Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Yeah. So a bit of a last me A bit of histology, um, bit of physiology. But I'm gonna focus a lot more on pathology today, Andre. Where things how things that can look different than normal. Onda a swell a z going to spend some time going up Donald X rays Because I'm a way you're the boss keeps coming. Um, that might be useful. We begin with the anatomy, have an embryo logical point of view. Your entire gut. Your digestive system is just is divided into the four gut, the mid cut on behind gut. And it's about it this way because they developed from three different embryologically origin's. So you're four. Gut is kind of what you covered in case in case six. In first year, the the upper GI I case, Where's what covering today is the mid gut, the hind gut. So this is from the distant duodenum all the way down to the canal that start with the mid cut. So I think the the most confusing concept for me, at least when I was going over anatomy of the of the nausea tract was just understanding what the peritoneum in the mesentery is and how it relates to the organs. So I think if we go definition by definition, the peritoneum itself is kind of just this this thin lining off the abdominal cavity on on the organs. The best way to think about it. If you think about the thorax, you've got your pleura right. I think it's very similar to that. So you could you provide to pleura in the thorax that lines the the outside of the thorax and you've got your visceral pleura that lines like the lungs, for example, they're organ itself. So similarly, you've got your parent any, um, in the abdominal cavity. You got your parietal and your visual part in here. You've also got this thing called the Mesentery and the Mesentery. Is this like, really think sheet of connective tissue? Um, that kind of runs along with the pleura over the prison, Um, and many times on dissension. It's main purpose is to just suspend the organs because your organs, if not suspended, would just fall down because of gravity. There's nothing holding them up and keeping them in place where they need to be, and therefore the mesentery kind of holds them in positions like an anchor on your organs. Hang from this mesentery on because they hang from this mesentery. It's also really convenient that the MESENTERY would contain the vessels and the nerves in the lymphatics that supply all of these organs. So what does this look like in practice? Looks like this. So if this black line of the bottom is like the abdominal cavity division, that's where it starts. You have your parietal parachini, Um, on. Then you have, um, your main visceral partney, um, which is this pink bit and your organs in between. So J is judging them and case kidney. So if you look at your kidney, your kidney isn't contact the abdominal wall with the parietal cars knee. Um, however, there is no medicine toe to suspend it at the bottom. It's kind of it's bare of the bottom. There's no mesentery, which is what's in direct contact with the abdominal wall. And therefore it's a retroperitoneal because it's behind the visceral Paris name. Where is the judge in, um, has this been of mesentery that suspending it to the dominant wall? It's not in direct contact with the abdominal wall itself, and therefore It's called Intraperitoneal because it's within it and it has his bit of off this, reporting him on the top of the bottom and kind of holding it down. That's kind of how you think about it. Hope that makes sense. So the other anatomical thing that's quite significance is if you remember learning about your lesson greater mentum, which is the connective tissue that is suspended from your stomach. Um, and they are suspended from the inferior of the superior aspect of your stomach. You have the less omentum above. On the greater mentioned below, the greater A mentor basically kind of creates this abdominal compartment below the stomach. Um, and this is significant because of water contains. So if you have that flap of greater momentum kind of folding over your intestines, okay, it's gonna forward over your transverse colon if you can kind of like, imagine, that's you. Have your stomach pancreas on, bend your transfers. Call on onto this greater. A mental is kind of folding over, right? So it's creating a compartment below. So you got the super colic compartment, which is just above the transverse colon, and you got the in for college compartment It's just there on on either sides. Off these, um, are the parent college gutters Casey of the right and left part collie gutters on drinking. Sometimes it's carbon. This because these are basically free spaces for fluids to float and kind of move around. Okay, so as the word gutter implies, it's kind of just a free canal fluids to flow. So things like blood or puss or vial can drain in these areas, as you can imagine due to gravity. When you're standing up, all these fluids are going to want to go downwards. They're gonna go on accumulate in the pelvis. However, when you're lying down on the sleep was move more centrally and they're more can move to the sub frantic spaces, which is above like near died from. So there's a significant because in times of infection and things, infection can spread. Ah, bleeds conspired on things like that. This is a quick overview off, like the innovation arterial supply and mean a strain, a judge off the guts. You can read your own time, but I thought I'd go over the out your own supply because it's high yield, something you kind of have to know Because if things go wrong with arterial supply, you know things can go quite wrong. It's quite it's worth knowing this. So with the mid gut, then we're looking at the superior mesenteric artery, but branches off the abdominal aorta. Okay, um, this happens at around L1 on it has significant branches on down. The first branch is the inferior pancreaticoduodenal artery. The best way to remember what these artery supply is just breaking down name so inferior pancreas and then do a dino. So you know that it's going to supply some part of the pancreas as well as some part of the duodenum because it's inferior. You know what supplies like the lower bit to the more distant portion of the duodenum and it all the blood supplies the head of the pancreas and the uncle a process. The next branch are the judge in a lot and ileal arteries that branch off on these supply the judging. Um, and I'll e um, Andi, if you remember the structure of the mesentery of the gentleman island which hook over again in a bit, you have these things called bars a vector. Which of these really fine capillary networks within the mesentery that supply these past the gut. And these come from the judges. Little ideal arteries. You don't have your middle colic artery just cause I wonder what people think. And someone tell me in the chat What the middle colic artery supplies. What does the middle colic artery supply Think about the would middle transverse code on. Exactly. And what is the right college artery supply? Yeah. Perfect. Okay, so, um, breast, remember, this obviously, is if you think about middle and rights if you think about the abdomen, um, you've got your sending colon on the right, going up. You got your transverse colon going across in the middle and in descending colon on the left, going down. And therefore these arteries are basically just named that way, so middle colic would be transfers, right? Colic would be ascending colon out that make sense, and then you're really a college artery, as you can imagine will supply. You know, the distant I'll, um as well as the cecum, the appendix, and a bit of the ascending colon is Well, then we have not reached, um the behind guts. So starting from the distant third off your transverse colon. You have your inferior mesenteric artery. The first branch is the left college artery. So using the logical just explained Can you guess what? The left colon cancer supplies? Yeah, exactly. Sending colon on the distal third off the transfers called on a swell. Yeah, a swell a sigmoid arteries, which surprises applied to see God call on on the Senate. Colon on the superior actually are three. Which again, surprise supplies. Correct him. This is a bit more straightforward. That's the inferior mesenteric artery. Now there's these things called watershed areas. Does anybody know what they are and why they're important Watershed areas, air that is supplied by two main arteries. Okay, that's close. Aceptable dyskinesia. Yeah. Perfect. Yeah. You guys all right? Um essentially their area off off tissue, which is supplied by the terminal branches off two main arteries. So if you have your inferior and superior mesenteric artery's, some of their terminal branches will supply one specific area of tissue and because it's the terminal branches there, the loss of the most distant branches. Which means that if there's any kind of hypo profusion, these are the first ones to get affected because their supplies already kind of weak. So you would think that because they have a new supply. If one supply goes away, it can be made up by the other and your rights. But really, I think it's more of a disadvantage because of hot gravy, the risk of hyperperfusion and ischemia to the main two watershed areas in the colon. I hear the splenic flexure over here on the rights on the Rectosigmoid junction. These the two main watershed areas and these the most vulnerable to hyperperfusion and esquina in the gut cake. A question of you guys. Somebody able to launch the pool, please. I don't have a pool. Yeah, I'm just doing it just by with the second. No worries. Maybe maybe get this one month. Sit in the trap. Ready? Yeah. Okay. Well, in the meantime, 62 year old woman on the ward complains of bloody stools on crampy left lower quadrant. Abdominal pain. She's just undergone a little vial replacement. She has a history of anti force related syndrome. Blood sugar Ray's like states, um, Coloscopy just alteration and Dema off the descending colon. What abdominal vessel is most likely involved? Just go up. Oh, going? Yeah. Thanks. Mike was quick. So the school during guys, I can't see what your answering to, like. Just take anything. If you don't know, Um, this one obviously require to know which artery supplies. What part of the guts. Okay, okay. I'm going to stop that. Okay. Shares, guys. Yeah. Amazing. Well done. 93% of you got it, right. Um, which is which is really, like, Good to know. Um so sorry, Mike, would you mind noting down? The percentage is just for this because what? Please, um Thanks. Um, but it thank you. Um, cool. Alright. Is left college artery. So I think really all, like until the last sentence. Everything else is kind of like useless. Like, all you need to read was that it was the descending called on and like, which blood vessel supplies it. But anybody know what this woman has? Like, why has you presented, like, what's going on? So after pain bloody stools? Um, just she just had surgery for valves. Um, she's got a history off from Ophelia, uh, crossing problem on. But mender guess Kenya. Exactly. You got all these risk factors for flopped? formation on. But the fact that she is going to surgery means that she's been, like, quite immobile for a while. Um, hence the lodging of the clots and the symptoms described that, you know, there's there's in fact it part of about. So she has probably skinny cow. Um, it's chemical itis, so let's we want a bit of histology. So, um, can anybody tell me what, um A B and C which parts off the wall? Which part of this? Which up between the bowel on the sections taken from Corvallis. Sorry. Going to stop that. Sounds me a second. Yeah, What is a B and C or was A or B or C, whichever one. Oh, what about that guy's? Yeah, it's it's chemo collectors. Not necessary scheme. Yeah, a judge in, um, be highly, um see, duodenum the out perfect spot on exactly what it is. Case of the duodenum. Um, can someone putting the chats? What separates the duodenum from other parts of the small bowel histologically? What is logical features are unique glands. Yeah, exactly. I think that's the main one. Yeah, solid guys. Good stuff. So I see the appearance of the villain which are quite quite shocked compared to a different part of the balls that you see later as well as the brightness lands. Yeah, anybody know the function of the brothers glands and then lost another questions today? But, you know, that would be helpful. What did the burners glands do? Yeah, exactly. So it's accurate. This outlined mucus that help the digestion. Basically, um, all those worth noting that the duodenum on the epithelium contains the's brush border enzymes on the steps that contain all these, that really enzymes were really important for digestion on these enzymes include protease. It's a breakdown of protein as well as proteins that breakdown cover height, enzymes, original carbohydrates. Um, why do you think that there are no like pace enzymes in the brush border? Need to survive us? Exactly. So if you remember your, um, your bile has to enter first on D, and in order for that, that's what leads in the duodenum. And basically, if if there's no bile than the fats can be multiplied and only once the fatter and multiplies, can they be broken down by these enzymes? Um, and that's why I don't have, like cases in your duodenum. Mostly great vision. Um, what separates the judging them from the other parts of both Histologically speaking like a circulatory. Exactly. The fold. Think it's circulatory and as well as the villa. So if you're under the duodenum, the villa, I will not shorter. Where is here? The board. Long and like. Lanky. But really the more the most like unique factor you'll see in histology would be east falls on these multiple falls because I calories and you'll see this on one and oscopy as well. Just the appearance of the judge in, um is very folded. Um, yeah, great. Finally, the ileum. Can someone tell me, um, the unique structure off the ileum that makes it so special? Payers patches Peter's patches. It's pain patches. Yes, great superiors. Patches Basically just tissues containing is lymphoid tissue Basically help, um, with infection and things from the other thing I will say about the structure of the guts, which I haven't mentioned so far on the others, is because is a just a note that the muscular slayers So you got your muscular mucosa in the middle, and then you really must loss external at the bottom and The reason I'm pointing it out is because if you compare it to the colon later, you'll see a big difference. It's just look, have just have a glass that now and then, Um, around that in your head, you could get back to that in a second. So only I talked about bars of extra and in the judgment. I'll, um, that's in the mesentery that supplies the gym of the aisle. Um, so just a bit more detail about that. So, like we said, the MESENTERY suspends these organs right on. Their four contained the blood supply on the nerves and the lymph lymphoids vessels that drain our supply. This issue. But you'll see that the structure off the mesentery in the General um, quite different, for example here and the judge. And, um, you can see at the vas of lecture which of these little arterials the very long Where is the ileum The quite shot on more complex, if you like. Um, there's generally more fat in the aisle, um, as well, um, Onda. As a result, it's quite, um, it was well complicated. Uh, cr that's an important difference Note. So we're going to the colon. Um, like I pointed out earlier in terms of, um, you cope with the muscular layers, you could see that I'm much much they could hear. The muscular is external is just so much thicker than it is in the small bowel. And this really just goes to show how important the large bowel is. The colon is in digestion and kind of mixing things together and moving things along. And it just kind of adopt a shin. I think, um, that's an important differentiating factor. But in the colon and the small bowel, your have lots of mucus to help things move along as well. Oh, the canal off really messed up the animation here. Anyways, the anal canal is the end of your hind gut. It's the bottom most bit before things leave on. Do you conception at the anal canal into two. So you kind of use the thing called the packs in a line. The Paxil made line embryologically the division between behind Gut on direct. Um, basically Okay, um, but it's really helpful because because they're so Enbrel, obviously different times they're origin's. The way they look is also very different, and their function is kind of all the different. Okay, so the best way to think about it is you compare things that happen above the pectinate line and things that happened. Bit of the pack. State line. Um, so if we talk about it vessels and supply, you got innovation. So above the pectinate line, you have a visceral innovation. You have the superior of axillary that we talked about supplying it. Ondas venous drainage is done by the superior actual vein that eventually drains into the portal vein through the liver and you have a lymph node drains into the internal iliac lymph nodes. If you compare this with the below the vaccinate line area, this is innovated somatic Lee. It's different. It's applied via the inferior actual artery, which is a branch of the internal Pretend a lot, not the information Terry on is drained by the inferior. It'll bring that drains directly into the inferior vena cava on doesn't go into the borderline, and it drains into the superficial inguinal influence. So these are just some anatomical difference is that really, like goes to show how different the Enbrel article origins were? Um, it's also useful to note that the sphincter in the above the person eight line The sphincter is under involuntary control like you can't control it, whereas these things are below it is under voluntary control. So when you go to over your bowels of what you're controlling, is your external anything in external in sync on The key difference here is to note that why the innovation has has clinical significance. So the fact that the internal and the internal parts the area above the pectinate line is innovated viscerally. This means that this does not like give this is not produce painful sensation when inflamed. So what? Somebody has internal hemorrhoids which is, you know, when they're straining and things to do. The's inflamed hemorrhoids are not going to cause pain because of the innovation. However, if someone has external in hemorrhoids where the mucosa is, um innovated by somatic innovation, this can cause severe pain like really bad pains that that's a really good clinical way off differentiating internal and external hemorrhoids. Okay, so a bit about got physiology is just cause we talked about the anal canal or just continue with that. So, um again, in terms of difficulty in thean turn ALS things like we said, it's not under voluntary control. It controlled autonomic Lee, but it's made a smooth muscle. The external sphincter is under voluntary control after 18 months of age, and it's generated by the prudent A love and it's made a skeletal muscle. So when you go to pull, the main thing you have to know is that your external sphincter relaxes and your internal spincter contracts. So it the best way to remember that is, if you think about like how the is pooling happens because of pressure differences. Have you applying a lot of pressure from the inside? It's gonna push it out to leave. So if there's a lot of pressure on the inside, when the internal sphincter contracts and the external sphincter relaxes, you kind of pushing, pushing the pool to leave, Um, so that's the way I remember it. In terms of gut motility, you're not gonna spend very much time on this. Could something just kind of to memorize, but and essentially, they're two main, um, sets of nerves present in your guts. Do you have your enteric nervous system that includes the Mayan track plexus, which is within the muscular layers off your guts and the cervical some because the plexus, which is located just before you go just below the mucosa in the gut in terms of movements kind of move things around, um, within the gut, either when you're fasting or just after having eaten a meal. You depend on these things called pendulum and segmentation movements, Paris static waves, as well as just the village to brush things along. Um, on day, when you're fasting, what can happen is your body, when you're fasting, has a way of cleansing its own bowels to like, kind of to clean your bowel onto, like, brush away any leftover Bitz or leftover bacteria. And it does this through this thing called the Migrating Motility complex. Um, not gonna go into very much detail about this because of time, but essentially, these happen like automatically, like you don't think about it just happens and and accept kind of clean the bowel when you're fasting. I would go back and revise physiological mediators off that movements like the chemicals in your tents in GLP one and motel in. These are significant effects on gotten too busy, and I go over them like weather released from and what they do, um, support. So this is like, really high yield part off medicine. And general, I think, is where nutrients are absorbed. And because this can impact because if somebody has a problem in one part of that bowel, it's going to affect what meters they can absorb, and therefore they have symptoms related to the nutrients and they're deficient in. So we start with the stomach in the stomach. You absorb f no alcohol, and you secrete pepsin and ACO to digest things with them off the duodenum, the duodenum, the main things that are absolved. Uh, chlorides calcium. And I use the main ions glucose, scallop characters and fractures, and you have by carbon enzymes that are secreted. Um, again, I'm sorry. It's just like you're just gonna have to memorize. There's no way around it. I haven't thought of a numb or like, I couldn't think of one. But if you think of one, please share it. Um, they moved the judges him in the judgment. As you know, fats are mainly it's very important that fast absorbed here and therefore your fats, as well as your fat as well. The fact, you're fat soluble vitamins A D E K as well as we were sort of providing. It's absorbed, you know. You have your bile and your enzyme secreted here, including, like pace. Um, your I'll E um, you absorb vitamin C B 12 bile salts and in your colon on you absorb electrolytes and water. The other thing your colon's your entire bowel is really important to doing is fluid balance. So when you think of fluid balance of the body, you think of your kidneys, right. But actually, the gut has a massive role to play because there's so much when you eat, you're actually taking a lot of fluid, like on the ward's, for example, like if somebody has to be somebody's fluid, balance has to be recorded like their record every cup of tea, every little like, um, every cup of day. Every Diet Coke, like literally anything that they drink is counted because they all add up the fluid balance. Um, so in a typical Pawson, you add fluid your gut by saliva. Why the food itself, by a bile by the gas X secretions such as pepsin HCO, pancreatic secretion like pancreatic juice, a swell as your colonic secretions as well. So all of these things have their own volume, and they all contribute in their own ways. On darling fluid guts Onda all obviously like this is a lot of fluid, and it has to be absorbed a certain amount to keep the balance in your body On most off this fluid absorption is done in the small intestine, and a lot of it is also down in your large intestine. So in terms of numbers, we're looking at about nine liters of day off in flow off fluids into your gut, which is a lot more than I would have thought on D. But 6.5 liters of this is absorbed in the small intestine, and a about two liters of this is absorbed by the colon and the remainder and just passed in stools. An important thing to know is that resistance to fluid flow increases away from the mouth. Um, and what this means is that as you go further down the guards, there's more resistance to flow of fluids on. I think that's why they're absorbed so early on here in the small intestine, and it's also promote anyone uptake because of the osmotic balance out of the pool. Patient has in malabsorption disease. She develops paraseizures and muscle cramps on her eating seizures. A prolonged QT interval. Which of the following structures is most likely damaged. More of you would be nice. Okay. Can we call it there? Yeah, Solids. Yeah, mostly gotta. Is the duodenum on everybody? Tell me, why is the duodenum in the chats? Why is the duty? Yeah, exactly. So, uh, this lady is displaying features this patient off hypocalcemia wishes parethesias muscle cramps on a proton qt interval. Um, and she would maybe have. She may have have a calcium yet because she's not absorbing enough calcium for moderate. Most likely the duodenum. Because this is where it stopped. That's why I don't say that. Duodenum. Okay, so that's what I think where things go wrong. How much doing the time? Give me a second. Okay, So let's talk about bowel obstruction. About obstruction is a big boy. He's really important. Very high your topic. But what causes it? Can someone tell me the most common causes of bowel obstruction? What is the most common cause? A small bowel obstruction occasions. Yeah, perfect vision. Yes. What is the most common cause of large bowel obstruction? Some of the politic islands. That's common cause, but not the most common cause. Well, cancer, colon cancer. Exactly. Why? So you're right. So, essentially, this is what it looks like. Okay, so you have a bowel, and if you have a lesion of lesions, are basically scar tissue from previous surgery on D thesis scar tissue, and therefore they can come in the way of things and and block the movement off things within the small bowel and therefore get obstruction with colon cancer. As you can imagine. Is this mass sitting in the middle of your colon? Just blocking the way on that can cause an obstruction. So what exactly happens about obstruction? So because there's a blockage, what's gonna happen? Is that a couple of things one food can pass, like even Eircom pass. And therefore you get this Gatien abdo distention a gas just builds up even like, um, and this dissension is be dangerous on do it because it's like vomiting on, because if it distends big enough, it can compress on the vessels that supply it and therefore can cause bolus Kenya Onda, Can someone named some really bad complications off this? If this gets bad enough, what can happen? Looking for one word? Perforation? Exactly. It can burst literally like burst and all the contacts, All the contents are gonna gonna like spill out. And this can cause infection really quickly. It's just bad. Um, yes, that's how is this present? Well off the large and small bowel obstruction present differently because they're affecting different parts of the guts. But they would both present with colicky abdominal pain. Can someone tell me why the abdomen pain will be colicky? Paris styles this. Yeah, because your gut is trying to move normally. Your gut is trying to move perception and digest things, but it's not able to get past it every time it tries to move. Getting this pain there, that's what's colicky comes and goes, Um, so in small bowel obstruction, you get earlier onset and more vomit because it's higher up on. Do you get later? Constipation obstipation, um, on. Do you get more severe abdomen distention in large bowel obstruction? Um, in terms of management, I think the most important thing, obviously is to people, would get after X ray, but the most definitive with diagnosing about obstruction would be a CT onda in terms of diagnosing it, you want to see how distended the bowel is, so the 369 rule is kind of a threshold. So if the small bowel looks like it's more than three centimeters dilated, and that could be a sign that it's more dilated than usual than normal on Go on Kick Cool week, SBA 78 year old man presents to any with colic, abdominal pain that sort of 12 hours ago, he reports not having opened his bowels in five days, which is abnormal for him. He has started feeling nauseated and has just had a bout of fecal vomiting. Examination shows diffuse abdominal tenderness and Auscultation reveals high pitched tingling bowel sounds. What is the most underlying likely underlying cause of this man's presentation? Could call it that for sake of time. Um, this is a trick question. Um on. Do you guys have fallen into my trap? So you didn't say Dejan and additions are a very common cause of obstruction. However, if you see this man's history, it points towards um, or large bowel obstruction picture and explain why and therefore the most common part common cause of large bowel obstruction would be colorectal carcinoma, not additions on. But but you would not be wrong. It's, uh, that's, uh, the most likely cause. The reason. It's large, well, obstruction. The main signs we see here is that obstetric constipation started early. It's one of the first symptoms. It's early. It's large bowel, usually second. Fecal vomiting. Speaker vomiting means he's vomiting feces, which means it's coming from quite down below in the gut, which is not, which is another sign that cut the obstruction is lower down, and therefore it's no longer just food. It's actually digestive PC's that are coming up on breast. The science are quite a generic bowel obstruction signs on that size. Large bowel obstruction. Yeah, great. Um, celiac disease, Celiac disease. You should know is not It doesn't mean you're allergic to gluten. That's not what it is. People do that all the time, and that's not what it is. You have just a hypersensitivity to this protein called biotin. Gliding is essentially like a metabolic products of breaking down gluten. Okay, um, just memorized that it is Associate it HLA DQ two and HDL DQ. Eight genes on what exactly happened. Is he like disease? Somebody eats gluten. Okay, on D this person, what's gonna happen is that this gluten is going to irritate I got TTG is an enzyme released from end of thelial cells in the gut that is going to modify glide in from gluten. TTG is released when there's like and when there's a small sign of inflammation or irritation. Okay, and it's going to convert gliding. It's going to convert gluten to glide, and but it's not gonna It's not a normal funnel guide, and it's a modified lighten on bath. A logical T cells are going to recognize this modified form of Blyden and react to it. Okay, And this is going to cause inflammation. So it's gonna affect. The problem is that you've got gluten. It becomes the wrong kind of modified Leiden. Your path, uh, pathological T cells and reactions modified Leiden to form this like autoimmune, messy response and therefore on you get chronic intestine inflammation. So obviously, if you think about it like if you don't eat gluten, you're not gonna have this problem because you're not going to trigger these cells. Therefore, this is important because when you want to diagnose somebody with celiac disease, if they haven't eaten gluten for the last couple of months because they're scared their CF disease, it's not gonna show up on Bloods because they're not gonna have TTG because they haven't been eating gluten. And therefore, in order to diagnose somebody see LAX, you have to make sure that they have been eating gluten recently so you can pick up TTG on their blood's now They were talking about diagnostics. Like I said, Should I mention this earlier you diagnosis? See the disease using on raised ttg I G antibodies on their blood's Okay, um, on it's really important. But because you're looking for I g A antibodies that you have to make sure that individual does not already have an existing RDA deficiency disorder because if they already don't have IgE antibodies in their body, they're not going to produce T. D g r G antibodies, and you get a false negative test for celiac disease. Um, the most definitive way of confirming celiac disease is doing an endoscopy and getting a biopsy because you're going to see something like this So this on the left is healthy tissue healthy ville I, and it becomes this thing on the right where you get like, lots of lymphocytes. Lots of teeth. Lymphocytes are infiltrating, place quipped. Have a place here on day. Just villus atrophy just looks very messy, as you can see over here. So that's Those are three main things you'll see on histology, which a diagnostic procedure disease and in terms of clinical signs are, remember that it exists you could get peripheral neuropathy on. Do you can get dermatitis? Herpetiformis. This comes up in SPS a lot in PT and things I just remember this. It's a blistering rash over the extensive surfaces is what you'd remember it in this world. Looks like. Okay, moving on to the big chunky boy. Um, inflammatory bowel disease and heart valve disease can be divided into other it of colitis and crone's disease. It's an umbrella term, so that's not about ulcerative colitis. First, they would talk about Crone's. We'll talk about how you can differentiate them so authors of colitis essentially is an autoimmune disease. Okay, um, it's a CD four T hutch to sell mediated immune response. There is associate it with P Anca Auto antibodies. Although these aren't picked up on everybody, it's not 80% of the population, but it's quite significant. So again, it's like better autoimmune response, right? What's gonna happen essentially, is that your T hatched yourself and not gonna act normally. It's an inappropriate immune response. They're going to basically mess up your mucosa, mess up the epithelium, cause ulceration, erosions and to mention the crosis of the cells in your bowel. And the most important thing to note, and also to colitis, is that big starts in the rectum and it moves approximately, and it never really goes off. It never goes past the large bowel, so it's restricted to the rectum and the colon on bit moves approximately. Tell her it looks like you can see that this is normal mucosa and look at the severe inflammation. You can see that the Vascularity has changed. It just looks very erosive. Looks very inflamed, not kind of looks like on endoscopy. There's an association with Ashkenazy Jewish people, a zoo well as instead as well, and HLA b 27 gene Association. You'll recognize that HLA b 27 is those aging with many other autoimmune disorders as well. And therefore people who have ulcerative colitis are predisposed vulnerable to having these other HLA b 27 conditions as well. Interestingly, smoking has has been seen to be kind of protective of all surgical itis like it like it's protective. It's a protective risk factor on be sore appendectomies, which was weird. It's only a disease that I know which does that, but it's an interesting point to remember that it's quite good for SPS. Um, on there's a little pneumonic you can use to remember the features off alterative colitis using also's with three C's just to describe the main features. The fact that you get alteration that happens in the large intestine on the rectum. Um, Onda a couple more things that I will explain in a second, but you can have that later. So what can you find and you test this person diagnostically What you gonna find? You're gonna find elevated inflammatory markers, just the R. P and yes, are. You find a raised fecal calprotectin when you do a stool test and you made a Texan P. Anca auto antibodies of it. You also might find on abdominal X ray. They'll have this thing called a lead pipe, a period which looks like a pipe. This is because, um, if you remember, the large bowel has these things called hasta on the holster. Kind of like a little like they're this bits of mucosa that are like make the colon looked very lumpy on day, the's basically disappear and give it this very non lumpy straight appearance, which is bad. You don't want that. And that's what they call that pipe. And you might get this note sort of colitis because of the inflammation. In terms of microscopic findings, it going with an endoscope, you're gonna find a very inflamed read if you noticed mucosa, ulcers and maybe even pseudopolyps. Um, these are basically polyps, lumps that are actually they're not cancerous. Andi. Importantly, on histology, you find descriptor obsesses because of the disruptive mucosa. But you also want find importantly, you won't find granulomas. I've highlighted that because you can contrast this with, um, disease, where you do get granulomas and we'll talk about that in a second. But that's the main point to remember until this legal features, The main thing you remember is that in other colitis patients usually present with bloody diarrhea. Bloody is the main word. Diarrhea, a swell as kind of lots of lots of poo. Symptoms like, you know, the urgency, the feeling of need, having to pull, having to prove very often associated abdominal pain as well. Okay, Crone's disease. So if you remember that initial endoscopy off other two colitis, and you look at this currencies one now because he's very different. Okay, so while it's the other two colitis, what, I'm gonna go back to that really quickly. As you could see, it's kind of everywhere the inflammation is through rows like it's not. It's everywhere. It's smooth. But in Crone's disease, you can see that it's quite patchy. Um, it is in these blobs is in these areas. It's not smooth, it's not. It's not throughout. But what differentiates it is the fact that it's it's throughout every one of them mucosa. So in all sort of colitis, Forgot to mention this is that the inflammation is restricted to the mucosa and the mucosa only maybe some mucosa and doesn't go past that. In Crone's disease, the inflammation can and erode all the way through the bowel wall. And this is really dangerous because it can erode and perforate and can cause things like fistulas, which is really bad in terms of pathophysiology wild. Also colitis with CD 40 hedge, two mediators, Currencies a CD 40 had 17 mediated. This is a different inflammatory response and cause the different inflammatory features like this. You get skip lesions, transmural inflammation, whereas other colitis smoking was protective in close disease. Smoking makes it worse looking can exacerbate or predispose somebody to developing this. Also, you see, cause is usually a lot like younger patients. So the most common ages of between 15 and 35 okay, again, in terms of our surgical, I just It was restricted the rectum and the large colon. But currents disease can be anywhere from the mouth all the way to your anus. It can happen anywhere, but most commonly affects the terminal ileum and the colon. Um, sorry about, um, edit the slide. This should say crone's disease, the's of the findings for Crone's disease. Again, you find alleviated Advantra markers and fecal calprotectin microscopically. Here you'll find noncaseating granuloma, which is basically like on microscopy. I couldn't get a picture. Relax you'll see this world, this boiling person of necrosis of necrotic cells, and that's called noncaseating granuloma, which you don't get in ultra two colitis. This currents disease. And also you'll see the information extending throughout all the world's off the bowel, not just the mucosa. On microscopic findings of an endoscopy, you find skip lesions like we saw a swell ascorbyl starting patterns, which is just like, you know, the very patchy, like if you just imagine cobblestone, which is very patchy and like looks like like stones on, Put together while and you see you might get bloody diarrhea. You typically get watery, non bloody diarrhea and ulcerative colitis. Usually you can get by diarrhea, but it's more common not to on. You will get symptoms of malabsorption as well. So commonly can someone tell you what the most common mile absorption symptoms might be due to increments? Disease? Um, on an it iron? Not quite yet. B 12. Yeah, be 12 vial salts. So because B 12 and bile salts are absorbed in the terminal, Ileum and Chron's disease most commonly effects the terminal ilium or local effect anywhere you most likely most commonly get smell of of symptoms do with total volume. So B 12 and bile salt my lips option on really quickly. You can get extra intestinal manifestations, things that happen outside your bowel. You can see clinically control times this construct with your eyes. You get inflammation off your sclera and the psoriasis like it alters your mouth. Angulus dermatitis is well, you can get these rashes on your legs. You can get osteoporosis. Um, get arthritis in like random joints on Only in Crone's you get Goldstone's and renal stones as well. Okay, I say these are related disease activity because the more severe the disease, the more likely the signs out to show up. Whereas you also have a list off manifestations that happen regardless of what stage the disease, your act, it can just be kind of It's associated So uveitis, um Pyoderma Gangrenosum, which is a like a necrotizing, much more ugly looking rash of a picture of it Later on your legs, as well as arthritis and clubbing. Andi, can someone tell me another some really common or two immune conditions that associated with the other two colitis that I like textbook altered colitis associated conditions? How does cause called God. Stones renal. Don't. I don't know. I couldn't tell you. It is one of those associations happy to look it up after this, but down syndrome of arthritis. Yeah, you're right. It's because actually be 27. You can? Yes, but the most common, like textbook one would be primary sclerosing cholangitis on order the hepatitis. So patients who have you see so many of them may develop plan was closing college isis, but may not work the other around. Um, so an order in appetite is a swell as well as ankylosing spondylitis. Is that Yes. There's just a picture of what these rashes look like for you to know. There's no great goods polities how these managed, um, To be honest, the first line treatment of both of these to induce remission are using aminosalicylate. So, like, five s A inhibitors, like a mesalamine on Ben, depending on the severity in other two colitis, you can add on steroids like prednisone. Um, on because his age typically add on is a vibrant surgery usually is most helpful ulcercolitis not cruise disease. But again, this depends on disease severity. How much it's affecting them. How symptomatic they are on. Do you can, like, cut out better that colon to help, basically. But the thing I want to talk about was different types of stoma bags. Uh, for some reason, I see these questions a lot on my think. It's just important to know how to different shape between them. Anybody tell me the difference between a colostomy and in the ostomy bag, polio, colostomy and ileostomy bag. Just any difference you can think of? Um, colostomy is flush. Know Spouts. Yeah, Lever. Yeah, she doesn't talk about anything else. It's in the name, really. Wife, um, sold Little conference. Where? The bowel. It's done exactly Exactly. Yeah, So you think about it. Your colon on is mawr. Well, it's everywhere, but it you put the colostomy bag on the left iliac fossa, which the left Where's the ileostomy? Which is where your small bowel mostly is, is the right electrode on? I think the most important thing to note is that the colostomy bag when it sticks in surgery, it sticks flush with the skin. It's stitched to join the skin where the ileostomy bag is spouted, where it's given this bit of a a spout like a like a plastic spouts that attach it to the skin. It's not directly it actually skin. The reason for this is because in your small bowel you have those brush for enzymes and they can be really toxic like they're really hard July tick. And if you flush them directly with the skin, that going to basically just eat your skin up and therefore you can't have them in direct contact with your skin, you could never stop. Um, and therefore you can use the spots. Where is the cost? Me? Bag it. That's not really a problem. And you can fax it directly with the skin. Your ostomy bag is also in the right. Iliac fossa contains urine and also spouted. Okay, not FDA. Oh, on this you just explained renal stones and Goldstone's and Chron's disease. Thank you. So do you want to launch the pool? Okay. A patient confirmed current disease develops paraseizures in her feet. She says she has had multiple falls a lot in the past weeks. On examination, there is complete loss of perception, vibration order the cause of this and I'm gonna call it They're very much time. Yes. Smashed it correct is B 12 deficiency. Um, basically, the fact that chest cause of it disease means it's more slightly going affect the terminal ileum, which is B 12, is absorbed. And therefore she'll get B 12 deficiency symptoms like peripheral neuropathy, which is what she has here. Great. Okay. C diff. I'm actually gonna get over this because you don't have time, but literally ups. I've explained everything you need to know about C. Diff on the slides is very easily like explain here. Um, you have any questions about it? The CRV emails later, but I think it's quite self explanatory. So I want to go on the bowel imaging, which is the bit that might be used with your skis on a little bit. About 10 minutes on this. Um, yeah. So abdominal X rays. X rays can be intimidating and hard to approach, but let's try to break it down and create a system to approach them that can help you. So, what do you use a normal X ray for? Why would you need it if somebody comes in with evidence off any kind of bowel obstruction, any kind of inflammation, like if you think there are some kind of colitis, or if you suspect something as bad as about corporation, you would get X ray. Done immediately on bit would help you kind of get idea what's going on in terms off the basics of the abdominal X ray. You need to be able to differentiate between small about large about what they look like. Okay, so the first thing just to look at is where they're located. Your small bowel, as you can imagine, comes start from your stomach and kind of loops on the center and then goes to the coast the right. Therefore, it's centrally located. Where is the large bowel? Kind of you're sending colon chance was colon and you're descending colon, and therefore it's in the periphery. It's more about contains most like liquids, liquidy food on there. If you're not gonna see much gas in it with a large about has a lot more gas and solid things, that's what you're going to see. The damn. It obviously is lot smaller, the small bowel, but the name says you can look at that as well. On another really characteristic sign is the little bits of mucosa that that make the ballot really lumpy. So it looks like a stack of coins. The small bowel Because these mucosal bets go all around the diameter off the small bowel where, as in the large bowel, they don't go all the way. They only go a bit of the way. So when you see these markings, going around the bowel is not gonna go all the way in the large bowel. That's good. Do different shading as well on the pneumonic. I'm going to use to kind of break down our normal X rays to kind of help interpret them is gases, masses, bones and stones. If you can drop that order, use that order to help you scan, and I have to actually to see what's going on. Okay, so here is an X ray, and I would like somebody to interpret it for me. If anybody is, like, comfortable enough to, um, you themselves and have a girl, that would be amazing would be good practice, but no worries have not, um, we're all here to learn guys. Literally. Give it a go. Um, okay. Sorry. Actually, don't do that. Uh, I just realized we're recording and probably should it um, the X ray interpretation. Demonic is gases, masses, bones and stones. I'll go over that further anyways. Um, concern Put in the chart what the first thing would be when you look at this X ray patient details. Yes, exactly. Okay. On then and then what's name? Date? Birth name is a birth. When comparison. Yes, Yes. Perfect. Good time taken. Good. What's next? Based on my previous side gases. Okay, fine. So what can you see? Validation. Dollars. A shin of what's selling colon. Does that look gastro to your just a little dilated, if that's normal, or did you have abnormal Upper left? Cordiant's gassed filled. Do you guys think that that bit of gas is no move? Yes, it's normal. Okay, like I mentioned earlier, your large bowel tends to have gas and feces in it. It's normal to see gas in large bowel. Look at the diameter. It doesn't look very, extremely distended. And that was unlikely to be abnormally descended with gas bones in terms of bones are in terms of masses. Can you guys see any abnormal masses at all? No. Yeah. They know of no masses. Okay, Bones, what about the bones? anything to note to the bones. The other is is normal. Exactly. No good. Good. And any stones that you can note, they look fine. No, exactly. This is a normal abdominal X ray guys. It is normal on D three. Gas against years normal. Large about. That's normal. It's not abnormally distended. If you look over here on the periphery, you could see the large body to the hospital. Over here is well, that make it look like large bowel. It doesn't go all the way across. Okay, um, that makes the large. Well, there's nothing really to note here. You could see bits of small bowel over here, okay? With the bit of, like, a bit of because some of the value a condom and days that they're very thin. They go all the way across over there. It's hard to see, but this is a normal of normal, actually. Cool. The gas is what you're looking for. Okay, So this abdominal, actually, for example, I would say this is abnormal. If you look at this better bowel here, this looks a bit up normally descended to me. Okay. What I'm gonna look at first is the location it's located centrally. Okay. Therefore, I'm already thinking are maybe it's small bowel. All right, then. I'm looking at the value A convent, a Z or the hasta. I'm deciding if you look at it is very thin. It goes all the way across and their phone thing gain. That's probably by the convent is in the car. Maybe that small bowel. And I think that looks fatter than usual. And therefore, obviously, you need a much better clinical picture with this. But, you know, that would be kind of this. What are abdominal X ray of small bowel obstruction might look like. Okay, it's a multiple gas for dilated loops of bowel. You can see the value. A convent is this one. Can anybody tell me what I'm looking at? What? What did the Yellow arrows pointing yet? This is a bit hard and we're gonna sigmoid volvulus. No. How do you know where the dieticians you to obstruction or not? Um, without the clinical picture, you don't know if you need. You need a history. You need a drink of background. So just the next way, you can tell occasions. Not really, but I could see what you mean that mild irritation? No, actually, this person has colitis, and it's called a regular sign where there's so much gas in the bowel that it's gonna kind of highlight the mucosal linings off. That better about this is called regular sign. Okay, when somebody has no more person, which is when there's gas in that Paris knee. Um, okay, um, what's gonna happen is that all this gas can also float upwards. Who has the diaphragm and give you what's called the dorm sign over here on. And that's what it is. Okay, next one, you don't gases. That's mainly what you're looking for now. Somewhat Mass is looking for any up, like obviously any abnormal enlargement you might see. Unlock liver shadow, Can't even liver usually very well because, you know it's a mask, but you might be able to see that it's particularly large little bit shadow or spleen. But the mucosa lining is good. Good mass. Look for Can anybody tell me what this might be? This is really This is really hard. Not gonna lie to you. I wouldn't have known this. Um let's take a while. Yes. Look at the location. Look where it is on the abdomen. Um, I'm looking some kind of mask fluid thing called stably Stone it it is pointing at more of a, uh, an area. Don't worry about, actually, it's very very mean of me. This is a ruptured abdominal aortic aneurysm. Okay, basically, what you can see is that the bits off the aorta are really, like distended. And you're seeing, like, the distended science sides here. Okay, that what you're seeing? Very mean of me, But I started being just in sick. Go bones, Bones, you're looking at any fractures. Are you looking for signs of osteoporosis? Any degenerative disease you can look for, um, on the spine as well as the same cream. And the pelvis is Well, this could either be incidental finding that could kind of kind of pointing towards something if you want. Um, so this one, for example, you can see lumbar scoliosis over there. Um, so that's an example. So you might find, you know, normal X ray and finally stones. You looking for mainly renal stones? Okay. Um, do you want to kind of trace? You want to trace all the way? Um, the course of the Eurasia from the renal pelvis on my hair here and you want to go downwards along the tips, the lumbar spine looking for it medially the bladder and go down there on this is a renal stone. It's a massive one. It's a very obvious one, but it may not be this big. Usually okay, on day, finally, some quick ones for you guys to try and identify. Can you have a go at looking at this abdurixit and give me an idea of what you think it might be? So use that use that process of, don't you? Okay, look at the, um, small and large bowel Let go by their located to decide whether it's more a large then decide gases, masses, bones and stones Small bowel obstruction at wise small bowel obstruction more is the small bowel Why is it not large bowel? What we see I love the comment is, um sorry, guys, is actually hasta um So if you look how dilated it is, it's massive like that Wouldn't you would not get that much that that big A dial aged allocation with small bowel like on day. It's just a lot of bacon wider on you can see the hospital actually go all the way. I know it seems like it, but it actually doesn't. And the location is well is located on the side, not the center there. Force more likely to be large bowel obstruction. Okay, This one, By the way, You know all of these about obstruction as there's other stuff. So just in case, um, all sort of color, it is interesting. I see what you mean, But that's not quite the lead pipe appearance. That's not a lead pipe would have, like, would not have those little squiggles. It be quite flat. Toxic megacolon. No, it's not valid enough to be talking like a colon from printing. Exactly. Well done, guys at the Santa Cholitis. Okay, so you see, these comforting patterns are wrong along the mucosa. That's the closest. Okay, this one? Yes. Toxic megacolon. This is a big, really late, like, really life threatening thing. It's optimally colon. It's like it's a sign of like, a systemic toxicity happening extremely dilated on the horse. Start basically gone. This is really bad. This is a bad emergency. Okay, cool. Onda. Finally, one last X ray. Um, most this no person in perfect. Yes. If you have perforation of your bowel, the gas is going to escape the gas gonna go upwards. And it's going to cause these gay cious like areas Bill your diaphragm, and that's what you're seeing here. Great on. But if you had a barium study done, you might see this cobblestone, some printed pattern on crows disease in somebody's barium study the MCT on. But, um, if somebody had a malignancy in about, you might find this apple core stricture where the neoplasms on either side Onda it's on. The normal bit of colon is like in the middle is called a topical stricture and is you take a new plastic growths in about Okay, that's me. Thank you guys for that are overrun. Um, you know, have been impossible to Toby, who has a really good presentation on infectious diarrhea and colorectal cancer. So we Yeah, Okay. Thank you. Flats on a, um I was really compressive on for a good listen to you three. Hopefully you have enough energy left to learn about infectious diarrhea on colorectal cancer. Okay, I'm going to start off by talking about code actual cancer. I know it's a hard. Uh um, They talk about on this important in bowel obstruction, but from a clinical presentation point of view, patients will be seen with fatigue and shortness of breath, and this is due to anemia. So when you get current rectal cancer, you end up getting a new vessel formation on these vessels will be weak and prone to rupture. And then when they rupture on you get blood loss three through your bowel on This isn't always obvious. Invisible can be. And that's another reason why you might get blood in your stools in colorectal cancer on get changed in bowel habits. PR Bleeding Like I mentioned 10 is Nece that sensation that you need Teo past stores, and that's literally due to the maths. And then, as a Honda is talking about, you got, um, large bowel obstruction. If the main emergency and canned rectal cancer on the obstruction can also need to perforation. Okay, Onda risk factors. So 50% of cases of colorectal cancer are actually preventable. Onda. This is due to your diet smoking on alcohol history. You can also be creative space todo after cancer due to family history, which I'll go into on D. Um, Also, I'd be the convictions like cranes and you see Okay, so early s p a. Um so if I could get a pole up, Okay. And 82 year old male, who has recently been diagnosed about cancer. You see that developed abdominal pain and vomiting on examination. His abdomen is distended and painful. He reports he hasn't passed those in 48 hours. Hopefully a lot of year. We're listening starters. Lecter. Where is this nines Obstruction, right, femoral Few. Okay. Oh, and, uh Okay, so this man's obstruction within was in the large intestine on, but that's because of colorectal cancer. First leave most common in the large intestine, as opposed to Teo this morning test in, um, but also not by the structure. More comment from the most common cause of my large bowel. Obstruction is kind of active cancer on. As for the esophagus on, you wouldn't get the same presentation cause a lot of his symptoms were abdominal. Great. The esophagus. You've got more problems with swallowing. Okay. Okay, um, onto the pathophysiology. So normally in health, your body controls growth and regulates that with closer oncogene on DCI Ms Presses so tumor suppresses a response boot for stopping yourself, dividing well her to conquer genes. Response School for speeding up so division on making the proteins to do that. So a nice analogy. It's. Think of a car on protonic, a genes of the engine driving the car forward. Well, she missed. It presses on the brakes so that cars moving nice and gradually at the speed you want it to your normal growth. That okay, however, you can get mutations in Proton genes, which then causes, and Uncle Gene. It's a the rast gene communicate to K Ras, and this caused this circulation on an increase. I'm in some great and you can get cancer. So here the engines racking overdrive and the car's going great a crack and then too much brace on getting the getting cancer. Now Chima suppresses our little bit different because I when a mutate, they're not causing the cards to speed up. It's just stopping the car from slowing down on. Do you have two genes? I'm sorry you have T crimes aims for the same type, so you have to jamespark siz on fabric. In this process, a PC is achiness press a gene on. Did you have two of these? Um, so if one gets damaged, it's not the end of the world because you still have one. Preferred providing the brakes. So here the cars moving fast there. But it's not that fast because you still got one functional gene. Um, however, if you end up with a mutation in the second gene, then you have no genius presses, and that's when you get cancer on. I'll go into the APC gene a little bit more, uh, as the presentation prism. Yeah, inherited condition related to Colorado. So quite nicely I'm going to talk about if a P S o f a p is familiar name Eclipse Pretty. Post this on the condition where on the whole of your large bowel will be covered in polyps, maybe hundreds of them on its duty. But the fact in the APC gene So a polyp in itself isn't cancer. However, the pool it can develop into cancer on If you don't get surgery to remove the large bowel, you end up definitely getting cancer. Um, 99% chance, however, and often if the polyps have found, then you end up getting surgery. Teo, remove them, and then you also get extra. Uh huh. Kalanick manifestations such as congenital hypertrophy. But the rational pigment at the, um that can be seen in a black dot on the endoscopy and then gardeners and drain on their coat syndrome. It's when you get extra clonic teamers or CNS tumor. Um, his. Here's a picture of the large bowel. You see, he's got 100 hundreds polyps on, and then I mentioned J pouch surgery. That's just the surgery done to remove the entire two of the not intestine on. Um, it's done by folding able small intestine from this chase shape. Um, which attach is Teo? The in a cloud. Um, and then that allows the patient have some sort control of bowel movement. Okay, so okay, another SBA a man presents being concerned about kind of active cancer. Mother had f a T. That's that's a mutation. The APC gene. Um, how is the APC gene? Best described. Okay, give you five more seconds. Cool. Three. See you one. Okay. Okay. The correct answer, which makes you got was the genius precedent to control division. Um um, that, like, is that before the APC gene is a genius. Presser. Um however, it's not a photo genius pressure, because I've asked what the normal A P C protein is best described as on D. It looks like mostly you got that correct. So I went, I went. I spent long explaining that. Okay, Lynch syndrome. The list on drone is a lot more common than on half a P on it. Seeing rid decrease on defect in mismatch repair genes Um, s H one and two. Okay, on. As a result, you get what's called microsatellite. Instability really get repeated sections of DNA a different length. Um so this is because the repeated sections would normally be the same. However, because there's been damage which hasn't been repaired because and mutation. Then you end up with different lengths of these genes. Um, and then just a nice thing to remember CEO. It's a new monitor for, um, the other cancers that you can get from lips and drain so I can about do but also and they meet you and they vary in on the risk of getting coronary actor and the mitral. Cancer is actually the same for lips and drink, So you're not more likely to get colorectal with an endometrial, Obviously, um, no. In May was on Joga syndrome. So this is a lot that comment on lynch syndrome? Um, that's one that you will be our starting exams on this is GI to the STK 11 mutation. Um, his old same with dominant on D. Um, instead of endometrial on a very in cancer, you're increased risk of breast ovarian cancer. I'm basically every patient went up for these hyperpigmented lips. I'm like, you can see in the face. So, um and then you also got these, um, hum optometrist polyps on that. Not like the comment afternoon, Mrs Polyps, And then more distorted in shape on their characteristic of put shakers and drink okay for screening that every two years on men and women are offered, um, screening on best from the age of 60 t 74. But we'll say 56 year old to included in that on you might have heard a fecal occult blood test, and that's what used to be used. How about the majority, um, of have a board, two years fecal immunochemical test bridge. Um, it's very similar in the sense that it detects small amounts of blood in the stools. And then if this is positive patients who referred, you can ask me, Um and then here is just the urgent to week referral. So for annual for 60 with iron deficient anemia, change in bowel habits, fecal occult blood and testing or rectal or abdominal mass. A patient is diagnosed with aggressive colon have no caste namer. His sister died from the same. I'm disease age 40. His mother died from ovarian cancer age 43. And what's the most likely cause off his cancer? Yeah, five seconds to three. Teo one. Yeah, nice guys. And we smash that. So most of you said links and dream on you'd be correct, because Liston Drome is by far the most common of all the conditions upset on. You're likely to get into mutual and ovarian cancer. I saw a few of you put a picture you get syndrome on. That does increase your risk off. Um, kind of back to cancer. Um, but we'll also be very cancer. How about that? Let's say syndrome is much more common on Onda. Um, yeah, you know, I smashed that. Say, I'm not going to explain it much more. A condition I didn't mention, um is and, um I I associate it with the process or sorry, I'm my head. And I hate that should be associated polyposis on. That's an autosomal recessive condition, which is very rare on but with the other conditions I've mentioned or to say more dominant. Um, just clarify. That should say, Am I hate, like, any question point Okay. Onto infectious diarrhea. Now, this is a topic that, um, took me a while to get my head around just because I I really prevent present. So similarly. How is that? Um I think there's a nice rate 80 categorize er, um, firstly, they These are the risk factors, so breathe in and brought it. Use, um, increases your risk off clostridium difficile on these specific and protects the clindamycin amoxicillin. Um, it's follows Boren's. Such such as ceftriaxone. They increase your rescue. See death than troppo. I'll go into that later. Um, gastroenteritis that common infections and diverticulitis and get an order a judge and then obviously underlying to see such a Z b c or cranes. Now, the two main ways that I found categorized Die bread infectious diarrhea is and so toxic or invasive. So and then try toxic, um, conditions yet infection that causes malabsorption from the GI tract that smell absorption of irons. But also, you get IV doctor lions specifically cool, right irons, um on this is normally GI harm from a toxin. So you might have cholera course being an effective chloride irons on. It's not due to the pathogen invading, um, the got war instead of the toxin that's causing the heart on. That's why you get watery. Diarrhea. Um, you don't get any invasion from leukocytes and you don't get blood. I love it in invasive diarrhea, and this is cells causing direct damage to the back. Got bored, Um, because the cells are infiltrating. That's where you get leukocytosis on a fever because the information and then the damage was, of course, is blood. So that's where you get blood in the stools herself. They're just going to stop by there in intro Toxic on. These are all examples of watery diarrhea. Okay, say the Communist form of traveler's diarrhea is by far intro toxigenic E. Coli Onda. Just make that that's go about one day incubation period, then yada is another cause on that's got a much longer incubation period of more than seven days on you get it from drinking contaminated water, often in hikers and campus, um, stuff or es. It's it's just, um, a bacteria that tends to come up pull over the place on this has a very short incubation period. Similarly, bacillus serious has, um, very short incubation period. Just wanted six hours on. That's what you got, man. You eat reheated rice. So as in units student, you might often get told you shouldn't eat reheated rice, but lots people do anyway, on that's why. Okay, And then we've already talked about Clostridium difficile on and that's treated with or vancomycin that last line. Okay, the neighborhood bacteria and viruses norovirus, um, makes people work, gets kids the most common cause of gastro and chartists on dust. Because it's very contagious on D. Um, it's also a common and house to a school is nasty ahead and increase shit on often this characterized by vomiting Reggie don't get And then off the other virus. Okay, Andre to virus. Um, there's a good vaccine. Correct virus, however, doesn't mean you won't get rid of virus. And in fact, almost everyone over the age of five had rotavirus at some point that they would have just had mild disease because of that factor. Nation okay on It's a leading causes severe diarrhea worldwide on it could be facing in Children moving on to a basic diarrhea say on salmonella and Perica. Obviously, everyone knows about some other, um, eggs and chicken. Um, and that's organic. Got wants to day incubation period. I don't know why salmonella studios or the headlines, but compiler back to the gym, and it's actually the most common, um, most common cause of bacterial gastroenteritis. Um, Andi. Oddly, you get complications. Such a Z Gillet Elaine bar syndrome on reactive arthritis. So that's question you might get asked. Okay on that. Another complication I've written for work together on D um E. Coli. Their A 157 is hate us. So that's hemolytic your ear. You remix and drive. Um, um, that could be really harmful on could be fatal. So together on D A koala koala. It's very want 57. Um, you gotta watch out for on D, um, again prevents. Present very similarly norovirus shigella vomiting after pain. Um, where is Nicolai? 0157. It's more for an eating raw meat or touching infected infected animals. Um, because they're in fact did. In fact, there's a lot of these on or all of these can present with but lab in the diagram. Okay, so a patient comes in complaining. Watery diarrhea. They do not have a fever and report no blood in their stores. They tell you they returned from Mexico yesterday on. The patient is concerned because she ate reheated rice three days ago. What's the most likely cause of organism of the effect of diarrhea? Did I ever pull up, Please, Neck. Okay. Give you a couple more seconds. Bye. Cool. Three. The one. Okay, stop the polar. It's I, um I'm a huge trapped into this question. Um, so although she ate rice three days ago, she's also returned from Mexico yesterday on. As a result, ENTEROTOXIGENIC. Coli is the most common form of traveler's diarrhea. So that is actually the single best answer. As for basilisk areas, um, that could be true because she did eat reheated rice. How that the incubation period for that, it's just 1 to 6 hours as the Rices eats and three days ago. So if she was going to get it all from that, it would have happened a long time before this presentation. Okay? That sort of being sneaky that, um hopefully that will help you remember that. Enter toxigenic E. Coli. It's the most common form of traveler's diarrhea. Okay, on that brings my part the presentation to the end. Thank you guys. So hanging about, Um, sorry we have around a bit. Onda. Yeah. We would be very grateful if you could read out in the pill out the feedback forms so we can help improve our sessions on dust. Make this teethies teaching sessions better after he had more enjoyable and so much. Both of you. Thank you. Both smashed it. Really well done. So no. Could you stop the recording? Is that okay?