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That's, isn't it? Good morning everyone. Um, my name is CJ, I'm here from the FT SSE M. Welcome to the second day of our M Sra prep series clinic, clinical topics. Er, today we're going to have, er, five sessions, er, on surgery, general, er, renal, er, we'll have one on CST interviews. Er, even if you're not looking at CST, maybe there'll be some interview pointers in that, that you might find helpful, uh, then on orthopedics or M SK and then gastroenterology to end the day. Uh, we'll be starting the first session on general surgery very shortly. Um, throughout, throughout the day, if you have any questions, comments, please put these in the chat and we'll read them out. Um, we hope you find today useful. Uh, please remember to fill in the feedback for the speakers as it is very useful for them and also for us to make try and improve these sessions for you. Uh, I would like to introduce our first speaker, Mr Khan from Royal Derby Hospital who's kindly given up time on a Sunday to come and speak to you. Uh, shall I start CJ? Yes, sir. We can go All right, good morning to all of you. So, um, uh, thank you for the kind interruption CJ. So, uh, I have been given a, quite a, a big topic to talk. Uh, so I'll try to do my best, uh, uh, to speak all about, uh, the, the key points within, uh, uh, this, uh, uh, one and one hour and 15 minutes time. So, please, uh, drop any questions if you got and then the CJ will, uh, let me know at the end of the uh, topic discussion. So, uh I'm gonna uh, discuss about uh the general surgery bit first and then, uh, uh a little bit of vascular surgery and um, uh uh some topics I couldn't, uh, uh I didn't prepare here, especially the uh the breast diseases, colorectal cancer, uh uh and anorectal disorders. Um because of the uh time limit. Uh, but I mean, uh if you want or if you can accommodate on a separate day, I'm happy to do that as well. All right. So first I'll start with the abdominal pain. So this is one of the commonest topics been uh asked in your, uh MSR exam. So, uh, the clinical scenario is really important, especially, um, when I looked at a couple of questions uh in related to the abdominal pains, what I noted is mainly they are asking about uh how good you are at your diagnostics as well as uh what is your initial management? So, I'm not going to touch in depth about the uh the management. So I'm just going to brief about the history, physical findings, investigations and then the basic management only. Ok. So if you look at the abdominal pains, why it is so important, you can see it's like huge amount of uh emergency admissions. And out of those half of them are related to abdominal pains in all age groups. There could be a variety of pathologies from most common a appendicitis to very rare uh types of hernias. So the main problem here is basically your diagnostic is are important because in this exam, you will be assessed as a general practitioner or a co trainee in uh surgery, emergency medicine and all. So therefore, you need to know about how to assess. So, in the history, all these patients need a a focused history. Uh So medical surgical anticoagulation and similar episode. In the past examination wise, you need to do a comprehensive abdominal examination, including vitals, uh preferably position. Uh But if you got a hernia, patient, always keep in mind to examine the patient on the standing position as well. Uh because some hernias only appearing on the standing position, good exposure is very important. And you need to ex uh examine all four quadrants of the abdomen and uh do not forget to examine the groins. Even if the patient comes with features of uh intestinal obstruction, don't forget to examine the groins very important at the same time, do not forget to examine the scrotum in males because they can, presenting with testicular eo comes with abdominal pain. And also if there is bowel pathology, uh, examine the rectum as well. Uh, some patients may not allow you to examine, uh, but at least inspect that will give lots of information investigations, you know, most of these. So I'm not going to, uh, touch in depth, but the key things are uh you need to look for a urine analysis. Uh Every patient with abdominal pain, especially uh you need to do an HCG in women with childbearing age. So that is very important uh and also uh uh ala level, especially in a patient with an upper abdominal pain, that's important imaging. So this is one of the uh the commonest areas, the controversies of which image uh we are supposed to do when there is in a patient with abdominal pain. Currently, uh abdominal X ray is very limited use. Um However, erect chest X ray is still there is a place especially uh if you are having a patient with api GST pain who comes with uh uh severe abdominal pain, you need to, the patient got a visceral perforation, mainly the upper gi PURs. So in those cases, uh the uh uh chest X ray will be really helpful because that will tell us whether the gas under the diaphragm is there or not. And also it will detect the level of pneumonia at the same time, abdominal ultrasound, very limited place in an emergency setting. However, it is helpful uh when you plan as a planned procedure uh to identify g stone renal pathologies and gynecological pathologies. So the CT is the most important investigation. Uh We do if you have a patient with severe abdominal pain, do the CT scan, you need to do a contrast CT scan if you're suspecting, um except the renal stones because otherwise we will be not able to come to a conclusion on certain pathologies. So they are for contrast CT and uh remember the contrast CT is safe, even the patient got deranged renal functions. Uh it can be done because the patient's life is more important than uh preserving the renal function. So later on, you can discuss and sort out the renal functions. There was a clear guideline uh issued by the Royal College of Emergency Medicine and the radiologist together on this issue. So therefore, uh remember you can use the iodinated contrast material in an emergency setting. Uh You don't need to stop any medication. You do not worry about the renal functions, patient's life first. So this is the important uh slide. What you need to know is a differential diagnosis, especially these are the questions when they give a description, you need to focus your attention on which area the pain is. What type of pain is that? And also uh the onset of the pain. So all these things comes into play. So you can see the common pathologies which can arising from each quadrant. But there can be slight overlaps. For example, the patient with gallstones may come with the gastric pain or then radiate into the um right upper ran. At the same time, patients with appendicitis, sometimes called central abdominal pain and then they move towards the uh right iliac fossa or sometimes around the suprapubic region. So there can be slight variations. But these are the common things just to say you have a little notice on your screen that says that med is sharing your screen. Thank you. And so I'm not going to talk about all these courses uh because some of them are some of them you clearly know. So I'm just going to highlight and then I can give you the slides later on and then you can go through them. So that got some information on it. Um Se OK. So if you look at the right upper quadrant pain. So these are the uh differentials. So um the gallstone related pathologies, biliary, cholecystitis, impy of the gallbladder, cholangitis again can come with the right upon pain, uh liver related problems, hepatitis, liver abscesses at the same time, do not uh forget the patients with level of pneumonias on the right hand side can come with uh right upon pain. So this is one of the commonest things we see uh when, when we get the referrals, the patient got respiratory symptoms. When the patient got upper abdominal pain, we we got referral last for gallstones. But if you look in deeper, they just have that level of pneumonia. So never ever forget to remember that costochondritis again, a kind of a, a common thing if you got a negative blood negative ultrasound, this is something that you need to look into, especially they can get uh localized tenderness over the rib cage, especially uh around forties. Uh female patients usually comes with this presentation. And also if you can't find anything, once you safely exclude everything, you can think about musculoskeletal pain. This is a little bit of uh things about the gallstone because it's been uh commonly asked questions in your uh exam. So remember the gallstones, they are male. It's a very common problem. Uh If you look at the uh the data, not very, very uh clearly specific about the uh the values, but average, there are 10 to 15% of adults in Europe got gallstones, but 80% of them are asymptomatic. They usually do not give any symptoms at all if you detect, sometimes you detected incidentally. But if you go in depth, they are not related to their symptoms are not related to ghost stones. Out of the patients who having gall stones, 90% of them are cholesterol stones. Ok. So there are three types of stones, cholesterol stones, pigment stones and mixed stones. The pigment stones are coming only specifically in certain groups of patients who got hemolytic disease, like uh uh hemolytic anemia, sperocytosis and all these patients. And they usually tend to develop them quite young age and uh uh other risk factors in general. Uh you know, these things, females, uh obesity age diet, uh and then rapid weight loss and also some of the infections. So likewise, there are many, many causes but these are a few of them. Uh and they can evolve into many complications and uh diagnosis wise. Remember the first line treatment, first line diagnosis of gallstone is ultrasound scan. Ok. It is not a CT scan because some of the gallstone do not appear in, that's not appearing in the CT scan. So therefore, you need to do an ultrasound scan. Ultrasound is very sensitive and uh that picked up that can pick up gallstones. Uh However, you need to keep the patient fasting otherwise they won't be able to see because the gallbladder need to be distended to see the stones. However, if you have a strong clinical suspicious, this patient got gall stones but your ultrasound is negative in those situations, you can go for a CT scan. Sorry, the MCP scan is highly sensitive again, that can pick up even a little bit of sludge or tiny stones in the gallbladder. If the patient is not a suitable or contraindication for MCP. The next option is called the endoscopic ultrasound that can be done, but these are quite difficult to get. But remember, the ultrasound is not the only diagnostic tool. There are some other options. So this is the uh the important uh uh pre clinical presentations. So the um the patients can get biliary colic on the diagram. On the right hand side, you can see when the stone go and uh stuck at the neck of the gallbladder. Then the patients started to get symptoms. So they get very acute onset pain. Usually they describe uh very severe pain which is very close to their childbirth. That is how most of the patients says and that can radiate alone the ribcage towards the back. But this is a typical biliary colic pain, but some patients may not have the typical pain. But in your exam, usually they will describe this exactly as it is because to let you identify that and they are very severe in intensity even though they're saying it's a colicky. It is not like a renal colic. They do not have a like a, a completely the pain going into the sero level. It usually having some sort of a baseline pain with some fluctuation. Important thing here is a time interval. So usually the pain lasting for less than six hours. If the pain is lasting for more than six hours, then it is unlikely a biliary colic. They may progress into some other pathology like cholecystitis and the patients who got biliary colic their uh bloods are completely unremarkable inflammatory markers, all normal. And at the same time, these patients often say that I get the pain when I eat uh chips or cheese or something like that. So that typically describe of a fatty meal diagnosis I uh mentioned about that before. So, uh in addition to the gallstone, they do not see any features of inflammation, that means the thickening of the gallbladder wall or pericholecystic fluid. So those are important and then they can identify something called the uh sonographic Murphy sign. That means uh in a cholecystitis patient. When you put the probe just above the gallbladder fundus, they can get tenderness that is called a Sonographic Murphy. It is highly sensitive for cholecystitis, but those features will not be there in biliary colleague. So the treatment you need to give the pain management for these patients. It's very important. And uh uh the nice guideline clearly says what sort of pain management you can give for those patients. And then you need to refer this patient to uh surgeons for elective laparoscopic cholecystectomy. This I saw in one of the questions whether it is a hot gallbladder or uh elective lab cry. So it is elective lab because this patient does not need any hospital admission. So you can do it as a planned procedure. Next thing, acute cholecystitis, uh similar picture, but they are pain lasting for a long time and they do have they are feeling a bit unwell. So they can describe having fevers, they will be just generally unwell. And when you examine the abdomen, you will find a discrete tenderness over the Murphy's point, which is about a couple of centimeters below the uh right side rib cage, the mid rib cage. So that is the uh area where the gallbladder fundus slice. So they can get tenderness and the bloods again show inflammatory markers, you know about that. And how do we diagnose there is something called the Tokyo uh uh criteria it's mentioned on the books, you can go through it. So, uh you need one item from each of these A B and C and then you can confirm the diagnosis. Then the scan will show some features of inflammation which is gallbladder, wall, thickening, pericholecystic fluid and the Murphys uh tenderness, uh sonographic tenderness. So, the treatment uh intravenous antibiotics and pain management, intravenous antibiotics, the gallbladder, the cholecystitis is not an infection. It is an inflammation. However, why we are giving antibiotics is to prevent it getting an infection. So it is sort of like a prophylactic but it helps. Uh and the definitive management is uh cholecystectomy. You need to take the gallbladder out. Ideally speaking, it should be a hot gallbladder. That means uh the current clinical indication saying you need to take the gallbladder within a week. That is what the nice guidelines is, but I'm not sure anywhere anywhere it's happening because it's so many cases and you can't accommodate them in the emergency. But for the exam purposes, always remember, the gallbladder need to come out on the same admission. So that is uh important acute cholecystitis unless the patient is really unwell, who need an optimization and all these things medically uh complicated. Otherwise you can take the gallbladder out. OK. And the empyema of the gallbladder happens when you got in a stone impacting at the neck of the gallbladder, not settling down. And the patient can get infection into the uh bile inside the gallbladder and it can form into an empyema. So that is literally an abscess in the gallbladder. So these patients remember they are really, really unwell and they are usually comorbid patients diabetics, elderly immunocompromised, they can get chills and rigger. So they are extremely unwell and associating with high mortality uh diagnosis. Again, usually because of the unwellness, we straight away go for CT scans to find out any other cause. And then you will find the image on the right hand side, very thick gallbladder wall. And also sometimes you can see the perforation of the gallbladder as well. You have to give you strong antibiotics and then uh you need to go for something called the gallbladder decompression. We call the cholecystostomy. We put a small tube into the gallbladder to decompress it and that helps a lot and the patient will improve. And then you can plan the procedure or if the patient is basically, if that facility is not available, then you can take the patient to the theater and uh take the gallbladder out. But it's extremely difficult operation cholangitis. This is again one of the commonest questions asked in your thing. So remember a patient comes with pain, fever with chills and dryers and deranged liver functions. This is an indication that patient got cholangitis. That's very important. So these are the three important things in empyema. You can get uh uh fever with chills and R and the right upper quadrant pain. But they are inflamma. They are um they don't have obstructive jaundice because there is no blockage in the duct system. So that is how you can differentiate. And again, they are significantly unwell patients. So these patients, again, you need to follow the SEP C six and make sure that they hit with antibiotics and then they get uh the decompression of their uh block system. So for that, usually you can use either E emergency CP or you can do a PTC that is called the percutaneous transhepatic uh cholangiography where you can pass a tube into the duct system uh through the liver and then you can uh put a tiny tube there. So that will drain the pus out and the infection settles down and then you can plan the refill tube procedure later on. So uh I added one slide on uh these stones just to let you know uh these patients do not typically come with right upper pain. They can come with mainly the epigastric pain, acute onset abdominal pain, colic type again. So then they will develop jaundice. So the inflammatory markers can be normal if there is no infection. But uh they are having a deranged liver functions. Ok. And if you do the ultrasound scan, you will find they got a um a dilated extra and intrahepatic ducts. But remember sometimes the intrahepatic duct dilatation takes about two weeks. So they are, you know, if you do a scan on a patient who had a stone yesterday, then the intrahepatic ducts may not dilated and then you can see sometimes the stones if you want to definitely confirm it, then you go for an MRI scan. MRI scan is very sensitive where you can pick these things up management. If the patient, this comes with symptoms, yes, you need to get a ERCP. Uh There are two options. One thing is you can do a ERCP, take the stones out and then plan to remove the gallbladder that is important to prevent these things happening in a day. Or else you can do an uh laparoscopic procedure where you take the gallbladder out and they explore the CBD and take the stones out at the same time. So those are the two options for symptomatic patients. Sometimes you find these stones when you investigate for some other reason. And then you find that there is a stone in the duct system. So a completely asymptomatic. But according to the nice guideline, they still say that you need to take these stones out via ERCP procedure, followed by a cholecystectomy because these patients can develop complication later in their life and they can be quite uh morbid. So therefore, you need to uh deal with CBD stone even they are asymptomatic. At the same point. I want to highlight that the patients who got completely asymptomatic with incidental, uh, stones in the gallbladder. You do not need to intervene. Ok. They are hardly giving any symptoms. So they are, you can't justify taking the gallbladder out when they are asymptomatic. But at some point, yes, they can become symptomatic, then you can refer. But otherwise, asymptomatic stone, you don't need to take out. The only indication is, uh, porcelain gallbladder where the gallbladder will become calcified because of some reason, then they're saying that there is a slightly higher risk that the patient can get, uh, gallbladder cancer later in their life. So, therefore, you need to take it out. Ok. So those are the important things that you need to, uh, remember asymptomatic, uh, gallstones you don't need to do. But asymptomatic, uh, CBD stone, you need to do the procedure and take the gallbladder out. Ok. Uh, so any questions on that CJ, that's fine. Questions fine. Ok. So, um, in terms of the, uh, right, lower quadrant pain. So again, you can see there are many, many differentials. You can see the important ones, acute appendicitis and then uh uh the Crohn's and all these conditions. But remember, the key things that I want to highlight is I'll discuss about the appendicitis most of you know about it. But remember, the appendicitis is not the only cause when they come to right iliac fossa pain, you need to think about other component and always uh keep in mind especially ectopic pregnancy in a patient with a childbearing age because they can die uh with ectopic pregnancy, rupture, but not because of appendicitis. So this is the commonest thing referred to us from the Ed saying, oh, this patient got r pain clinically appendicitis and then uh uh at the same time, the pregnancy test is positive. So the gyne ask, uh can you exclude the appendicitis? No, we can't unless we go into the abdomen, but they can easily do a transvaginal scan and exclude ectopic pregnancy. That is a life saving thing because if it ruptures, the patient can die. Ok. So do not ever, never ever miss those things. Always uh do the beta CG level. That is very important. At the same time. Sometimes the male patients, they come with uh right-sided abdominal pain with some groin pain and then um you examine the abdomen, there is nothing but always examine their testicles because the the testicular torsion can come with r pain because of the referred nature. So therefore, those are very important things. And at the same time, um there can be other conditions like ovarian cyst structures, ovarian cyst, uh twisting and all these things. So these are very important thing uh to exclude. So, appendicitis, I'm not going to do uh in depth, but I want to highlight a few things. One thing is they are they do not have very high temperature unless the appendicitis got infected and forming into an abscess. The appendicitis patient do not get high temperatures, they usually get low grade temperatures. So if it is a very short history, always think about other pathologies, like it could be a pyonephritis or it could be a viral infection. So especially mesenteric adenitis sometimes can give rise to uh high temperatures because of the viral nature. So think about those things. OK. So those are the key points they highlight in your uh exam questions uh in the description. So you need to pay attention for those those are important. OK. And uh uh and at the same time, depending on the location of the appendix, the symptoms can be varied. For example, if the appendix is basically pelvic, they can get diarrhea at the same time. If it is retrocecal, sometimes you may not see any tenderness over the if the tenderness may be on the flank. But in typical, in your exam point of view, you'll get the typical scenario. So therefore, you need to uh look into the typical scenario that is very important. Don't think about a very rare atypical conditions. So, uh in terms of the uh blood, you will see the raise inflammatory markers. Usually it is a leukocytosis and uh with raised CRP but acute setting. If it is a very short like 24 hour history, the CRP level may be normal. So, uh but still there are uh white cells may be raised diagnosis. How do we do uh most of the time it is a clinical diagnosis. But uh any, any patient, uh any female patient, we tend to do an ultrasound scan, uh of the abdomen and pelvis to make sure that the ovaries are normal at the same time. Uh because of the possibility of uh they can get other uh simultaneous pathologies. So they are always uh go for an ultrasound in a female in a male patient. Ultrasound. Basically, there is no uh value because we are not going to confirm the diagnosis with ultrasound. What you are planning to do with ultrasound in female. Even you exclude the other pathologist. Ok. If you want to confirm the diagnosis of appendicitis, you need to do a CT scan. The CT scan is a choice. So any patient who is over 4045 sometimes this cutoff can be varied. But remember when the age goes up, there are sometimes a patient with cecal cancers, they come with appendicitis. So if you go there without doing a CT and you find a big cecal mass. Uh, then, uh, you will be in trouble. So there are four patients over 40. Then you need to do a CT scan to exclude, uh, bowel pathology like a cecal pathology. That helps a lot. Ok. Treatment, uh, evidence coming up saying that, uh, you can treat these patients with, uh IV antibiotics. But remember, uh, IV antibiotics, uh, with conservative management is a choice. But however, we preferably, uh go for surgery because the reason is there is a high chance of the uh appendicitis comes again and again, at the same time, the hospital stay will be long, at least they will stay in the hospital for a couple of days and then their quality of life and then subsequent uh uh effect on the uh work and everything. Significant factors unless the patient is really comorbid who will not be fit for a a surgical intervention. We currently go for diagnostic laparoscopy uh and appendicectomy. Uh And at the same time, remember if there is a fecalith uh within the appendix, then uh that never going to work with antibiotics. So you need to take the appendix out. Ok. So those are important things uh which may not ask in your exam but you in your real life. So, uh I didn't touch about the others as components like mis diverticulitis, ectopic pregnancies and all. But remember those are the differential diagnosis you always need to think about when it is a right iliac fossa pain, right flank pain. These are the differentials, acute pyonephritis. Think about uh remember atypical conditions, retrocecal appendix, ureter colic, right side, diverticulitis and colitis. Uh so right side diverticulitis is not very common in the European population. It is quite common in the Southeast Asian population, but still we see them. And at the same time, sometimes the the sigmoid diverticulitis can come with ri pain because the sigmoid colon is very uh uh lax. Therefore, it sit on the bladder or towards the right side. So the inflammation may be on the right hand side, not on the left hand side. So therefore, those are important differentials for epigastric. Uh So the common things acute gastritis, sometimes the patients following alcohol intake. Uh this is a common thing. They refer to us saying, ok, you get a patient uh with a acute abdominal pain, epigastrium had a alcohol yesterday and now in severe pain. So these patients, it could be gastritis, it could be pancreatitis or it could be a rupture pep peptic ulcer. So therefore, you need to think about those. So always think about the worst scenario. Uh So they also need to make sure that that is excluded. OK. At the same time, never ever forget the other conditions. For example, the patient can have ischemic heart attack, they come with the gastric pain. So they are for ECG is very important for these patients. So always do the ECG to make sure that there are no ECG changes and also the gas under the diaphragm. So they are for uh erect chest X ray. So this could be a scenario where you will get and say, what is the next step of management? Always, you need to do the erect chest X ray and ecg to exclude uh the cardiac and the uh the perforated viscus. So then you can think about other cases and um I'm gonna discuss a little bit about uh the pancreatitis because this is one of the common things. Uh we let you will get and uh so the diagnosis of pancreatitis is very important. So according to the current uh uh guidelines, you need to have two out of three criteria. One thing is clinical where you will have a typical pain, the patient will have an acute onset, severe epigastric pain and they will describe this kind of a worst ever pain they had and they're going towards their back. Ok. And it is very agonizing type of pain. Then when you do the blood investigations, you need to do amylase level or a lipase level. And that should be more than three times upper normal limit. Ok. So marginal amylase rise, amylase is not very sensitive investigation, it can raise in other conditions even in cholecystitis, peptic rupture. Uh so amylase can be raised. So, therefore, this value is very important more than three times upper normal limit. So if you have both these conditions. You don't need to do the imaging, you got a diagnosis, but any of those are not there. Like if your amylase level are not traced, but clinically highly suggestive go for a CT scan. So CT scan will tell us whether it is pancreatitis or not. OK. So those are the important things you need to remember. You don't need to do a CT for each and every patient you do only when it is needed. Ok. So uh as I mentioned earlier, if the amylase level is marginally raised, think about other conditions, peptic ulcer, perforation, cholangitis, severe cholecystitis. All these can give rise to marginal raised amylase but amylase is over 1000. That means definitely it is uh suggestive of cholecyst uh suggestive of pancreatitis. So the pancreatitis can be um caused by many causes but commonly in uh in our city, it is gallstones, 80% of the time it is gallstone, it could associating with a high alcohol intake as well. But other causes are there, for example, like they can get autoimmune pancreatitis and they can get uh with some toxins, some medications. Uh if you can't find the exact course, you need to investigate for those. But uh the primary thing is once you diagnose within 24 hours, you need to get an ultrasound scan of the abdomen to exclude gallstones. So each and every pancreatitis patient even they show that they got a high in alcohol intake you need to exclude gold stores. So that is very important and they can have this interstitial and necrotizing pancreatitis. But at your level, you do need to know in detail and they can have a severity depending on mild, moderate and severe. Uh So these things are here, you can refer the management. The key thing is they need to be resuscitated these fluids. This is the most important thing. Remember, pancreatitis management is supportive. So it is there is no surgical intervention accurately. What you need to do is you need to resuscitate the patient. Well, otherwise they can get secondary complications. Ok? They can go into renal failure and they can go into s all these complications, but fluid management is very important. So all the details are here. What is the choice of the fluid? And then uh how should we re uh resuscitate the patient? So just go through them and that is important pain management again, very important. So there was a controversy whether we can give IV morphine for these patients because they identified there is some effect on the sprinter of or uh but uh it is safe. You can use IV morphine uh if needed in these patients or even oral morphine, you can use, remember, antibiotics. Currently, there is no place for antibiotics because of pancreatitis per se. Ok. It is an inflammatory condition. So they are you don't need to treat. However, the two indications are one thing is if you get a patient with other infective pathologies, like if the patient develop a chest infection, cannula site infection, then you need to treat antibiotic for those but not for the pancreatitis. Or else if you see the imaging, there is any features of infected pancreatic necrosis, then yes, you need to treat with antibiotics but otherwise there is no place for antibiotics. Ok. Nutrition wise, these patients, the previously we tend to keep them nil by mouth until they improve. But the things has changed, you can't feed them provided they're able to tolerate it. Ok. So, but if not, you need to treat them with IV fluids to make sure that they improve it, right? Ok. So uh any questions? Uh CJ, no questions at the moment? Brilliant. All right. So and then uh left upper quadrant pain. Again, these are very infrequent. OK. Remember these are very infrequent even in our clinical practice. You hardly get a referral with left upper quadrant pain. But if you get it, think about this. Ok. So splenic abscesses, splenic rupture, splenic infarction, acute splenomegaly. I recently had a patient with splenic rupture. The patients who got uh diseases like myelodysplasia or uh um uh the hematological malignancies, they have a massive spleen and they can undergo necrosis. Uh So they can get infection, they can get rupture. So this is a clinical scenario. You will get you, they will describe this patient with a myelodysplasia or something. And then comes with this, then you need to think about these things, ok. So these patients, you need to refer immediately to the hospital. If you are in the GP practice or if you are in the hospital, you need to get the surgical opinion as early as possible. So that's very important, left lower quadrant pain. Again, this is one of the commonest scenarios. Think about the diverticulitis at the same time. Do not uh forget other conditions. OK. You can get left-sided, ovarian problems. You can get hernias, femoro lingu, uh constipation sometimes can give rise to pain. But remember, the constipation do not change the inflammatory markers or they do not give any significant tenderness. So they are constipation should come lower down in the list. OK? Colitis again, very important and also the musculoskeletal pain. Uh So the diverticulitis, since it's common, I just put a, a slight few slides on that. Uh But remember the left sided diverticulitis is the most common thing because that's the narrowest part of the colon where you can get high pressure. So they are diverticula are more common on the uh sigmoid colon. So therefore, they can get left sided diverticulitis quite frequently come to that right side. OK. And uh there is a spectrum of presentation like asymptomatic diverticula into complicated uh diverticula. But you don't need to know in detail. But just remember that uh when you think about the differentials, you will find these things often, these patients are constipated and also they are middle age to elderly category of patients. Uh Even though we see young uh diverticula in young patients, I don't think they will ask that type of questions from you. So remember those are important and management wise again, what you need to do is if it is uh just a diverticulitis, you can manage with antibiotics, you don't need to do any surgery. But if they develop complications like a rupture of the diverticula causing abscess of peritonitis, then yes, you need to take the patient to the theater and deal with it. Ok. Uh periumbilical pain, again, common presentation. So, um you can get appendicitis in these patients early stage, uh then meric adenitis or me, remember these three conditions, you can have the similar presentation. So this is how you need to differentiate. You need to use your clinical knowledge, appendicitis and MS very, very difficult to differentiate clinically centric adenitis. Yes, you can because probably they have a viral infection a couple of weeks ago. And then uh you can get a bit of a tenderness and then your inflammatory markers are not expected as uh appendicitis. But their presentation is quite similar, also the small bowel obstruction and then uh complicated hernias centric ischemia. Again, very important thing. Remember, centric ischemia, how they describe is a typical pain. They will get a very acute onset abdominal pain and when you examine the abdomen, that's fine. But the pain is out of proportion. So that is a clinical scenario. They will give you get a patient with a uh acute abdominal pain out of proportion to the clinical examination findings. So that is a patient where you can suspect centric ischemia. Ok. And these patients often having lots of comorbidities, ca they have vasculopath. So they have hypertension ischemic heart disease history, peripheral vascular disease, or sometimes they may having an atrial fibrillation where you can get an embolism. So therefore, are those are the category of patient that will give you in the clinical description which allow you to identify and when you do the blood investigation, their lactate levels are often high. OK. So these are the important clues for centric ischemia. So uh this is what I basically highlighted. Uh remember it could be because of the thrombus or embolism. If they are, if they can get an embolism, if they got a, if they have vasculopath, they can get thrombus. So if it is a thrombus like in a heart attack, that can same thing happen in the uh meric vessels and give rise to centric ischemia. OK. So uh the all the details are here you can go through later on. OK, fine. So that is all about the abdominal pain. So I covered multiple topics there. Uh And I thought basically that would be the clinical scenario basis would be the beta version. So then you understand it. Uh any questions from the abdominal pain, uh ac no questions. Brilliant. So I'm gonna uh discuss about the intestinal obstruction. So, remember there are lots of slide here. I'm not going to talk about all the slides which you can refer later on. I will highlight the key points only. Ok. So the intestinal obstruction, the key thing, what you need to remember is the anatomy. OK. So uh anatomy of the gi tract that comes with the full gut, mid gut and hind gut. So this differentiation is very important to localize the location of the pain. Any f structures, you will get the pain on the epigastric region. OK. So that is upper quadrant pain, uh sorry, the epigastric region and then per the periumbilical strip, you can get the patient with midgut structures. And if it is a high in gut structures, you get the pain in the lower abdomen. So those are the important things that you need to uh remember and that helps a lot when you are identifying what could be the pathologies. Ok. So until second part of the duodenum uh from esophagus stomach. Uh and until second part of the rhythm is fogo and from that point onwards, until uh the junction between the distal transverse colon and the. So distal distal one third and the proximal two third, that junction that is considered as uh mid cut. So until around like this region, you will see that midgut and then they are onwards. It's hi gut. OK. So that is very important uh which you need to remember because, so that is why the pa the patients who got problems in the appendix, the patients got problems with the small bowel, they get periumbilical pain. Ok. So that is very important to remember. OK. And then uh in terms of the uh obstruction, so this is a broad classification, remember, they can uh the broadly is small bowel obstruction and large bowel obstruction. So each of these can have a mechanical version and a non mechanical version. OK. So the small bowel obstruction, they can be mechanical obstruction where there is an organic course that you can identify and there is a one that you can't identify. So the bowel obstructed bowel is not working, but it is not, there is no mechanical cause so that we call the paralytic iris. OK. Large bubble. Similar thing you can have a mechanical obstruction and then you can have a functional obstruction, the functional obstruction variety we call the pseudo obstruction. OK. That means in the sense there is nothing. So, remember that is very important and the pseudo obstruction does not talk about the small bubble. It is to always talk about the large bubble. OK. So that four types are important. So mechanical small bowel obstruction uh is there? So the courses. So this is the one of the most important slides I would say because this is what they're gonna ask in the exam they will give a clinical scenario. And I ask from you, what could be the reason? OK. So the additions are the most common reason for small bowel obstruction. 55 to 75% of the patients comes with adhesions. Sometimes the patient never had any operations in the abdomen. But if they have something like a diverticulitis or some patients following endometriosis or sometimes following even a cesarean section, they can develop adhesions inside or sometimes they can be a congenital adhesions. So anything is possible. So therefore, additions is something that you need to think about. Ok, then the hernia, you need to look at the hernia, especially inguinal hernia, femoral hernia as well as incisional hernias. So these are very important. And the other scenario is internal hernia. I don't think they will ask in your case. But remember the patients who underwent operations in the past like a gastric bypass operation, they can develop internal hernia. That means a bowel loops going through another loop of bowel. So that cause internal hernia. It is life threating. They can die if you identify and if you do not intervene. Ok, malignancy, very low frequency in small bowel. Remember, so they, they can be very, very uh rare, they won't ask from you. And the other rare causes are Crohn's disease can cause strictures and they are for small bowel obstruction, Goldstone ileus where you can get uh the large gold stones which has been there for a long period of time and then they just forming a fistula in between the gallbladder and the duodenum. And then you fall into the small bowel, uh, and then go and obstruct at the terminal ilium. So that is called the gallstone ileus. Ok. So that is a cause for small bowel obstruction. It is not a, uh, like a gallbladder related pathology, intussusception very infrequent. But remember, it can happen especially in Children. And if it ha happens after age of 9 to 10 years, you always think about there is an elite point causing the intussusception. That means you need to take the patient to the theater and you need to take out that piece of power because it can happen again and again. Ok. And uh, volvulus, small bowel, volvulus, very infrequent. But remember in Children, especially newborn ones, it is, it can be a course where they, uh, bilious vomiting, ok. Radiation induced injury, malrotation and all these things are, there are very, very weird causes but commonly it is additions. So that is what you need to remember. So, clinical presentation, how do you differentiate large bowel and the small bowel? Remember the small bowel obstruction, they comes with predominantly vomiting. Ok. So they come with predominantly vomiting. Abdominal distension is minimal. Ok? They have nausea, vomiting and then bilious drainage, uh, bilious vomiting. And at the same time, they have a colicky abdominal pain. Ok. So they will have, they will give you very clear clues to identify whether it is a small bowel or large bowel. Ok. And they are often dehydrated because of their vomiting. And again, they do not open in their bowels because bowel movements are not there. Uh So those are the important things to remember. Ok. Uh, in compare, how do you differentiate from the large bowel obstruction is large bowel obstruction, mainly causing the trouble at the distal end. So their vomiting is less frequent. They mostly coming with abdominal distension. And at the same time, lower abdominal pain and uh bowel not open. And at the same time, they basically uh ha sometimes may not have vomiting at all if it is a closed loop obstruction, that means if they are uh termina, uh if the ileocecal junction is competent, so then the things can't move back into the small bubble. So they are, they do not get vomiting at all. So they are, uh, those are the clues that you can identify. It's a small bowel or large bowel obstruction. So, uh you can go through these things, uh what could happen and then remember the differential diagnosis, large B obstruction, para gastroenteritis, centric ischemia, uh initial evaluation, I will leave these things for you to read. But again, uh I want to highlight if you have a patient with a small bowel obstruction, look for the abdominal pole for the scars, incisional hernias and the groin, for the groin hernia. So those are very important. Ok, investigations. Uh, so if you want to confirm the small bowel obstruction, we do not do, uh, x-rays. Now, we don't do X rays. We go for a CT scan because abdominal x rays can be sometimes misleading and you can't get any information you want. But the CT scan is a choice. Uh, it's highly sensitive and highly specific. It will tell us many important things what could be the cause, where is the obstruction and how bad the obstruction is and uh whether there is any possible cause that we can see and any complications like whether there is any bowel ischemia or a perforation. So all these things basically let us know through the CT. So they are for the preferred choices. CT scan. OK? You can do some other things like ultrasound scan in young patients, pregnant patients because who can't have a CT scan. But they have a very limited value in those. The MRI scan is a choice. OK. So this is what you can see if you do an X ray. For some reason, if you see this kind of pattern where you can see the bubble loops, you can see it's like a stack of coins. So if you see bubble loop like that in x-ray, it is always pathological. Remember you should not see any small bubble loop on abdominal X ray. If you see any small bubble on abdominal X ray, that is always pathological. OK? You need to investigate further. This is what you see on the CT scan. On the right hand side, you can see dilated bowel loops. Usually when a bowel loop is more than 3 to 3.5 to 4 centimeter, we call it is dilated bowel loops. So suggestive of obstruction. Ok. And you can see around the wall, around this fluid filled cavity, there is a nice enhancing wall. So that is always reassuring that tell us the blood supply is intact. Ok. So those are important things. How do we manage? So, almost always conservative management. So, unless the patient is very septic and Peric suggestive of perforation, you don't need to take the patient to the theater. You resuscitate them with a breath in circulation and keep them power rest. You do a drip and you put a tube in drip, uh suck them and at the same time you the give the IV fluids. Ok. Nasogastric tube helps a lot. It prevent the patient uh recurring vomiting and they are getting aspiration and uh the other complication. At the same time, it gives significant relief for the patient. Ok. And uh how do we manage? So usually what we do is we leave the patient for a bit until the nasogastric tube is dry. And then we do something called the gastrograph. So which is a water soluble contrast meal. And then usually 95% of the time this is successful, we don't need to do any operative intervention because most of these are because of the adhesions. OK? However, if you can see a hernia or if you can see any obvious cause that we can see for the small bowel obstruction, those patients want to resolve with the small a uh gastrography, those patients need to go to theater. OK. This is only for the adhesive, small bowel obstruction. So uh I put the indication when to take the patient to the theater. Even the I you uh just go through them. And the paralytic again, that is a version that you can get, especially the patients who got a small bowel obstruction with uh without a course, they can often happening after the operations, ok? Because of the non mo no mo mo mobile, small bowel mechanical large bowel obstruction. Uh So 25% of the large bowel obstructions are due to large bowel. Remember here, the commonest cause is malignancy, OK? Compared to small bowel obstruction, the large bowel obstruction, 60% of them are due to malignancies. This is a key point that you need to remember. OK. And then there is significant portion due to volvulus, sigmoid, volvulus is the commonest followed by uh cecal and the other causes are very infrequent. And at the same time, the clinical presentation varied, you can go through them acute and uh chronic, uh uh large bowel obstruction, the things are there, uh which you need to highlight, I summarize them before as well. Uh differential diagnosis and then how do we evaluate them, examination, investigation, what you can do uh especially the CT scans as well. This is what you see on x-ray. You can see a abrupt cut off here. This is a colonic gas which can be seen in a normal person but the small bubble loops you should not see. So that is a abnormal always and this cutoff is because of a tumor. Ok. So those are the important things you need to see. This is what you see on endoscopy. Sometimes you can see the cancer with a partial obstruction and the important management is again, more or less same. But remember large bowel obstruction is unlikely to resolve by its own. So they also need to go to theater at some point, they need to go to the theater and intervene. That is the difference between the small bowel and the large bowel obstruction. OK? Sigmoid ulus. Again, one of the commonest course, you will see these patients when you do surgical. On course, very common, especially elderly patients who are in nursing homes or they are bed bound patients and they got a very long sigmoid colon and they are having uh constipation, especially the patients on psychiatric medications. So they can go into alveus. On the right hand image, you can see that it is a twisting of the bubble. And this is a real life image where you can, when you do the operation, you see it's dead bubble. So that is why you need to identify and then uh the diagnosis wise, abdominal X ray will uh give us some clues, but the definite intervention would be uh CT scan ct will tell us exactly how it is. So how do we manage if the patient is not septic patient is just having soft abdomen, no evidence of peritonitis. What you can do is you can do a rigid sigmoidoscopy and pass a flatus tube. So then you can decompress the uh sigmoid colon and that helps a lot. If you can't do that, then you can do a flexible sigmoidoscopy and then you can decompress. But if none of them are successful or the patient is having features of sepsis, then you need to take the patient to the theater and do a surgery. Usually these patients have end up in a stoma. That procedure we call Hartman's procedure where we take out the sigmoid colon and create a stoma. So the stoma will be on the left hand side. Ok. And then previously, they describe about these fixation techniques and all, none of them are effective. So either you do surgery or you manage the patient conservative management. Ok. Cecal volvulus. Again, it is one of the rare conditions. However, uh what I want to highlight in this one is compared to sigmoid ulus, the cecal vuls, you can't manage conservatively if a patient diagnosed with cecal vus you need to take the patient to the theater and do a right chemical omy. There is no place for decompression with the flexi the uh colonoscopy or uh doing any any other method. So it's always a surgical indication. OK, then malignant large bowel obstruction. So this is uh something that you need to uh I supposed to discuss that one in the colonic cancer. But the most important thing I want to highlight is if you look at the percentages, you can see the cancer distribution. It is very common. On the left hand side, the sigmoid colon and the descending colon and the anorectal region. Ok. So, uh, in terms of the obstruction, why it is so common on the sigmoid is because there is a narrow area of the colon. Ok? But if you look at the rectum, which is quite large, so the obstruction is rare, cecum quite large. The obstruction is rare. At the same time, the right hand side, the fecal matter when it comes to it, it is quite liquid because it is a small bowel contents come. So they are for obstruction is limited. But when it comes to the left hand side, they become more solidified. So they are for the obstruction is much more common. Ok. So those are the important things you need to remember. Management. I told you all patients, uh, should have a CT scan, you need to assess the fitness and then you need to take the patient to the theater. The options are, you can do a resection, you take out the piece and then do a definitive surgery or you do a defunction stoma, that means you, you got an obstruction. So what you do is you put a stoma proximal to that. So then you can let this fecal matter comes out and you prevent an emergency operation. Ok? Or else we can do a stenting uh stenting, you can do stenting through the tumor, but there are very limited indication. But remember these are the options available for you. OK. So you obstruction. Again, it is a uh sort of functional version of the uh large bowel obstruction which you need to uh go through. It's called the Ogilvy syndrome as well. Lots of wording. But uh uh the important thing is you don't need to do operation for these patients. They should resolve spontaneously. Remember in these patients, if there is a case scenario with a patient with a low potassium level, OK. Always think about your obstruction because they are hypokalemic patients usually prefer to you with bowel obstruction, abdominal distension. But when you uh look at their bloods, they are very low potassium. So that is the only treatment is you correct the electrolytes and then they will improve. So management everything is there, you can go through it leisurely. OK. So then any questions on bowel obstruction, CJ, nothing for bowel ruction that I can see just one other question from before. Uh can you please go through the signs of peritonitis in general? You can get rebound tenderness in appendicitis, but that does not necessarily mean it is ruptured. Yeah, that's true. So uh first thing is uh rebound tenderness. So, rebound tenderness, it's a bit of a like a difficult thing because ideally speaking, the person who's examining the examining first is the one who can really elicit the rebound tenderness. Ok. What you do is you press around the abdomen and then you take out the hand instantly and then the patient should feel pain more than when you press it. That is called a rebound because the appendix come and hit on your peritoneum. When it is inflamed, it can cause severe pain. But if uh if again, another person go and examine the patient, now the patient knows that this will happen. So therefore, they just guard guarding the abdomen, voluntary guarding. So therefore, you won't be able to elicit the rebound tendons free again and again. Ok. So I agree it is not indication of a perforation and it is an indication of inflamed appendix. Ok. So, uh it, the rebound tendons is not an indication of perforated appendix. Ok. So, appendix can be perforated. Uh But uh even with the normal nonperforated appendix, inflamed appendix, they can have rebound tendons in terms of the peritonitis. What you need to look at is if they are in a slide, you can go through it as well. But in a patient with a peritonitis, what will happen is they will have the localized or uh if it is, it can be a generalized peritonitis or a localized peritonitis. OK. If it is localized, the area where you got the peritonitis, when you press, they got tenderness and they have a guarding. The guarding means basically, when you press the abdomen, you will see the muscles are contracting uh because as a response to that, so it is an involuntary guarding. OK. And then the other thing is called the rigidity. Rigidity means basically when your abdominal muscles are all in a contracted state. So that is called a rigid abdomen. It's like a board like rigidity. When you examine something, it's very rigid, there is no softness at all that indicates a patient got a generalized peritonitis. OK. So there is a bit of a confusion on uh how these things are, but most people basically use them uh in a uh in an appropriate way. What the, what you need to understand is the pain tenderness guarding and then rigidity. Those are four different words. So which can comes at different stage of the disease. Ok. So abdominal pain comes first, then when you involve the peritoneum that become tender and at the same time, they can have a bit of a a guarding when it is quite intense inflammation and then it will become generalized, then it goes into a called rigidity. OK. Is that all right? Yeah. OK. So I hope basically I answered the question. Um but I, if you need any clarification, just drop a message and then I'll clarify further. OK. So uh next thing I'm gonna talk about ge just gently about the abdominal wall hernia. So all of you know, these things, but I just want to highlight uh very few information. So this is a generally what is uh abdominal wall hernia? That is a con protrusion of the abdominal contents through the weakness of the abdominal wall. It could be a primary hernia, there are no previous operations done or it could be a recurrent hernia where you had operations for the same reason and comes the hernia again or it could be an incisional hernia where you made in a surgery for some other reason and then the hernia develops through that. Ok. That's the incisional hernia. So the broadly the risk factors for the hernias are either they have a weak abdominal wall, that means they are elderly patients or they had a previous abdominal operation or they get a, they have a congenital uh tissue disease like Danlos syndrome or something. So they have a weak abdomen. The other thing is they have a raised intraabdominal pressure. So the patients who got ascitis, pregnancy, obesity, uh chronic cough COPD kind of things. So these patients are basically having weak abdominal uh increased abdominal pressure. Frequently they can get herniation ok. So those are the broadly two risk factors for um hernia complications. This is again a very uh important point because people use these words quite uh inappropriately. You can get a patient uh with a hernia completely asymptomatic or they can develop pain or mostly dis discomfort. Ok. Then sometimes a hernia basically can be a reducible hernia. It comes out and then it goes back in, ok. When they are lying down position, it goes back in. So that's a fully reducible hernia or it could be partially reducible, the hernia comes out and it goes back in but only to a certain extent. So that is partially reducible hernia or it could be completely irreducible. That means the fully reducible hernia. For example, a patient who got a fully reducible inguinal hernia can come to the emergency department saying that, oh my hernia is not going back in and it is painful. So that is accurately irreducible hernia. Ok. So that is uh irreducibility or some patients can have a hernia for a longer period of time, which never goes back in. So that those are the patients who got an incarceration, that means the hernia contents comes out and they form additions to the uh the hernia ring. So therefore, they don't go back in, but that is not an immediate problem because it's been there for a longer period of time. So that is called the incarceration. The patients who get the hernias comes out and then they do not go back in sometimes uh later on, they can cut off their blood supply. So those are the patients we call the strangulated hernias. It's a strangulation. So it's basically got a narrow neck. So it strangulate the content. So it can cause compromise blood supply. Initially, they cut off venous drainage, then they cut off arterial supply, then they become gangrene. OK. So that is a spectrum of things a hernia can progress into. Ok. So that is what you need to know. Sometimes some patients highlighting uh it's a cosmetic reason that comes. So those are the things that uh the complications could happen with hernia. So this is a inguinal hernia, so very common uh condition. So all of you know about this, all of you have seen it. So 75% of the abdominal hernias are inguinal, remember 95% of them are in male patients. So they are so common because of the weak area, which is inguinal area. There are two types, uh mainly two types, there are many other but remember mainly two types, which is a direct inguinal hernia. And here you can see the clinical way. The way how that we differentiate is this inferior epigastric art relationship. OK. So you can tell before the operation to a certain extent, this is a direct or indirect. But the only way that you can 100% confirm that it is during the operation. Ok. You can see that is a relationship to the inferior pig gastric. If it is medial to inferior pig gastric, that is a direct hernia. If it is lateral to inferior p gastric, that is an indirect hernia. Ok. That is how you differentiate direct hernias are more common on the elderly patients. Uh and the indirect hernias are more common on the younger patients because this passage we call this peritoneal lining is per persistent. It's a kind of a persistent, persistent vaginalis. Ok. So it is more common in uh younger patients compared to direct hernias in terms of the presentations, groin lump and remember the key point is they are hernia there. This lump is basically above and medial to the pubic tubercle. OK. So above and medial to the pubic tubercle that is important. OK. Management, you have two arms, you can explain to the patient and you can explain everything and you can say that look, this is what the options available. Some patients say that conservative management fine. We we are OK with that, OK. But some patients opt for surgery, then we do the hernia repair. It could be open or laparoscopy and now the robotic comes into play and it is usually a mesh repair. OK. So that is important in comparison, the femoral hernia, this is a very important element you can see on the right hand side, the femoral canal here which basically having three compartments and the medial, most medial compartment is the one which usually call the femoral canal where the herniation comes come through as a lower image. In comparison to the uh inguinal hernia. These are infrequent hernias. OK. And the other thing is this is more common in females. However, that doesn't mean that femoral hernia is the commonest hernia in female. No, 80% of the hernias in females are still in, only 20% of them are femoral hernias. But in compared to males, 95% of them are inguinal, only 5% of them are femoral. So that is a difference. OK. And the other thing is when they comes to you, 40% of the time they comes as an emergency admission, they come with strangulation, OK? Because these hernias are difficult to see. So they come with strangulation. And the other important thing is you need to operate these patients, ok? Even you detect them incidentally, even if they in emergency, you need to operate them, there is no place for conservative management because they are high risk of strangulation and when you operate, you need to operate early as possible. OK. So that is a key message I want to give comparing inguinal and femoral umbilical hernia. So this is other uh the bit of a controversy. So you can see the top image that is umbilical hernia. The bottom image is called the paraumbilical hernia. You can see the difference, the umbilical hernia, the entire um protruding out. Ok. There is no umbilicus. You can see, but in paraumbilical hernia, you can see the umbilicus is asymmetric. It's coming from one side in the top and bottom end or inner side. Still, you can see the umbilicus which is asymmetrical. That is the way how you can differentiate umbilical and paraumbilical, umbilical hernias are very common on new bones, ok? Because of the abdominal wall is not the strength. So it is quite common. But 99% of them basically resolve by its own by the age of 3 to 4 years. So that means you don't need to operate umbilical hernias in Children unless they go to preschool. If that doesn't settle by preschool age, then yes, we operate them before they starting school. But otherwise you don't need to compared to adults, adults, if they develop an umbilical hernia, that is always pathological. It's because of due to some reason in the abdomen, you will see these things, mainly the heart failure, patients, cirrhotic patients or in pregnancy. Ok. When there is any interest intraabdominal pressure in adult patient, you don't need to operate either unless it go into a complication. OK. So there is no because they are medically so complicated. If you operate, they will get a recurrence. So you only operate them. If there is a complication, that means if there is a skin necrosis or if there is a rupture, then you operate. Otherwise you don't. OK. That's the difference between adult and Children, paraumbilical hernia in comparison can progress with time. So therefore, when the patients basically comes to you with symptoms, then you can operate them. And uh usually simple operation, uh usually your suture repairs will do, but sometimes you may need to put a mesh there if the defect is big. Ok. However, there is a place for conservative management provided you explain to the patient and the patient agrees you cannot conservatively manage, especially if a huge patient obese patient who willing to reduce weight. So then let them weight lose weight. Otherwise, what happen is you operate them and then they comes again. So the recurrence chance is high if you do not reverse the uh underlying pathology. OK. So that is very important. OK. So then just a brief thing about the abdominal incision, uh just seizure, just remind me when my uh time is over. OK? We have another five minutes but we can extend the session by 10 minutes because there's a bit of a break in there. So people want to ask questions or they're happy for you to continue, you know, we can continue on. We do have one question that was given, which is what's the difference between pseudo obstruction and palli ili. So the both of these conditions are functional obstructions. OK? There is no mechanical course. The paralytic ileus happens in when it is small bowel, then it is paralytic ileus. OK. So that means you got a small bowel obstruction, but there is no mechanical cause. So that is paralytic ileus. When it happens in the large bubble, then it's called a pseudo obstruction. That's the difference. OK. So it's both functional but one happen in the large bowel, one happens in small bubble. You can see that one clearly in the slides. When I give the slides, you can see them. So it's all in details there. OK. So then other thing is I just want to show some incision. So this is sometimes can come in your exam, they will give a diagram and or they can explain you a thing and then just want to tell you what sort of incision use for. What sort of surgeries you can see the midline incision here. So it is basically one of the commonest incision we use for emergency operations, anything you can do through the midline. Uh then you got this ca incision, which is the right side subcostal incision which you we we used to do for uh open cholecystectomy. You hardly see them because we don't do anymore. Then you can extend that incision towards the left hand side like a rooftop incision. Then that is used for upper abdominal big operations, like if you want to do a liver resection or if you want to do a liver transplant, that kind of thing, they use this uh rooftop incision and then you can have a paramedian incision. Now, nobody is going to use these things. So it's old operation. So nobody is used. And these transverse incisions are also very rarely in use. OK. So midline incision is common coccus incision. You need to know rooftop incision, you need to know. And then you can see there are two incisions on the R which is one called the grid. Other one is called the lens. So these two incisions are being used for the uh open appendicectomy. The green one is called a muscle splitting where you go in, you split the muscles, you don't cut them. So that is the one lance incision is much more cosmetically uh uh favorable operation because it usually covered when you use an underpant. And uh so the lance incision again is a choice when we are going to do an open incision, open appendicectomy. Now, OK. Now, most of the appendicectomy, a keyhole. Uh but in case if you go with the open, you can use a lens MRI again is uh uh basically you can use that one on the right hand and left hand both. But they are usually used for kidney transplant as well as you can use for tho uh use those things for femoral hernia repair as well. OK. And the festal incision you all know we to use, especially the gynecologist prefer to use these things. And also the laparoscopic colorectal surgeons tend to use this one. They do the surgery laparoscopically when they want to take the specimen out, they make a festal incision and take it out. Ok. So those are the things that I want to highlight. Ok. So shortly abdominal stoma, uh this is one of the topics that uh people get confused. So that is why I want to highlight them. So, stoma uh anything that you create surgically uh on the anterior abdominal wall to drain in the visceral contents, you call the stoma. OK. So it's a, you bring the viscera out to the abdominal wall and it should be surgically created. It is not a spontaneous one. Ok? And if it is a spontaneous one, they will call the fistula. OK? If it is a spontaneous, that's become a fistula, but it is surgically created, it's a stoma. So there are broadly many, many times you see all these 31 thing is colostomy when you bring the colon out, ileostomy, when you bring the small bubble, mainly the ileum out and the urostomy where you bring the ureter out. Ok? And there are some other varieties as well. Sometimes you can bring the esophagus out called the esophagostomy. You can bring the stomach out, called the gastrostomy or you can bring the gin out called the GT. So any of these names, depending on their variety of functions. Uh Most of the time, uh it is for the drainage of contains, that means you bring the colostomy to drain the fecal matter. Small bowel contains ileostomy. So likewise. Or else it is sometimes used for fixation of the bowel. For example, if you got a gastric valvular a stomach twisting, you want to fix the stomach. So use AP tube that is called a percutaneous uh endoscopic gastrotomy. So that use for fixation of the uh stomach or else for the feeding purposes, if you pick tube, you can use a feeding into the stomach or you can use in the uh feeding indigenous stomy again, uh following major operations to feed the patient. So those are the main functions of the stoma. And at the same time, depending on the appearance, it can be end stoma. You can see on this image, this is an end stoma, only one end or this could be a loop stoma. You bring a loop of bubble out and then make an opening and then you create a thing. So that become a loop stoma or it could be a double barrel where you cut the bubble and then you bring both things out so that it is a double barrel stoma. So likewise, there can be many versions, but this is what you need to know in nutshell. OK. If you think about the colostomy, you can see on this, there are different types of colostomies. OK? But commonly, they are left side stoma. You can see on the left hand side, you can take sigmoid colon out. So it's a sigmoid colostomy. It could be a descending colon out, it's a descending colon, colostomy, then you can take transverse colon out transverse colostomy. So, likewise, depending on the piece of bowel, you take out different purposes are there. But those are the stomas. Usually the left-sided abdominal stomas are the easy to manage ones. Uh but the upper abdominal ones are very difficult because you bend, there is a skin crease. Often they can derise to complication. Ok. So the different types, depending on the part of the bowel purpose. OK. So if it is a decompression of the proximal bowel, if you get a tumor here in the sigmoid colon, you can't operate this patient because patient is so unwell or patient is frail. In that case, what you do is you do a stoma on the proximal bubble on the trans scone. So then the patient's obstruction is gone, then you can plan leisurely whether you need to operate or not. So that's a decompression. OK? And sometimes you fixation, the cecal fixation, but it's very infrequent or sometimes you do a diversion stoma. That means you got a very bad perineal injury, either trauma or a a burn or something like that. So if you allow the patient to pass stools, normally, what happens is that area get contaminated. So therefore you do a diverting stoma uh to prevent the bowel contents going into the rectum. So that is kind of a thing, different purposes. You use the stoma and it could be a temporary stoma. It could be a permanent stoma or depending on the type loop endo double barrel. OK. So the features, this is again, important thing allow you to identify it's flush to the stone uh skin. That means you can see, you can't see anything coming out of the skin. It is just at the level of the skin and usually very solid contents comes out through unless it is a proximal uh large bubble stoma like uh uh ascending colon and uh variable location depending on the part of the bowel use. And the common surgeries, you will get this heart's operation. When you take out the bowel emergency, you bring the uh descending colon out oils and do a perineal resection. That means you take the distal rectum, perineum anus and everything out. So there is nothing to joint. So there are four, it should be a permanent stoma. OK. So those are the common indication but there are many other situations you create stoma in comparison to a large bubble stoma. This is a small bubble stoma. You can see it is a small uh thing comes out of the skin. This is called a spout. You need to create at least 2.5 centimeter spout. Why is that? Because not like large bowel content, small bowel contain, contain lots of acid and bile. So that can cause irritation of the skin. So they are unless you create this kind of a thing which allow the things to fall straight away into the stoma bag. The patient can get lots of skin complications. So that is why you need to create the stoma uh the spout and uh depending on the part of the bow values, uh you name them eos omy purpose again, the same duration types. So spout liquid content usually on the right hand side. OK. But remember it can be anywhere, they are often difficult to manage. Why? One thing is a skin irritation. Other thing is it a liquid content? So usually they can get high output. So therefore, the patient can go into dehydration, electrolyte imbalances. So lots of problems. Remember the proximal, the stoma, the complications are more OK. If they are very proximal, these patients are often very difficult to manage. OK. They go into renal failure, they are very difficult distill the small bowel stoma that is better. OK. So that is the important thing. And then the commonest operation subtotal or total colectomy, you take the entire colon out, then you have, you end up in a small bowel stoma or if you've got a large bowel obstruction, then you may have to create a uh ileum ileo stomy where you basically want to drain the content. Or else if you do a big operation like an anterior resection, you join the large bowel together. But this patient had preoperative radiotherapy of chemo. So high risk of anastomotic leak in those patients to prevent the uh to protect the anastomosis, you create a stoma on the ilium. So the bowel content come to the ilium until that anastomosis heal. So that kind of purposes are there. So they are usually easy to identify. Uh they are often on the right hand side. Ok. Mhm. Sorry. I just, uh, I think I went through these things. OK. We have one question about stomas, which is what the uses of end versus loop versus barrel. Stomer, double barrel stomer when we use. So it, it is again, very uh subjective. Uh remember usually in stoma are used um as a definitive procedure, for example. Now, uh the, as I mentioned, the previous one, if it is a subtotal colectomy, OK. What we do is we take the entire colon out. So you got only one end of the small bowel. Either you need to join this one with the distal end or you take that out to the skin. So that is endo OK. Similarly, when you do an Hartman's procedure, large bowel, you bring the descending colon out to the skin. So it's a stoma in a loop stoma, what happen is you bring just a loop of bowel, especially when you want a diversion. Like when you got a perineal injury, you would create a loop colostomy where you need to divert. So there is, you don't resect the bowel. What you do is just bring the loop of bowel out and make a small hole and stitch into the skin. Ok. So whenever you want to close it, you just take that out and then you just join that, close the hole and put back into the abdomen. So that's a loop. Stoma double barrel is basically when you want to resect, when you want to chop off bowl, what you do is you chop off that segment of bowel, but then you are not sure whether you can join these things together or not because the patient may be unwell or the patient's bubble may be just very disproportionate in that type of situation. What you do is you just create a double barrel, you bring both loops out. OK? And then whenever you want to close, you don't need to do a big midline laparotomy. You can just dissect around the uh stoma and then you join them together and put back in. OK. So it, it, it's been a bit of a like a complex thing. Like there are many, depending on the surgery. Many, many uh indications are there? Sometimes we discuss, oh, what's the best option for this patient? And what, what should be the best thing because there are multiple options available. But that is what I briefly let you know those are the situations where we use them. OK. All right. Do I have time to go through the vascular? A quick go through? The next session is at 1030. So if we just keep going until then because it will be useful. Uh If people want to take a quick break, there's the recording. Um But we'll go through the co this is also useful. There is in things like AAA S. It's important to know about screening and that. So the vascular surgery wise, uh remember there are only three w vein, artery and lymphatics. Ok. So the venous wise, what you need to know is varicose vein, you need to know about the venous thromboembolism, ok. Arterial wise, you need to know the peripheral vascular disease and the AAA the lymphatic wise, you need to know about the lymphedema. So these are the only things you need to know in vascular surgery. And uh so the varicose vein again, you can go through the slides. There are very descriptive things about it. But remember the definition uh about the varicose vein, they should be dilated to the superficial veins, should be larger than three millimeters. If they are less than three millimeters, they are not varicose vein. OK? And there are various stages you can develop the varicose vein. Ok. So there is something called AC EP classification where you look at the clinical, that is C E that is etiology. A is basically again, uh depending on the thing and the P means pathology. OK. So you can, this is ac classification, the clinical variety. You can see how they can progress completely asymptomatic into the ectasia or uh reticular veins. Then to the varicose vein, then edema, eczema and pigmentation, lipodermatosclerosis, healed venous ulcers and active venous ulcers. So that is a spectrum you will see in varicose vein. OK. The risk factors are mentioned here. Clinical presentation is also mentioned here. Remember there are some controversies because when I go through some of these question banks, they talk about basically the management. But this is a nice guideline management which is mentioned. Uh if a patient is having bleeding varicose vein, you resuscitate the patient, send to the secondary center, you need to send for the vascular opinion. OK. There is no stopping. If the varicose vein are not bleeding, then what you need to do is you need to uh explain to the patient what is happening. You give them the self care advisors, the factor modification, which I mentioned earlier and you refer to the vascular unit. If they are symptomatic, you do not refer only cosmetic per se. Ok. You will refer the patient only if they are symptomatic. If they have pain, ache, discomfort, swelling, heaviness kind of thing or if they do have skin changes or other complication like a skin um lipodermatosclerosis or uh uh skin ulcers. Also that kind of thing you need to refer or else if they have like a superficial venous thrombosis. So that kind of thing, you need to refer these patients. So remember these criteria are very important. I think they're gonna ask them in the exam if there if none of those things are there. But you know that patient got varicose vein, you offer them compression stockings. Ok. So that you have to offer class two compression stockings. There are four classes, class one to class four, class 12 and three and four, depending on the pressure level at the ankle, the pressure higher the pressure, it become class four. But for these, you need to recommend class two stockings. class two Stockings. The problem is they are very effective. However, they are difficult to uh keep them because of the pressure profile. And uh uh but before applying, make sure that you exclude arterial insufficiency because otherwise the patient end up in a dead limb. Ok. So that is very important. And uh but if the patient got any criteria for referral to the the vascular center, then you need to refer them not the compression stockings. Ok. If the patient is pregnant again, you need to recommend them. This is common and most of the time it resolves after delivery. So therefore you offer them compression stockings only for the symptomatic relief. Ok. If they want a surgical options, these are the options available. You can use thermal ablation, that is either radio frequency ablation or laser ablation or you can use sclerotherapy or surgery. So, those are the options available. And uh I mentioned here, how do you exclude the arterial efficiency? Uh insufficiency go through them that is very important as well, OK, we measure the ABPI not the pulse. OK. Remember the pulse can be a misnomer. Uh There are ABP is the most important thing. So then I highlighted about the deep vein thrombosis and at the same time, uh the frequency, the risk factors as well and also the uh the complication that could happen and when to suspect and also what are the other things you need to suspect in these patients? And how do you diagnose uh DVT and what are the investigations and how do you treat them? Ok. So all the details are here with a summarized version. So you can go through them and they are important. They are according to the nice guidelines. OK. And then uh uh unprovoked DVD. How do you investigate and what are the things you need to do? So all these things are here and then briefly about the peripheral vascular disease. Uh you can see acute limb ischemia and chronic limb ischemia. There is a classification which you need to remember. This is important. Acute limb ischemia is a sudden a decrease in the limb perfusion. Sorry, spelling mistake, limb perfusion that threatens the limb viability. Ok. That is acute limb ischemia. The chronic limb ischemia is not like that. It is chronic, any test three component. Some patients can have problems in the vascular supply but they are completely asymptomatic. OK? Or they can have intermittent claudication. Remember this typical description is important. They will ask, how does the intermittent claudication happen? These patients started to walk and after a certain distance, they started to get the pain in the limb. Ok. Because at the rest, their blood supply is ok. But when the muscles are working, the it needs more blood supply. So when the val the, when the blood supply, when the vessels are narrow, they can't give this supply, then they develop pain. It's like angina similar to angina that is called intermittent claudication. Then what they do is they stop there, they wait for a certain time and then they can start walking, then they can walk the same distance again. Ok. So we call this distance as claudication distance. OK? There are some conditions where you get the pain after some time and then you stop and then you start walking soon after that, you get the pain. So that is not intermittent claudication. Ok. So those are the things you need to know, intermittent claudication, venous claudication, neurogenic claudication. These things you need to differentiate, they will ask in the history. Uh And then they are, they are the claudication distance become very shorter if they carry a heavy weight or if they are climbing uh uh sort of like a hill. So then their claudication distance become quite less. Ok. Critical limb ischemia is a situation where even at rest, your blood supply is not enough. So that is critical limb ischemia. This happens when you've got a significant narrowing and they can get rest pain and they can get uh arterial ulceration or even gangrene. So that is a critical limb ischemia. So you need to know these thing three very carefully. Ok. That is very important. And so I discussed about the acute limb ischemia, the course and all and how do you diagnose them? So these are important. Ok. Remember uh the way how that you identify them, there are six piece which you need to know and how to differentiate it's become embolism or thrombosis, acute limb ischemia can happen because of two things embolism or thrombosis. How do you differentiate them? These are important for management. And there is another one called the Rutherford classification which usually talk about at what is uh sort of like timeframe, we need to intervene maybe too much for you. But just re remember, this is helpful. OK. And then what are the options available? How do we manage and all these things again, chronic limb ischemia management, different things, intermittent claudication, critical limb ischemia. How do you manage everything? Is there? Lifestyle modification, symptomatic management and the surgical intervention and when to do those things? Ok. In comparison to intermittent claudication, all patients with critical limb ischemia should be referred to vascular intermittent claudication. You don't need to, you, you, you uh refer them at certain points. OK. So those are the important things. And then uh I touched a little bit about the abdominal aorta and screening, I didn't go and deal with too much of things. But what you need to do is this slight, this component here eligibility criteria for AAA screening in UK. So this is the one they're gonna ask over and over again. Ok. So all men, when they become 65 years, they will get an invitation to go for a uh 11 ultrasound scan females do not get in not uh females are not invited. Ok? Because they are risk of aortic. A aneurysms are very less. And uh if they don't want to get a, get a scan, you can opt out. Ok. At the same time, uh if at birth, if they are registered as a male, even now they are female still, they will get the invitation. Ok? So these are important things you need to know it's an ultrasound scan and then uh it me it's mentioned about what will happen depending on the outcome, what to do and then uh a bit of advantages and disadvantage of screening. Ok. So these things are important, just go through them. At the same time. I mentioned about the head injury. There is a bit of a thing but all the details are here. I think uh you can go through. I think my time is over now. Uh CJ. Thank you very much, sir. Um I think we'll have to wrap the session up now because we're due to have another speaker. Come on So everybody will take a five minute break. So we'll go stop broadcasting for that time and our next speaker is going to come and sit their slides up. Um, so I'm just gonna stop broadcasting now, so I'll be back for five minutes.