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Anatom of the esophagus. So I, um, I tried to write this presentation based, um, initially on just my memory. Um And that's why the first three questions are highlighted in red because these are the things that II felt and I still feel come up again and again and again, whenever you're practicing, whenever you're looking at questions, whenever you're quizzing people, um, that it, you know, this is the stuff that comes up. So, um, the exam is focused, we're talking about OG surgery. Now, a lot of people's experience unless you work in a tertiary center that OG upper gi is gonna be benign surgery, hiatus, hernias gallbladders, that sort of thing. And that's, um, and that sort of creeps into compatibility, which I'm, which I'm not gonna talk about today. Um, but actually if you work in a tertiary center, then we're talking about cancer resectional work, but that's so focused that actually most trainees wouldn't have come across those kind of patients. Um And therefore, you know, we know that that's not gonna come up, there's a few bits and pieces in here that just for knowledge that we, that I've put in. Um, but I think you need to kind of start the basics really and um go from there. So the kind of key questions that I've written out here are, what's the blood supply to the esophagus? Number one, what level does the esophagus pass through the diaphragm? What accompanies the esophagus through the diaphragm and then they sort of, there's topics that I'm not gonna go into, but there are other things to start thinking about. ok, think about the posterior mediastinum. So, you know, a bit of a giveaway there, the esophagus goes through the posterior mediastinum. Um What are its borders? What are the structures that go through it? What are the constrictions of the esophagus and name the epithelial epithelium covering the esophagus and that we will talk about because again, it's relevant and it comes up quite a lot if we start with the basics. Um you know, the esophagus is a 30 to 40 centimeter fibromuscular tube. It begins at the level of C six. Now, that's something that um if you get asked a question about that can be your introduction to the esophagus. And immediately if, if I was on the receiving end of that, I would think, OK, this person uh they know how to do exams, they're confident and that, you know, that's a great introduction way through it. And again, it depends on what your sort of time um is looking about. So, um we're moving on to the next bit and I think this is, um this is quite bulky and we're gonna take our time to go through it. Um If you're asked about what the arterial supply of the structure is, there are gonna be two follow up questions in my opinion to that. OK. Um The two follow up questions I've written up there. They are, what's the venous drainage of that structure and what's the lymphatic drainage of that structure? Um OK. The other thing again that I think is a bit of a running theme and this is just about just general kind of MRC S tips and tricks really is that I've just told you that the, the esophagus as a 30 to 40 centimeter fibromuscular tube. So if you've got something that's 30 centimeters long in the, in the body, is it likely to be supplied by one artery? And the, an the answer is no. Um I put lots of questions in here. People like, feel free to, for people to go up. But I don't wanna, you know, if people don't, don't need to necessarily contribute to it. So I will answer my own questions. But essentially, um so that leads you on to explain your answer for what the, what the blood supply to the esophagus is. And you can then say, well, the, the esophagus has a segmental blood supply ie it's not just supplied by one artery. So again, as you would, with any tube, you can think about upper middle and lower one third. So the upper third is supplied by the inferior thyroid artery. The middle third is direct branches of the aorta and the lower third is by branches from the left gastric artery. Ok. So again, in this sort of vein of building up and adding to your knowledge, um you need to, you know, I think the best way to learn for this sort of thing is to then be thinking, OK, what's the next question could be, you know, this, this might not, this is unlikely to be a, an entire segment on the esophagus. So they might say, ok, you've spoken about the inferior thyroid artery. Well, what's the inferior thyroid artery? Where does it arise? And again, another high yield topic. And I know that you have had previous sessions on um the blood supply, uh you know, major vessels in the body. Well, you need to think of then about the subclavian artery as well. OK. And so you will, you know other things that you will learn for the exam are branches of the subclavian artery. Ok. Well, that's broken up into three. The first branch is the vertebral artery. Um The second branch is the internal thoracic or internal mammary artery. And then the third branch is the thyrocervical trunk. Ok. So where's the inferior thyroid artery likely to arise from? Ok. We know what the branches of the subclavian artery are. The third branch is the thyrocervical. It's got thyroid in its name. So that's the branch then for the inferior thyroid arter, but you need to add and build up onto that and think actually, ok. What are the remaining branches of the subclavian artery? Ok. So there's a pneumonic that's commonly used for it. Vitamin C plus D. So we've done the vi T vertebral, internal thoracic thyrocervical and then it, it'll be essentially and the cost of cervical and then the um dorsal scapula and then it, then it becomes the axillary artery. And again, you need to be thinking about, OK, one of the branches, axillary artery. So every step of the way, II think my, in my experience the best way to kind of go about this and learn this is to um is to always be asking questions about what's next, what could come up, what, what drains into what, what links these structures. Um And that, that's, you know, again, everyone learns it in a unique way. But for me, that was the best way of adding layers to this. So, um we've already, we've spoken about them, the upper third, the middle third and the lower third. Now again, we, if we go back a slide, uh I've asked another high yield question, which is what accompanies the esophagus through the diaphragm. OK. I've just told you that the, the lower third of the esophagus is supplied by branches of the left gastric artery. So the left gastric gastric in its name, the implication is now that, that supplies part of the stomach and we're gonna come on to that. But, um, if the left gastric artery supplies part of the stomach and also the lower third of the esophagus, the likelihood is that, that needs to pass through the diaphragm. And therefore, that's already one of your structures that, you know, has passed through the diaphragm. So in just asking that question, we've built it up to say, actually, we know what the blood supply to the esophagus is. Ok. It's segmental, upper third, inferior thyroid, middle, third, direct branch of the aorta, lower third, left gastric. Ok. We know what our branches to the subclavian artery are. Ok. We've got a pneumonic for that and we know that the inferior thyroid arises from the thyroid, cervical trunk. And we know a structure that's also gonna accompany the esophagus with the diaphragm because we know the left gastric supplies the lower third of the esophagus and it also supplies the stomach. So just with one question, we've answered so many other questions. We've gone into the neck, we've gone into the abdomen and we've gone into the, we've remained on the thorax of the esophagus as well. Um The next series of questions we go into it again is venous drainage. Ok. So venous drainage, it, you don't have to, you know, if you're stuck and you think, ok, I think I know what the arterial supply is, then the chances are that the, the venous drainage is gonna match this as well, isn't it? So, again, the venous drainage is segmental. So the upper one third is supplied by the inferior thyroid vein, the middle one third. Um So if something has direct branches from the aorta, we know there's a structure that sits on the right of the posterior mediastinum. It drains directly into the S VC and it is formed from ascending lumbar veins. And also if you, and also gets feed from the left side of the chest as well. Well, that's the azygous vein. So the azygous vein drains the middle one third of the esophagus. And then guess what, again, the lower one third of the esophagus that drains into the left gastric vein. And, um, we're gonna come on to probably that a bit later on. But again, knowing what the venous drainage of the esophagus that opens up the next set of questions and the next link when we talk about portosystemic shunts lymph, um again, the sort of the, the wisdom that I was always taught was ok, lymphatics follow arteries. And I think that I, you know, broadly that is true. But um, when you're doing the MRC S, you need to know a lot more about um, the, uh, the drainage of the, you know, the, the lymphatic specifically, there are certain things that are expected to you and other things that aren't later on. I'll show an image of the no rotations from the stomach. That in my experience is not something that I've ever been um expected to know. I've not been asked specifically, you know, even at work by consultants in OG because I think that that's FRCS level. So it's the next level. But having an awareness and saying actually, OK, I know roughly what the lymphatic drainage of the stomach is, but it, but it's more complicated than that. And the relevance of the lymphatics, you've always got to be thinking, OK, what's the relevance of this? Well, the relevance of the lymphatics are that when you do resectional work, that's where, that's where your sort of boundaries are taken from. So, um in terms of lymphatic, it's again, upper third, deep cervical, um middle third, mediastinum and then lower third is celiac. And again, that makes sense because the left gastric arises from the celiac artery. Um So, um epithelial surface, we again, my experience is that you if, if you're gonna get asked about the epithelial service, I think this applies to when we're at work, when we're training, you know, when we get locally trained and in terms of the exam as well, um my experience of the epithelial surface is that um you, you're only gonna get asked that if um there's a clinical relevance. So, um the epithelial lining of the esophagus is nonkeratinized, stratified squamous epithelium. Um So the other key area, you know, think about things that we um would also be asking about in terms of epithelium and, and you can think about things like the rectum because that again, there's a difference there and it demarcates a difference between cancer. Um I'll answer my own question here. But in terms of the esophagus, the reason we want to know about that is because of Barrett's esophagus. You know, there's a clinical relevance to something that will come up in exams. And there's also really relevant to the to our patient population in the United Kingdom. So knowing what the epithelial surface is, particularly anything about part B which is a very, very clinically focused exam. There's a, there's a relevance to why you're being asked that esophageal constrictions. Again, I think this is kind of, it's it's information that you might have to learn constrictions. Um You know, if you're talking about a 30 to 40 centimeter tube structure, then you're gonna get asked about constrictions. I think there's lots of similarities, obviously, they're completely different organs and not stressing that. But in terms of the questions and the way that you build up your knowledge, if you think about the ureters as well, because the ureters again, are these uh tubular structures. They have a segmental supply, segmental venous drainage, they have constrictions, big part of the certain structures and the esophagus is the same. So, you know, just from the nature of OK, what's the basic, what is this basically we're talking about here, we're talking about a tube. So in terms of constrictions, um II do see some variations on this, but broadly speaking, they talk about the first being cricopharyngeus, which is a, a muscle pharynx, um the second being aorta and then the third being the right cross of the diaphragm. Um So I think um we've kind of started off there with it. Uh Again, this is a lot according to me. But if I was asked a question about the esophagus as a um as a newly qualified foundation doctor, I probably wouldn't be able to, to get through very much. And I think that's because again, because it's quite specialized because it's um I don't remember getting asked lots and lots of questions about the esophagus at med school. Esophageal operations are tertiary hospital operations broadly. So, therefore, you know, they, they're not expecting you to be an expert in it. But all we've done there is asked the really basic questions in terms of OK, what is the esophagus? What's its blood supply? What's the venous drainage? What's its lymphatics? What's its cell, um epithelial lining? Um And are there any constrictions now, the kind of the diaphragm will come on to next? Because again, but the key thing from what I'm saying is that everything that you talk about, um you want to be adding layers onto it. So, um building that picture of thinking, OK, what can I ask myself next? OK, I can ask myself about what the branches of this artery. Um So I'll just do a, a sort of 12th pause there. Let me catch my breath. Uh because I realize I wanna transmit for any kind of questions specifically about that. Cool. OK. We'll move on. So, um again, really for you, I'm sorry, is there some questions? I fine um in the year of that. So um in terms of other high yield topics, I think the esophageal hiatus, um basically structures passing through the diaphragm, really high yield information. Again, my experience is that gets asked a lot, the esophageal hiatus. OK. What level is it at? It's at T 10, what passes through with it? Right and left and right, vagus nerves and the um left gastric artery branches, which we already knew because we talked about blood supply. Um I'm gonna mention these, they're beyond the scope of what we're talking about today. But you need to know about the uh the cable opening at T eight. and they also opening at T 12. OK. This is, I think med school, you would be expected to know roughly what level they were. And the main structure that passes through the MRC S level, you need to know specifically what structures pass through them. You know, where did the phrenic nerves pass through? The phrenic nerves have their own uh hiatus. Where's the azygous nerve pass through? Where's the thoracic duct pass through the, you know, you're building up layers. Now, the expectation of knowledge is more, but from the esophagus point of view, t 10, left and right, vagus, nerves and left gastric artery. Um ok. So again, um stomach anatomy physiology, and I've steered away from the physiology quite a lot because, um, I think it comes up, but in terms of II really wanted to hit stuff that I felt was high yield and it comes up the most so name the parts of the stomach that's, you know, it's an entry level question, but it will be the thing that starts, you know, it might be the first question, your uh in your in a station or it might be in, you know, it might be showing a picture of it. Um What's the blood supply to the stomach? A transpo plane? Apologies is about my sort of terribly blunt wording. What structures lie in the transpo plane which we'll talk about and then layers encountered in midline. Nay now, because we're not, whenever you're talking about these things, you need to be think, you know, you, you won't just get a question in my experience just solely based on the organic question you might do, but there will be other elements to it. Um So one of the key things is about layers going through to the abdomen. Well, the stomach lies in the abdomen. If you're talking about doing an operation on the stomach, you will be going through layers. Uh the stuff not highlighted is stuff that I think is still useful. Um Again, I'm not gonna specifically talk about it, but I think it's relevant, it comes up. So, ligaments in the stomach is really important. Um You, you think about the gastro colic ligament um and then you think about less omentum. So things like hepatoduodenal and then other ligaments that come off it that have blood vessels in them um that are involved in the supply of the stomach. Um And then cells producing uh hydrochloric acid and cells producing gastrin. Again, this now comes up into relevance into pathology. So when we're talking about things like ulcers, that's where you kind of want to go. Um I'll go on to the next question. So I apologize for the, the reason that image quality is so bad. Um is because um I drew this uh in order to sort of encapsulate everything and II don't know if you can see my arrow. Um But essentially, you know, as with the esophagus, as we were talking about the first question might be OK. What are the, um what are the parts of the stomach? Um And then it will be, what's the blood supply? Well, I've already told you that if they ask you what the blood supply is, there's gonna be two follow up questions as well and those questions are gonna be ok. What's the venous drainage and what's the lymphatic supply. All right. So um the, the blood supply is all linked, you need to know. Um And I know you had a looking at the Southwest Surgical Society, I know there was a talk um on major blood vessels as well. So if we look, if you look what highlighted sort of nine here centrally, um that's when the majority of the blood supply to the stomach originates and that's the um celiac artery. So for the exam, you know, there is an expectation, my experience is that you will need to know uh what the branches of the aorta in the abdomen are. So there's, you know, the unpaired branches and the paired branches and on top of that, you'll need to know what level they arise. Ok. So when you're asked about, OK, what's the, the blood supply to the stomach? You can say, OK, the blood supply uh originates from the CDAC artery, which origin is at the t 12 level of the abdominal aorta. Um And then you need to go into more details, but that's your kind of uh entry level um question. And then the other things that might come up from that are OK. Well, what level does this uh superior mesenteric artery arise? Ok. That'll be L1. What, what level does the inferior mesenteric artery arise? Uh That'll be L3. And then at what level does the, the common iliacs arise? Ie the termination of the abdominal aorta? Ok. L4. Um and, but you also need to be able to, to know the pair branches. But understanding that anatomy will also help you with everything else. It will help you with your sort of general understanding of where um you know, of the structures that are anterior and posterior in the hilum of the kidney. You know me saying that doesn't make very much sense now, but it does when you look at the images particularly with the aorta um and the inferior vena cava as well. So, I don't know, I'm hoping that you can see kind of roughly um the images. So anything with a horizontal line underneath it. Um And I know that people have been asking for slides and things. I'm happy to send the slides, but I'll probably send it on a powerpoint because it's got the links and references and things to everything. But um so it underneath underlying one. So that's the gastroesophageal junction. So this is the esophagus coming down, it passed through there or to at um at T 10. Um and now enters the stomach. Um Two is the, the fundus three which is curving round is the greater curvature of the stomach. Um four which you can see here just marked sort of the inferior aspect of the body is the um gastric antrum five is the Pylori uh six coming out of the summit. That's the duodenum as well. And then seven which my terrible handwriting is on, there is the lesser curve, then we go to arrows. So arrows are signifying blood vessels in this diagram. So eight is really easy is the abdominal aorta. Nine is the celiac artery, which we already talked about. Um, there are three main branches that come off the celiac artery. So you've got the left gastric, the splenic, uh and the common hepatic. So 10 here, that's the left gastric and you can see that runs down and supplies uh part of the lesser curve of the stomach as well. 11, it's hashed because uh it runs posteriorly, but again, it arises from that celiac artery. So, you know, it's only one of three things. Ok. It must be the splenic artery. Then, um my drawing has tried to, tried to sort of demonstrate that it's um a tortuous because that's how it's described in textbooks. And, and when you see it, you can sometimes see, you know, recognize that it is, it is a tortuous looking archery as well. Um In terms of um So 12 here, this is the right gastric. Uh and this comes off the common hepatic which is here, um uh which is 13 and then 14 again, is a branch from the common hepatic. And it's the gastroduodenal that then gives rise to um this artery here, which is the right gastroepiploic. And it also gives rise to the superior pancreatic called duodenal. Um And then that leaves us with 17 up here, which is the left gastro, which is a branch of the splenic artery. And then up here you've got short gastric vessels, which are a branch again of the splenic artery, the stomach, I think, um, is more familiar to people for lots of reasons. Um, but I think the blood supply is something that you have to look at a few times. It's a bit more complicated, but once you start realizing it, it, it sort of makes complete sense and the way that I, in terms of your building blocks from here, um we talked about the superior pancreaticoduodenal. So you need to then think about, ok, what's the, what's the blood supplies after to the pancreas? What are these structures in relation to the pancreas? Um Where does the splenic artery run? Obviously, it runs to the spleen, but it gives off branches throughout there as well. Um And it runs through one of those uh one of the stomach ligaments that I referenced in then earlier, um the question of things to consider um with the tail of the pancreas as well. So I think this is a, this is quite a good example where you, you can kind of just rope, you know, you need to learn what other parts of the stomach. And again, if you're not, if you're not involved in cases or looking after patients that have lots of kind of gastric pathology, then it can be one of those things that I think that seems a bit distance. I found this really quite easy to learn for, um, not for part A but for part B particularly because I've done a, um, an esophageal gastric job. Um, so it sort of made quite a lot of sense. Um, and you'll find that, you know, throughout it, is it, you know, if you, if you're, you know, passionate in orthopedics and you, and you're doing a trust grade job in orthopedics or um you know, you did a foundation job, you've done taste of those, you know, upper and lower limb anatomy, it's gonna be really easy for you, but you might find this more difficult. Um I'm trying, you know, I'm a core trainee with vascular is, is what I wanna do. And so, um by having done AAA an OG job, this kind of makes quite a lot of sense really for me. Um The other question that we talked about going back is the transpo plane. So there'll be, you know, there's multiple levels that again, I think high yield information where OK, the transpyloric plane of L1. So what structures are gonna pass through that? And to start with you, look at it because it, it will come up in questions in part A um And it will come up in questions about B and it will just be this huge list of structures that you don't really have an appreciation for when it takes time and you go through it and then eventually you think actually this is starting to make a bit more sense in terms of, um, you know, I know what's in relation to that, for instance as well. So if you think about the transport plane and I, again, my experience is you're not, if they are, if someone asks you about that, they're not gonna expect you to, to list off exactly what's in there. But as long as you start, you know, you give kind of 5678 answers that are, that are good and accurate and set of confidence. Then someone says, actually, they have an appreciation of where anatomical structure is. So you can start from one side to the other. You think about sort of um the hepatic flexure of the codon. OK. That's in the trans product plane. We're coming over a bit more fundus of the gallbladder. That's in the trans product plane. The Pylorus by the name is in the trans product plane. You know, the origin of the superior Mesenteric artery. We already talked about that and I said that you need to know at what level, these impaired branches and unpaired branches if they also arise or the S MA L1, that's the trans product vein, um the formation of the portal vein. And again, we're gonna go on to um venous drainage of the stomach in a minute. But um the portal vein is, is formed by the splenic and superior mesenteric vein, but that's formed at L1 um kidney Hiler, um Hiler of the spleen, um sort of high level of the spleen splenic flexure of the codon. You know, those are all things and all of a sudden, actually, you, you've listed off quite a lot of structures there. Um that, that fit within that uh transplant pain. I'm just gonna have a look and see if there's anything else that I have missed, which I don't think there is um layers encountered in the midline laparotomy. Again, it's difficult. I don't wanna sit here and just sort of go through things again and again. But your, these are questions that will come up all the time. And so it might be that you're um that they're talking about an approach and it's unlikely to be the stomach because that's a very specific niche operation. But it might say, ok, you're doing um an open cholecystectomy. OK. So, you know that that's gonna involve incision in the upper right abdomen. What layers are you gonna go through? And certainly, what layers are you gonna go through for a midline laparotomy? So all of a sudden, it's not just, you know, being quizzed in theater by a registrar or by a consultant, it's got a purpose to it in that you're doing this operation now. So you're doing an open appendix. Uh What layers are you gonna go through? How is that different from doing a midline laparotomy because it is different. And the, and the expectation is there that you, you have a really good understanding of those layers and, and where you are. So, um and again, you need, that needs to be, that's high yield information. So that needs to be really on the top of your tongue. And you can practice that as well. If you're, you know, if you're regularly in theater, you, you can say, OK, I expect you to go through this there. You know, one of the questions that I remember as a foundation doctor that came up all the time was um registrars and, and consultants want you to know what we, we'll ask you what this structure is as they start their incision and invariably in my experience, it was scar as fascia. OK. So, um that's another kind of high yield topic. Um So we're gonna move on because I'm aware that time is taking away from us. So, um the li the references to the images are in here. This is a PDF form. So it won't work, but I had to sort of change it to present it. But um I think the image uh of the venous drainage to me makes sense. It matches what we've talked about in terms of arterial. Um So you've kind of got gastro apple veins that drain into the superior mesenteric vein or the splenic vein depending on if it's on the left or the right of the greater curvature. The short gastric veins drain into the splenic vein because the short gastric arteries arise from the splenic artery. Um, the left gastric vein drains directly into the portal vein. Um and the right gastric vein does as well. And you can see there that, that union between um, hispanic vein and uh the superior mesenteric vein give rise to the portal vein. What level is that at? Oh, yeah, we've already covered that. It's at the point the, you know, transporter. Um sorry, the um L1 is in transponder a plane. So you're just adding again layers into it. This is not just a question about what's the venous drainage of the stomach. This is a question about where L1 forms. Um is that everything they'd say about kind of venous structure? Yes, I think it is. But again, the other thing to think about here is, and we'll come onto this, but we've talked about um the portal vein there and you can see that the left gastric vein drains into the portal vein as well as the sort of that area of the stomach that you can see it's draining. We also know that it drains the inferior one third of the esophagus. So all of a sudden, we're now saying, well, the inferior one third of the esophagus is drained into the portal system, but the middle third of the esophagus is drains in the az into the azygos, which drains itself into the S VC and the upper one third of the esophagus strains into the inferior thyroid vein. So, those are both systemic circulation. So your next building block again? Is that ok? Well, uh, um we've got a, a structure that is partially drained portly and po and partially drained then systemically. So all of a sudden, ok, this is a site of portal, systemic shunting. So if you have a patient with portal hypertension and there's the, the the chance of developing viruses. Well, guess what we all know, you know, everyone will be able to tell you at a medical school um that esophageal viruses are, are as a result of having portal hypertension. But that's why. Um and just from knowing then the esophagus, the anatomy of the esophagus, you know exactly why that causes it. And again, a high yield topic in my experience in the exam will be the sites of portosystemic shunts. Ok. So rectum area of liver on the likes and understanding that and the rectum is very similar in terms of if you understand the venous drainage, which makes complete sense. But I think sometimes that um when you're at medical school, there's lots to learn and you um and anatomy, you know, frequently people say II went to XY and Z and therefore, I don't know anatomy. Well, you know, everyone has to start again and, and study for these exams. The other image um is about lymph node stations. That's just to highlight that. It's not as easy. So, it, it follows the arteries exactly as we said. But this, that sort of beyond, um, the scope really? I think it's Fr CS, it's, it's talking about, um, total and subtotal gastrectomies. Um, and then what lymph, no medications you, you take from them. Um, so what I put in at the end it's difficult because I appreciate this is a lot of this is just me talking to you. But the next kind of phase of the presentation that we'll just do for a few minutes, um, is clinical cases because the exam is not only gonna be about OK, what's the anatomy? You, you know, you can get a station that might be the anatomy of, um, of a structure, but you could also get a clinical case where, um, you've got a presentation of a patient that comes in to see you in clinic and you, you take a full history, you might have that same patient and you're given that clinical vignette. Um, but you need to do an examination if it was part B, um, or you might get given some pathology or a pathology report uh in part A or part B and then you need to answer questions on it as well. Um So, you know, an example of a clinical case that I just uh made up, but I think relevant to what we're talking about tonight is a 55 year old male patient presents uh to you in general practice with a six month history of heartburn. Ok. So it all those good things and again, it's designed more to be interactive, but you wanna take a full history from that um patient and make sure that you kind of know everything that um that you think is relevant, um and make sure that you're thorough in that. But you need to obviously be targeted if, particularly if an exam it's at six minutes on examination. If what you actually can examine it then and then having an awareness of. Ok, what are the nice guidance criteria here for um for referral under a two? What, what traditionally a lot of us would know as a two week wait kind of pathway, but essentially an urgent cancer pathway. Again, I don't think I, from my point of view, I don't think I spent lots of time rope learning, nice guidance. Um I think some of it we would all know anyway, but, but in terms of specifically remembering, ok, dysphagia, do you know dysphagia? Ok. We know that most people present with dysphagia and need some investigations to find out what that is. If you're over 55 have you got weight loss, upper abdominal pain reflux or dyspepsia then? Yeah, the chances are that you're gonna be seen pretty urgently as well, but just having that awareness of, ok, again, w what your differential from someone presenting at 55 with heartburn if they're a smoker, if they drink a lot of alcohol. Um, if there's any family history specifically, are you thinking about? Ok. Is there something going on at a cellular level here? So, is there a change, um, that might prompt it? And all of a sudden we go back to the question that I asked at the beginning that's highlighted and read, which is what's the epithelial lining of the esophagus? Because all of a sudden that becomes very relevant. Um And if we go to our next page, as if by magic, so that patient, you've taken a full history, you've examined them. Um They're referred via a two way pathway to upper gi surgery. I about the spelling mistake and they have an urgent endoscopy and, and this is what you find. Um So then your questions, you know, you thinking about this at every step. OK. Am I getting? Is this a pathology station? Um Is this a uh history taking? Is it examination um is it anatomy station? OK. What is Barret's esophagus? OK. So you then you to think about definitions as well. Um And that again is a high yield um thing to cover. So lots of the resources that you'll read around for MRC S will talk about um definitions. There, there isn't really, you know, I can't say to you all this is the, the way to remember definitions. You just have to have a definition in your head that works for these sorts of things. Um, so what is Barrett's esophagus? Ok. It's, it's a metaplasia, um, which is the changing of one differentiated cell type to another well differentiated cell type. In the case of Barret's esophagus. This is from non classis squamous epithelium to uh glandular epithelium, either from the stomach or the, or the small bowel. But that again is a high yield type topic that's gonna come up. Um And it's all centered around one organ in the body. So I think that's how I, you know, it's again, we're just highlighting this sort of building block of just knowing um one organ in detail. That's the clinical relevance. We've already talked about it. Why do we worry about Barrett's esophagus or we know what we worry about Barrett esophagus because it can undergo dysplastic changes and then that can lead to invasive cancer. Um, risk factors for it. We talk about smoking, uh being male caucasian obesity, alcohol in increasing age over 50 the treatment for that. It's again, you're not, you know, um the way that I went through it is I didn't expect to be asked um in loads of detail about, you know, essentially consultant level treatment, but just having a, a vague idea and understanding of the these patients need surveillance that can be adjusted depending on what the histology looks like. You can give ppi killer to people with Barret's. So if there's an element of dysplasia that surveillance might increase or surveillance might change or they can undergo other treatments, there's ablation type treatments. Um, and again, I don't think anyone's expecting you. What? And I, and I don't, you know, I'm not an expert in this. I don't, II wouldn't be expecting to see patients independently, you know, with this or managing them. But for the exam purposes, it's just about having an understanding of where it is. You're not going to be asked at the kind of Fr CS level, but you need to have a broad kind of um a board understanding. So, um, the next kind of bit that I put in, um, is about esophageal cancer. Um I think this is not, you know, I would have quite liked it at the time. I think if my exam had, had a bit more, I've had some stuff about lees because, um, you know, as with everything, if you work in it and have it injection with a specialist part of medicine, if it comes up, then, then you will just know more. Um I don't think this is on, you know, I don't think this kind of stuff is gonna come up, but esophageal cancer is something that you need to think about. Ok, we've already told you what the epithelium is. So you can have squamous um carcinoma or, or you can have a adenocarcinoma. And again, that's, that's feeding into that bar, it's that change that you can see on the image. So you need to think about what the risk factors are for that type of malignancy in the same way you would for a colorectal malignancy. Um But are you needing to know what the exact treatment is for it? No, I don't think you are. Um I did put in an LGA because um for interest really, I remember as a foundation doctor being on call um and going to see I LG OSI did my foundation jobs um where I work now as a co trainee and um essentially being really, really intimidated by it because I didn't really understand what the operation was. I didn't work in that team. Um And it, you know, it felt quite stressful but it, so I just included this really as a, as a broad understanding of um and this picture again, the links on there in the reference, but it's from um the British Journal of Anesthesia. Um And I think it's quite a good picture and just highlights really what happens in terms of the operation. But this is an operation for cancer. I don't think you're going to be um expected to know about it. You might be asked about kind of complications, but that won't be complications specific to the operation. It'll be complications that relate to any operation. So you need to think about a stock phrase. You might get worried and concerned and think OK, II don't, I've never even seen one of these operations, but again, high yield topics, we're talking about consent. And when you consent, someone, you talk about this factors when you're a trainee or when you're, you know, an sho in surgery every day you'll be consenting people for procedures. Um, and so all of us, I'm sure will have a stock phrase of, ok, what are the risk factor? You know, what are the risks, bleeding, infection, scarring? Well, you're already doing it then. Yes, there might be a, a few more specific marks for these procedures, but I don't think that's going to uh be make or break if you think about large abdominal resections and in this case, you know, thoracic resections as well, you're thinking about pneumonias, but you've got a joint there. So a joint happens in lots of abdominal surgery. So, anastomotic leak. Um, it's just something that, you know, I remember seeing or someone talking to me about questions such as that. And I think, um, it, it's not about the, the actual operation because if you've never seen one of these again, I, I've only seen one because I worked in a firm that did it. But I think it's, it's just something to have a think about and I included it partially for awareness, but partially because uh you will get asked, you might be asked to consent patients, but you also could be asked to, um, you know, discuss the risks of a procedure, um, with a patient and you might not, you know, you might not have seen that, that procedure if I've been asked about, um, an orthopedic procedure to consent someone for it. Now, I, you know, I would understand the principles. I'm sure of an orthopedic of a specific orthopedic procedure. Have I seen one in the last six months? No. So, but it's, but it's about just, you know, having a system in place of knowing, ok, whenever I talk about consent or risk factors or risks of an operation, I always talk about these things. Um and you can go from there. Um and then this sort of segues in really to our next kind of topic it's related to OG but it's also just highlighting that um your, the kind of as part of the examinations and this is more part b really and it would be the second part of the, of the M SAS part A as well as clinical management or critical care. So it forms that knowledge component as well, but you need to be expected to talk through um kind of emergent situations really. The other thing that I don't know, you know, I don't know everyone on the on the call in terms of um where you are in training and things. But um if you're applying for core training as well, then then you know that there are clinical cases as part of core training and you know, this sort of thing is just important to do and, and everyone does this all the time. Um But you could get this case, so you could get this vignette where you're essentially giving you a brief or your vignette, which is a 63 year old presented with massive hematemesis. They're showing signs of um uh cardio distress essentially because they've got a heart rate of 100 and 15. Um, and they're slightly hypertensive at 90/60. What do you do? And then you need to, to talk through that in a succinct manner. Again, my experience or my view is that you need to have stock phrases for this. So, um you know, I would, I would assess and resuscitate in an a to a approach and then you actually want to go in and talk about it. So I would assess their airway. Is this patient talking to me? If so, I have less concerns about their airway moving on to bi want to get monitoring on this patient. And hopefully that's uh happening concurrently. While I'm assessing the patient, I would think about putting 15 L of high flow oxygen through a non rebreathe mask. Uh I would have a listen to their chest, I would have a feel of the chest on both sides and just talking through what you're what you're assessing for it. So, if this was the case now, and we're talking about from an OG point of view it might be that your, their airway is patent. Um But what I'd put in terms of my brief, all the information that I would give you, I can say, but actually you can see that there's vomit bowles that are full of bright red uh blood essentially give you some more numbers in terms of respiratory rate. You'd move on to see you'd want to get uh bilateral IV access wide, more access at that point. Then someone might say, well, what, what are you taking from that access? And you need to talk about blood? Um, so what blood tests do you want you to justify each of those? We're going back to the sort of med med school teaching, but it's important because you do this every day anyway, but you just need to think about it. Um, are you gonna get gas off at that point? Are you gonna get a grip and save for clotting? What are you gonna give them to resuscitate them? That this is all the information you need to know? So all of a sudden you've gone from, ok, this is an anatomy station about the stomach to, I know actually, I've got a 63 year old who's got a massive hematemesis, um, and is showing signs of shock. How are you gonna resuscitate them and, and you'll keep going through that. Um, if, if we're talking about that, you need to think about what your differentials are. So differentials from massive hematemesis. We'd be thinking about varices. Well, guess what, that goes back to our portosystemic shunt or we'd be talking about, you know, is this, is this an eas of ulcer? And then again, you need to think about, ok, the pathology of the stomach, um, in terms of, um, what are the risk factors for causing ulcers? H pylori nonsteroidals, all of that sort of stuff. So, it, I'm just trying to highlight again that you're, we started with the anatomy, we started with physiology, pathology. And now we're building up to actually what you, what we all do clinically and we see people in hospital. Um y you know, having a basic understanding of the timings for endoscopy with people with massive he um with hematemesis, what your approach is at endoscopy to. And again, you're not, you're not an expert. I, I've never seen um someone having an endoscopy who's having a huge bleed at the time of it. I've managed patients afterwards, intensive care and I've managed patients um coming in with, with hematemesis, but, but I'm not an endoscopist, I don't know how to do OG DS, but you just have that general awareness of OK, I know that they can use um medication. I know that they can physically try and clip them. I know that they can use uh thermal um to try and stop that bleeding. Um And just having that sort of, you know, general awareness of roughly, you know how we deal with emergencies. Um As I said, this is kind of, this could be part of a critical care station, but it could also be um there'll be a knowledge component to it. So you might get to the end of your critical care management and they might say, ok, tell me the two biggest risk factors for this. Uh what, what you mentioned about using this drug, what's his me mechanism of action? So it's not just a sort of black and white, this is what your station is sometimes it is. But if you're doing well and you're getting on, um then you, you, you can ask more questions. Um fine. So um it kind of leads me on to pathology. Um These are just a few things that I put down that I thought um would be useful in terms of the exam of having a basic understanding of and some of them are more important than others. I think Barrett's, you know, we've all, we all learn about Barret's from quite an early stage. I think having a good working understanding of that is useful. Achalasia. Again, I think having a good, not good understanding, but just having an awareness of what it is. Esophageal webs syndromes that are associated with esophageal webs. And then cancer. Again, I don't think you need to know in detail, but you might need to know what the, you know, what the common types of cancer are looking at the stomach. Ok. Ulcers. What are the common causes of ulcers? What are the locations of ulcers, you know, posterior anterior site ulcers. How do they present? What's the difference? Um And then tumors as well. So if you're getting really asked about pathology, you know, not, you won't know everything. I mean, some, some people will and, and that's great, but just having a basic understanding but that all stems from. Ok, I'm gonna start with the stomach. OK. What is it global? Um uh What it, you know, what's its global structure? Uh What are the key areas of the stomach? What's its blood supply? What's its venous supply? Um What's his lymphatic drainage? Ok. What do the cells in the stomach do? So I talked to the top about, ok, which cells secrete HCL, which cells secret gastrin. Where are these distributed? Ok. All of a sudden then if you come to a critical care station, well, all of us can manage that and we'll talk through it. But at the end, when they say, what are the two biggest risk factors for this pathology? What your differential diagnosis? What's the management for this? You're just getting back into that sort of pathology physiology that you knew before. Um So that brings us nicely to the end. I realize I have been on transmit for most of this. Um So we talked about the MRC S, the exams themselves. Part A part B, part A I did a while ago so I have sort of basically part B is much more recent. Um So if you got specific questions on that, I'm happy to answer them, esophagus and stomach anatomy again that, you know, I'm sure you could do an hour presentation on each of those and spend lots of time. But I think it's about, for me, it was about trying to get some information over that was high yield stuff and about using it as stepping stone and building blocks and thinking about what else comes up. A lot. The clinical cases are just I illustrate that you, you know, one minute you might be talking about the blood supply to X organ, but the next you might be talking about real life clinical management, but you can't forget um or go back to those general principles because they will come up. Um And we've thrown in some general advice along the way and the resources. So the presentation when it comes, if I'm happy, as long as it's sort of shared through this. But um it's got all the links in terms of references to all the images. And then I most of what I was talked about is not anything from these resources, but these are just general good resources for the exams, I think. Um And those are what lots of my colleagues have also used recently for vision. Any questions? Thank you so much, Sam. That was a great teaching and it was really, really helpful. Um Any questions you have for Sam, it's done. Silence, nothing for now. It was understood. Hopefully. Um In any case, we will. So this presentation you can access it again if you want on our middle page. Um If you do have any questions.