulcer colitis. OK. So I'm gonna go back uh two slides. The reason why I'm gonna go back is because I've mentioned here, oh, I've mentioned histology and colonoscopy. So one other thing that they love, they love throwing in in the exam is like the histological findings. So in the, the how to distinguish ulcer colitis from Crohn's disease, I got this question wrong. So I'm making sure that you guys don't get this wrong. So just make sure that when they mention that the histological finding mentioned that it's a granular with, that's noncaseating inflammation with transmural inflammation, deep ulcers in the fissures and it has skip lesions. Then that's your Crohn's disease. So gran uh granuloma form that is formed with noncaseating inflammation. That's Crohn's disease. OK. However, if it's non granulomas inflammation with crypt abscess, goblet cell hyperplasia and pseudopolyps, ok. That you need to think about as ulcer colitis. So I'm just, I just wanted to touch up on that point since we were on investigation. So those would be your findings as well. And that will help you distinguish between the two. Ok. Now, sometimes they will talk about, ok, we will do some imaging as well because they've just presented uh acutely to ed and we need to do a quick investigation. So a quick one would be to do some um x rays, OK. Uh But the ideal for a flare up would be ct the urgent ct. So in that you could notice uh whether you can, it can help you distinguish if there's a toxic megacolon or if there's any obstruction in the bowel. OK. Uh In terms of the X rays because I just mentioned the x-rays. So for ulcer colitis, when you do the x-rays, you will see a thickening of tur and you'll see a classic thumb printing sign. OK. So sometimes the question stems do mention that as well and that can kind of signal you towards ulcer colitis. OK. Now, if it's a chronic case of ulcer colitis, they would also mention a lead pipe colon appearance. OK. So that's also something to keep in mind in terms of Crohn's disease. Um ideally, you would want to do a barium study because that helps us to um basically see deep penetrations and um stenosis that might be within the terminal ileum with the thickening of the wall so that we would call it the rose to ulcers and cancer string sign. So that's another one that they love mentioning in questions as well. Ok. So Crohn's um you would like to because you have these strictures, you have these um fissures that might, might form. So you'd like to do uh MRI as well and an MRI would be uh able to help us to see if there's any small bowel involvement as well. And if there's any severity that can cause the fistulas to develop. Ok. So, um yeah, I just wanted to mention that as well over here. So, uh this is the sort of like summary of what I've been talking about. So, um if it's rectal sparing, um you know, uh Crohn's might be most likely because in ulcer colitis is from the rectum onwards. Approximately if it's a continuous one. Think about Crohn's disease. Cobblestoning Crohn's disease because it's transmural, it's going in deep and you have skip lesions. So it gives that cobblestoning appearance. OK? I had mentioned about the granuloma formation. That's Crohn's disease. Again, radiographically, if you have small bowel involvement again, that's Crohn's disease most likely. OK. Stricture formation, Crohn's disease. So this is kind of giving you a snapshot of what I was talking about earlier. Um in words now, OK. So in terms of management, now, remember I mentioned about um management So in terms of management, you would involve gastroenterology. Ok. So you'd get them on board. It's uh when you confirm for confirmation of diagnosis and initiation of treatment, if it's a complex case, then you would because Crohn's disease, remember it's extensive, it can, it can occur from the mouth all the way down to the anus. So you would want a multidisciplinary team to help you out. So for that one, you will have um your gastroenterologist, you'll have general surgery involved. You can have nurses, dieticians, all of them would be involved to help the patient. OK. So patients who do come in with acute flares of the disease would reu uh would require acute management, which is more suitable to be done in the hospital. So they'll be admitted. So what, what we're gonna be doing is for the acute flares the first time, what we're gonna give them is we're gonna give them IV hydrocortisone. OK? With fluid resuscitation and prophylactic heparin. OK. Second line. Uh if that's not working, second line, we'll give them uh immunosuppressants. So azaTHIOprine or mesalazine and then third line, if that's also not working, then you go for your biologics. So, Infliximab and Aden as well. Um and if, if, if it's isolated perianal disease, then we will give them metroNIDAZOLE. OK? Make sure that you avoid any antimotility drug because we wanna avoid toxic megacolon formation. OK? Now, to maintain remission, we will give them azaTHIOprine, OK? And an alternative to that would be methotrexate. Now, remember I had mentioned way earlier that smoking was a risk factor for Crohn's disease. So whenever necessary, give them advice on that as well. Ok. So in 70 to 80% cases because it's an extensive disease because it, uh, uh, affects these patients, 70 to 80% of them would eventually undergo surgery. Um, and mainly that could be due to complications, recurrence or failed uh medical management. So, in that case, you would go for a bowel sparing approach. OK? Um So there are variety of surgeries that you can perform. So, II have a good image that kind of summarizes the four different types that you could do. So just give me one second. OK. So you have uh ileocecal resection, which is basically the removal of terminal ileum. OK? Where there's the stricturing within the terminal ileum, you can also go for a small or large bowel resection, which is removal of that bowel. OK? And then connecting it uh connecting the, the um remaining segments together. So forming an anastomosis and then uh you can next go for what we call perianal uh drainage. So if there is an abscess uh in there, you can drain it out and give antibiotics as well. And you can also do what we call stricturoplasty, which is basically if there's a stricture, just open it up. Ok? Um Now those who are high risk patients before you operate them you want to make sure you have optimized them before you do any of these operations. So that's another thing you need to make sure before you operate on those patients. OK. OK. So in terms of uh ulcer colitis management, so remember I mentioned like it was really good to make sure you know whether it's mild, moderate or severe ulcer colitis. Now this is the reason why we want to know. So again, just like I mentioned for Crohn's, these patients will be referred to gastroenterologists and they will uh confirm the diagnosis and then they'll be under uh an MDT that specifically deals with this. So if they are under mild to moderate ulcer colitis, and if it's just the rectum that's involved, then they'll be given topical uh rectal uh aminosalicylates or oral ones. OK. And if the remission is not achieved, then you would add either a topical or an oral corticosteroid. Ok. Next, if it involves the rectum and the s uh sigmoid. And also if it's the whole left side, then we would go for either topical uh aminosalicylate or we would go for a high dose oral uh aminosalicylate or switch it with a high dose oral aminosalicylate and a topical corticosteroid. If that's not working that we, we will stop all of the topical treatments and then offer an oral uh oral amino uh salicylate and an oral corticosteroid. OK. Now, if it's extensive, then you would go for a topical one. And you would also add a high dose of the oral one as well. And if that's not working, just like the above, we will stop all of the topical ones and then offer them a high dose because it's expensive. So we'll move on to a higher dose of the oral uh corticosteroid and aminosalicylates. And if it is severe colitis or an acute flare up, in that case, we would uh like Crohn's disease, we would hospitalize them, give them fluid resuscitation, give them prophylactic heparin. OK. And in this case, we will give them um IV steroids as your first line. Uh If steroids are contraindicated, you will give them IV cycloSPORINE. OK. No, uh surgeries. Now, surgeries would be done or indicated if there's an emergency or it could be an elective procedure. So, emergencies, when would that arise? Ok. That would arise if you have a toxic megacolon, if there's a perforation or if there's uncontrolled bleeding, and what they would do is basically, they would either do a segmental colectomy, which is removing a segment of the colon or they would do a subtotal colectomy. OK. Which is basically doing a resection of the bowel with the stoma. I would highly suggest after this uh have a look at the uh abdominal stoma and past medicine like all of them cause uh some of the questions do come around stoma as well. Um And about 25% of the patients hospitalized for acute, severe colitis would require colectomy anyways in terms of elective procedures. So, elective surgery, you would go for a proctocolectomy. Ok. And then ileal pouch, anal anastomosis, which is is often the intervention of choice. So basically what happens is it's done in three stages. So the first stage is they do a subtotal colectomy with an an ileostomy. In the second stage, they do the complete uh proctocolectomy, which is the removal of the colon and the rectum. And then they form this pouch. OK, with a temporary ileostomy. And in the third stage, they would reverse that. OK. And then um curative would, like I mentioned, curative would be a total proctocolectomy, which is the total removal of it. Now, if you do the ileal pouch in an anastomosis, the complication with, with that would be uh pitti which is the inflammation of the ileal pouch. And how would you treat that? You would treat that by giving them ciprofloxacin and metroNIDAZOLE? OK. Are we doing that? Uh good guys. Um Is everyone with me? Is there any questions? OK. All right. I'll move on to colorectal cancer. OK. So, um as the slides mentioned over here, it's the fourth most common cancer in the UK. OK. And how does this form? So, basically, there's a change in your normal mucosa. So, from your normal epithelial uh mucosal cell, it becomes ade adeno, it becomes an adenoma. OK. That adenoma can be present for 10 years or more before it becomes malignant. Um, and then it becomes an adenocarcinoma. So most commonly these patients would come in with a common complaint of, oh, I've noticed that I have a change in my bowel habit or I have this unexpected, like I have this weight loss that I'm having or I'm having this severe pain. Uh, now on the side, as you can notice here, I've put the nice guidelines, what the recommendations is in, in terms of referral. Um, so if they are more than 40 years old and they have unexplained weight loss and abdominal pain, they need to be investigated for bowel cancer. Ok? If they're more than 50 years old with unexplained rectal bleeding, they need to be referred for suspected bowel cancer as well. And if they are more than 60 years old with iron deficiency anemia and change in bowel habit, they also need to be referred for bowel cancer. And if they're, we'll come to the test as well. If they're, uh, fe fecal blood test comes positive as well, we need to refer them for bowel cancer. So, in terms of the clinical findings, ok, in terms of the location of the cancer, so it can be on the right hand side, it can be on the left hand side. Ok. So if it's right-sided colon cancer, you'll have someone coming in with abdominal pain, they will have, um, anemia. So iron deficiency anemia, most likely they will have a mass on the right hand side. And if there's a mass present on the right hand side, that usually means that's uh a late sign uh of that. So, um that's the case in terms of the left sided colon cancer, these pa uh patients will come in with change in bowel habit, rectal bleeding tenderness, uh and a palpable mass on the left iliac fossa or when you're doing the pr exam, you'll be able to notice a mass there. Ok. So screening, so I'd mentioned the, the blood test, right? So you'll do a fit test basically. And it's offered every two years to men and women aged 60 to 75 because that's the age group that's more likely uh to later on develop cancer or this is the age group that if you pick on, you can have an earlier intervention into that. If it's positive, then you need to do a further investigation via colonoscopy because colonoscopy with biopsy is your gold standard for this. Ok. Uh You would also, when you're doing uh your in early investigations, you would like I mentioned earlier, you would also check for um, your full blood, full blood counts. You'll be checking for your iron deficiency anemia. You'll look for clotting factors. We would also do ac ea tumor marker test and that is really a key as well because it helps to monitor the disease prevention. But if you want to confirm your diagnosis for that, you need to do colonoscopy with biopsy. And if that's not possible, then you end up doing a ct colonography. Uh instead. So sometimes, you know, in the questions they can ask you um patients for some reason, we are unable to do colonoscopy, what would be the next best uh investigation. So, in that case, you would say a CT colonography, OK. In terms of your other investigation. So if you want to stage any cancer, you end up doing a CT scan. OK. Uh And if you are concerned about rectal cancer, then you'll do an MRI uh of the rectum. OK. And that is to check for the depth of the invasion. Um and also to check for the, for the need of the preoperative chemotherapy. So it helps us to analyze for that as well and you can do an ultrasound as well. Now, I've also mentioned here, the duke staging as well. OK. So this classification is important as well because again, that will help us with uh our intervention. So just have a look at this as well in your own time. Uh Because stage A stage B, stage C and B, again, it helps us to uh analyze the extent of the spread of the tumor, whether it has any lymph node involvement or whether uh it has metastasized. So just have a look in your own. Uh It's really a key for the exams as well. OK. So in terms of the management um you know, obviously you will have your um, colorectal surgeons will be involved and along with them, you'll also have the multidisciplinary team to help support the management before and after the surgery. So, the curative um management for these patients is surgery, chemo and radiotherapy, um are often as um sorry as offered as adjuncts or palliative treatment depending on how extensive the disease is. Um, if there is a bowel obstruction, ok. So you would either do a decompressing uh colostomy or you will do a stenting. Ok. Surgeries. So, you have 12344 different types of surgeries that you would offer. If it's an emergency, you would do a heart men's procedure. So, um if it's on the right hand side, OK. So you'll do a right hemicolectomy and that's more likely indicated if you have a cecal tumor or ascending colon tumor. Ok. If you have on the left hand side, uh or if your, if your descending colon is uh involved, you would do a left hemicolectomy. If your sigmoid is involved, then you do a sigmoid colectomy. OK. Now, uh the one that I would really like to highlight because this one I remember doing question the other day and I got it wrong. It was around these resections. So you have the anterior resections. So anterior resection are for high rectal tumors. Ok. So you have um those are typically five centimeters more than five centimeters away from the anus. So if they say in the questions, so say, for example, they did the d somehow the D ra exam and in that they were able to notice a rectal mass and somehow they said it's more than five centimeters away from the anus. They will ask you, uh they've asked you to pick out a, um one of the options uh in terms of the surgery, you will pick anterior resection. OK. Um Now this one, what it involves it, it leaves the rectal sphincter intact. OK. And what you end up doing is defunctioning loop ileostomy to protect the uh protect the anastomosis. Uh You can also do what's what we call an abdominal perineal resection. So that's for your lower rectal uh tumors. So those are the ones that are less than five centimeters away from the anus. So that will be the approach that you have. OK. So mostly if you do end up come, uh facing a question, it will be one of these uh that typically come and confuse um, confuse us when they appear on the question. And Harman's you'll be doing as an emergency procedure. Ok. Chemotherapy, radiotherapy. Uh you just need to know that it's an adjuvant. It's mainly chemotherapy for advanced disease, um mainly for c colorectal cancer. Ok. So you'll be using this regimen. So you'll be using Folinic acid, you'll be using uh fluorouracil um oxaliplatin. OK. And this helps to significantly improve the three-year disease. Survival in these patients with advanced presentation of colon cancer. You would also, you could think about radiotherapy as well for rectal cancer. OK. And palliative care again, like I mentioned, it's for those patients who have very, very advanced uh colorectal cancer presentations. Um And the main um goal of this would be to provide adequate symptom control and help to reduce the cancer growth. Um OK. So, yeah, uh I would mention that and then we'll move on to the next bit. So we're going towards the last few. So I'll talk about diverticulosis diverticulitis. And then II believe I'm gonna also touch upon appendicitis and mesenteric adenitis. So that will be the end of this presentation. So, diverticulosis and diverticulitis. So what is the diverticula, a diverticula or diverticulum is an outpouching of the bowel wall. Mainly the sigmoid colon is involved and it occurs in those individuals who are over the age of 70. Uh So they have a weakening in their bowel which causes this outpouching to form. So, in this outpouching over time, what can happen is bacteria can accumulate and if the bacteria accumulated, it starts to proliferate and then the pouch can become inflamed. Ok. So common risk factors for this thing you need to be aware of is uh age low, dietary fiber, obesity, smoking, family history, and uh use of nsaids. So there are three types of um I guess presentations that can affect the diverticula. Uh So you have diverticulosis, which is the asymptomatic presentation of the diverticula. So, basically, it's the formation of the diverticula and it's usually an incidental finding. Um when uh we're doing imaging and scans diverticulitis is the inflammation of it. Ok. And diverticular disease is the third one, which is an intermittent colic lower abdominal pain and the patients will also come in with altered bowel habits, um associated nausea and flatulence. Ok. So, in terms of the presentation for diverticulosis, as I had mentioned, it comes out asymptomatic C uh found on CT imaging diverticulitis, they'll have acute abdominal pain, sharp in nature, localized mainly on the left hand side in the sigmoid region. So left iliac fossa region worsened movement and they'll have a decreased a appetite as well. Ok. When you examine them, ok, when you do the abdominal exam, you will notice that they have localized tenderness. So if that's the case diverticulitis, and if they have a rigid waterboard rigidity on the abdomen, then that's peritonitis. Ok. In terms of the investigations, you will start off with the basic initial ones. So you'll do routine bloods. Ok. You would also uh do fecal calprotectin as well. Um You'll also do and save you. You can also do urine test to rule out any urological causes. And the imaging of choice here you would do is a CT um Abdal scan. And in that again, in the question, they will mention thickening of the colonic wall. Um They also mention pericolonic fat stranding abscess formation if there is an abscess. So if they ever mention that, think about um in terms of the questions, then they'll say pain on the left uh IAC fossa region. So think about diverticulitis and also the age group as well. Um if it's uncomplicated diverticular disease, OK. So then you can end up doing flexible sigmoidoscopy and not colonoscopy. Um Oh I realized I have not switched the slides. Uh My bad. Um OK. So if it's a suspected uncomplicated diverticular disease, then you would rather do a flexible sigmoidoscopy and not anoscopy. And that is because you don't want to perforate the diverticula. Ok. In terms of the management, if it's uncomplicated. So, um it's not extensively uh symptomatic, then you just give them simple analgesia and give them oral fluids. If it is an acute inflammation, then you need to give them antibiotics. IV fluids, analgesia. And hopefully that should improve within to three days. If not, then you need to repeat aging to check for the progress um of the disease. And then um if there are diverticular bleeds again, just it can be self-limiting. If it's significant, then you need to stabilize them by um basically doing either. Um you can stabilize them by doing a surgical resection in terms of surgical management. You've tried everything it's not working, then you wanna do Hartman's procedure. Um Yeah, that's, that's kind of it for that in terms of appendicitis versus mesenteric, adenitis, appendicitis. Appendix is a small. Um So I just realized it didn't switch the side. So, appendix is basically a small finger shaped pouch in your um intestine that is located between the small intestine cecal region and the large intestine colon. So it's one of those vestigial organs. So those organs that no longer have a purpose, but they're there because they used to have a purpose uh before. So, appendicitis is the inflammation of the appendix. And it is commonly seen between the age groups 10 to 13 years old. And it's a common cause of right iliac fossa pain or right, lower abdominal pain uh in this age group. So the presentation would be that mainly these um these patients would come in with dull uh peri pain that would later migrate down to the right iliac fossa, which then at that point becomes very sharp and localized. They would also say that they have fever, um they have reduced appetite. Um They're not eating that well, they might be vomiting due to pain and they might have diarrhea as well. OK. When you examine these patients that you will notice that the classic rebound tenderness and percussion. OK? Over the Mac Burney Point. So, on this image, as you can see, that's the, that's the right and left and right in between one, that's your Mac Burney Point. OK. So when you touch that they will have a rebound tenderness there um or tenderness when you percuss, OK. Um If the, if there's a mass that you can feel there, then that can be an abscess, some special signs that you need to be aware of because they like throwing it in the question. Um Is the Rosin sign which is basically pain in the right iliac fossa and palpation of the left iliac fossa? OK. And the, so sign is when you extend the right hip, uh you'll have the right iliac fossa pain, OK? And if that's present, then it's a, the appendix is retrocecal. In terms of the investigations, you will again start with the uh initial bedside. So, urinalysis, pregnancy test, you're doing the case of females and routine bloods as well. In terms of imaging, uh you could start off with an ultrasound and then your goal standard to confirm that would be a CT scan in terms of management. Ok. You would think about if they're unwell. If they're septic, you wanna start off the sepsis, uh six bundle. Uh If there is a mass, um you need to think about giving them antibiotics as well before surgery. Surgery is your definitive treatment. So you do a laparoscopic appendectomy. Ok. You can use either an open or lens approach uh for that. Ok. Uh The next one we have is Mesenteric adenitis. So basically, Mesenteric adenitis involves the lymph nodes in the mesentery. So these lymph nodes are basically being shaped organs, ok? That contain white blood cells they called lymphs. So, mesenteric adenitis is the inflammation of these lymph nodes within the mesentery that connects the intestine to the abdominal wall. Ok. And mainly this is located in the right iliac fossa region. The, the reason why I have mentioned this in particular is because it's commonly misdiagnosed as appendicitis when it's not, it's commonly seen in Children, adolescents, typically after a recent uh upper respiratory tract infection and their presentation again is similar to appendicitis. So, right, iliac fossa pain uh in terms of investigation, again, you'll do a CT or ultrasound. OK? And in that, you will see a normal appendix, however, you will see also enlarged lymph nodes in the right iliac fossa region with some ileal thickening in terms of management. It's self-limiting, it goes away. So, yeah, guys, thank you for listening. This is the end of my presentation. Uh Do you guys have any questions? Massive. Thank you from me and everybody watching. That was a really good talk and thank you so much for such a detailed slide which will be amazing for revision. Um I will enter the feedback form the chat. Now, if you fill it in, you get that certificate, I was talking about um and you get those discount codes and also some access to the slides and recording. Um If her is that she's probably gonna live my life again and tell what is on next week. But la OK. Right. If my phone lets me, I don't know which is really bad, but here we go, we have next week. No, my laptop's now frozen, which is fun. Next week we have E and D part one and part two to make sure that you follow us to be alert about that and come along to those talks as well. Also a massive thank you again to can. Thank you so much. That was really informative and yeah, that's it from all of us. Thank you so much. Have a nice evening and fill in that feedback form. Goodbye. Thank you as well. Thank you flo for giving me this opportunity and I hope uh everyone got to learn something. I know it was quite a lot, it was intense. Um I'll definitely send the slides your way cause uh it was something requested um by the audience. So thank you so much. Everyone. Have a good evening. Perfect. Thank you so much. Bye-bye. Bye-bye.