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Uh Hi, everyone. My name is Angela. I'm an F one working in Oxford. Um I literally did finals like less than a year ago. So um it feels really crazy to be presenting and giving talks on this now. Um Yeah, so without further ado, I'm just kinda gonna launch into it. Let me know at any point like if you want to like stop or if you want me to go over something. I like happy to answer questions during tutorial. Um Michel, I actually can't see the chart. So could you just like tell me if any questions come up? Would that be? All right? Yeah, I'll let you know. Thank you. Um So yeah, so y you're on mute again? OK. No. Um I know you guys are sitting the m this year and the like list is like a massive long requirements of what exactly need to know. So I've tried to like um like throw that away into like symptoms and conditions. So like things you should know for like the writtens and for cases and then like conditions that you should know. Um I just want to kind of caveat this with the fact that I can't cover the entire um sort of curriculum in one go. It's physically not possible for me. I've tried to cover what I think is patent and things that I find people find confusing and I've tried to kind of go into a bit more depth so it's gonna be more depth and less breath. Um because there are lots of things in finals which are just memorization and I'm trying to cover things conceptually. Um So this for me is supposed to represent that. Um Yeah, and if at any point you are confused like or you're confused like after the lectures are I'm happy to take questions by email, feel free to email me. I'm happy to answer. Um So yeah, so our first SBA is on ment. I think I put the code up for the ment at the beginning. Um Let me if I switch to ment, I think you guys should be able to see it. So I'm gonna do that. Um So you're the working in a and you've been asked to see Michelle Roberts, a 53 year old woman who comes in complaining of pain in her stomach. She said that it used to be intermittent, but now it's a constant sharp pain. It's in the right upper part of her stomach. She has been worried that she has a stomach problem and has been feeling nauseous all day on examination. She is tender in the right upper quadrant but is not notably jaundiced, no changes to urine or stool, no recent travel abroad or changes to diet. I have some obs for you and her most recent set of bloods. What's the most likely diagnosis? I'm just gonna quickly switch to the m so I can open it. Just give me one second. Um Yeah, and the mentality code is 39875967 for you an answer. Let me just give you a few moments to read through and pick what you think the best answer is. Oh, ok. Um So yeah, it's kind of cystitis for those guys. Um So in your right upper quadrant, you've got a lot of different um sort of organs and bits and pieces. So this is a very rudimentary diagram which kind of demonstrates what exactly can go on in the right upper quadrant that can cause issues. So you obviously have your liver, your gallbladder, your biliary tree, you have your duodenum and you have your pancreas. Um And basically issues can arise with all of these organs and cause right upper quadrant pain. Um So I'm gonna start by just explaining a little bit about sort of the different types of bilary problems that you can get. Um So here's my little kind of diagram that I agree on pathway. Um So your liver connects to your common hepatic duct. So you have your right hepatic duct and your left hepatic duct and then you get your cystic duct joining in and that forms your common bile duct. And essentially, you can have sort of problems like you can have gallstones arising in any kind of part of this sort of the lower half of the biliary tree and causing problems. So, starting with cholelithiasis, which is literally just gastro inflammation in the gallbladder. These are usually asymptomatic. So people don't really feel any symptoms with this, but occasionally these can kind of move into the cystic duct and then can go on to cause inflammation, which is cholecystitis. Um You can also just get inflammation of the gallbladder while it's um so you can get like information Google when it's not, there's not even like a ster in there. Um So those are specific cases which can arise like post ICU and in terms of exhibit pressure as well. Um or if you had like an insult to the gallbladder as well, it's not related to um a gallstone moving further down, then you have choledocolithiasis, which is actually just formation of a gallstone in the common bile duct, which is not actually causing any problems with um like inflammation or anything like that or anything being backed up. And then you have sort of ascending cholangitis, which is where you get like inflammation everywhere. Um And that can lead to your very typical symptoms of your like, right, right, right. Upper quadrant pain and jaundice, um kind of form your chaco triad which is very kind of typical of cholangitis and then moving into your like Raynaud's pentad when you have like the low BP and the confusion as well. Um So this is considered to be an emergency, like it's really important that these patients get managed in the hospital really quickly as it has very low. Um sort of, it's like not very good prognostically. Um survival rates are quite low as well. Um So many patients will need potentially an ICU stay if they have cholangitis as well. Um So it's really important that these patients get treated urgently. Um then you have your pancreas and then if you get sort of a gallstone which blocks the um of vata, which is the most narrow part of your um of common bile duct tract, then it can cause a pancreatitis as well. So I think it's something that 85% of pancreatitis like acute pancreatitis is caused by gallstones. So it's a really important thing to be considering when you're looking at the cause of a pancreatitis, say, yeah. Um and then just generally about gallstone management. So with asymptomatic gallstones, it's usually a watch and wait strategy that's sort of employed and you kind of just expect that something will happen and when it becomes symptomatic, the risks of taking someone to surgery just really outweigh the benefits of them having their gallbladder out. And so as a result, it's usually just um expectant management, then if you have a cholecystitis, um, you have anti antibiotics and analgesia. It used to be that you give them antibiotics to wait six weeks for the inflammation to go down and then you take the gallbladder out. But now it's actually there's an advocate for early laparoscopic cholecystectomy within a week of diagnosis, which is supposed to kind of need to take the gallbladder out. Um, the complications I've listed here are actually kind of risks of cholecystectomy and just leaving the cholecystitis as well. Um So specific, like you may get asked in the exam or the written, any specific kind of complications you're aware of, of course of cholecystitis. So this is some listed for you there and then cholangitis again. So you can have the complications that you have with cholecystitis and then you can have like kind of acute pancreatitis, inadequate bry draining hepatic a abscesses as well. The way that cholangitis is managed is with IV antibiotics and analgesia. And then you do an ERCP after 24 to 48 hours and this is just like your ERCP kind of process. So essentially, it's just a really, really long endoscope which is kind of put down the so esophagus all the way through the stomach into the duodenum. And then the aim is to kind of just take out and extract kind of the bile, the stone that's causing the problem. Um So yeah, so that's um moving on to pancreatitis specifically. So, um you may be familiar with sort of I get smashed. Um a kind of acronym that people used to remember things. I do want to highlight that you get like it's supposed to be like 15% and up sorry. Um like no sorry gallstones and ethanols around 85% of all kind of incidences of in incidences of pancreatitis. I do want to also point out that especially in kind of patients who may be at risk of getting cancers and things. It's worth considering hypercalcemia as a cause of pancreatitis as it can be one of the first indications that someone may have a cancer and it's usually not really picked up. So worth considering that if someone does come in with the pancreatitis and they don't have any gallstones and they don't really drink a lot of alcohol. It is there is a potential that they could have a cancer. So it's worth doing like a cancer screen. Um People can also have like pancreatitis after E RCP. So after the removal of the gall stone just because it can cause inflammation to the area as well. Um It's worth mentioning the pan the pancreas is a retroperitoneal organ. So you'll get sort of acute pain and you may, patients may feel it going to their back as well. Um And then one of the pathognomonic kind of signs are like Turners, um uh Turners and Collins signs. These are really, really rare. I don't think I've ever seen a patient who's had these. Um, but they're just things to know for exams. And nowadays, the modified Glasgow II criteria is what is, what is used to predict the severity of pancreatitis. So, while it's hypercalcemia, that kind of is a cause of pancreatitis, hypocalcemia is sort of supposed to be a negative prognostic feature. So that's just something worth keeping your head as it comes up quite a lot in finals exams. Um So yeah, so for management, the way the pancreatitis is managed is very much like a, it's a very holistic strategy. Um You want to admit patients, you want to really make sure they're medically optimized. So you want to be giving them fluids, you wanna make like monitoring their input output, you want to be giving them a lot of pain management because like pancreatitis is a very painful thing to have um worth giving considering IV antibiotics. But that's sort of not routinely offered. Patients are generally kept nail by mouth. And if they are not improving within 5 to 10 days, then they will consider starting gin energy feeding or potentially TPN, then you can put like a R treatment. If they have like ongoing vomiting. VTE prophylaxis is offered to all inpatients and so early nutritional support as well. Just kind of making sure they're optimized because there's not a lot that can be done from pancreatitis perspective. And then in terms of complications, the main things to look out for are pancreatic pseudocyst, peripancreatic fluid collections and S um S can put for patients in ICU as well. So it's just worth considering keeping those things in the back of your mind. Um So yeah, so moving on. So PSC and PBC, like I know these are covered quite extensively in path. So I'm not going to go over them in a lot of detail, but essentially the primary differentiation between sort of PBC. So PBC is sort of intrahepatic involvement with fatigue and pruritus. You have antimitochondrial antibodies and complications of cirrhosis. And it's usually treated with aci deoxycholic acid um which is not considered to be like prognostic and more just helps with sort of symptom management. Whereas primary sc in cholangitis has that classic association with ulcerative colitis. And also really key point is that it's linked to cholangiocarcinoma as well. So that is something that's just worth keeping in your mind um that association because you can get asked about that. Um Yeah, so um going back to the SBA um so she is very clear, like it's a very kind of classic picture of a cholangitis, probably had episodes of biliary colic in the past and now has sort of an inflammation associated with like the c uh with the um with um cholecystitis, sorry. Um And she's got like the white blood cell, so rise and the CP rise but not as not jaundice like it's fairly stable. Um No changes to urine or stool. So it's not like a block in the common bile duct. It's more likely to be just a kind of cystitis. So, yeah, we're done. Uh, moving on to the second SB now I'm just gonna, were there any questions about that before I go on? Yeah. Cool. All right. Um So yeah, I'm moving swiftly on. Could I wait? Give me one second. I'll be back. Um So yeah, so you're the f one working gastroenterology. You're bleed to come and see a patient presenting with jaundice and acute confusion. Their history indicates that they drink up to 60 units of alcohol a day. You speak to him and his friend, you speak to him and his speech is slurred and he seems to think that he's at a restaurant and is asking for the menu. His friend tells you that he's been like this all day and it was a bit worrying a and you have already started him on IV PEX and are commencing chlordiazePOXIDE reducing regimen for alcohol detoxification. What would be the single most prognostically beneficial medication to help with his confusion? Ok. Cool. OK. Yeah. So the answer is lactulose. So we'll go through why that is. Um but first I'm just gonna ask you what are the causes of low cirrhosis? And there are quite a few. So um just listen for me. Mm Yeah. Fantastic. Um So your Hepatitis alcohol, fatty liver, fatty liver disease, autoimmune hep C Wilson's good, a lot of good answers on that. Um So yeah, these are the causes I have. So you have like alcohol, non alcoholic, fatty liver disease, uh infection, malignancy, metabolic. So the really rare rare ones like alpha one antitrypsin disease, hemochromatosis or disease like storage diseases. You have your autoimmune. So like pulmonary cirrhosis, autoimmune, hepatitis Crohn's comes and cholangitis, your vascular ones like your chronic but Chiari syndrome, which is sort of a vascular um pick a block and then you have your drugs. So your amiodarone and your methotrexate, which is why when people are on methotrexate, it's really important that they have LFT S regularly um to check that it's not kind of damaging the liver. Um So, yeah, yeah. So I kind of just wanted to point out some of the things you may see in your cases because these are examples of patients with chronic stable liver disease as opposed to like acutely decompensated liver disease. So you may see things of like Parma, erythema, some gynecomastia, some spider telangiectasia and dres contracture. Um Those are the kind of things that you can go potentially find on the wards, especially if you are in gastro because you'll see like people who have acute decompensation will probably have these features. Then if you have a patient who's got portal hypertension, it's likely that they'll be admitted and they'll be acutely unstable. Um But you'll see things like the kit kit Medii and sort of the um, ascites as well, which is quite a classic feature. Um Then with decompensated liver disease, you kind of get the ascites, you get sort of the like, really like, they can be quite floridly jaundiced as well. Um You'll get the asterixis or the liver flap. Um, they may have some sorry encephalopathy, they, they may have some bruising as you can get sort of clotting derangements when you have very severe liver disease. And you can also get hepato renal syndrome, which is essentially you get like sort of sponge neck vasodilation and then that kind of activates your renin angio intestinal aldosterone system. And basically, you get like reduced renal perfusion overall and you get sort of this hepato renal syndrome when your like kidneys start packing up essentially. Um So you have, so when you go on gastroenterology, if you've been on gastroenterology, like when I was on gastroenterology, a lot of the doctors were like, we have a proforma that we fill out and we just make sure that all patients get this. And this is the kind of the ga the decompensated liver care bundle. So they do like a whole host of investigations. So blood cultures and a cystic tap ct scan and the fibro scan, which is like a specific scan. It's like an elastography or something which looks at the quality of the liver. Um Funny story is that my, one of my um kind of partners on placement, did a fibroscan on himself just after a sports night and it was actually quite high, um, and panicked and then did it again like a week after when he'd not been drinking and it was fine. So it can also go up in like acute cases as well. Um Making sure you do AC or score. And IV PEX is given, especially if patients have kind of been drinking for a prolonged period of time, they may be kind of vitamin deficient. So it's very important looking for any type types of infections. So if they have an, if they do have like SVP, looking to treat the source and considering human albumin solution as well. Um if they do have an AK, then suspending all the diuretics and nephrotoxic drugs, making sure you're doing daily weights and fluid, restricting them as appropriate if they have GI bleeds IV tele Vitamin K if they have prolonged copt, considering like F FP, considering transfusion, doing an early endoscopy if they are encephalopathic. So you have lactulose, which is a prognostically like the best kind of thing you can give um for encephalopathy as it basically helps trap ammonia in the gut um by converting it into a nonabsorbable form of um ammonia. So it helps kind of pass soft stools, which is really good and it stops the ammonia from being like reabsorbed into the bloodstream and then going to the brain and causing encephalopathy. And also making sure they have a high calorie diet as that can also um sort of help prevent or like not necessarily improve but kind of stop the encephalopathy from progressing. And then finally VT prophylaxis as with all patients. Um cool. Ok. Moving on to ascites, the ascites is like when you have like fluid collecting in kind of personnel space. Um it's really important that this is kind of tapped. So you can test to see if this patient has portal hypertension or doesn't have portal hypertension, they have portal hypertension. So the sar is up, it's very likely to be a liver cause. But it's also worth considering other kind of cardiac and portal vein thromboses as causes as well. If they have a low SAR, then there may be something else going on. And these are just some of the kind of things you could consider. Um one of the most common causes of a low SARC is nephrotic syndrome. Um And especially in certain communities of people, they may have also had tuberculosis in the past. So it's worth considering if they've had tuberculosis, then they could have a tuberculosis peritonitis. Um So, yeah, from a conservative perspective, you want to kind of fluid, restrict them, reduce the dietary sodium and just kind of keep monitoring it on a day to day basis. Medically, you can give them prophylactic oral Cipro if their acidic protein is less than 15. And it's worth giving them aldosterone antagonists as well. Um then from a procedural perspective, the kind of the best thing that can be done if they have 10 societies is therapeutic price and tet. But one of the main things that is worth kind of um doing is making sure you're doing large if you're doing any large volume drainage. So more than 5 L, they will need an album on cover which um kind of helps prevent the risk of paracentesis, induced circulatory dysfunction, which has like a very high mortality. Um because you're just taking off so much fluid in one go, they need sort of some sort of fluid replacement. Um And human human albumin solution is considered the best of fluid replacement in those patients. And then also considering like a tips procedure in some patients as well as that can also help with ci worth consider worth uh remembering though that in patients who do have um ascites if you drain it, the likelihood is it will come back. Um Because ultimately the cause of the ascites is the liver dysfunction and the liver dysfunction is not something that's gonna be resolved, especially if you're cirrhotic and they are acutely decompensated. Say yeah. And then I kind of just wanted to talk about OD and paracetamol as it's quite, it's more common than you think. Um So just worth considering. Um So basically harking back to like 1st and 2nd year when you go through the liver conjugation pathway when you take too much paracetamol, it overloads that conjugation pathway and you get the production of N Qi which is a toxic metabolite. When you're taking a history, you want to know the timeframe exactly how many tablets when they took them, what their intentions were. If it was sort of unintentional overdose or if it was an intentional overdose, because if it's intentional, then you need to do a full psych screen and get the psych team involved early. You also want to know about alcohol because acute alcohol reduces nap Q and chronic use actually increases it. So it's worth just doing a screen nap. When you examine them, you wanna make sure that they're not like jaundice, oliguric and caop paic. Um usually in the 1st 24 hours, they may be asymptomatic and they may have like some nausea and vomiting, but then after 24 hours, they'll be like hepatic necrosis will set in. Um, if you've not seen this chart before, you may get familiar with it. Uh especially if you do like an ed kind of job. So this is a paracetamol nonogram. It's a treatment nonogram. And basically it tells you the concentration of paracetamol at four hours. If it's above the line, you treat, if it's below the line, you don't. Um The only caveat to this is if they've taken a staggered overdose and you wanna make sure you're treating the way it's managed is if you, if they've taken, if they've come in within an hour, then you can give them activated charcoal. NAC is what is dictated by this no uh mammogram here. Um And it kind of varies depending on local guidelines as well. So it's worth kind of checking locally what's given. Um And then you have the liver transplant uh which can be offered in patients who have a acute overdose. And that depends on the King's College criteria um which you can go in and learn your own time. OK. And then you can consider discharge if the sort of at uh kind of goes down and it's less than two times the upper upper limit of normal. And the inr is kind of normalized. If not, then bloods need to be checked. So 8 to 16 hours later to check their S and IR as well. Um oh, moving on to viral hepatitis. So, viral hepatitis is um something you're probably fairly familiar with. I'm hoping um this is just a very quick stop. So this is your vitamin, this is your Hepatitis B virus structure. Um So your, your, your e antigen, your core antigen, which is what helps you dictate what exactly is happening to your patient. So if you've been unexposed ever to kind of HEP B, then everything will be negative. If you have an acute infection, your antigens will be up and your IgM will be up. Um But you won't have. So the anti uh HB S um if you've had a past infection, then you'll have all of the antibodies. Um, and then the antigens and if you have a chronic infection, then your surface antigen will be up and you'll have your anti HBC um IgG as well worth noting that when you're vaccinated, it's only, um, the, so the surface antigen that you get, it's not the kind of, you know. Yeah. So you only get like the anti HB surface um antibody, you don't have the core antibody as well. Um No, and then just looking at Wilson and hemochromatosis mainly because I feel like sometimes people just get this confused. Um Wilson's is copper overload and hemochromatosis, iron overload and it's as simple as that. Um So focusing first on on Wilson's disease. So you get neurological features due to um basically, it's similar to Parkinson's features, you have kind of the Parkin the typical Parkinsonian features and those are your neurological features. Your psychiatric features may be things like depression, um which is how like patients generally tend to present. Um And it's worth kind of considering that as a differential diagnosis, especially if you can kind of see this Kaiser flash of ring um in their eyes as well. Um You can get Fanconi Syndrome, which is a type of renal tubular acidosis and then also hyperparathyroidism as well. The way it's kind of um investigated is that she's looking at serial and plasma concentrations. Um and the upshot is you have low ceruloplasmin. So you have reduced bound serum copper and increased free serum copper. Um Rarely anyone ever, like, I've not really seen like a liver biopsy with Rhodanine stain done, but I'm sure it is if patients do have horses disease and then what you give is penicillAMINE, like which it's a, it's a copper chelator. Um So uh hemochromatosis is known as bronze diabetes and it's literally just like um hypergonadism, heart failure, arthritis. When you're examining patients, you can ask them to kind of um squeeze their knuckles. And if they are not able to do that, sometimes it can be like putting it in the context of the clinical picture, it could help you come to the diagnosis of hemochromatosis. Um and then the way you kind of test for it is with um looking at your ferritin studies, it's worth kind of taking this with a pinch of salt as ferritin. Um like we can also be affected by other things as well in acute face. So, by looking for hemosiderin deposition in hepatocytes and then gene testing as well. Um And then the way that this is managed is with phlebotomy bene section. And if that doesn't work, then desferoxamine, worth noting that the complications of this is HC OK. So back to our initial question. So as we've explained, lactulose helps keep ammonia in the gut. So which is why that is what is the most beneficial um sort of laxative to be giving not because of its laxative sort of properties, but because of what it does in the gut to induce the bowel movements, which is why you want to be giving lactulose. Also. One other thing to note is this patient ends this sort of stage one in the West Haven criteria, uh which measures encephalopathy. Usually sleeping pattern disturbance are one of the earliest signs of encephalopathic patients. They basically go from being like sleepy to even more lethargic to being like agitated and then being comatose. Um So yeah, so that's how they kind of move through that criteria. Ok. So moving on to our third SBA let me just um any questions by the way about that four speed off to the distance? Oh cool. Sorry. Could I see the SB again? Yeah, of course. Sorry. Like I feel like I've not actually read it. Let me read it. You f one working GP your next patient is a 61 year old lady who is concerned about uh swallowing. She has noticed that it has been getting progressively worse over the last six months and she feels that she can't swallow very well. It has impacted her eating habits as she feels she eats less due to the difficulty. She mentions she has been having more difficulty with liquids, more, more solids and she feels like something is stuck in her throat. When asked she mentions that she feels her clothes do feel a bit looser but she suspects that it is because she has not been able to eat. She has previously been treated for reflux disease and says that the medication doesn't help. What is the single most important investigation that needs to be done next? I'll, like, be flipping between them. So you can, sorry, my washing machine is really, really loud. I don't know if you can hear it but about to take off. Ok, great. So that's just, oh, fantastic. Yeah, so, agd, that's what we're looking for. Um, so, yeah. Um, now I'm gonna make you list some causes of dysphagia. Amazing. Fantastic. I wouldn't. Um, so, yeah, so these are the causes that I've kind of come up with and I've tried to organize them a little bit by, um, system. Um, and the kind of targeted investigation you can do to rule in or out. Um, the thing that I would say, which is most important is making sure that you're ruling in or out cancer. So if you do see someone in primary care and you're worried that they have cancer, you wanna refer them for a two week pathway, two week. Wait. Um, the main thing that you have to make sure you're doing first is sort of a fecal blood test, um, to look for any obvious. Oh, wait. No, sorry. That's the colon Ka. Um, the main thing I wanna make sure you're doing is you're looking for red flags. Um, so you're asking them about like weight loss, you're making sure they're kind of fit the, the age bracket. You wanna know if they've had any kind of obvious progressive symptoms, things like that. Um, you wanna also make sure that they're, um, like if it's been like a progressive thing as well. So if they've had like issues with just solids or just liquids, um, and looking for kind of any other signs that might indicate, might be something else. So specifically looking like things like crest disease. Um if they have had like a hiatus hernia, if they do have like a peptic ulcer, um and then also looking for any obvious signs of compression as well. So if you like do an examination of them listening for like mitral stenosis, um looking for any signs of lung cancer, um any signs of kind of thyroid disease and like screening for your thyroid diseases as part of that as well. Um So you kind of wanna be making sure you're doing a holistic assessment on these patients and there could be any she. Um So yeah, so I just listed kind of red flags there. So your weight loss, loss of appetite, hematosis, Melina and it progressive and persistent. And then these are the kind of things you want to be asking your patients specifically to do with wondering. So what the onset was the character time where exactly it feels sometimes if patients have like a pharyngeal pouch, they'll note like they'll have like, recurrence aspiration pneumonias and they'll feel like their breath is really smelly. They'll have like, hematosis or they'll feel like they're kind of regurgitating on their food as opposed to if, like, a patient has like a globus or something. Like, they feel like something's stuck in their throat or they actually have like, an obstruction at the top or any part of, or any part of the esophagus. They'll feel like they can't really push the food down, but they won't necessarily have any kind of regurg things that are going on there. Um One thing I haven't mentioned is if they have any specific trauma to the throat, like, even if it's been like iatrogenic trauma or anything like that, it's worth kind of asking about any procedures that they've had to like the neck, the throat that might be impacting their swallowing, um or any kind of caustic things that they may have swallowed anything like that. So, yeah, so now we're gonna do a spot, the diagnosis, which is super fun. Um So, yeah, hopefully everyone's ready. Cool. I'm gonna, I know it's difficult to read a chest X ray in like 30 seconds, but give it your best shot. Ok. Yeah. So that was a hiatus hernia. So this is a very kind of typical chest X ray which shows hiatus hernia. Um It kind of just looks like a globe and it's not really the heart, it looks like it's behind the heart almost and you can kind of see the fluid level and that's sort of um the fluid level in this. Yeah. So this is the third one. Fantastic. Um, great. And this is the last um kind of spot diagnosis. Yeah. Esophageal spasm. It's a bit of a tricky one, this one. But um yeah, essentially, um you can see like the diffuse esophageal spasm, you can see it like the wi the wiggly lines are kind of what indicates that it's a kind of a spasming action. Um So I'm all done. Um So yeah, I've got those kind of in there for you so you can like look at them, you know, in time. Um So yeah, so the single most important investigation needs to be done next. You need to be making sure you're ruling out cancer. So GD is what you do. Um And this is the final SBA uh let me read it. Actually, you're the F one working in Ed Tim Green. A 62 year old gentleman has rushed in as he's vomiting Frank blood. He is known to alcohol rehabilitation services but has recently relapsed. His wife who is with him says that he was recently fired from his job and got incredibly depressed. She found him at home vomiting blood and she called the ambulance when you see he is pale responding to a voice with a vomit ball on the side of the bed. His BP is 110/70 heart rate, 124 sp 297% on room air respirate 24 temperature, 35.8 degrees. He has vomited two bowls full of blood. You fast leave the gastro team on call to come and see the patient for an OTD. What is the most appropriate initial management for this gentleman? Mm. Mm. All right. Um, yeah. So let me, yes. Yeah. So that one was a tricky one, right? Because you would have thought that we need to get tele immediately, but it's really, really important that you remember that. Um, the first thing and the most important thing that you're doing is you're making sure your patient is stable, you're making sure your patients not kind of acutely unwell, you're not like 100% sure what bleed. This could be, it's likely to be a viruse bleed, but it could be a bleed from somewhere else like it could be like a peptic ulcer disease, for example. So it's the best thing to do in any given situation is work for your A two, take your blood, do everything that needs to be done and make sure the patient is prepped, um because they will need blood and they would need like a cannula before you can give IV 10 depressant in the first place anyway. Um, so just kind of catching you a little bit. Um, so I kind of just want to go assessing the acutely ill, more patient as it's something you'd be. It's the most important thing that you'd be doing. It's an F one and I think it's something you should feel prepped to do. So when you're walking through your A two assessment, it's really important that you're looking, you're feeling, you're trying to have a listen as well and you're kind of doing the things that you need to be doing to stop this patient from going into hypovolemic shock essentially. So you want to make sure you're doing an FEC using these FTS glucose clotting screen and cross matching 4 to 6 units of blood. Hartman's is the best solution to be resuscitating with as it's kind of physiologically similar to um plasma. Um So you can give heart's to restore intravascular volume. You wanna catheterize them to make sure they've got a good urine alpha and you wanna be correcting any clotting abnormalities, making sure that you're maintaining their blood, the HB levels, the platelet levels and everything. So they're kind of optimized for surgery. And when we not find the surgeons really early to tell them this patient is like going to be unwell, this patient is going to crash. So you put it like your 2222222, if you feel like really worried and you want to be taking like vitals every 15 minutes. So heart stops. So yeah, hearing all kind of things, you should be thinking and when you're thinking of bleeding from the upper gi tract. So it's worth thinking about sort of endoscopy, high dose PPI if it's a peptic ulcer. Second line is things like referring to IR and then if the endoscopy is successful and unsuccessful, then a laparotomy, if they have a perforated pel ulcer, then IV antibiotics, analgesia ng tube for stomach decompression and then they will most likely need laparoscopic surgery or, or, or open surgery if they're very, very acutely unstable. Um So they basically do this thing called an a mental patch repair. And most of these patients who have a mental patch repair will be, will go to ICU initially because it's quite a large surgery to have. Um, if they do have a gastric ulcer that has perforated, then you want to make sure you're doing a histology to exclude any cancer. The variceal bleeds, you're giving IV 10 apressin. Um, you want to be giving about 1 to 2 mgs IV repeated 4 to 6 hours. You're checking inr and giving Vitamin K if it's prolonged and then prophylactic antibiotics, which potentially may reduce mortality and severe hemorrhage. Um If they do have uncontrolled bleeding, then you can put in the sun and more tube. I've seen this done once and it was in itu. Um Yeah. So, um and then if they do, like if they have viruses and endoscopic virus or band ligation, if they have gastric viruses, then you could do endoscopic sclerotherapy and then a tips procedure, endoscopy fails. Um So, yeah, and then your aftercare after Vasil bleeds is just making sure that the patient is on a nonselective beta blocker. So like propranolol or carvedilol, and then you can do, you can go back and do endoscopic and ligations at two week intervals to make sure that all the viruses have been eradicated. Um Once the patient is a bit more kind of clinically stable as well. So, yeah, so for this patient, it's really, really important that you're making sure that they're stable, first and foremost, because they're currently actively vomiting blood and he's pale, he's only responding to voice. It's very likely that this patient is heading for like a downward turn, um just walking through all the other kind of answers. So pantoprazole would be specifically if you're worried about peptic ulcer tram acid was actually found not to be um kind of clinically indicated in patients who specifically have um upper gi bleeds. It's indicated if they have trauma, if they haven't bleeds from any another location. But upper gi bleeds specifically, there was a recent clinical study that found that they're not and then o negative blood again would only be indicated once you've done your bloods. And you can see that there's um like a HB below 70 like you want to make sure you're following clinical guidelines at all times. Um Yeah, that's the end of my presentation any questions from anybody. Um Anything you want me to go over anything you're confused about, happy to answer anything. Please, please fill in the feedback.