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Uh Grant. Perfect. Okay. So I'll keep it a bit brief. I don't want to waste any more of your Friday evening. No, Cassie slides. Can you see the slides like this? We kinda okay. I'll just keep it light. Uh, Grant. Okay. And sorry to waste your Friday evening, I'll keep it nice and brief and I'll just get through it. So to, um, this is a talk in general surgery, you'll know the team already. Um This is our sponsors Wesleyan and the M D U and I just keep it brief. I'm Doctor Erin Dornin and thank you very much, Doctor Greenlaw for inviting me to this. I'm working the same hospital in Scotland, uh, in Lanarkshire Hospital, Monk lands. I'm currently in a placement in care of the elderly, but I've got an interest in surgery because you're gonna general surgery is a big topic. So I'm just going to focus on abdominal pain and I'll make it even more brief this time. So I just sort of keep it geared towards Oscar level stuff slash F I one stuff I did put some questions in, but I'll just skip through those and you can always go back and look at them again at the end, I'm hoping by the end of this lecture that you get an idea of different differentials, surgical differentials and nonsurgical differentials of pain in the abdomen. And then a way that you can rule these in or out. And I an idea of like how we as fy ones and juniors can treat these patient's and then an appreciation of how the seniors will treat them. I'll just put this diagram up here. I think it's a very nice schematic that allows you to see um pain in all different areas and includes both surgical and nonsurgical, um types of differential diagnosis of pain. I won't dwell on it though, we'll move on forward. So, the way I'm gonna do is I'm just gonna start in the right upper quadrant and I'm gonna work my way around in a clockwise fashion just to give you a rough at like a case for each type of pain. So, just a quick revision of the anatomy, a little bit familiar with that and talking about right upper quadrant pain, it's good just having your mind. And I'm just gonna assume we all know, don't move on. I think it's also helpful, just have some definitions in mind. So close if ISIS is stones in the gallbladder, whereas choledochal with ISIS is stones in the bile duct, we've got biliary colic is the pain that's going to be caused by either of these conditions because of the Paracelsus of the bile ducts in the gallbladder to get by all into the stomach into the second prodigy. Codeinum. Um, cause cystitis is information as a result of this in the gallbladder, Collinge itis is inflammation of the bile duct. And then the empyema would be a build up due to obstruction of a gallstone of pus in the gallbladder. So case we've got a 40 year old female, she's going to come in saying she's got pain in the right upper quadrant. She's said this has been pretty sudden onset in 24 hours. It's intermittent. It's not there all the time, but it's a sharp type pain. She's also been a bit feverish and had some nausea but not vomited. She's got a background of hypertension and she previously smoked but doesn't really drink at all. And it's still working. I won't go into this pool specific of an abdominal examination, I think as an F Y one, you have been told before 80 is the way we manage patients' and that allows you to incorporate everything in a very nice and organized manner. So she's been able to give your history. So we know he's patent. She's a bit tacky apneic, but her saturations are okay. Her chest is clear, which I think is good, especially to know especially the right upper quadrant pain because it could be a lower lobe pneumonia that's causing the right upper quadrant pain. He's a bit tachycardic but not hypertensive. She's actually hypertensive, but we know that from her past medical history, she's got a fever, her sugars are fine and then moving more too. And the abdominal examination, you can see that she's got a slightly large body habitus, but her abdomen is soft. Although it's for it's tender to even light touch in the right upper quadrant and Murphy's. I hope we're all aware. So when you ask the patient to take a deep breath in, press in and then you're gonna get a sharp inspiration. When you press in the right, upper quadrant is confirmed by doing the same test on the left upper quadrant. I think this diagram here is a nice little schematic. It just shows sort of the main three differentials that you would have for this type of pain and how you can differentiate them. The recall. It is just gonna be the pain but no other symptoms. Acute cause cystitis is going to be almost like acute Collinge itis but doesn't have the jaundice and pain in the right upper quadrant fever. And jaundice is the common service called triad of symptoms called shark cuts. Uh poor prognostic factor is that becoming what we call Rhinos pent had? So we had two more symptoms which is confusion and uh low BP or hypertension. So they've become acceptably shocked. I'll leave this question just for a second for the benefit of the recording, but I'll just move on the correct answer is a so simple test that will, you'll see is the running theme for all these different types of pain. But you'll do a CRP and full blood count mainly for the white cells and inflammatory markers to see if they're raised. You'll always probably want a set of using these, especially if somebody's been vomiting, although where a lady wasn't. And that's just to check whether they've got any electrolyte disturbance or even an AKI, if they've been vomiting quite a lot. LFTs, looking at the liver enzymes to see if there's been any damage, which be more indicated if there's a gallstone in the gold in the, in the bile ducts. But alphos will be raised in any obstructive picture in the gallbladder, whether it's in the gallbladder or whether it's in the bile duct. So A L P would be raised. You've got a fever is page and if you want to do blood cultures just to rule out any other sources of infection or to see if this has become a septicemia. Imaging. Um abdominal ultrasound is the main sort of imaging that you want to do in the initial step, but it's not the gold standard. If that's, you know, thinking of a multiple choice question in uh in an exam or whether it be in a Noski uh abdominal ultrasound will confirm or deny whether there is actually gallstones in the gallbladder. So whether this is a diagnosis, it will show you whether there is a thickening of the gallbladder, which should be indicative of color cystitis. Um And I will show you if there's any fluid in there with such as the can empyema. But the gold standard test would be an M R C P. And I think it's better just to show you the picture rather than talk about it. So similar to a presentation we have before you can see quite clearly anatomy there, you've got the pancreatic duct joining onto the common bile duct to the sphincter of oddi and then working up from there, you've got this area of hyperdensity or blackness and scan and that is the gallstone behind it. You can see the CBD or the common bile duct is dilated. So, uh dilation of greater than six millimeters is pathological. I think it's actually this question is, may be worth just dwelling on. I'll leave it for a second just so you can have a look. You don't need, it doesn't need to be interactive just for your own learning. And the correct answer is A, I'll just focus just in the essence of time. A is the correct answer rather than deep because as an F Y one, you should be able to make decisions such as fast the patient for theater. So keep the mail by mouth and minister analgesia and start antibiotics. Whereas D is just starting antibiotics, although you will ultimately speak to your senior about this patient you could have done a lot more before you spoke to them. Some move on again. I'm just these questions, the way I worded them was the way that a med school woodward them, um, the next best step rather than just the next step. You know, it's, they're, they're very specific and wording, um, management. So we've got here conservative then a definitive, but the conservative is also going to be your, why would use an antiemetic? Would use an antiemetic of the vomiting? Yes, you would. And you can use anything such as advanced trainer, say cuisine. Um and that can be IV and then as soon as you start to get better, you can then give them um oral, uh they're conservative management is going to be your initial management. And just as we described back in the question, so they're gonna need a lot of fluids. Have you been vomiting? Antiemetic would be warranted? Give them IV antibiotics that will be uh dependent upon your local guidelines in Glasgow. It was what we call triple therapy or IV Amoxicillin, metroNIDAZOLE and gent, um or gentamicin being gent. If they were allergic to amoxicillin, that would switch to Vancomycin and gentamicin analgesia, you can give a sub cut in the first instance and then you can switch that to oral. Um you could improve at this stage and then you can send them home in Orlando Biotics and then this leads into the definitive management. So it's acute cholecystitis. You're going to want to do a cholecystectomy and the safest way to do that be laparoscopically. So, let's say they have got better with conservative management. You bring them back in 6 to 8 weeks because the fact that there's been acute cause cystitis, the gallbladder's been inflamed, it's going to create he's Asians and it's going to be more at risk of having a gallbladder preparation. So you want to leave that at the time. If, however, when you're doing your conservative management, your patient becomes more unwell, becomes septic, their inflammatory markers are rising. You probably if it's still within the 72 hour window to take them to theater then and there because conservative management has failed unless they have put in the RCP. If it's a diagnosis of choledochal with ISIS so stone in the bile duct, then the gold standard for that. Sorry, Erin. Yeah, someone's asking the chat, would you use an anti emetic if they were vomiting? Yeah, I think I already answered. I'm keeping an eye apologies, apologies, apologies. No worries. But thanks for keeping a tab on the same. Um E ERCP. Uh Yeah. Goal center management is less invasive than the laparoscopic procedure. Although it will come on to later in the talk, it does have its own complications, central domino pain or for the purpose of this talk, we'll call it epigastric slash left upper quadrant. So we've got a case. 55 year old man. This is a very common presentation of the patient's that we saw in the west of Scotland, epigastric pain. He's had a bit of a binge across the weekend. It's been pretty sudden, uh, it's been radiating through to his back. The only way he's able to relieve it is by bending forward and then eating and drinking is making it worse is very, a very co morbid patient with diabetes, peripheral vascular disease and previous and Steny. And you can see it as sort of a social history that he's got a history of alcohol access. So moving onto examination, he's giving you the history. So we know his airways safe again, his technique and tachycardic, the two first clinical signs to go up in any um sort of acutely unwell patient, although his chest is clear and his saturating find an oxygen on rumor's doesn't need oxygen. This gentleman is hypertensive and he's also got a fever. So he's likely septic. Um, we can see from his blood sugars that are nine, that's nothing really to worry about. He's got know in type two diabetes, it's going to be poorly controlled if he's a, if he's got a history of alcoholism anyway. Um So that's actually pretty good. Um And then lastly coming onto abdominal examination again, it's soft. So we're not worried about peritonitis, which will be important in a second. But we can see that when we palpitation gastrium, he's got pain. So just a question I'll just leave this on for a second, but it should be hopefully quite obvious that the diagnosis is pancreatitis. So looking at the differentials, um certainly this type of presentation pancreatitis is gonna be your top differential. But going back to why I mentioned that is not keratolytic, a perforated duodenal ulcer would be a very close second in your differentials, especially in somebody that drinks. Um But the fact that is not part genetic almost clinically rules out that diagnosis because if you've got perforation, Adam, and it's gonna be a diffuse abdominal tenderness rather than just epigastric pain and soft. Um, other diagnosis here right at the bottom, aortic dissection still want to consider because that has got a classic history of central pain radiating through to the back. Although the fact that it's and the abdomen, that's more likely we're thinking of Stanford type be here. But again, the history doesn't really match up and the BP, there's no, the question isn't giving you differences in blood pressure. So that's less likely diagnosis, investigations to rule these in or out. So, again, simple CRP, full blood count and you're looking there again, inflammatory markers, you could also look at the mean capacitor volume, the MCV in the full blood count because if he's got a history of alcoholism, you'd expect that to be raised using these. Again, this man's been vomiting. So you're going to want to give, you know, potentially fluids and it's good to know what sort of fluid you're going to have to give or how fast to give them LFTs. If he's got history of alcoholism, you're going to want to check that, especially things like the albumin as well in this pacific sort of presentation. A calcium and an A B G. Although maybe you wouldn't do them in another, uh, presentation of abdominal pain there. Key here and we'll come back to that and that's more looking at how severe certainly pancreatitis is. And then lastly to confirm a diagnosis, quite sort of quickly, you'd use an Emily's are more sensitive lipase. Abdominal ultrasound is useful for ruling out other causes in the area. Again, looking back, it would be referred pain from the right upper quadrant. Maybe it's just that is a poor historian or it's just presented a typically um a CT abdomen is going to be your key sort of imaging investigation that you use in these patient's maybe not so much an acute step stages, you will be able to see inflammation around the pancreas. So therefore, making a diagnosis of pancreatitis more likely, but you use the ct abdomen to look at and monitor the patient as they progress through the course of their, you know, their disease because it will be able to ideally identify any complications and how to manage them. And I'm on it would all very familiar with. Remember it all if, if you're able to, I just focus on the first four and change the eye to eye. A tra genic being the ERCP G for gallstones, E for ethanol and then T for trauma. There, you're most common causes the last, the last four or four or five or less likely. Another question. Do very quick with this. It's not scorpions. There you are. Um, it's gallstones, um closely followed by alcohol and then E ERCP. So as I was saying right back in the right upper quadrant pain, very good test. Gold standard for treatment of choledochal a thigh Asus. However, a it has a very sorry how to word it. It's a test. That's a procedure that's got a lot of complications. And that one, the main one being pancreatitis because you could take a very healthy patient, treat their condition of gallstones, but then give them a lifelong condition of pancreatitis. So it's a very, it's a procedure to be taken not lightly and you need to make sure that your patient's gonna be fit for it and clearly explain the risks to them which we'll come back to. Here's the Glasgow severity score pancreatitis. So these patient's can get very unwell very quickly and there's not really a surgical management of them other than what we will come to, other than just what we do as an F Y one unless they require more severe multi organ support. So any sort of monitoring of all these parameters is very key. And that's why in A B G, unlike any other surgical presentation is probably quite key here. But yeah, we've had that a score of greater than three is severe. So management, it says initial, but it's pretty much the, the main management for these patient's, you're gonna keep them know by mouth because they're vomiting. You're gonna need to give them a lot of IV fluids. And I say lots because I hope we're familiar with the concept of third spacing. But very briefly, if or not, we've got fluid inside the cells and then they've got fluid in the extra vaccine like the intravascular compartment. So the vessels, if the fluid is in neither of these places, the body can't use it. And that's what happens to pancreatitis. Fluid just gets lost into interstitium into the, into the spaces between cells, but not within the cells. And therefore, although they look very overloaded there, maybe edematous, they may have ascites there that they're actually very under loaded because they're not, their body is not able to use that fluid. So you need to give them a lot of fluid. Um Again, this will answer the question, the chat, you will if they're vomiting, give them an antiemetic. And IV initially, I know geez again, pyrantel early IV morphine, sub cut, morphine, something like that. And you need to very closely monitor these patient's and very closely monitor them by the parameters that we saw on the previous slide, if able to treat the cause is. So ERCP, I've put that there. If they've got gallstones causing the pancreatitis, then ERCP would be the first line of the first line treatment for that, stop drinking. However, unfortunately, if the pancreatitis was caused by the ERCP, there's not really any way to treat that and that's why it's an unfortunate procedure to perform because you can leave somebody with this potentially chronic condition for the rest of their life. And then lastly, you want to manage any complications which will come to, to the complications and each one basically leads into the next. So if you've got pancreatitis, you've got inflammation of pancreas, there's a potential that you're gonna get necrosis of it. And then because you've got the crosis, you've got dead cells, you can then get infection in there. The infection can become an abscess that abscess can then form either a pseudocyst or you can have fluid gathering in the area because of the inflammation. And then lastly because of all of these, you can get a progression to chronic pancreatitis. It's a very horrible condition to have. We saw a lot of patient's in Glasgow with this, especially because we were actively uh I was in the hospital that was the pancreatitis unit. Um And you've got these very healthy patient's that and then having to go to ICU for multiorgan support when it was just an ERCP that caused it left eye. Look out for the pain. I'm going to keep this very simple and just do a question to sort of discuss it. So I'll leave that there for a second. Yeah. Uh huh. So the correct answer is b is this recorded um should be. So just tackle left. I like fossil pain with the, with the definitions here. So, Diverticula voted for diverticula osis. Sorry. His presence of diverticuli and diverticuli is the out pouchings of the bell mucosa diverticular disease as is sort of the first part of this man's presentation. He's got constipation is when these diverticular diverticular cause constipation. And then diverticulitis is when these diverticuli become inflamed. So they don't just cause constipation. You're now causing them to become a bit feverish and causing them to have maybe tachycardia and raised white cell count. And then lastly perforated diverticuli is when you're gonna have, that was a perforation of the battle. So a diffusely tender abdomen, peritonitis very unwell, very potentially septic. And that's kind of the main sort of things you need to know. But um that particular particular disease, right? I like foster pain, very sort of barn door presentation. A 19 year old female um has had this pain started around about her belly button but has now moved down to right, Alex fossa. Um It was a bit of a dull ache for about a week, uh 23 days. However, now has become very, very sharp in the last 24 hours. Um It's not ready at anywhere. She's nauseous but not yet vomited and she's lying still in the bed. When you're looking at, when you're taking the history from her two young fit, 19 year old, she's a nursing student northern past medical history on exam technique. But saturations are clear, like as, as, as most of these surgical patient's. Um she's to Kartik and a little bit borderline hypertensive but not yet, anything too much to worry about and she's got a bit of a low grade fever at 37.9. Um So, yeah, not septic, but potentially heading that way. And then you find that she's tender even just to like palpations in the right ALEC Phosa. And when you're pressing on the left hand side, you're getting the same pain, sir. I'll just leave that there for a second. Questions tried on Tuesday. Cope sign. That is another name for the up traitor sign, which will come back to in a second. Yeah. So objector sign is when you get pain in the right Alec faucet elicited by internal rotation of the hip. And so I sign it's pain is elicited in the right iliac fossa when extending the hip perch is a bit of a weird one. I wouldn't, this was from a surgical best answer book. I wouldn't do a digital rectal examination on, on these patient's. But surgically if you get fluid gathering in the pouch of Douglas or so between the bladder and the anus, you can get pain when you do perform a digital rectal exam, but I wouldn't do that on your patient's and I never have was most appropriate initial investigation. And isn't this patient? So leave that there for a second. It's a great answer is D uh serum HCG. If you got a 19 year old female, you need to rule out an ectopic pregnancy before considering any other diagnosis. Even if we're thinking that it's a barn door appendicitis with umbilical pain radiating to the right alec fossa topic, pregnancy is gonna be your top differential in a female penda site is second. And then you've got testicular torsion isn't likely going to call, you can have other symptoms associated with and I'm sure you've had other electric describing it. Um The pain is going to be more in the testicles themselves and you're not able to raise them. However, you could still have, you know, it could present typically and just have right Alex fossil pain. And then lastly, Michael's diverticulum. So I don't think there's anything else other than what's on this slide that you really need to know as a medical student or even as an F Y one, a couple of facts about it. I got would urine HCG. Yes, you can use urine. However, most certainly in the center that we were working in, they didn't, even if there was a urinary pregnant pregnancy test, they'd still want a valid uh serum result to confirm or deny. So, Meckel's diverticulum is just an atypical anatomical variant, that 2% of the population have a little pouch and this, this little diverticulum can become inflamed and therefore replicate features such as, um, appendicitis. However, I've never come across, it's usually only medical schools that ask about it, investigations. So again, crp full blood count, looking at inflammatory markers, white cells, seeing if they're raised using these, you've probably got most cases of appendicitis or certainly this girl, I remember her, she's been vomiting. Um, you know, you're probably gonna have maybe a potentially a low grade AKI. So you're gonna want to give a lot of fluids and using these are always important for that serum or as we've seen in the chat urine is, is valid theoretically. But depending on the unit you work and they'll probably want to serum HCG um, imaging CT scan. So you don't necessarily want to be giving every patient, especially with a very barn door appearance of a appendicitis, a CT scan. But it is there if you're trying to rule out another differential diagnosis, um, abdominal ultrasound is probably better in younger people, especially kids. It's very common way of ruling and everything out appendicitis. And then if there is no clear cause for the pain, you can take them to theater for a laparoscopy, but that's very annoy ideal. You don't want to take a person for a procedure was the definitive management and we can just leave that field learning. It's appendicectomy. All the others are correct and we, as fy ones will do a lot of the others, but the wording is definitive. So, so they were, um, analogies. They're, they're gonna be sore, um, paracetamol if you've got a fever and, and that, that goes for any of the previous examples and you can give paracetamol. IV, just be careful with that. Make sure they're not an oral as well. IV fluids, vomiting this before this lady, she had a low grade fever probably doesn't need antibiotics, but it depends in certain cases, appendicitis even more modern. And then Children, younger Children and in your pediatrics block, they usually can get managed conservatively with antibiotics and never need to go to theater. But understandably a lot of parents sometimes just would prefer that they go for the procedure. Pence Ectomy. You're as an F I one, get them set up for theater. If it's looking like it's an appendicitis, prep them, get the group and save done so that they can be cross matched if they need any blood, close relation screen. Always important to know before you put a scalpel to anybody's belly just to know if they're going to be bleeding uncontrollably. I mean, it's obviously unlikely in a younger person, but they could because they're so young, they could have an undiagnosed hematological condition. Simple stuff fast, them, give them the IV fluids and we won't. And even even at our level even that maybe a clinical fellow level, you wouldn't be consenting for the procedure. It should only be the person that performs the procedure that consents them. So cause you know how to, you know what to explain to them. You know, what complications are the potential risks for the procedure. So that's the way to do it. And then finally, the definitive management would be a defense ectomy. And then lastly, uh diffuse abdominal pain or peritonitis. So, the youngest guy is, had very sudden onset question, please. Could you slow down and ask us more questions? Uh, of course, yeah, I was only going faster because of all the technical issues at the beginning is a Friday night. I wondered if you wanted to, um, sort of get on with your evening and all the questions you'll be able to, you know, this lecture will be recorded, so you'll be able to pause of the slides and then test yourselves later. But no worries. And so 38 year old guy has had a bit of a grumbling, dull ache for about a week. But now in the last 24 hours, it's become more sudden and he's started vomiting. He's not passed any flotus. And, um, he's not been able to maintain any oral intake and made it very barn door this case. I mean, I did meet this patient, but yeah, he had a previous surgery. Um, and otherwise is, uh, social history doesn't really drink at all or smoke. So an examination, we've got a, you can see immediately is respirators greater than all the other patient's. We've seen these very technique and saturations are still okay not warranting oxygen therapy at the moment. He's very tachycardic and he is hypertensive. Uh he's got again a mid grade. They say a fever is 37.5 and above. So it is low grade but nothing to be too worried about just yet. But this patient here is, as you can see, corporate, he's, he's shut down. Uh He's shocked. Um, he's lying very still in the bed. He's rigid. He's not even allowing you to touch his abdomen. There still is a bell sounds but they're fine. So, differential diagnosis in this patient would be obstruction, um and differential diagnosis of obstruction in sort of most sort of common would be adhesions, hernia, malignancy. There's sort of your top three. There are other things such as a volvulus, but that's gonna be very uncommon and that is more common in your slightly older patient's um uh peritonitis, perforated viscous, you know, gallbladder, appendicitis. If that pops, you've got all this muck and dirt in the abdomen, you're gonna get peritonitis, perforation of separate them too because I've put perforations like a duty, an ulcer, mesenteric ischemia, lose all the blood supply to the abdomen. You're gonna get a very tense and painful abdomen and then a rupture, Tripoli has sort of the same logic as the previous previous examples. Um again, just uh I'll leave this there and I'll move on quickly. So you can always pause it in your own time and go back and test yourselves. Um Because I'm presuming some people haven't had their finals. So hopefully these questions might be a little bit helpful or even for Noski. But the most, the most initial investigation would be an abdominal X ray, the most uh the test, the gold standard that will confirm or deny. Oh, diagnosis would be a CT abdomen with contrast. But uh the most initial first step would be an implement. It would be an abdominal X ray. So let's white cells again, crp, recurring theme here using these if they've not got any oral intake because they were vomiting up everything you, you've likely got maybe like a metabolic acidosis. They're going to be vomiting a lot. You're going to need to give them a lot of foods LFTs, put that in there because if you're ruling out differential such as a perforated gallbladder or something, you're going to want to be able to tell whether you've got deranged LFTs. They're feverish, any feverish patient, blood cultures and then to rule out the diagnosis of mesenteric scheming, I always lactate. But even in these patient's have not been eating, they're not been drinking, it's likely they're going to have a bit of an anaerobic respiration. Um So elect is important to check and that you know, it's also part of your septic screen and we have a septic patient here. So first initial exam, first initial investigation, abdominal X ray, hope we're all familiar with the rule of three's, but just in case you're not three centimeters is the normal bowel with in small bowel, six in large bowel and nine centimeters for the cecum, anything above that would be considered pathological. And lastly, just for differentiating, differentiating between small and large bell, we've got the valvular convent is in the small bell. So you've got lines radiologically that will cross the entire picture rather than the house tra or the outpouchings in the large bowel, which you will have an incompletely ct abdomen contrast gold standard test like the definitive one for obstruction. You're gonna be able to see where it's obstructed. It's called the transition point and see what's causing obstruction, whether it be a hernia or whether it be a volvulus or whether it be um malignancy. And then if you've got a patient, maybe that isn't septic, but you don't know the cause of the obstruction. You can always do a diagnostic laproscopy could likely will be adhesions that you might find management or management that we're gonna be doing is F I ones that we will be doing uh sepsis. Six, do that there. The vomiting, keep them there by mouth and you'll be familiar. I hope with the term dripping sucks. It's the idea that we're going to be giving them fluids and we're going to be at the same time having an N G tube, as we see here, this can be wide bore free drainage. So that, that make sure they don't aspirate any of the contents. If you're clamping it, then there's a potential that clogs and then any of the contents of the N G tube regurgitates back into them and they could aspirate lastly. I know. Geez. Yeah. They're gonna be very, very sore. These patient's and with a bill obstruction, you can manage it conservatively. If it's just a sub acute obstruction, it could be the cause could be an alias. It could be POSTOP, it could be 24 hours, 40 hours POSTOP. And just because of the, you know, the trauma to the body of having an operation, the get up the, but the, the gut where the bill starts to slow down. In which case you're just going to observe them and see how that goes and like they just do the initial management and just continue with that if you have a clear cause. So our case here with a 30 year old man, he had the dependence ectomy that was converted to open. So it's very likely that he's had it's adhesions causing a small bowel obstruction. In which case you need to um definitively cut away those adhesions to open the bill back up hernia, that's a hernia. And then if it's cancer, you maybe want to consider an emergency reception or if there may be more going down the palliative, it would be a stent. So that again, that would be us, that would be making that decision. And lastly, just to finish off the lecture, if I hadn't, I'm sorry for all the technical issues, I would have gone through just some past paper questions that I found. Um, but what I'll do is I'll just go through them slowly now. So that for the recording, you will have them all and uh you can go back and look at them in your own time if you need to or want to. And that's the answer is there. Um I chose a wide range because sometimes the general surgical questions might not necessarily be what you think to be general surgery. It could be anaesthetics because it's all related to the specialty. A bit of a whistle stop tour. A lot of complications at the beginning. I'm happy to take any questions if anybody has any, either via the screen or via the chat, can that result? So, yes, it can do because it's still invasive into the procedure. You can um cause like uh even just like next to the uh to, to the, to the structures around can cause inflammation in there and then therefore cause adhesions. Thank you. How do you watch your card? And where do you find it? That's amazing. Thank you so much for coming to do the talk tonight and uh we appreciate it was a fantastic talk. And yeah, there might be a few kind of last minute questions, but we'll leave you to ask them just there. But again, I'm sure everyone will agree with a fantastic talk. And thanks again and for organizing it and speak. No worries. And eight minutes past the time, I see MRI scan. So diverticula osis, that is the presence of diverticuli. The outpouching of the bowel diverticular disease is when these diverticuli becomes symptomatic. So the patient will maybe just mention they've had some constipation or maybe a little bit of blood in their stool, but there's no fever, there's no abdominal pain. Uh there's no tachycardia as a result, you know, no indications that have become infected or inflamed if that makes any sense regarding the accordion being available and not the best person to answer that. But I'm sure my colleague, Doctor Green Mobile be able to explain. Yes. Thank you. So, how would you know if someone has diverticula osis? Uh you might never know and a lot of people can be incidently found, I mean, care of the adult at the moment and it's a diagnosis that is found exactly just found incidentally. Yeah. Or people will go for chronic constipation or symptoms like that, start getting investigations for I B S etcetera. Then it's fine. We've got diverticuli very common in the West, not so common in um Asian populations and that's just due to diet and West, it's more carbohydrate, heavy Asian populations. They use more spice from a solid and that's a bowl irritant. So it gets things moving through the gastric uh gi tract and therefore it doesn't cause constipation. Okay, thanks. That's right. It seems like that's the last of questions. Thank you very much for all your patient's and thank you for Jeremy on a Friday night.