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Hello. So I am or I know one of the two of you. Ok. So I'm or one of the gastro ss today, I'm gonna speak on a gastroenterology subject. So I'm gonna speak on acute severe ulcerative colitis and the management of it. So I just thought I'd start with a little bit of a background on ulcerative colitis. So it's the most common form of inflammatory bowel disease. It has an equal, um there's an equal amount of males affected as there are females affected. It's characterized by diffuse continuous inflammation that is confined to the mucosa and the submucosa of the colon. So the inflammation that usually originates in the, in the rectum. Um and that would be the most common site of ulcerative colitis and it can extend proximally. Um And it does so in a continuous manner, which makes it different from Crohn's. Um it never extends uh beyond the e ileocecal valve. There is an increased risk of colorectal cancer. So patients with ulcerative colitis, they should have colonoscopies every sort of 2 to 3 years as a screening process. But also with that, um there is an association with the longer duration for which they have ulcerative cutis. The increased risk of colorectal cancer, is there, the longer the duration and, and the more severe the ulcerative colitis, the increased risk of colorectal cancer is there as well. So, some of the symptoms then, uh, we may see when patients present to any. And I thought I'd do this topic basically because we've had quite a lot of people present recently with, um, flares of, um, quite sort of severe flares of their ulcerative colitis. So I thought it was quite topical, you know, to help people with and stuff. So some of the symptoms that they may experience is some diarrhea, some uh fecal urgency plus or minus incontinence. They can describe um, defecation pain and that they get relief whenever the bowels open. Um, quite often the people, uh, patients will describe, um, getting up in the middle of the night to go to the toilet, they'll describe some tenesmus, some tummy pain and then we'll have some systemic upset in the terms of uh fatigue, malaise anorexia and fever. So in terms of assessment, it's like any patients you see in it's ABC D and should do APR exam as part of your assessment with these patients. Um, initial sort of investigations. Um, we look for blood count, looking for anemia, looking for white cell count. You're looking for ue any signs of dehydration NFT CRP. Um, and then some of the electrolytes to ensure that the electrolytes are ok. Um, in the context of these patients, probably presenting with um, not really and drinking and, and lots of diarrhea. So, with an abdominal x-ray, uh, you're looking for any evidence of toxic megacolon. Um, it's important to send still cultures for or s but also c diff as well. So this is kind of what we'll focus on is, is, I guess how we should be looking at the severity of symptoms and how we should be classifying that and then what to do based whenever people fall into this severe, er, group, so true love and wits criteria. Has anybody heard of it? Seen it? Yeah. So really, whenever you're seeing patients, um, in any percent of these symptoms, um, it's really important to, uh, look up the guidelines on this and there is, um, I don't know if you are familiar on the hub, there is a acute severe, uh, colitis protocol management. Anybody seen it. So, it's, um, it's a really, really good guide. It sort of tells you what investigations are important, it gives you this, uh, table and it then gives you the onward management. So it's a really, really good quick, um, guide and to make sure you cover everything with that. And specifically today, what we'll be looking at is the severe, um, aspect of it, which is classified as greater than six bloody stools per day plus one of the other points here. It's also important to sort of flag up with this table. It doesn't necessarily mean that they don't have to, they would still be classed as a severe fla if, um, the stools aren't bloody as well. Thank you very much. Um, yeah, so it's still classed as a severe flare even if the stools aren't bloody, but there's greater than six and one of the other, um, components are, are met. There we go. So then, oh, admit, thanks. Keep pointing that out as we go if that's ok. Uh So I guess why is it important to be able to know how to recognize these patients and treat them appropriately? So, 25% of patients with ulcerative colitis will have an admission to hospital with an acute severe flare. And that's kind of representative, I guess it's been gastro almost two months now and we've had quite a lot of people in the last few weeks. So it's common enough and there's a significant uh morbidity and mortality um associated with it. So it's important to promptly um have these patients on the appropriate management. Um And it's important for both gastroenterology and colorectal surgeons to be involved and aware of these patients. So, the management and this is very clear in the protocol, um which is very helpful. So it's really important to give um enoxaparin and to start IV hydrocortisone and to ensure that they're on bone protection and then to start them on the five A S A enema and suppositories, some oral five A S A. Um and then some paracetamol for pain. So special considerations, it's important to avoid nonsteroidals. It's felt that there is, and there was kind of mixed guidance in the literature about this. But um, on the whole, it's important to, it's felt that we should avoid nonsteroidals, it's felt that there is a, um, association with um, a trigger in the onset or a relapse of ulcerative colitis. It's also important to avoid antidiarrheal medications, anticholinergics and opiates so that these can, um, exacerbate dilatation of the colon and lead to di more difficulties with these patients. Um, so I thought I'd flag this up before because I know it's kind of come up whenever we've been collecting people in. Um, I guess sometimes people, um, whenever they see people on the take, um, they can be a bit concerned about prescribing Noxa for these patients because they come in with lots of bloody diarrhea. I guess it's really important to remember that patients with inflammatory bowel disease are at increased risk of blood clots in the first place at baseline whenever they're there and having an active flare, this increases to about eight times. So it's quite a significant increase and therefore, it always should be started unless the person is hemodynamically unstable from, from a breathing perspective. Um, and I guess the question is you might think, why are they so had such a high risk of bleeding or such a high risk of uh forming blood clots. And the literature sort of points out that basically with an acute flare and because there is a systemic inflammatory response, there's high levels of coagulation factors and prothrombotic cytokines, which predispose them then to um quite a significant risk of, of blood clots. So, um it's always important to test for um C diff infections in these patients. Um interestingly, um it's more common um to have c diff in ulcerative colitis than it is Crohn's. And unlike the general population. So we often think of patients with C diff, we think of the elderly people, um patients that have been on lots of antibiotics. Um we always sort of think of always of that cohort of patients. But actually, uh patients with ulcerative colitis are, it tends to be that they can still get c diff at younger ages than we would expect the general population. And, and there's not necessarily just as sort of a heavy use of antibiotics and PP I use as there is with the general population. So it's just important to always test for it. Um The initial management of the patient that has a severe flare and also c diff is to commence antibiotics and steroids as well. So if there's no response to the initial therapy, um so it's estimated that 30 to 40% of patients fail to respond to that intravenous steroids alone. And usually their response is reviewed daily. And if the patient doesn't respond by day three. They should have, um, a review by the surgical team just to put on their radar and get an assessment. I guess that they're not going and they're not clinically improving. So, if the steroids don't work, I guess, then the next line is, um, what's called rescue medical therapy. And that's, um, in form of Infliximab and, uh, cycloSPORINE important. Um, and I guess that's more important, I guess for the Gastro team is, is that before you would, um, start anybody on biologics, there's a, a sort of a screen of blood tests and investigations that you have to do, um, mainly the blood test in involved, you know, screen for viruses, um, screening for hepatitis HIV CMV and TB screening. Um, and that's all before you would start somebody on biological therapy. So patients then that don't respond to the rescue med medical therapy that started and then they will definitely need, um, further surgical input in relation to whether or not they would actually need an emergency colectomy and then it indications for a colectomy. So, um, if there's evidence on admission that the patient has toxic dilatation, um, they should have intensive medical therapy within as much 24 to 48 hours, but that's providing that they are stable enough to sort of trial that intensive medical therapy if they don't respond within 48 hours or they develop di of their colon whenever medical therapy um, is ongoing. They should um be referred urgently to surgery, surgeons for a review of whether or not they need to proceed with surgery. So a second indication would be a perforation or a massive lead, a failure to improve on biological therapy. That's really fa somebody's just added my. So that's really the sort of crux of my talk. Has anybody got any questions? So I think most pe the second half are uh can quite it. Um, but, uh, any questions, did you, is any questions about any things have been through to the ones that missed the end of it? So it start to pop up so much. All right. Just start maybe. Right. It was a brief talk. Pardon? Oh, any questions on, oo. Um, yeah, I think we're all good. Yeah. Oh.