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In our MRC S party revision sessions. Um If you missed the previous sessions on vascular and applied physiology, they are available on um the LFT SS um med account. So, um you can watch the recordings there. Um I'm very happy today to be joined by Alec Mattos, uh CT two in South London. Um who's gonna present today on colorectal surgery? So I'll hand over to you now a look. Thank you very much. Cool. So, thanks. Yeah, good evening everyone. So, yeah, my name is Alok. I'm just gonna be giving a talk on some colorectal surgery, more of the clinical aspect. Um And we, we it'll be a very informal session. So any questions anyone has, they can ask me, uh interrupt me at any point. Um So we're talking about essentially anorectal disease. Um pr bleeding today, cancer stuff. Um Right leg fossa pain, particular appendicitis, left leg fossa pain, diverticular disease, um and then inflammatory bowel disease. So, as a question, you guys need to think about this first. So in clinic, you're seeing a 20 year old female with five months of offensive anal discharge. He's wearing pads daily on examination. There's an epithelial defect at five o'clock position two centimeters from the anal verge. Um So it's M CQ. So what do you think is the diagnosis? So you can think about that for a few minutes, uh, for a few seconds. So, in this case, like a fistula, um, and a fistula is essentially an abnormal communication between two epithelial surfaces. Um In this case, she's having this history of offensive discharge. Um, and on examination, you're seeing this defect, um which all indicates a fistula. If it was a fissure, you'd be thinking it would be quite painful. You'd have to be having pr bleeding, external hemorrhoids, you'll be seeing um a mass externally. Um Again, you'd be noticing pr bleeding, um, squamous oar is quite rare in this age group. And again, similar thing with rectal. So expecting bleeding. So, next question. So this lady, same lady has got Crohn's disease. Um And she's actually coming with current anal fistula. So how would you manage this fistula? So, again, have a few seconds to think. Oh, there's a poet. Yeah, I'll, I'll pop some polls up. They're all generic. 12345. But then the question screening people can close them to see them. So hopefully that should work. Ok. Excellent. So I think that's given some time for people to put an answer down. So can you see that answer? So the answer is a loose seat on. So I'm not sure if anyone's actually um put that down. But essentially, if there's a patient who has inflammatory bowel disease or eat and with a fistula, you're not going to be jumping in to do any, um, complex surgery at this stage. You wanna drain the sepsis. Um, and, oh, yeah, I can see that, you know, 75% shows that so very good. Um, you don't wanna be jumping in and trying to drain the sepsis in the acute setting. What you want to do is insert a seat on and allow sepsis to drain. Um And then you can do more definitive management at a later date. Um ok. So let's talk about it. So we'll just go through these topics now. So bomb surgeons, there's quite a lot here. Um Some of these topics do come up in the exam, some are slightly more higher yield than others. So we'll go through this relatively quickly. So, anal fistulas, as I was mentioning earlier is essentially um communication to epithelial surfaces. There's usually an internal and external opening. Um This normally starts because of glandular tissue. Um That's no, that's normal glandular tissue in the intersphincteric plane, which is spaced between the internal sphincter and the external sphincter. Um And you can see that in the diagram on the right. Um What happens normally is that there's a history of recurrent um anorectal sepsis or abscesses that form because these glandular tissue get blocked off and you can get infections and that pressure with that collection of pus can then start creating and developing this fistulated tract. Um So normally the most common form is an interpin um fistula. Um Again, in the history, you can notice that there will be recurrent episodes of sepsis. There may be a background secondary course to this like inflammatory bowel disease or cancers too. Um Oh, sorry, I clicked next stent. Um And as I said, most of the secondary to abscess formation in the cryptoglandular spaces. Um it's a quick recap. So the way we classify fistulas is via the parks classification, but just to recap some anatomy. So we have obviously the rectum on the top here which then communicates the anus and the dentate line. Um dentate line is basically the point where it moves from columnar epithelium in the rectum to stratified squamous epithelium, which is found in the anus and then becomes keratinized at the anal margin. We have an internal sphincter complex which is smooth muscle and it's involuntary control for continence. And then you have an external sphincter complex which is under voluntary control. So in the part, ification, you can have 24 types of anal fistula. Most common is intersphincteric. You can also have transsphincteric. So it goes through the internal sphincter, but then partly goes through the external sphincter. You can have uh suprasphincteric which goes above both complexes and they can be extra sync, which doesn't include the sphincter complexes and they usually higher up Um That's good. OK. Next is the good sole rule which again is quite high yield. S you, this describes the location and the tract of the fistula. Um what we have if imagine the patients in the lithotomy position, supine legs up and you're looking at the anus. If the fistula tract is in the anterior half, then the tract is likely to be following a straight path and from the internal to external opening, if it's a posteriorly sighted fistula, and normally it opens at the 6 ft position and it normally follows a curvilinear path towards that six o'clock position. When you assess a patient for fistulas, what you're trying to answer the question you're answering is, is this a simple fistula or is this a complex fistula? And the way we do? And the definition of a simple fistula is essentially involving the lower third of the um external sphincter. So if you look at the picture here again, the sphincter, you can see in the diagram if it's involving the lower third, that's a simple fistula. Um And if it's a complex fistula, it's normally higher up or it involves uh multiple tracts or there's an underlying condition like inflammatory bowel disease. So, in your examination, this is what you're looking for. So you can examine them. Um do a digital rectal examination and use a proctoscope to have a look inside and see if you can see the internal opening. MRI is the gold standard because that gives you a very detailed evaluation um of the fistula tracts. And it can tell you if there's multiple tracts and um it can also give us more understanding of the underlying cause. Um And then when you take them to theater or if you're going to take them to theater, you can then do an examination under anesthesia. You can use a metal probe to then delineate the anatomy further. The management for fistulas is essentially healing the fistula openings and any associated tracks. Um But you want to try and minimize any change in continence. So that's the goal of management. And there's a number of management options you have for fistulas. So the first one is a fistulotomy. So fistulotomy are essentially a procedure where you put a metal probe in, in from the external opening into the internal opening of the fistula, then you use your energy device, um diathermy and you cut down um onto your metal probe and you lay this fistula tract open and allow it to heal by secondary tension. It is useful um particularly when only a part, the sphincter or the fistula, only partly covers goes through the sphincter complex or the sphincters are not involved at all. That way, you can go and cut down straight, straight down to the fistula tract and you won't be affecting um continent of the patient in the acute setting. If there's an abscess, you wouldn't be doing fistulotomy or anything like this, you would just do an incision and drainage, let things heal up and then you'd come back and do this fistulotomy a couple of weeks later. So if it does involve the simple complex, um you can't cut straight down because then you're gonna render them incontinent, which is not to go here. So then the other option is a Seton. When Aceon is essentially a piece of thread, it can be usually nylon like suture material. So you pass through the fistula tract. Um I normally use a metal probe that has a hole at the end, kind of like a sewing needle. And you pass that through the fistula tract, you pass the nylon suture in and you pull it across and then the nylon thread is now into the fistula tract. You can then tie it off with some knots. There's two modes as I was alluding to earlier, a simple um mode where you just leave it to allow drainage or sepsis. But then there's also a cutting mode. Um And this is useful, especially if you wanted to try and cut this entire fish in the tract and lay it open. Um But you don't want to give them incontinence. And the mechanism or the thought behind this is that you put the suture material in, you tighten it and it creates a level of pressure at the posterior aspect of the fistula tract. Um And that slowly cuts the tract and the muscle, but because it's done over weeks, so you tighten this like c one material every 12 weeks or multiple weeks. It allows time for scar tissue to form at the muscular junction. So the at the smooth muscle wears. So over time, you're cutting this entire tract out, but you're allowing the smooth muscle to heal behind it with scar tissue. So you end up having a ring of smooth muscle or the internal sphincter with a bridge of scar tissue. So you don't affect the incontinence. And so the studies show that incontinence afterwards, about 12% usually liquid and usually gas but not, you know, profound fecal incontinence. The outcomes are pretty good and then you can get some more complex things like fistulectomy and an electro advancement flaps. So, in these situations, it's usually for high fistulas um which are not amenable to the other two methods we've mentioned, you start with fistulectomy. So you pass a probe in, you then dissect the entire fistula tract out and then you make a cut in the submucosa of the rectum. Um as you can see in the diagram on the left and then you make an advancement flap, so you can cover the internal opening. Um So it's a slightly more complex procedure, but it has pretty good outcomes at 80% success rate. Um about 10% of patients having continence or continence issues. Um They are anal plugs. So the last one, I think is the last one on um fistulas. So essentially, this is a material of collagen that you can use to plug the entire fistula tract. Usually before this, you have six weeks of C to, to allow drainage or sepsis. And then this doesn't, by sending a collagen plug, you don't actually damage any of the thing to muscles. And the collagen material essentially solves and incorporates into the smooth muscle um and creates AAA tract that should be completely closed up because of the collagen material healing rate is about 50% in this, but it doesn't affect the muscle. So if this doesn't work after C one, you can then move on to more complex um like procedures and operations. OK. The last one is lift procedure. So lift procedure is a location of inter the fistula tract. So you put a proctoscope in, you make a dissection down between the external or internal sphincter, you then pass your probe. So you can protect the. So you know where the um fistula tract is and then you can suture, ligate or suture, the um two ends of the fistula tract and then cut it off. Um This technique is especially good if you have a procedure that's going through both um external internal sphincter. Um usually before you do the procedure, you leave a seat on in for about six weeks and the cure rates. So, early reports are about 90%. But more modern data show there's somewhere between 60 90% cure rates. So that's another good option. Ok. Next question. So we're a 23 year old lady and she's presenting with a posteriorly sighted fissure which of the following would be the most appropriate next management step. So I'll give you some time to think about that. Ok. So let's see the answer. So as a GTN, um let me see what the people have said. Ok, cool. So yeah, I think everyone 100% everyone has said GTN, which is excellent, very good. So as a young lady who essentially has a fissure um law's procedure is when you do an anal dilatation and we don't do that anymore. Um Most patients would not be keen on having their anus dilated with like a balloon. Um The thought behind that used to be that you can relax the um internal sign. Um but it's come come out of fashion, injection of Botox would be second line internal thing toomy in a young woman will be um will not be first line um Endo advancement cola more complex diseases and no normally used in fissures. Um So GTN will be the first line option here. So uh always a fissure. So, anal fissures are essentially um tears that occur in the m sliding of the anal canal um that cause severe pain when especially when you're defecating and can lead to cause bright red rectal bleeding. Usually it's found in the posterior, mid midline, it's 90% of cases in the posterior midline and it's distal to the dentate line. This may come up in your exam. Um And in women, it can be anterior, usually women who have given birth um or if there's an underlying condition, you can have an anteriorly sighted fissure if the fissure is not posterior or not anterior. Um and it's going laterally, then you should start start thinking of other causes. Um So some other underlying conditions like like Crohn's disease or inflammatory bowel disease. Um whoops, this has come up. Ok. So, um af is can be classified as either acute or chronic. Acute is within six weeks and a chronic fis fissure is usually longer than six weeks. Um And we discussed um uh primary and secondary causes examination. You can do APR but pr is extremely painful and normally patients won't allow you to do a proper pr so you can look at the anus itself. And as you can see in the picture, you can actually see the um tear in the mucus lining. Um If you want a further examination, normally, patient would need to be taken for an examination under anesthesia with a proctoscope to further evaluate this, especially if you're considering or thinking that this is not the underlying condition behind it. So the treatment is normally conservative. First, we try conservative for many weeks first. Um That's all the guidelines say. So you start with stool softeners, make sure that they were well hydrated. You wanna make sure that they don't have hard stools, but m most of the causes of primary FACS is because of constipation, hard stool, causing trauma and damage to the mucous lining. So you wanna make sure that the stool is soft. You can then use GTN or Ditiaz paste. And the mechanism behind that is that it relaxes the internal sphincter um which reduces the spasm and pain and then allows healing of that mucus um surface in resistant cases which have not healed. After, let's say um a a few weeks, months, even of the conservative management, we can then consider Botox injection um or a lateral internal sphincterotomy. But in women, we will not be jumping to an internal sphincterotomy straight away. We'll try Botox first and that's because there is an increased risk of incontinence. And especially if you give child birth later on advancement, flaps would be only in very resistant cases that have not um improved with all the other measures discussed. Um Data show that syncor does produce the best healing rates. Um but it can cause incontinence of up to 10% of the patients. Um Other conservative measures also like sit spots and these kinds of things because the warm or the water can help relax the swims as well. So later in Sy, so the way you do this, you put a proxy in, you identify quite some of the other you know, operation earlier, but you make an incision um in the mucous membrane down into the internal sphincter and you can cut the internal sphincter um with any device or with scissors all the way down at the dentate line. Um And you hope that the external sphincter can take over the continence for the patient. Um But again, about 45% of patients immediately POSTOP will have fecal incontinence. Um But in five years, it's about 10%. Um and only 1% will have incontinence, incontinence to solid stool. Um And the cure rate is about 90% for internal THC toomy. It, it's pretty good. Ok. Next topic is hemorrhoids. So, hemorrhoids are essentially swellings in the aor vascular cushions. Um These cushions are found at the classical 37 and 11 o'clock position and they're drained by this valveless hemorrhoidal veins which usually follow the hemorrhoidal arteries. Um They can be either uh also the anal cushions like physiologically, their function is to assist with um maintain incontinence. So these hemorrhoids can be internal or external internal, meaning that they're above the dentate line, usually painless or they can be external, which means they're below the dentate line and they're usually more painful. Um Risk factors include chronic constipation and excessive straining. Um A lot of these patients actually have a lot of issues with when they were growing up and you know, the way they were potty trained and if they've had previous um they have Children, they've had prolapse, they've had damage to the pelvic floor. Um The biofeedback model or the biofeedback um mechanisms of um going to the toilet can be messed up a little bit. Um And then this can then start causing these excessive abnormal straining patterns which then causes um these hemorrhoids to occur. Um And then obviously, pregnancy was raised intraabdominal pressure, immun ascites. These kind of things can also increase the risk of hemorrhoids. Um Symptoms are normally bleeding, post defecation, it can be painless. Um It's bright red bleeding. Um and it's not mixed with a stool. It's normally in wiping what's in the pan of the toilet. Um It's a grading system, the A SRC S grading. So grade one for hemorrhoids essentially means that there's no prolapse. Um But it's just form hemorrhoidal vessels. Grade two is prolapse but it reduces spontaneously. Grade three is prolapse, but if a man you would reduce it and grade four is prolapse. Um but manual reduction doesn't work. Um These hemorrhoids can um become thrombosis and they can become extremely painful and swollen examination normally in dre is normal. Um So you may in clinic or setting, you can then do a procto proctoscopy. Um And if you're concerned about any underlying conditions, you can refer to colonoscopy, further evaluation. Um Many patients when they come in for hemorrhoid artery surgery or hemorrhoid surgery, they will have had a colonoscopy beforehand. The treatment, you start off simple. So, conservative things first. So laxatives um ensure you have fiber in your diet, water, um, analgesia for the any pain that they may be having pain. If there's thrombosis and acutely painful, you can use ice packs, you can use lidocaine gel, um, or you still a gel even. Um, if conservative management is not in, not getting better, is not helping symptoms and the patients are having ongoing pr bleeding from the hemorrhoids, it's causing them a lot of pain. Um Then you can try um the procedures for these patients. So if it's a 1st and 2nd degree hemorrhoid, um you can try a rubber band ligation. So that's so that's from the image on the left. You use a suction kind of device um that you then insert over the hemorrhoid and then you can fire a rubber band at the base of the hemorrhoid. And the hemorrhoid essentially will slough off as the vascular supply is cut off. That is good for grade one, grade two hemorrhoids. If you have grade two, grade three, you can then go, you can then do hemorrhoid artery ligation. You can use an ultrasound or you can use no, you don't need to use an ultrasound though. So you insert a proctoscope and you make suture. It's normally at 3 7-Eleven o'clock position and the sutures essentially cut off the hemorrhoidal artery, blood supply to the hemorrhoids and they shrink. Um And then for larger grade three grade four hemorrhoids. You can do a hemorrhoid artery, um hemorrhoidectomies or you can do stapled hemorrhoidectomies. Um That's the image on the right. So you essentially make a the incision at the heal base um and use your energy device die to cut it off. Um With these, especially with this operation, they, they, they will have severe pain after the operation. Uh It will be excruciating pain for actually, for about 2 to 3 weeks. You have to warn patients before you do this procedure that yes, it's painful, but you may cause the pain to be worse for the next couple of weeks before things settle down. Um And normally you won't be giving them um, like in a strong analgesia after the operation. Um Other complications with these procedures is anal stenosis recurrences can occur as well and it can become incontinent to feces. Ok. So itchy bumps. This, um, there's a lot of information here. Essentially. What may come up in the exam is, or, or the examiners think that the only cause of pruritus an I is, is worms and you can use a sticky tape for this for pinworms. Um, and they're called ob Aicar. Um, there are other causes that causes itchy wors, um, diabetes, for example. But I think the most high yielding to realize is that in the exam, the commonly asked question might be something to do with the worms. Um But you guys can have a read through this. Um in your own time. Later on, anal rectal abscesses are very common. Um, normally causes pain and swelling. It's similar. We kind of discussed this in the fistula, um um a part of this talk, but again, it's interesting to play where it's glandular tissues and that of the abscesses normally form. Um and then they can then spread um via fistula tracts actually to these other regions. So, ischiorectal, um, intersphincteric or perianal supralevator, abscesses don't normally occur by themselves. Um Usually it's if you've done an incision and drainage of an rectal abscess and you have an sho it gets a little bit excited and cuts through the muscles behind it. You can then actually see the infection into the supra region. Um There are secondary causes. So, inflammatory bowel disease, malignancies. P ID, tools to be aware of the common organisms are E coli and bacteroides. We'll talk about that a bit later on, but essentially anaerobes. E coli is a of anaerobes. Um And they normally found the colon. Um And so that's usually the bacteria that um would cause. This management again, is an EU A um in theater and then do an incision and drainage. Your eu A used to look for any fistulated tracts. You won't do anything with a fistula, but you need to identify it in theater, but you just do an I and D. Um And then you can do five tests in insert CS to allow drainage or sepsis, but he won't be doing any laying open or won't be doing anything further than that pilonidal disease. Again, um This may come up in exam too. So pilonidal sinuses are essentially in the intra region. Um And where the hair follicles are, essentially the sinuses can form, especially if they become infected. Um There's an idea that pits form where there's this a pit formation that can occur and these pits can, can become infected. Um One of the ideas is that what actually happen is that in particularly hirsute or hairy people, um hair from the back from the perineum can actually go into the pilonidal region and they can drill into um this region and then create these pits. Um Everyone supporting that idea is that barbers get pilonidal kind of cysts or sinuses in between their fingers. Um which again, kind of supports the idea that these hairs may be drilling into these areas causing these pits. These pits can. Um So you're gonna have 22 modes of disease. Here. One is pilonidal sinus disease where you have these pilot where these tracks and they can you know, continuously discharge kind of pilot material or you can have an acute um abscess which is swollen, very tender, warm to touch, et cetera. So management for an abscess would clearly just be an incision drainage and ensure they have good hygiene and you'd recommend them to have la the laser hair. Um removal to try and prevent this occurring. Um And the elective setting for patients with pilonidal sinus disease. So, there's chronic discharging um pits, you can do a number of different procedures. Um One is an excision and the sorry you're making you excise the pits out and you lay it open and allow it to heal by second re intention. And then there's more complex things like Kodak's procedures and bacon, which is, you know, shown on the right here. Um Essentially you create a off center elliptical incision, you then cut out the pits um and then you can create an advancement flap and then you suture, suture, that advancement flap. The reason you don't want to do a cut straight in the midline is because in that region, you're moving around bending, you can cause a lot of shear forces. And so you get wound adhes. So this technique usually creates better outcomes um postoperatively. Um Cool. How about rectal prolapse? This? Yeah, this does come up as well. So, rectal prolapse is more common in patients who've had multiple um in particular vaginal deliveries or had complex traumatic um obstetric history. What normally you find is that you can have internal um so there's internal prolapse and external prolapse. Internal prolapse normally presents with some rectal fullness. Um The sensation of tenesmus, um external prolapse can become ulcerated and they can make you um incontinent. Um rectal products can also be partial thickness or full thickness So, in partial thickness, the rectal mucosa protrudes out the anus, but in full thickness, the rectal wall um or lay the wall protrudes out the anus. Um Diagnostic workup can include colonoscopies, um doing anal sphincter muscle studies, um and an examination of anesthesia too. Um in the acute setting, the way you treat this is you try and manually reduce it and you can cover the sugar to try to reduce any swelling. Um And then try and manually reduce it. Um More in the elective setting, there's a number of procedures that you can perform. Um Essentially, there is a Perineal approach, which is the Dior now or there is the intraabdominal approach, which is, which is a rectopexy. So on the left, you can see the rectopexy normally in laparoscopically, um you put a tape um anterior to the rectum and you can suture that the um pro or s promontory to try and prevent rectal prolapse. Um Older studies would say that actually the vey had much better outcomes um and had a quarter less um recurrence and the perineal approach, but more data, obesity, it doesn't show there to be a huge difference between these um these techniques. Um So in, but what the, the way you, you think about is if you're younger and fitter, you'd go for the rectopexy. Um But if you're old and frailer, you would then go for the Perineal approach. So that can be Delorme's procedure. Um And Delorme's procedure is usually only if you have about five centimeters or less than five centimeters um of prolapse on the anal margin. The way this technique works is that you make an incision through the mucosa. Um you then place a number of sutures um across the mucosa and you tire them off and you cut the excess mucosa off. And then when you tie it off, it should collapse back into the anus, um preventing that prolapse segment. Or you're essentially cutting out that prop prolapse segment. If the prolapse is larger than five centimeters, and you'd use an al me and that's essentially a rectosigmoidectomy. So you're actually cutting the rectum and sigmoid through the perineal approach, creating a primary anastomosis. Um And then hopefully, that prolapsed segment has now been excised out. Um Again, the two approaches give similar outcomes. Um But the only difference is I want you out is if there is a prolapse that's larger than five centimeters. Um In the exam, if they ask if they have a young patient who has prolapse, you would obviously want to do back to vaccine. If there's an older comorbid patient, you do the Peroneal approach. Um That's the takeaway from this slide. And then we have anal cancers and then there will be another question after this one. So, anal cancers are normally squamous cell carcinomas. Um and they arise below the dentate lines. The dentate line remembers where squamous cell or yeah, is where the squamous cells are. Um, risk factors for anal cancer or anal neoplasia is HPV. So 90% essentially have HPV. Um but it can be due to other conditions like Crohn's and HIV. Um if the cancer is five centimeters from the anal margin, so if you look at the picture in the bottom, there's anal canal and there's anal margin. Um if it's fighting the anal margin, it's classified as skin cancer. So we won't be touching that. So it's in, if it's within five centimeters and it's classified as an anal carcinoma. Symptoms are normally rectal pain, rectal bleeding, discharge a mass that you may feel on examination. Um Investigations would include a digital rectal examination. Um You do proctoscopy and then you do an examination under anesthesia and take biopsies from this in women. You have to think that the common cause is HPV. So if she's having anal cancer, then you wanna be thinking, is there a survivor core vulva cancer in both too? So make sure she's had a smear um imaging for these cases. Do you wanna get a ct of the pelvis for staging? You want an MRI scan for the T staging and then you want to do an ultrasound scan and perform a fine needle aspiration of any lymph nodes. Um So just to quickly recap some of the lymph nodes spread um in, in anal, in the anal region. So approximately. So if it's in the um upper part of the anal anus. Uh lymphatic drainage is normally to the perirectal paravertebral lymph nodes. Um just above the dentate line, drainage is to the internal predental nodes and the internal iliac system. Um And if it's below the dentate line, um it normally goes to the inguinal um lymph nodes um the way you manage it. Um And actually in the bottom line, you can see that there's a link to nice guidelines. So you can read through that in your own time as well. But essentially, there's an MDT approach, almost all patients have chemo radio therapy. Um So in the exam room, that's what you would want to put down as chemotherapy first, uh except for T one N zero. So T one. So in anal rectal cancers, T staging is not based on the depth of submucosal invasion, which is what you do in colorectal cancers in anal cancers based on the size of the tumor. So if it's less than two centimeters, then it's classified as T one and there's no. And if there's no um metastasis of spread, you just a wide local excision and then you check the margins. Um And if the margins don't involve cancer, we're good and we don't need to get any further. But if it does involve um the margins after a wide local excision, you don't normally do further excisions, you then just do chemoradiotherapy and outcomes are very good afterwards. Anything further than T one you would do chemo radiotherapy MDT approach. Um And the thing with anal cancer is that they're very sensitive to radiotherapy. So normally we have good outcomes. Um But if there is spread and there's further involvement of other th structure structures, node involvement metastases, um then you'd be doing an ap resection um and even a pelvic exenteration. Um but on the top right corner, there's a nice flow chart to go through all the steps um for anal cancers and the nice guidelines are linked to the bottom too. So you can read through that as well. OK. Next question. So 60 year old man presenting with pr bleeding, his heart rate is 100 and 10. His BP is 100 systolic over 70. They have a history of a left iliac fossa pain. You started to resuscitate the patient, what is the diagnostic investigation for this patient? So I'll give you some time. OK. So OK. So a mix of responses. So we can talk about this actually because um uh like what? So I think people who said colonoscopy, some people ctb the pelvis, the question and the CT angiogram, no one said. So in this case, we essentially have a patient who's got pr bleeding, he's in shock. So he's tachycardic and his BP is low. So he's apr bleeding in shock has a history of left Ilic fossa pain. So we're thinking it's probably diverticular bleeding. Um We're resuscitating him. So we want to make a diagnosis here. And when we say diagnosis, we want to identify where the bleeding point is and then try and treat it. A colonoscopy. In this case is a very high risk, especially as we're thinking it diverticular disease, there's a risk of perforation. Um O GD, we don't think it's an upper jaw bleed here. He's got a history of left leg fossa pain. So we're thinking this is probably lower jaw. Then the question is, is it a CT Abd Pelvis or CT angiogram? This patient, what we're looking for is a bleeding point that interventional radiology can embolize um a CT ABD Pelvis. Normally, when you ask a protocol, the scan doesn't include an arterial phase. It's normally venous phase. So you what we want is a CT angiogram and actually be a triple phase scan because we're looking at the arterial phase and seeing is there any act active extra position or blush that um highlights where the bleeding point is coming from? Um Now does everyone is like you get if you, does that make sense to everyone? Like does that, is that clear why we wanna do a CT angiogram in this case and not do a colonoscopy, for example. Um So we talked about and yeah, you can does it make sense? OK, fine. So we talk about in more detail anyways, we go through this properly. So the number of causes of lower giant bleeding. So the commonest cause or one of the commonest causes diverticular disease, um especially with an aging population. Um It can be in ischemic or infective colitis. Um Any rectal conditions we've discussed already, cancers, angiodysplasias, which is an arteriovenous malformation, inflammatory bowel disease and radiation fortis. So, the commonest cause is diverticular disease, um cancers. Um and then the other causes like inflammatory bowel disease and angiodysplasia. Um So the way we um treat um low RD I bleeding is basically based on the B SG guidelines. Essentially what you do is you fate the patient, you localize where the bleeding is coming from and then you control that bleeding. Um In all patients, you'll be checking their medication. Are there any, any anticoagulations? Are there on antiplatelets? We talk to our hematology colleagues and we can get their advice on how we can reverse it. Um We also want to resuscitate the patients. So we start fluids, we start blood products, putting out major hemr protocols if we're, if we're struggling. Um and then we want to then find where the bleeding point is. So we calculate a shock index score, which is what they have said here. But essentially, if the systolic BP is below 100 and the heart rate is over 100 which is what we define normally a shock, then we go to this side on the left side of the flow chart and that's a CT angiogram um as we discussed earlier. So if the CT angiogram show it's positive I ie it shows a point of bleeding. There's two options. One is Ir or one's endoscopy. So if it's showing an active contrast blush, um and normal CT angiograms can pick up 0.5 mils per minute. So we're talking about literally drops of blood um on the CT scan can be picked up. What we do is ask Ir colleagues to try and embolize it and they can hopefully stop the bleeding or we can do a colonoscopy. So we can do from the bottom or we can do an O GD. If it's an labor, you bleed, they, they can use all algo and plasma coagulation to try and stop the bleeding point. Um If Ir fails, you can then try colonoscopy. If colonoscopy fails and you haven't an iron, you can try Ir um if both of us fail, then we're, we're, we're in trouble. So we are, it's gonna be a tough, tough day. Um If that happens um on the right side, there's the Oakland classification. So this essentially looks at um how high risk of bleeding is. So you calculate the Oakland score if the patients were stable gi bleed, ie there has some people are bleeding but it's um um but it's, they're not shocked, they're not really unwell with it. So they can calculate the open score and that can make you make a decision about is the patient um safe to go home and you can, can be followed up with an outpatient colonoscopy or do they need to be admitted and then have an urgent colonoscopy as an inpatient ie the next day. So you can use the Oakland um school for that. And that's based on age, the older you are higher risk men, higher risk um digital rectal examination findings. So if there's bleeding and that's another bad side. Um and then again, signs of shock and any HB drop, the one thing to say about low G bleeding though is that m most of the time, like 95% of cases will just settle spontaneously. So you don't need to be doing any interventional work. Most patients just settle it by themselves. Often younger patients, patients who are here more dynamically stable and they will just stop bleeding by themselves. Um It's very rare that you will end up having to do IR or any um big interventional work for this. Um So, and as I alluded to earlier, we are surgeons after all. If the lower gi bleed, you cannot identify it. It's gonna be a really difficult day in the office for all of us. Um In that case, they're continuing to bleed, they're hemodynamically unstable. Um And you're not able to identify the bleeding in using a scan or with scopes, then it's usually mandates the patient going to the theater, you put them in the lithotomy position. So, and this, this is we pop them to sleep and then we can do one last rigid or flexible scope in theater to see. Is there any bleeding points? If not? And the patient is still bleeding? Um, and they're still shocked, then we'll have to do laparotomy. You would walk the small bowel to large bowel. You'd be looking for any cause of bleeding that we can identify, such as that causes a tumor if you can't find a bleed. But from the history is um suggested that there may be an upper element to it. You could open a small bowel, so do an on table enterotomy pass an enteroscopy and then see um is there a bleeding point in the small bowel? If there is, we can do a uh small bowel resection with a primary anastomosis. If you think or if intraoperative, you can identify a large bowel um localized point of bleeding. Um They can do a segmental colectomy or let's say you done an ir you done a colonoscopy and you identify the bleeding is in the colon, but you can't get control via IR or colonoscopy. Then you know, go in, do a laparotomy and then do the segmental bowel resection. If you can't find the bleeding point, then you may have to do a sub to colectomy and an end end iost toy. Um The morbidity in this case is very high. Um And potentially the bleeding may not even be in the large bowel. Um And that can lead to really bad outcomes. So it's a very tricky situation. But this is the logic or the way you think about approaching a patient with um a lower joint bleed. But really for the exam, just remember we the patient get act angiogram, you want the patient to be bleeding because then you can actually see it in the CT scan. Um and then you can then target your treatment with IR or colonoscopy. That's it for a little child, I think. Yeah, good. Next question. So we've got a psych patient that's presenting with abdominal distension, some vomiting and constipation. Uh The CT Abel shows dilated large bowel without a transition point. So what is your top differential diagnosis? Yeah. Ok. Let's have a look at the insulin. So it's a pseudo obstruction. So I think I'm not sure how many people said sigmoid ovular. So it a sigmoid. Most of you guys said uh pseudo obstruction, which is very good. Um Sigmoid volvulus, if we do a CT scan, it will show the sigmoid volvulus. Um But this is showing dilated large bowel without a transition point. If you had a sigmoid volvulus, you have a twisting of the bowel. So you have a cutting off point which is where the twist occurs. Um It might get a swirl pattern in the mus entry. Um But because the entire large bowel is dilated and there's no cut off point, you're you're not thinking of a actual obstruction like a large bowel obstruction or a sigmoid Boulis. Um, and the CT scan hasn't picked up any cancers. Um, or to the patient who has got psychiatric histories, they may be taking antidepressants or antipsychotics, these things can increase the risk of pseudo obstruction. Um, so in this case, the most likely answer, the correct answer is a pseudo obstruction. Um, so we'll just quickly talk about knowledge about obstruction. Um, but we can talk about that. We'll talk about the pseudo obstruction first. So, because that's what the question was beforehand. So, essentially pseudo obstruction is an interruption and the autonomic nervous system that surrounds your colon. Um, and that can result in a reduction of the smooth muscle tone, um, in the bowel wall. And so the bowel wall become super dilate it. Um, and the function is then lost. Um Normally there's an underlying condition for this. So this can be electrolyte imbalances, endocrine disorders, um, like hypothyroidism, um, hypocalcemia. Um, it can, it can be due to medications, opiates, um, antidepressants, psychotic antsy medication. Um, if you've had recent surgery, if you've had, um, sepsis, um, and the neurological conditions like Parkinson's and multiple sclerosis, there's normally something underlying with pseud obstruction. So the management is try and correct that. So try and correct the electrolytes treat the underlying conditions. Um, there's always talk about mean, I've never seen it used but, um, um, literature does say that it can be used. Um, and it can give really profound outcomes actually if um all the other factors haven't worked. Um So neostigmine is essentially um a acetylcholinesterase inhibitor normally used in MS. Um but essentially it does the same mechanism. So it um allows improve, it, improves the muscular tone in the large bowel, um which then constricts it and then relieves the um pseudo obstruction. But normally these patients need to be put into HD and monitoring because it has a lot of side effects like drooling. They're completely cardic, et cetera. Um That's pseudo obstruction, the large bowel obstruction, generally speaking, you wanna get a diagnosis. So sometimes A&E may refer with an X ray of the abdomen. Um But you want act scan because a CT scan will tell you if there's a transition point and it will also tell you what the underlying cause of the obstruction is common causes of large b obstruction is cancer. Um It can be diverticular structures and boils. Those are three common causes. So, if you have a cancer causing, um, if you have a cancer causing the um, obstruction, um from the CT scan, you have enough options in the way you manage it and the way you treat it. And actually, I am assuming this, um But actually, let me just mention it obviously, with large obstructions. The way you're going to treat this patient is, you know, resuscitative accordingly, give them tubes, know by mouth, um, catheterize them, et cetera. Um and the clinical findings is in that case, you know, vomiting, abdominal distension on pr examination, there'll be a empty rectum. Um, but just make sure that's like the classical art about obstruction, isn't it? Um But yeah, so if you have a cancer and this is the right side of the colon, you can get away, you want to get rid of the obstructing lesion, you can do a right hemicolectomy and we'll talk about this more on the cancer segment. If there's a left side, you can do a left sided hemicolectomy and you can apply anastomosis. If there's perforation. If there's any adverse features, you can do a heart ones. So you can do an a rectal stump and an end um and then in more palliative settings. So the patient has multiple comorbidities. Um If they're very frail, if you calculate the needle score, which is a National emergency lab for you audit um score and if the, if the morbidity and mortality are very high, you can then do a stent um and then I can relieve the obstruction. Um And then you can do things like chemo radio, the or you can just do the stent in and then manage them palliatively. If the cancer is in the rectum, then it's a bit more complex entity because rectal cancers normally require or rectal cancers respond very well to um chemoradiotherapy. So what you'd want to do in this case is do a defunctioning loop stoma stage the cancer and then do def definitive work. Um rectal cancer resection later on. Um then there's diverticular disease. So, diverticular disease over time with a chronic repeated inflammation can cause strictures. Um in those cases like antiinflammatory B disease can cause the same thing. You can then do a Hartman's procedure which is, you know, endosy and a rectal stump. Um And then for Bolar, so ovular is essentially twisting of the bowel. Um On the right side, there's two pictures. Um they're both different types of ovulation. So the top one is a classic coffee be sign. But what, what you notice is that the, the way it's pointing is from the left elect fossa up to the right upper quadrant. So that's a sigmoid WVUL. But in the bottom picture, you can see that it's pointing from the right elect fossa up to the left upper quadrant and that's a cecal ovules. Um So that's the difference between the two pictures. Um with a, a sigmoid ovulist, you wanna convert that, you know, emergent twist of the uh sigmoid into a elective issue. So what, what you do is you do a flexible sigmoidoscopy pass a flatus tube in and try and decompress that twisted segment. Um And then next day, the next day in the morning, you can then do your more definitive procedure. Um If the per patient has perforation, if they're peritonitic, um then you're mandated to do a, a heart procedure. Um, yeah, that's, that's all you, that's all you can do essentially in that situation. Um, electively. What you can then do is a, essentially a sigmoid colectomy because the sigmoid is twisted. So once you relieve the emergent situation, you can then do a sigmoid colectomy and call your anastomosis. Um, co less you can't get away with doing colonoscopies and, you know, flexible sigmoidoscopies and tubes because it's too far down. It's too far across the colon into where the IM is attaching, isn't it? So you have to do a right hemicolectomy for um a cecal ovules. Um There's other things like cecal vascular where the cecum can actually flop anteriorly and then curl on in itself and then cause an obstruction as well again where you treat it as a hemicolectomy. Um That's um I thought that's a lot about it. I thought the questions next but is there any questions up to now? Is everything making sense? There's a lot recovering, I think. Um But does that, does that make sense? Everything? Uh Yeah, everything's uh really clear for me anyway. Thank you. OK, perfect, perfect. Let's see the next question. Um And we're halfway through. So let's, let's do this. So we have a 42 year old um with cecal cancer kind of couple this. So that's good. CT shows invading tumor with some regional lymphadenopathy. So, what is your best initial treatment? So, I'll give you some time. OK, I think that's it. So, let's see. So, the answer was a white hemicolectomy. I see most of us did pick a white hemicolectomy, but I think some people picked radiotherapy and chemotherapy. So let's talk about this, uh, mixed cancer. Yeah. Good. Um So normally, um with a cecal cancer, um, or a right sided tumor, you would just take the cancer out. Um And then you would stage it um with histology and you then discuss an MDT and then you can do chemotherapy radiotherapy. Um, well, not radiotherapy, chemotherapy, radiotherapy is not used for bowel cancer except the rectum. Um, the bowel is too mobile. Um And so radiotherapy doesn't really give good outcomes and you can get radiation proctitis or radiation colitis. Um So you don't normally do radiotherapy or you don't do radiotherapy for large bowel. Um, chemotherapy is an adjunct that you would use. Um, but the treatment is invariably going to be a hemicolectomy. So you're gonna remove the tumor, you're gonna remove the lymphatic pedicles. Um And then if there's any residual tumor um from histology, then you can do chemotherapy afterwards. So you're just gonna go straight to your hemicolectomy. And that's, that's why that's the correct answer. So we talk about colorectal cancer, which is quite a dense topic. Um But essentially colon cancer starts normally with a adenoma. Um And this is the idea of this thing called adenoma to carcinoma sequence, but it's essentially the progression of a normal mucus mucus lining um to form a chronic adenoma or colorectal polyp. Those polyps then become dysplastic. So the cellular structures uh and nuclear structure start changing. Um and then it eventually turns into an invasive adenocarcinoma. Um And that's the adenoma to carcinoma sequence. There are some genes implicated in this pathway. So there is some hereditary element to it. Um The adenoma polyposis coli genes, a PC gene um is a tumor suppressor gene and in condition like familial adenomatous polyposis, um that gene is knocked out. And in F AP you can have patients quite young who have 100s and 100s of polyps in the colon. Um and they usually require, well, they require surveillance early on, but then essentially a pan proctocolectomy and then there's Lynch syndrome. Um but the H and PCC is a hereditary nonpolyposis colorectal cancer gene, which is a DNA mismatch repair gene. Um And that's knocked out in a condition called Lynch syndrome, which is, you know, linked with other cancers like endometrial cancer, um which you know, so all that comes up in the exam as well. Um So these are the genes that are implicated in the sequence um of colorectal cancer development. Um what you need to do with these patients. So normally the way the patients would present classically, you know, like they may have um loss of weight, they may have a change in bowel habits, they may have pr bleeding. Um They may present as an emergency discussed earlier as a obstruction, usually quite rare though. Um, but if you have any suspicion um about these patients. Um And actually in the next slide, I've actually got the nice guidelines for when you'd want to refer um to lower gi um where que lower gi cancers. Um, so your mass change in bowel habits, iron deficiency anemia. And there's a stratification based on weight. You get a fit test if the fit test is over 10, um then you prefer as a two week weight. Um and then get essentially a colonoscopy. Um the colonoscopy at that point, you then identify what kind of polyp this is. Um And or is it already adenocarcinoma? You take a biopsy. Um and then you'll be discussing the histology findings in MDT, you'll get a CT chest out of the pelvis for staging. Um And if the tumor is below the peritoneal flexion, you do an MRI scan of the pelvis. And this is to allow you to make a plan for mesorectal dissection and excision. Um That's what I say. That's fine. So good. So your MDT approach, um if there's a rectal cancer, there's two elements here. So if it's a rectal cancer, you wanna get the staging first, which we done now with the MRI scan, if it shows at one or two tumor. So in the top right corner, it shows you what T one and T two are. So it's either submucosa or muscularis propria. Um so the depth of invasion, but there's no no metastases, then you can do these different procedures. So you can do a transanal excision um or you can do an endoscopic submucosal excision, which is this diagram here or you can do a total mesenteric excision and talk about that in a second. So you can do transanal or ESD, which is endoscopic approach. And you essentially go in with a scope, you identify the tumor, which is, you know, T one T two. So it's only in the submucosal muscularis propria. Um And you inject essentially saline um underneath the tumor and you dissect that tumor out. Um and you send it off to histology. Um Normally that's, you know, outcomes are quite good, but it needs quite experienced um surgeons to perform it. Um So that's your um ESD total mesorectal excision is essentially a rectal and sigmoid colectomy with mesorectal dissection. Um So you're taking out all the lymph nodes and all the blood vessels, um which is more of an involved operation. And then for um any tumors in the rectum that have no spread or are invading deeper than the mesorectum or involving the mesorectum. So, T three T four, then in these patients, you give them pre op radiotherapy to reduce the tumor size. And then you do the resection of surgery, which is the rectal sigmoid Colectomy with a mesorectal excision. Um And the, on the, there's the nice guidelines there but that's essentially nice guidelines summarized um for colon cancer as we discussed earlier, if it's like a rectal, if it's a ascending tumor, sequel tumor, you resect it and then you do chemotherapy. If on resection, it's shown to be at four plus cancer or there's nodal involvement, then you get chemotherapy, but invariably, invariably you would always do a resection in the emergency setting with colorectal cancer. So there's an obstruction, there's a perforation. And this left side, you can do apartments or you may need to decompressive colostomies. And in a palliative setting, you can do stenting. Um Those are nice guidelines. So busy slide, that's a good slide. Lots of data points here. So this table on the left um comes up in many places, but essentially, it just shows you where the site of the cancer is and what your resection would be. So essentially, if there's a right sided cancer, you do a right hemicolectomy. And what you wanna do is take out the pedicles because that's where the lymph nodes spread occurs. And that normally follows arterial supply to that region. So in the diagram of the right, you can see um the alter and aorta one of the branches, the superior mesic artery at the level of L1. Um and that gives us, you know, ileo juin branches, but it also gives, gives us the Ileo colic branch which supplies the appendiceal artery, which is appendix and caecum also gives off the right colic branch, there's an anterior and a posterior branch to that. And there's also the middle colic artery and there's a right and a and a left branch to the middle colic. And then there's this watershed area which is where the marginal artery is. And that's a communication between this middle colic from the supra enteric artery and from the left colic, which is from the inferior mesenteric artery. So when you're doing a right hemicolectomy, you essentially want to cut out the ileo colic um arterial supply the right colic and the right branch of the middle colic because that's where the lymph node spread is most likely going to occur. Um And then you create an ileo colonic anastomosis and the mees entry and the blood supply is all taken out and sent off to histology and then we can get our nodal spread and our um staging from that. Um if it's a left sided tumor. So, splenic fracture, left colon, um then you'd want to be doing a dissection, obviously, a le a left sided hemicolectomy, but you'll be taking branches from the left um colic artery. Um an advantage of the SMA A and the S MV and the inferior means vein too. Um And those are all divided and removed. If you're having lower tumors or sigmoid colon, you'll do an anterior resection. Um So that's essentially where you cut out the sigmoid rectum and then you create a primary anastomosis between the anus and the colon, um or the anus or the lower rectum and the colon. Um And then there's either anterior resections can be um high or low. But essentially, that's summary of it. It's quite, you can do that as well in your own time. And the anus we've already discussed um post polypectomy. I don't think this is a very high yield. Um But this is the um BS GS guidelines on um cancer resection, surveillance and post polypectomy resection. Again, you guys can have these s lies and read them, but I don't think it's a very high yield. OK. Next question. So we've got a 19 year old woman, she's admitted with two days history of worsening, right? Iliac fossa pain. She's been nauseated and vomiting on examination. She's markedly tender and the right iliac fossa with localized guarding the urine dipstick. And the BT HED is negative blood test shows a raised white cell and a raised CRP. So what's the most appropriate course of action? I think this might be an interesting one for people. Let's see what you guys say. OK. Yeah. Yeah. Yeah. Um I think one person responded so that wait a bit longer, I'll give him a few more seconds. OK. So I think we, let's, let's see, answer that. So that's interesting. I think it always leads to open point having a lot of questions and a, a lot of debate about what, what you would actually do. So we've got open appendix and we've got an abdominal ct scan. Look at the guidelines in a second together. It's a young woman. Number one, so we would try not to do a CT scan for her. Um Number two, we'd gold standard approach is a laparoscopic appendicectomy, not an open appendicectomy, especially in a woman, especially a young woman like this. You're always going to have a differential of a gynecological cause of her symptoms. Um It could be a ovarian or tubo ovarian disease or an abscess. Many times I've gone in. Um thing is an appendix and we go there and we look at the appendix space and it looks completely normal and it ends up being in a pathology and we have to call gynae colleagues to do a um salpingectomy. So, actually laparoscopic approach is the way we would go. So we'll do an open appendix in a, in a young woman. Um And then the question is actually the first line, maybe could have been an ultrasound scan. Um But in this situation, we have a young patient who's got classical symptoms of appendicitis, she's not pregnant and she's got raised inflammatory markers. So her risk score, if you were using any risk appendix, appendicitis, risk scoring systems would be high risk of appendicitis. Um Platamine is potentially a gynecological cause so we could do an ultrasound scan but we wanna try and minimize um you know, all it does is delay us going to theater. Um and she probably does have appendicitis because the score is quite high or she would score very highly. So you just a diagnostic lap, you'd identify the cause, either Gyne or appendicitis and then you treat it there and there. Um I hope that makes sense, but we look at the guidelines together now. Um So appendicitis is essentially caused by obstruction of the lumen of the appendix. Um that causes bacterial overgrowth. Um You get acute inflammation, that inflammation then causes venous stasis. Um A venous stasis then causes increasing back pressure that then can lead to necrosis and then that can lead to perforation. So you can end up perforated appendix and that's the cycle of how appendicitis occurs. Um Normally the obstruction is because of a fecalith, but it could be even cancers, especially in older patients. Um This, I've highlighted bacteroides here. So this is something that may come up in the exams too. The question of what bacteria is normally implicated, especially in a perforated appendicitis, the reason. So the the colon is full of e coli, we all think that yes, there's E coli in the bacteria is the most, most common bacteria inside the in the colon. Um It's an interesting bug though cos it's a fecal um anae so you can use oxygen. Um but it can also work under anaerobic conditions too. Um But when the E coli is thriving and having a great time, such as in this, you know, appendicitis, it will start to reduce the oxygen levels. Um And that creates a really nice environment for back to then thrive because it's a um um ana so normally in more chronic conditions like a, you know, gangrenous necrotic perforated appendix, you're gonna have a higher concentration of bacteroides. Um So if the question comes up, that's what you're saying. Um And that's why we give you metroNIDAZOLE as well. Cos metronidazol is very good for bacteroides. Um when you treat appendicitis, um normally the pain is presented with periumbilical pain and then that migrates to the right iliac fossa. Again, the bio the the mechanism behind that is because paraumbilical pain is because of the visceral peritoneum. So the appendix is part of the mid cut. Um and the mid gut is referred pain to V level of T 10, which in the umbilicus is um and then it moves to the right ileac fossa when the parietal peritoneum starts to get irritated and that is a dermatomal branch is more specific. Um The patient can have vomiting but you wouldn't expect them to have excessive vomiting. There may be anorexic. Um two examination will be very tender at mc's point which is a third from AYS to the um umbilicus. Um investigations get a year in depth to rule out, you know, UTI S um get a pregnancy test on women, get routine bloods, do radiology. So we talk about this now. So ultrasound get atb us requiring gynae causes and Children get an ultrasound scan, cos you want to radiate them and then pregnant women, you can do ultrasound scans or an MRI scan. MRI scans are not that available. So, ultrasound scans is what you'd use. Um in older patients, you can use act scan or there's equivocal finding or you're not sure you need a CT scan and that gives a very high sensitivity, um, to identify appendicitis. The management is essentially a lap appendix. Here's an appendiceal mass. So, appendiceal mass essentially where omentum is flopped over the appendix and is wrapped around it. Um, usually in the setting of um, the small perforation of the appendix in those cases, the, the masses surround the appendix. And so it's kind of predictive already. So you can just treat with antibiotics. Um And then you, you can do a delayed interval surgery in a couple of weeks. So if you went in now you'd be dissecting all that omentum away from the appendix and it becomes a much more like tricky operation. Um The other thing is in Children, they tend to present doing quite well and then they become very unwell very quickly. The reasoning is that the mentum isn't, doesn't drop all the way down into the pelvic region in Children still growing. Um So when they perforate, they don't have that nice protective mechanism of like an appendiceal mass that the mentum wraps around, they just perforate, it goes everyone abdomen. There was a study there, the wift um trial, the right fossa trial that was done in 2019, 2020. And it has some interesting findings. Um They looked at different scoring systems which we talk by in a second right now actually. So they found that actually the scoring systems are slightly different for men and women. Um A good score is the appendicitis in inflation response score is good for men. Um But in women, they don't appendicitis score is good. And essentially all they did is they added female and they dropped you mark of that. The reason being in that is that in the risk score, they found out that a lot of women were getting normal appendicectomy. So you did the appendicectomy sent to the histology lab and it, it, it showed no inflammation um that because there is more diagnostic uncertainty in women um with white fossa pain. Um But anyway, these are the two scoring systems that they came up with uh or two scoring systems that they recommend. Um So in our case, she was a woman for sure, but she had at least 24 hours of pain. She had white lower codon pain for sure. She had pain relocation. We'd assume she did, but we don't know, white lower coordinate was tender. She had quite severe guarding her white cell was up and her C RP was up. So the score in that in this case would be high. Um And if you look at the word society of emergency surgeries flow chart and this is the consensus statement in 2020. Essentially, they say if you're a young adult with symptoms of just acute appendicitis score them, if the score is high, like in our case, we discussed, then you essentially will take them to their term. If the patient is young, if the patient is over 40 you get a CT scan because of course, it could be an underlying tumor or cancer or something else like a diverticulitis with the sigma that's flopped over to the right side. Um So that's why in the, in that answer, the answer was going straight through laparoscopic appendicectomy or laparoscopic diagnostic laparoscopy. Um, because you are following essentially the worst flight emergency surgery guidelines and you're following the advice of the rift trial. If there's an intermediate risk, you can get an ultrasound scan and there's a low risk. Again, you can get an ultrasound scan. Um And if that proves appendicitis, then you can progress to do appendicectomy. Is that right? Let me see what I just showed you the answer. You don't mind. 6 to 29 next 10. Does that make sense? Appendicitis? By the way, do you think there was some differing answers is a appendicitis? Makes sense to everyone? Good. A high yield topic. Uh Yeah, that, that was really helpful. So I'm really clear. Ok. Ok. Good. OK. So um next question. So 62 09 with a left ilio, the pain and pr bleeding CT shows a three centimeter pericolic abscess. How would you manage him? Um OK, cool. You've got a few responses now. No mixture of responses. Most people said IV antibiotics it looks like. And the answer is IV antibiotics. So there's a mixture of responses. So let's talk about it. Um um So clearly what, what we're thinking is um the left fossa pain is because of diverticular disease and there's a pericolonic abscess because of this. So this is a complicated diverticulitis. Um Now, do we want to do antibiotics only or more? So, the, the, the guidelines state that if it's less than five centimeters, um the abscess size, um then they normally heal on their own. So you give them antibiotics and they do really well and you don't need to do anything else. If it's more than five centimeters, then you can do IV antibiotics plus drainage. And that can be either um ir drainage or you need to go in and drain it um laparoscopically. So, in this case, because it's three centimeters, um abscess, you just do an IV antibiotics. So that's, that's the reasoning behind it. So let's talk about diverticular disease. So, essentially diverticula is sites of weakness that normally occur between the tia coli where the via erectile penetrate the colonic wall. Um And you get some increased Luminal pressure. It can break down at this point. Really, if you look at the anatomy, it makes more sense. So the outer layer, there's the muscularis externa. Um and that's important, it's implicated in diverticular formation. So the outer longitudinal muscle layer, so there's a outer longitudinal. Um So if you look at the bottom white picture here, you can see that there's a circular muscle and there's a longitudinal muscle in the muscularis propria. So what happens in the small bowel is that they are both continuous, but in the large bowel, the longitudinal muscular layer becomes the tia coli. So you're essentially losing an entire layer of the muscularis propria in the colon. Um and that strengthens the tia coli. But then it means that the surrounding areas are weaker and then where the blood vessels. And you can see the picture on the left where the blood vessel of the res recti penetrate into the colon that then creates a further site of weakness. And then these patients who have chronic um like constipation, um increased intraabdominal um pressures. Um that can then lead to essentially small herniation of the pockets, which is what the diverticular are. And these diverticular can get blocked and they can cause diverticulitis. Um They can over time with inflammation cause structuring which we discussed earlier. They can cause pr bleeding. We discussed, they can call fistulas and they can perforate um CT scan where you get in an acute setting cos that tells us the answer straight away. Um mild, mild diverticulitis and we discuss as antibotic but you, you classify. So the classification is either simple or complicated. Um complicated is any abscess or any proliferation? Simplest, none of those. So if it's a simple diverticulitis, you just give antibiotics. Um if it's complex, um then you can use a hint of classification that can be radiological or can be intraoperative stage. One is just a pericolic abscess. So in that case, it was a pericolic abscess. Stage two is a pelvic abscess. Essentially, it, there's some pus around of the colon. There's some pus in the pelvis, there's pus everywhere. Stage three and there's shit everywhere with stage four the way you manage the patients. So stage one and two IV antibiotics plus or minus drainage. So if it's less than five centimeters, you don't need a drain. If it's over five centimeters, then crack on and get a drain in there or drain the sepsis or drain the pus. For stage three, it's a bit more difficult. You can do a laparoscopic wash out. Patient may require resection in heart's. And the stage four, you're definitely gonna be doing a heart's, there's fecal peritonitis everywhere. So you need to do AAA rectal stump and an endocolostomy. You can't do a primary anastomosis because there's poo everywhere. So the anastomosis would break down cool. I think that's the only border particular disease. Hopefully, that makes sense if there's any questions. Let me know. Ok. Next topic, 40 year old man presenting with jaundice, multiple bowel structures. He's got a history of bloody diarrhea for five months now and he's got an enterocutaneous fistula. So, what is your top differential diagnosis? Ok. Elbow and the inside. I think that's going the right. Everyone's had Crohn's disease. Yes, too. Very good. Yeah. So it's quite classic, isn't it? Um, the jaundice in this case is, um, maybe a slight curve born because normally you get primary sclerosing cholangitis in UC, but it does occur in Crohn's disease. Um And the other things that are pointing towards Crohn's disease is the strictures which are more common. Um, and the fistula formation, um especially enterocutaneous UC doesn't involve the small bowel. Um And so you're thinking that this is more likely to be Crohn's disease. Um, other than UC, there isn't much indicating ischemic colitis in this history, like a history af or um, clotting disorders or something, something like this. Um And he's quite a young man. Um And then it's unlikely to be pseudo colitis as blade area. Um, but you're not thinking there's any history of like c diff or antibiotic use or something to indicate ac diff infection, inflammatory bowel disease. Sometimes we get involved as surgeons. It's usually treated medically though. So, e ulcerative colitis versus Crohn's disease. So UC involves the large bone, the large bone only. Um Crohn's disease is the entire gut formaster anus has mucus involvement only but Crohn's has transmural involvement and that's why we get the fistulas. UC um has macroscopically crypt abscess formations in Crohn's. You get granulomatis disease and you see the macroscopic findings is continuous inflammation starting from the rectum, traveling all the way up over time to the um pro to the um caecum, you can get some backwash ileitis, but it doesn't actually involve the ilium itself. Um And then you get these things called pseudopolyps, stenosis pseudopolyps where the ulceration has occurred. And then it creates these mucus bridges on normal mucus surfaces which look like pseudopolyps. In Crohn's disease, you get these skip lesions um and these deep fidgets and they look at this coli and appearance that you can see on the right. Um There's also this thing about fat wrapping in Crohn's essentially the starts to migrate. Sometimes it's like the appendix, you know, but like the fat starts and momentum starts to move around where all this inflammation is occurring. And that's called fat wrapping. Um And that can be is a pathogenic finding on MRI scans of the bowel for Crohn's disease. They cystic Crohn's disease. So we'll talk about more, a bit more about Crohn's smokers have a higher risk of Crohn's disease. Um They presented abdo pain, diarrhea blood mucus in the stools, investigation of fecal calprotectin is normally quite high in um inflammatory bowel disease and it can be a good marker to monitor response to treatment. Um You want to do a colonoscopy and a biopsy of the tissue. And that shows us the granulomatous disease and that can be diagnostic of the Crohn's. Um there's a Montreal score for severity which looks at your age, the location. So is it an I or is it colonic? I colonic? Is it upper disease? Um and also how is it behaving? So, is it a strict, is it perforating or penetrating? Is it non structuring? And this can give you a severity score for Crohn's disease. Um There is a number of extraintestinal features of Crohn's, many of them overlap with UC. Um So the M SK features like arthritis, um skin conditions like erythema, inos pyoderma gangrenosum. So, in the top right corner, you can see a picture of stoma patients had a Crohn's disease like you had an ileostomy after protocol. Um I can see that kind of ulcerating skin lesion around the stoma and that's essentially a pyoderma gangrenosum may come up in exam too. Um eyes, you can get eps, scleritis, anterior uveitis, um hepat. So it's commonly closing SCS cholangitis can occur more so with, but it can occur Crohn's. Uh and then that can lead to cholangiocarcinomas. Um because of the in Crohn's, you can get terminal, the most common site actually is term I terminal eal disease. Um You can get reduction of absorption of bile salts in term of your ilium and that can increase your risk getting gallstones. Um because bile sals help in dissolving and breaking down gallstones like normally. So that's, that's why you get higher risks and then there's a risk of renal stones too. The management for Crohn's. So medically, you wanna optimize it first. If there's an acute flare, get them into remission, give them steroids and resuscitate them. You don't wanna maintain that remission. So you give the immunosuppressives and the biological agents like azaTHIOprine infliximab. So the TNF alpha inhibitor and then you follow them up because there's a risk of cancer. So you follow them up with cholic surveillance, then you may need surgery. Um And because the common site is um stricturing terminal disease. If it does become strictured and causing symptoms and issues, then you can do an eye or cecal resection. Um If there's small bowel involvement, you may require small bowel resection. Um We've talked about Perianal disease and the f and abscess drainage and inserting ses. Um if you have strictures and you have stricturoplasty, um and then potentially the patient, if the patient has large b involvement and it is causing symptoms and pr bleeding. Um and it's not um responding to medical management, then they may require a subtotal Colectomy or a Panoptic Colectomy. You will not do limited colectomies in these cases because of inflammatory response. The Crohn's disease will occur in other parts of the large bowel and then you are essentially wasting time, you might as well just remove the disease. Um So that's what you do. Um, the, the aim in Crohn's, especially in surgery is we want to try and minimize the amount of bowel that we're cutting out because it does affect the entire bowel. Um, so you don't want to cut everything out. So you want to try and minimize that. Ok. So, ulcerative colitis, I think we talked about a fair art already. So it's less common smokers. We've talked about the way it spreads. We talked about colonoscopies. Um They truly have. And what criteria in the top of the right corner in terms of the severity of disease. Um You can read as well, classic findings, pseudopolyps in the bottom, right. Um And then the lead piping. So that's of chronic disease. You start losing that haustra in the large bowel. Um So it looks like looks very straight. Um And that's a classic um lead piping management of UC. So again, similar. So try and get remission, get steroids. Um And then you can use the A thio infliximab to maintain in remission. In ulcerative colitis, you can have emergency situations such as toxic my colon um where the entire colon becomes super dilated um and inflamed because of the colitis and that can lead to bleeding, but it can also lead to perforation. Um In these cases, you do a subtotal colectomy and then, and ileostomy, remember you see on your attacks, the colon. So, essentially, that's curative. You get through the entire colon um and you leave them with an ileostomy in the elective setting because again, this affects the colon. It's a bit curative. You can do a proctocolectomy and you can develop an ileo anal pouch. Um and then you can see the different types of pouches on the bottom, right. So you can breath these s pouches. J pouches, essentially, they create some continence. Um because you're removing the entire rectum and sigmoid and that creates some volume for um like a capacity storage mechanism. So you, you can have some bowel like a normal bowel function. Um And in older patients or in more frail patients, you can just get away with an endo iost toy. I think that's what I've said for this. Ok, fistulas. We kinda talked about fistulas um earlier, but we'll talk about more in the different times, not this peral fistulas by the fistulas. Um So again, because of the transmural inflammation in Crohn's disease, you can get fistulas forming. Um And usually as long as there's no distal obstruction, they should um heal on their own, but you can get fistulas forming between the bowel and the skin, which we call enterocutaneous. Um You can have enteroenteric or colonic, um that normally leads to patients having um malabsorption, having abdo pain, diarrhea. Um You can have rectovaginal fistulas and that normally presents where patients essentially ping or like, you know, passing gas um vaginally. Um And then you can always have enterovesicle fistulas where you're passing gas and poo into your bladder and you have cystitis, your current uti is passing um, gas into your, your urine as well. Um With enterovesicle, the way you treat it is you find the bowel that's stuck, do a bowel resection plus a catheter inside. Um And then usually that small hole in the bladder should close up on its own if it's larger, can suture it. Um In rectal vagina, we can actually do similar mechanisms to that advancement flap where you can create a advancement flap in the mucosa to try and close that um opening of that fistulated tract. Um and then enterocutaneous fistulas. I think I've got something. No. Yeah, something about high output. So normally with the enterocutaneous fistulas, um you try and prevent any distal obstruction and things should heal up. You can try and dry up the um the bowel contents. So you can give them potentially TPN, you can give them octreotide, omeprazole try and reduce the volume. Um It gives them bowel rest and that should hopefully resolve um that fistula or that fistula tract is give some bowel rest. But this this entity of high output stoma and this is the topic that does come up in the exams. I think this is the last thing we're going to talk about. So high output stoma um essentially where you have more than 1.5 to 2 L in a 24 hour period. Um of sto output and the high, high output into a cutaneous fistula is defined as greater than 500 mils, um, in a 24 hour period and low output is less than 200 mils. Um, in that same time period. Um, normally there are issues with bowel resection, especially in Crohn's disease is that you can get this thing called short bowel syndrome or short bowel, which is essentially less than 200 centimeters, um of, of bowel from the D day flexure. Normally, it's about 275 to 1, 1000 centimeters. So it's not about the amount of bowel that you were sect in theater because if you took out 500 centimeters from somebody who has 1000 they don't have short bowel. But if you took out 100 from somebody who only has 275 to start with, then they will have short bowel. Um So you need to and usually as a surgeon, you should be measuring it after the resection to see how much bowel is left. Um And so this idea is that you can have this easy fistula that forms before the 200 centimeter mark from the DJ flexure. Um And that can essentially create this artificial short bowel and then you can create because there's that short bowel, you aren't able to, you don't have enough space to absorb all, all of the content. You can end up having high fistula outputs. Um The way you manage. This is you try and dry everything up. So you make them, you don't let them eat, you put them on TPN, give them bowel rest and hopefully, and usually things dry up and the fistulas close. Um, but for high output stomas and for fistulas, you can get them um oral hypertonic fluid restriction. So you fluid restrict them. You can use s say mark solution like oral glucose, electrolyte solution to try and um maintain reabsorption of um fluids and water. Um Give them loperamide, which is an a um a, a non opiate um with non essentially acting opiate essentially. Um and it can help prevent the diarrhea and reduce secret and reduce the amount of fluid um anti medications. So, antagonists, PPIs um and octreotide can be useful to try and reduce secretions. Um And then if there's distally any colon or other small bowel that's not in circuit, you can try and reconnect it. So you can try and lengthen the bowel. So if you've had an eye, eye stoma, for example, you can try and take down the stoma and bring it back into circuit, um if it's possible to try and prevent high output stomas. So this question does come up, but essentially the takeaway from, from this slide is short bowel is less than 200 centimeters. Um And high output stomas are defined as those two. Normally, you can try and um reduce the secretions with octreotide. Um and patients may require TPN to try and dry up these fistulated tracts and give the patient bowel rest so that things can close up on their own. I think that is it. Oh, yes, that is it. Questions. Any questions? That's a lot we've covered. I am sorry where everything makes sense is everyone happy with that. Yeah, that was, that was really great. Thank you, Alec. There's no questions in the chart at the moment but um if anyone does have any questions, feel free to um send them to us on whatsapp over the next few days and we can pass them on as well. Um I've put a feedback form in the chart if everyone can fill that out. Um That would be great. It's, it's really short and it's um really useful for a lot for his um portfolio. Um Yeah, that was great. Thank you very much, Alec. Mm ok. Thank you guys. That's good. Um Yeah, as you said, any questions just let me know as well or text me. Thank you everyone. Bye.