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so Hello. Good evening, everyone. Thank you all for coming. My name is Lucy and I'm part of the National Surgical Mentorship Society, or N S M s team. And I'd like to give you a warm welcome today to the sixth installment of our MRCS part a crash course lecture series. Now, before I hand over, I'd like to quickly go over what N s s is all about. So our aims are two fold. Firstly, we want to match mentors and mentees together from different parts of the country to help prepare students for a career in surgery. Secondly, we want to adequately train surgeons from C t 12, s, t eight. So become successful mentors through a pre made virtual course. Now this course will be done on a rolling basis, and it's you'll be assigned as mentees sign up and they'll be matched to the trained mental throughout the year. So the benefits of becoming a mentor, uh, numerous to list some of them. We aim to cultivate a professional skills in teaching, communication, organization and leadership. You'll be aiding the development or professional development of a future colleague whilst you strengthen your CV and develop self reflective techniques. Um, sign up. Links on how to get involved can be found out in front of the QR code. If you follow them, will also be putting them in the chat. Throughout, we are monitoring the chat, so please feel free to ask any questions you have, and we can give them to the speaker or any questions about SMS. We'll we'll try and answer throughout the talk as well. Please do check out our instagram and social Media is page to keep up to date and get the latest information about how to become mental menti and about future lecture series. And I'd like to take this opportunity to please remind you that at the end there is a feedback form we'll share. Um, if you do fill out feedback, um, certificates will be provided, and it really is helpful to both of us and the tutors or the lecturers today. So without further ado, I would like to welcome today Speaker Ibraham, a course surgical trainee at the Royal Liverpool Hospital. So take it away. Thank you. Good afternoon. Everyone remember him like Lisa said kindly, um and I'll be talking about the acute abdomen and, um, presenting them questions for you all to answer. Hopefully, you guys will find it useful. Um, so when we think of the abdomen, this is an image that should come into our minds, and we should It's really helpful to divide the abdomen into different areas. Uh, quadrants is a good way to start. And I want this image to remain in your mind when we go through the questions today, Um, and we'll refer back to at the end of the day as well to see what we've learned. So that's the first question. Is a 50 year old female presents with a history of right upper quadrant pain and joint? This, um, she's reporting the urine being dark stools are offensive and difficult to flush. Which of the following explains the dark urine? So it is an increase in your E. A seclusion is an increase in unconjugated bilirubin, bilirubin, urea reduced enterohepatic circulation for increase in conjugated bilirubin, urea or five or E increased urinary urobilinogen. So, please, we'll wait for a minute for everyone to answer. It looks like he's quite popular right now. Okay, I think that's that should be every one I think, um well, there's a couple more. We'll wait for a minute. Okay? So I just got some information here so we can go through the how you get the bilirubin and how it's how hemoglobin is broken down. So essentially, hemoglobin is broken down in the spleen. Um, him forms. The form becomes unconjugated bilirubin, which passes through the blood, and it's conjugated in the liver. So with this patient, it sounds like they've got obstructive jaundice. So any obstruction in the liver is going to cause an increase in conjugated bilirubin passing into the blood and also the urine. So normally, normally urine should contain any bilirubin. However, when they're obstructive jaundice, conjugated bilirubin is excreted in the urine, giving its its color Um and yeah, essentially, that's why you get pale stool as well. Because of this obstruction, Uh, these are some eponymous triad and pentasa is that, uh, I found in Colon Colon Ghitis. Uh, I just thought I'd mention them here as some. This is often something that comes up in questions related to the right upper quadrant and, uh, these sort of things as well. Um, so, yeah. Charcot's tried and Reynolds pen Tad, and this is just a reminder of the anatomy. So essentially, what's happened in this patient is any sort of blockage in the common bile duct or moving backwards. Um, and the answer. Only 22% of you guys answered it correctly is an increase in conjugated bilirubin urea. And this is because of obstructive joined us that's causing this and the second question. So 48 year old female presents with abdominal pain and six episodes of bloody diarrhea every day. Um, she's complaining of pain in her knees and elbows and recent visual problems. So what's the most likely diagnosis is that collagenous colitis, diverticulitis, infective colitis, tuberculosis or ulcerative colitis? This one's a little bit easier. I think I should mention that the first half of these I think I have come up in previous MRCs question the last half. I I sort of made up based on what I remember coming up, and I find those ones a little bit easier. It's possible. I think there were nine responses last time was away for nine this time as well. Yeah, I got nine. Yeah, I think most of you want to do it correctly. which is nice. So, yeah, So this was ulcerative colitis and in inflammatory bowel disease. And these are the different things, you see. So with the visual issues, it's probably uveitis or something similar. And, um, it can present with arthritis as well. These are all the extra intestinal manifestations of inflammatory bowel disease is found in Crohn's and ulcerative colitis. In this in this in this question, it said bloody stools, which is much more common in ulcerative colitis. Usually a Crohn's colitis picture as non bloody stools was just diarrhea. Um, so yeah. So the correct answer as 55% of your answer is ulcerative colitis. Well done. Um, this is a little bit of a different sort of question, so, yeah. 56 year old male presents with acute episode. Yeah. Strict pain and vomiting on examination. He's got guarding in the upper abdomen. Um, investigation revealed the following. Um, so these are the blood results. I'm going to read them out to you can do that yourself. But what do you think is the cause of the condition that this patient is suffering from? So is it alcohol? Is it, um, gallstones is gall stone in the bile duct Or is it hyper parathyroidism or high cholesterol or mumps? So we've got nine responses. I think I think you guys are thinking of the right pathology, but not the cause, the correct cause of the pathology, and we'll find out why. So I think in terms of the pathology, its pancreatitis and alcohol is generally the most is the most common cause. So you guys are right in that regard. But in terms of blood results the most the abnormal finding is the calcium got hyper calcemia. And as you all must know, um, Hypocalcemia is one of the causes of, uh, pancreatitis. And they've got primary hyperparathyroidism. So they've got a high calcium level. Um, what's interesting to note with pancreatitis and calcium is that hypocalcemia causes pancreatitis because it leads to a center cell injury and necrosis, which is sort of like a domino effect. If it happens in one sell, it happens in the cells next to it as well. And that's how you can get a necrotic necrotic pancreatitis. Um, but once pancreatitis is is established, this causes hypocalcemia because of fat necrosis and sequestration of calcium ions there, and that's Why, when you calculate severity of pancreatitis, using the last, um three score calcium of less than two is an indicator of like it gives you a point, and more than three is severe pancreatitis, and they need an I t. U admission and monitoring. So, um, that's something interesting to know. So just if you can remember one thing regarding pancreatitis and calcium, it's hypercalcemia causes it, and pancreatitis can cause hypercalcemia by the ways you guys, I think you guys have got the right pathology, but it's just because that was incorrect. Uh, this is the same question again. Yeah. So, yeah, the answer was primary hyperparathyroidism, which caused pancreatitis. Um, so 53 year old man is discharged after a reversal of a loop colostomy 10 days later. This time, gentleman is re admitted because of vomiting and colicky abdominal pain. On examination, there's a swelling in the loop colostomy site with tenderness. What's causing this is a hematoma. Is the adhesions Is there a leak? Is there a stricture or is it an obstructed incisional hernia? We got 13 responses last time, so just wait till gets 13 again. I think more people are joining which is quite nice. Yeah, I got 13. Okay, Good job. I think that's pretty split between, uh 34 and five. Um, which is interesting just talking about it right now. So no one said hematoma, which is good, Um, adhesions. I think it's way too soon. 10 days after an operation for adhesions to develop if this patient. But they probably had previously just Yeah, it's possible. But I think with the presentation is less likely they have. They've had a reversal of the loop colostomy. So yeah, there's an initial operation would have been before, and then a lot of people have had an anastomotic leak, which is also a possibility, but vomiting, colicky abdominal pain less likely, um, and stricture as well. That's a possibility as well. That's true. But it's another something else here. So essentially, what happened is, um yeah, they've had a loop colostomy, which has been reversed. I thought I just thought I'd talk about different types, different types of storms that present in colorectal patients as well. So the two main types would be like a small bowel ones, so ileostomy and colostomy and compared to large bowel ones which are colostomies and this is the general position of where they'd be found. And the main difference visually would be that the ileostomies and the judge an ostomy will be more centrally sighted. They'd be spouted because of the acidic, um, sort of, uh, discharge from them Or, uh, the bowel contents that are, uh, that come out of them. And because it damages the skin, so they are generally spouted to the higher up, whereas the colostomies are more flush with the skin. Um, and there's a lot larger in size, generally as well. And usually the idea of the small bowel. Stormers, I'll have a higher output. Um, so, yeah, it's obstructed incisional hernia. And these are quite common off the reversals of loop colostomy. Uh, because essentially, um, loop colostomy is, uh, they have a high risk of developing incisional hernias because of the high risk of developing postoperative wound infections and such operations. Um, and that's essentially why this This gentleman has probably developed, um, incisional hernia there. Um, yeah. And in terms of hernias in general, um, the most common types of hernias around 70 75% of her knees or inguinal hernias. I'm just talking about some other things as well. Um, followed by femoral hernias, which are more common in females. And then you've got the more rare ones. So epigastric hernias and umbilical hernias and then incisional hernias only only around 1% of all hernias that present um, yeah, so this obstructed, um, Incisional hernia cause the bowel obstruction, which is why this patient is vomiting and has colicky abdominal pain. The colicky coming from Paracelsus and these are essentially only repaired in the emergency list. If there's if there's obstruction and there's a risk of bowel, necrosis of prolactin is high and things like that. But when there's a mature incisional hernia with a wide neck, they may be left and repaired electively, which is a much safer option. Other things that increase the risk of developing an incisional hernia or any hernia would be a steroid. Use obesity and chronic coughs. Question five. So a 75 year old gentleman is admitted with sudden onset severe generalized abdominal pain, vomiting and a single episode of bloody diarrhea. On examination, he's he looks unwell. It's got fast a f. He is diffusely tender, but his abdomen is soft. What's the most likely cause of his symptoms. Is the pancreatitis pelvic inflammatory disease? Unlikely. It's a man, um, and military can function a ruptured triple A or a small bowel obstruction. Maybe this one was a bit too easy. I think I was being lazy by the time I made this one. Oh, I think this is when I started to make them, I think. Yeah, probably. Okay, about 15 last time. We'll wait till 15. Someone put pelvic inflammatory disease. Interesting. Okay. Should get one more. It's fine. We'll just, um I just move on. So So, Yeah, so it is a military can function. Um, yeah. So, essentially, I just wanted to talk a little bit about the abdominal aorta and its branches. I think that's important. So they it's important to know, uh, at which vertebrae level. These vessels relieve the abdominal aorta. Um, so, in terms of unpaid branches or singular branches celiac trunk, at T 12, the superior mesenteric artery at L1. And the inferior mesenteric artery L3 a good way to remember what they supply the celiac, uh, celiac, uh, celiac access supplies. Um, the four gut and sm a supplies the mid cut and, um, the I am a supplies the hind cut, um, in terms of large bowel, all the way up until to two thirds of the way across the transverse colon. It's the superior mesenteric artery. And after that, there is the inferior mesenteric artery. And in terms of something like this, um, this would present with either one of them being, uh, being a clot there. And this this is a gentleman. You know, this gentleman suffering from fast day after, it's probably a contributing factor of them throwing up a clot. Um, and yeah. And also something to remember with a patient like this that the symptoms are the pain is out of proportion for what they're presenting with. So, yeah, it's mesenteric infarction so very well done to the 73% of you who got that. Correct. Um, question six. So a 19 year old female admitted with the right side of abdominal pain, they ended up having a laparoscopy where multiple adhesions were found between the liver and abdominal wall. That's the most likely cause of symptoms. Is that colecystitis Public inflammatory disease, appendicitis, very interaction or small bowel obstruction. And I'm hoping most of you get this one? Correct. I'll wait another minute until 6. 55. I think there's a couple more people who can answer. Okay, everyone. Good job. So, yeah, it's pelvic inflammatory. Disease fits you, Curtis. Um, so yeah. So, essentially, I just want to talk about common presentation that you might see. Um, when an acute abdomen is referred to you. Um, yeah, in in terms of acute complications of pelvic inflammatory disease. So this is one of them. Is Perry hepatitis with this young woman is suffering is presenting with that fits you Curtis syndrome. So, around 10% of women who's got you've got a Q p i d have this. They've got right upper quadrant pain. Might have some pleurisy as well. The LFTs are usually normal. Might be elevated. Sometimes they can also develop a tubo-ovarian abscess. Um, and it's usually found in the pelvic ultrasound. Um, in terms of chronic complications, um, around 10% end up getting some sort of infertility in the future. Um, and this chance, this this rate is increased with recurrences. They get chronic public pain, and the chance of developing ectopic pregnancies in the future is also increased um, in terms of, um, using different sorts of criteria to diagnose, um, Publix. Lung disease. Laparoscopy is the most effective way. Um, yeah. Question seven. So a 78 year old man is walking to the bus stop when they suddenly developed severe back pain and collapse. He's brought to any and on examination blood. Systolic of 90 heart rate, 110 abdomen is distended and tender but soft on examination. What's the most likely cause of the abdominal pain is the mesentery can function is the diverticulitis. It's perforated. Is it erupted Triple A anterior for an anterior to operate or a retroperitoneal one, Um, and or a small bowel obstruction. You guys are along the right line. It's just good to know this is something you have to. So as as an F two, I was on A and E, and this is something you have to pick up on as soon as possible. So it's a good job. You guys on the right track with three and four. One of them is correct. One of them is wrong. So about 15 ounces already. I think there was 17 last time, so we'll give it a minute until we get 17. That's okay. I'm very impressed. Good job. Give it one more minute. Mhm. 16. 1 more light. Okay, well, just just a It's a good job. So it's a retroperitoneal Triple A that's been ruptured. I'll tell you why. So, essentially, if it was an anterior Triple A that's ruptured, the patient wouldn't wouldn't have survived until they reach the hospital. Um, because it's in the retroperitoneum. It's sort of, um, in a way and encapsulated. So this is what you would see when you had a laparotomy. Um, when you're going in to repair a ruptured Triple A, that's retroperitoneal retroperitoneal an anterior one would just bleed into the abdominal cavity, and then the patient would just lost minutes. Unfortunately, um, and the fact just some more information to the fact that the patient has a systolic less than 100 and it's suspected that they have a Triple A that mandates an immediate laparotomy. Um, and this is sort of the generic pathway that's used. So if there's any clinical suspicion of a ruptured Triple A, if they're stable, then they go for a CT scan stable, meaning, um, over here it says BP above 70. Um, but I've seen some some centers use the BP over 100 and then on the CT scan, they can work out whether IV are is appropriate or not. And that's something Vascular surgeon. Various centers are various criteria, and if they are, then they go from the va. Um, the thing about the va uh, endoscopic, uh, prepare essentially, is that it's It's a treatment, but it's it's not a cure. An open repair of a Triple A is a cure, and it has, um, longer. It lasts for longer, whereas an IV are generically just only lasts for eight years. That's the average lifespan of Boniva repair. Um, so if the patient is unstable on presentation to A and B, um, they essentially they don't go for CT. They go straight for, um, laparotomy. Question eight. So a 17 year old man is admitted with abdominal pain. He's had intermittent right electrical pain for the last couple of months, a negative colonoscopy and negative gastroscopy, which were investigations done. But for iron deficiency anemia, pain is worse after meals, an inflammatory markers and normal. What's the most likely diagnosis is it a superior mesenteric artery syndrome. Is it acute appendicitis? Is it Hirschprung's? Is that Meckel's or is it an annual A pancreas? Wait a couple of minutes for the rest of the people to respond. I'm glad no one said. Acute appendicitis. It's good, because knowing, and that's probably what they're referring as. Okay, good job. We'll just we'll just move on. So it is Meckel's why the meckel's So, um, they've got anemia, so Meckel's can sometimes contain, um, ectopic gastric mucosa. So whenever someone eats something, this gastric mucosa also thinks it's in the in the stomach and produces acid. And this can cause ulceration and bleeding, which can lead to in deficiency. Anemia something you guys keep in mind with Michael's is something called the rule of Twos. So approximately 2% of the population, um, in the West, that is, um, has meckel's diverticulum. Males are twice as likely as women to have Meckel's. It's usually 2 ft proximal from the ileocecal valve. Um, it's two inches in length. Generally, around 2% of people of people who have meckel's, um, develop complications, and there's two different types of heterotopic because it's got it can either have a gastric mucosa or pancreatic because within it, so the rule of two. That's a nice way to memorize stuff with my clothes. And, yeah, I know it's a bit sure, but I think that's that's all the questions I thought they'd be more interaction with the audience. I thought it would take longer, but yeah, but this is something that you should always keep in mind. I know some of them were out there. Not really. They comin abdominal presentations. But in the exam, what I found was a lot of them were not bond or they were sort of convoluted questions with regards to abdominal pain, whether it might read like a a common abdominal pain. But it was out there quite often. And, for example, with the pancreatitis question, how they wanted, everyone knew is pancreatitis. But they were asking what was causing the pancreatitis. So that's something that's quite commonly found. And, uh, the part that's what I found personally. But this is You should always have this in mind as well. Uh, but mostly did really well, so well done. Um, continue practicing, and I hope your exam goes really well. Uh, thank you for listening. That's great. Thank you very much for him for an excellent presentation. I hope the audience find it useful. I'm sure if they've got any questions they can put in the chat. Now, if that's okay with you. Yeah, absolutely fine. Great. So, guys, So if you've got any questions, please do put them in the shot. Um, and and take advantage of having Abraham here at the moment. Um, in the meantime, I'm going to remind you again, If you can fill in the feedback forms, you will get a certificate. And it's really useful for speakers and for us as a team to try and improve and make sure we're tailoring it to what you need. Um, thank you very much for coming tonight. We do have another session. I believe it's tomorrow night, But please do check out the instagram social media to keep up to date with everything that's going on. Um, and to be able to sign up in time. Um, so we haven't got any questions so far, but we have got some thank you starting to come in. So that's great. So I Decker that so thank you very much. you're, um you're welcome. Uh, we've got a question there. Can you see it? Yes, Uh, for superior mesenteric artery syndrome. What would it present us? So it would be similar, but there wouldn't be the iron deficiency anemia, so you would get pain intermittently after eating. Um, and that would cause pressure in the superior. So essentially, it's because of I think there's a ligament that goes over the superior mesenteric artery. That, like, um, like, pulls on it in a way, uh, so you wouldn't have the iron deficiency anemia, But you would have similar sorts of symptoms in terms of intimate, but it wouldn't be right Elect foster pain. It would be more epigastric pain as well. So epigastric pain intermittent associated with meals that would be superior mesenteric artery syndrome. Um, and I think this is, uh this might be interesting for some of you, but there's a Gray's anatomy episode with the superior mesenteric artery syndrome, which presents it seems like, perfectly so. Yeah, that's brilliant. Thanks. Great excuse for watching. So thank you. Want to go on eBay? And that's a great session. And I think we've got a lot of people here saying that so thank you. We will end the session there. Um and we look forward to welcome you all back shortly. Take care. Bye, guys.