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Summary

This on-demand teaching session, led by Dr. Dan, a medical professional from Northwestern Liverpool, focuses on the examination, history, investigations, and initial steps necessary for the successful management of acute surgical conditions. To assist in consolidating this crucial knowledge for medical examinations and practical implementation, the session poses scenarios and case studies related to various conditions, spanning from appendicitis to sever abdominal pain. Referencing the UK MLA curriculum, Dr. Dan's instructive discussion covers common presentations of these conditions and the interlinking nature of their symptoms. This session is beneficial for medical professionals seeking to broaden their understanding of common acute surgical conditions.

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Description

  • Interested in surgery? 🔪 💉
  • Need some extra revision with finals looming?

Mind The Bleep are running a brand new Finals webinar series covering Surgical conditions and presentations.

For out first session we are covering Acute Surgical Conditions and Presentations in General Surgery. There are a great many of these so we will cover some conditions in the respective subspecialty sessions coming up. Conditions and presentations are based off the UKMLA curriculum for Surgery and Gastroenterology.

We will go over presentations, clinical features, assessment and investigations, as well as management, particularly focussing on the role of a foundation doctor.

The session will be recorded if you miss it or want to watch it again!

Also feedback is much appreciated so that we can continue to improve further sessions.

Learning objectives

  1. By the end of the session, participants will be familiar with common acute general surgical presentations and conditions, and will be able to identify the initial steps to take regarding exam, history, investigations, and management.
  2. Participants will gain an understanding of the importance of acute abdomen and learn how to effectively approach a patient suffering from severe abdominal pain.
  3. Participants will become proficient in acute abdomen history taking and in understanding the importance of obtaining details such as demographics, risk factors, history of complaints, past medical and surgical histories, and medications allergies.
  4. Learners will be able to identify the early signs of appendicitis, particularly in younger patients, recognize the symptoms, and perform a thorough examination to confirm diagnosis.
  5. By the end of the session, participants will be knowledgeable about the management of appendicitis, including the benefits of initial supportive treatment, when to seek invasive surgery, and the process of choosing between conservative and surgical treatments.
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Computer generated transcript

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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hi guys. Can anyone, um, pop in a message onto the chart if they can say slash hear me? Yeah. Grand. Um, ok, cool. Um, I'll get started then if you can also see the slides. Um, right. So today, um, I'm Dan, I'm one of the F ones from Northwest currently working in Liverpool. Um, I've also just started recording if that's right with people. Um, today we're gonna be talking about some acute surgical conditions, uh, to help you, help you, hopefully help you revise for the finals. So, what we're gonna do, we're gonna cover some common acute general surgical presentations and conditions. Um, initial steps you might take is an F one. So exam, history, investigations and the initial steps and management. Um, so I've taken these presentations and conditions from the UK MLA curriculum. Um, the ones I've highlighted and read are the ones that I'm gonna try and cover today. Um, couldn't really get all of them in. There's quite a lot and, um, gonna try and spread them out over a couple of other talks. Um, so we've got a fair amount of ground to cover with those. Um, why we got a picture of Ryan Gosling. Well, um as I've seen him played runner 2047 where um he's talking about interlinking. And the point was mainly just to highlight how presentations and conditions as quite a lot of interlinking together. A lot of, a lot of presentations might correspond to um a condition and vice versa. So to start off with, um we off with a 65 year old man called Tommy Aiken presents with ve with severe abdominal pain. So, have a little think about how you would um approach this. What are the initial steps you would do if your consultant says, right, go ahead, see this man. So um basically this, this is a section that um it's kind of focused on the acute abdomen. So what does this really mean? It's, it's kind of um it's probably the most important um surgical presentation. Um It's quite common, it's basically undifferentiated, severe abdominal pain. Um And I guess a good starting point is always kind of trying to start with that. A two A approach, especially as an F one. Um If you don't know, kind of where to start off with, there's a lot of things that can cause an acute abdomen. Um And really, you, you, one of your main initial roles is to try and find out how unwell they are. Um So there's a large differential and as you can see in those pictures are just there on the right, you can categorize it anatomically. Um It's probably the easiest way to split things up. So the different quadrants or the different um you know, sections of the abdomen, umbilical epigastric, right and left iliac fossa. And so you, you're also gonna take that history and initial exam just highlighted and read the three three kind of things you wanna be having in the back of your mind. You know, are you having an acute bleed? Uh, are you having a perforation, ischemic viscera? Because those are some of the emergency, uh, presentations and conditions that you just wanna have in the back of your head and we'll come on to all of those just in a little bit. Ok. So history, what kinds of things do you want to know? You want to know the age gender, you know, if you're thinking about gyne pathology, demographics, risk factors. Are they smokers, uh, lifestyle things, um, occupation, job. Um, there's a lot of things that come into that history of complaints. Socrates, key thing, um, whether they've had any trauma past medical history and surgical histories are often important can give you clues, uh, social history plus sexual history, um, particularly for things like P ID, um, medications allergies, you know, the, the ample history gets mentioned quite a lot in surgical history taking. So that's allergies, um, medications past medical history and last eatin, I think. And that's cos, you know, a lot of the time, if you think someone's gonna go to surgery, then you wanna keep them nil by mouth. Ok. So here I've just sort of uh constructed an approach that you might use. So the initial A two E um and that can be concurrently with the history if they're that unwell. But you might, a lot of the time you might take the history first, um, start with an A two E fix any things that are glaringly, you know, wrong oxygen saturation, put them on oxygen, um have a look at their hemodynamic scores. So BP, pulse rate um gonna wanna start some IV fluids, you know, in a lot of patients have a think about blood products, get a group and say cross match analgesia is probably a big one that you'll do is an F one. So prescribing analgesia antiemetics IV fluids, all those supportive things, maybe they'll need antibiotics if you think there's a sepsis picture going on. Um and catheter and fluid balance are also important. And then on the examination, um you know, you split it up into those four bits. So inspection palpation, concussion, auscultation, you know, what kinds of things are you looking for? Any scars? Are they distended. Has got any jaundice, you know, things like Cullins, Cullins sign, which will come on to you later. Um When you're palpating, think about things like Murphy sign, um guarding rigidity, peritonism, rosing sign. Again, things we'll all come on to in a bit precaution have you got any precaution, tenderness sound, particularly tympanic auscultation, bowel sounds, you know, are they obstructed basically? And then basic exam, uh, investigations, things that you're probably gonna wanna do on most people. Uh, an E CG. If nothing else just to get a baseline urine dip. Um, cystitis and urinary tract infections can present with abdominal pain. Pregnancy test is a key one in any woman of childbearing age that you never, you never wanna forget to do um bloods as well. So basic labs, uh VBG ABG in a lot of surgical patients, you're probably gonna wanna do a clotting and group and save just as a standard uh and any cultures that you think uh might be relevant that could be like sputum cultures, blood cultures, stool cultures, if they with diarrhea and some basic imaging. So uh abdominal X ray, if you're thinking obstruction, for example, chest x-ray, have you got any air under the diaphragm, any perforations? Uh and then CT is probably the big one. Surgeons love CT S. Um can't get enough of them slash CT angiograms if you're trying to find somewhere that's bleeding. Um And then ultrasound in some key cases like in Children or um pregnant women, things like that. And then probably another thing that's key to remember is y you're probably never gonna be on your own with these things. Um You're always gonna escalate to the person above you and um you, you, you and I would be doing everything yourself. So don't worry too much about that, but it's good to know um, what's available to you. So, uh for our first condition, we're gonna start off with a scenario 23 year old male referred into S AU with abdominal pain, right, lower quadrant, some nausea and a low grade pyrexia. So you can probably guess that we're coming on to appendicitis. So, what is appendicitis? It's the most common surgical condition requiring surgery. So, it's very common. It's an acutely ala inflamed appendix, commoner in younger age groups. Um So how does it actually develop? Well, the appendix is a hollow kind of tube at the bottom of the caecum. And usually what happens is it gets obstructed by something that can, it's usually a faecalis. So a bit of hard poo that gets stuck in there, but it can be, you know, tumors in rare cases or uh inflamed lymphoid tissue. And then what happens is the bacteria multiply, um everything gets a bit inflamed, uh an edematous causing increased pressure, cutting off the blood supply. It all becomes a bit ischemic necrotic um and eventually can perforate. So, um what does it present with? Well, classically starts with like generalized, dull, um central abdominal pain, um and then evolves into a sharper, more localized, right, lower quadrant pain. Why does it do that? Because initially the um visceral peritoneum um gets inflamed and that's innervated by the autonomic nervous system. So, it's it's not as well localized. Whereas later on the parietal perineum gets um inflamed and that's, that's around the, the, the inside of the abdominal wall cavity and that's innervated by the somatic nervous system. So that's why it's more sharp and localized. Um So, yeah, nausea, vomiting, anorexia, sometimes diarrhea and urinary symptoms if the bladder um gets a bit inflamed as well. So, on exam, you'll probably find tenderness in the right iliac fossa at Bernie's point, that's two thirds along the way from the ace and um umbilicus. Sometimes you can get guarding um rebound tenderness, precaution tenderness if there's localized peritonism. And so what do I mean by localized peritonism? Well, it's an infla inflammation of the peritoneum just around that little area uh as opposed to a general peritonitis, which is um seen in more advanced pathology. So that's a generalized inflammation of the peritoneum. Uh And in that, you classically see rigidity. So a hard, a very hard abdomen as opposed to just tenderness in one point. Uh you might see ring sign. So that's a sign where if you press on the left hand side. So on the left iliac fossa that can replicate the pain in the, on the right side, sometimes you might see what's called a SA sign. So that's on extension of the leg, you get pain um pain in the hip region and you know, sometimes you can get a serous abscess. So an abscess around the cerus muscle in appendicitis, but probably, probably not one to really focus on too much. Uh, and as we said earlier, there's a wide differential diagnosis. So, although it is often a clinical diagnosis, a lot of, a lot of surgeons tend to get CT S just to make sure. Um, and, you know, it, it can identify any, any other mimics that might be causing it, you know, any gyne things, any renal urological mimics. Ok. So you'll probably notice a pattern in, um, investigations and management. You'll always kind of start with the basic bedside things. So, always starting with the bedside investigations, simple things, urinalysis, pregnancy test and a management. You're always gonna start off with those initial supportive um, resuscitation kind of things, fluids, analgesia, antiemetics, um, and then bloods, you're gonna do your, your basic bloods, FBC using these L FTC RP clotting and group and save, like we said, in case I need to go to the theater, any cultures, you think I might need the spike in temperatures. Um, you might get some blood cultures and then imaging as we've already talked about CT is probably what, uh, what you're gonna get in most people if they're pregnant or if they're Children, you might consider an ultrasound, but it can also just be a clinical diagnosis and you might just take them for a lap, uh, laparoscopic investigation just to check. And so after that initial fluid resuscitation, uh most people then go to surgery. So that's still the gold standards taken out of the appendix. It can't recur, um, in some cases though, you, um, you might see patients getting treated conservatively just with antibiotics and it tends to be, you know, older patients who are more frail or co comorbid patients. Um, you know, you, you weren't very fit for surgery but obviously there's a higher, much higher risk of recurrence cos you've still got a, uh, an appendix on you. Um And so what else was I gonna say there's a coup couple of other things with appendices. Um Sometimes you might see an an appendiceal mass. Um and that it's, it's an inflamed appendix, but it's covered in sort of this mass of omentum. Um And what you do in those scenarios as you treat it conservatively, um you tend not to do surgery on those. Um, some important mimics Campylobacter might present like appendicitis with right, lower quadrant pain. Um Things like Meckels, Crohn's Ileitis, ovarian torsion cyst structure, ectopics, you know, they're all in those lower fossas. So just, just be aware of some of some of the conditions that can present similarly. Ok. So moving on to the next 1, 55 year old woman with a history of gallstones, alcohol dependence comes in with epigastric pain radiating to the back and nausea and vomiting. So, what does that make you think of? Well, we're talking about acute pancreatitis, of course. And so that's inflammation of the pancreas, obviously. Um, so, um, I've added a quite a nice acronym here about the causes, um, get smashed. So these, these kind of give you, it's a nice easy way to remember. Um, some of the rarer causes, but most of the majority are caused by, caused by, um, either gallstones or ethanol. So that's the majority of the ones you'll see. Sometimes it can be idiopathic. I think about 10 to 20% causes. Don't um pancreatitis don't have a cause. But um yeah, commonly gallstones and ethanol. So what actually happens? You get um overactivation of the digestive enzymes in the pancreas. So, you know, it's got that exocrine function. Um It's got the lipases which autodigest the fats and the fat in the pancreas and surrounding tissues, blood vessels which can cause hemorrhage. Um because it's an inflammatory process, you get a lot of fluid shifts. So vascular permeability, vasodilation causing fluid to shift um third spacing. So a lot of the time you're gonna need to aggressively treat with IV fluids and resuscitate. Um and it's associated with a lot of complications. Uh it can progress to multiorgan failure, pancreatic necrosis infection. Um We, we'll come on to some of the um complications in a little bit. Um Oh Another thing I wanted to point out was with, with the autodigestion of fats and the fat necrosis. Um interestingly, you, you get um you get a reaction with calcium with the free fatty acids. So, what happens a lot of the time is you get um hypocalcemia cos it's all consumed um creating this kind of chalky deposits with the free fatty acids. So, clinical features. Um so as in the vignette, severe epigastric pain, which radiates to the back nausea, vomiting, depending on the severity. You can have features of shock and hemodynamic instability as well. Think about third spacing causing uh hypotension. So they might, they might have hypertension, tachycardia, high new scores. Um Other, other things that, that, that, you know, they might have guarding distention, especially if, if they get uh an ileus while they have pancreatitis. Um So features of obstruction, reduced bowel sounds. You might, you might see these on exams, colons and uh gray turner signs. Um So as we talked about because of the um release of the enzymes, they can break down the blood vessels and cause hemorrhage. Uh So Collins is, is the one on the right, the periumbilical bruising with great earners is on the flanks on the left. Um And that's a sign of retroperitoneal hemorrhage. Um You might also see jaundice if the cause is gallstones and it's, you know, obstructing the the common bile duct. Um So, investigations as we've talked about, I always want to start off with those bedside ones in terms of the bloods or your usual customers. Plus, remember, calcium, um, amylase is probably the key diagnostic one. So either either serum amylase or lipase probably depends on your trust, but I think most places still use amylase. Um and that uh you'll, you'll typically see three times the upper limit uh of normal amylase in a patient with pancreatitis. And although it's diagnostic, it doesn't actually give you very good information about monitoring um all the severity of pancreatitis. So really just kind of limited to that diagnostic capacity and imaging. Similarly, CT s always a good bet with surgical scores. Um surgical conditions, sometimes you can use ultrasound. If you're worried about things like perforation or obstruction, you can get um chest or abdominal X ray and we'll just come on to the risk scoring, I think in the next slide. So one of the ways to stratify the severity of pancreatitis is using a modified Glasgow criteria. Um Again, it's a nice acronym, it's remembered by pancreas. So po two H neutrophils, white blood cells, calcium, as we've already talked about renal, that's urea, not creatinine. So, more than 16 urea um enzymes, LDH and ast albumin and sugar, which is glucose and each one of those counts for a one point I think. And if it's more than three, then that's severe, you wanna consider getting some early HD or ITU input because because more severe pancreatitis is associated with um complications which we'll come on to. Um So management is mainly supportive. So you're really gonna wanna focus on that aggressive uh IV fluid resuscitation, um strong analgesia, they're gonna be in a lot of pain, so strong uh opioids, uh antiemetics as well. If they're vomiting a lot, you might, you might consider putting in a R tube to an NG tube to help drain and decompress things, especially if they've also got an eyes at the same time. Um So yeah, fluids, strong, um strict fluid balance. Sorry. So you're gonna wanna catheterize them, see what they're putting out and then depending on the cause. So, as we talked about, there's a lot of causes. You can um treat the reversible causes like an E RCP with gallstones. Although it's obviously quite tricky cos E RCP. If we go back, one slide does actually happen to be one of the causes of pancreatitis. So, so sometimes a bit of a balance of balance of judgment, isn't it? Um Managing complications will come on to getting ID input if you need and then definitive management after the pancreatitis is settled down. So it's caused by gallstones. You might get a lap early, you might wanna try and get on top of alcohol management as well if that's causing it. And um in, in patients, it tends to be in patients who have alcohol dependence, but repeated bouts of pancreatitis can cause chronic pancreatitis um later down the line. So next slide, talk about complications. So I've split this into local and systemic complications. So um probably one of the most common ones you'll see is odds. So acute respiratory distress syndrome. Plus minus some pleural effusion. And that's why the, the PO two is one of the um one of the risk score factors. Uh And that's also another reason why you might want to get it in early uh hypercalcemia. As we've talked about, the calcium gets consumed by the free fatty acids forming a chalky deposit. Where do you get hyper hyperglycemia? Well, the pancreas also has an endocrine function. So, um destruction of the islets. L your hands means that your insulin production gets affected. Um D IC. So, you know, you're gonna be watching out for those clotting factors. Um trying to get hematology input if you need ileus, as we've mentioned a couple of times. Um so it can shock the bowel a bit. Um And then you're gonna wanna treat as an obstruction. So NG tube IV fluids. Um and then also because of all the third space shifting, you might also see AK I particularly thinking about that prerenal um hypovolemic etiology and then local things. So you can get pancreatic necrosis, it's dead tissue, uh that can become infected. So you gonna wanna monitor their temperatures. Um And the C RP. So, you know, you might, you might see patients who get, um and you just constantly get temperature spikes. The C RP is just like 300 for like a week. And um you know, you, you might, if you get act, you might find that uh there's a bit of infection there, you can get abscesses, uh, you can get pseudocysts. So, what's a pseudocyst? It's not a real cyst because, um, normal cysts have an epithelialized wall. But, um, pseudocysts, they, they don't. So it's a food collection containing enzymes, blood dead tissue. Um, they tend to form a few weeks after the initial episode and they're prone to infection. They're prone to hemorrhage. They can sometimes cause local compression symptoms. So, if you imagine the pylori of the stomach's just above the pancreas, then sometimes you can get gastric outlet obstruction if they get big enough. Um Most, some of them resolve spontaneously. So about half of them get better on them by themselves. But uh other times you can get endoscopic drainage of them. So through the stomach or sometimes surgical um portal vein, thrombosis cos if you imagine the splenic vein and the portal vein, it runs behind the pancreas um leading up to the liver. So sometimes that's affected as well. And as we've talked about hemorrhage, so if the blood vessels get digested, then you wanna monitor that hemoglobin and possibly start thinking about some blood transfusions as well. Um And if they do get a hypocalcemic and one of the things you can consider is giving them some calcium gluconate. All right. So next uh scenario 44 year old female, previous appendectomy, two cesarean sections is admitted with abdominal pain. Her bowels haven't opened in a few days and she can't keep down food. So this is supposed to describe a obstruction. So, what is an obstruction? Well, and obstruction is a mechanical blockage of the bowel. So there's usually something, um, actually blocking it. Um, and that's as opposed to a pseudo obstruction or an ileus where it's more of a functional obstruction. The bowel isn't actually blocked but it's just not, you know, it's just not moving, it's not peristal. Um, but what can, what can cause obstruction? So you can, you can get small bowel obstruction and you can get large bowel obstruction. You can get obstructions which are inside the lumen inside the wall of the bowel or, um, outside the wall of the bowel. So there's a couple of tables there showing, uh, some of the common causes. I think in exams, the, the ones you're gonna wanna think about are these ones in the top table. So, thinking about things like adhesions and hernias, particularly for small bowel obstruction. Those are the most common ones. Uh, large bowel obstruction. You wanna go to malignancy, diverticular disease or volvulus as the main ones. Um, and so what have I written? Fluids, fluid loss and third spacing. Why does that happen? Well, if you think about getting a, um, an obstruction, think about that proximal limb of bowel. If you think about that proximal limb of bowel getting dilated, um, it gets dilated and then you get contractions of the bowel and then you get fluid shift into the bowel. So again, it's another example of third spacing. Um And so IV fluids and fluid resuscitation are another kind of key principle of management. So what clear clinical features are you gonna get? So, abdominal pain, distention, vomiting and then constipation, those are the three key clinical features, you're gonna find an absolute constipation. So that, that means they're not passing wind either. So it's an important question to always ask patients um ie passing wind, passing flights. Um, and there's a bunch of causes which we'll come on to. Um, an important thing to mention is this concept of a closed loop obstruction. So, what does that mean? Um, most people have a competent ileocecal valve. So that means, um, you don't get backflow of stomach, um, intestinal contents through the ileocecal valve. So, if you have an obstruction, distal to that in the large bowel, then you have this section of bowel through which things can't escape. Um, and that's called, that's, that's called a closed loop obstruction. Um, and that will just, that's a surgical emergency. Um, it will just get bigger and bigger and eventually become necrotic and perforate. Um, so next slide investigations, you could probably guess these, um, I'm just gonna do the simple bloods again. Remembering that amylase cos pancreatitis is always a, a differential. We want to rule out with acute abdominal pain, get the group and save clotting VBG for your basic electrolytes and lactate. Um, abdominal X ray So that's quite a common, um, thing. You're gonna, you're gonna see and request with, um, bowel obstruction, 369 rule. You might have heard of. So, three centimeters, generally the upper limit for small bowel in terms of diameter, six centimeters for the large bowel and nine for the cecum any more than that. And, and, you know, you, you're worried that it's dilated, um, pathologically. Um, and then, you know, a lot of people also just get CT S as well just because of how um available they are now. Um So in terms of management, your um initially going to be conservative. So there's this thing called drip and suck. So drip, that's like an IV drip and you're gonna resuscitate them as we've talked about uh suck. So that's the NG tube. Um So like a rile tube wide bore um ng tube to basically decompress the stomach and intestines. Um just relieve some of those symptoms and obviously analgesia antiemetics, things like that. Um I just go back one slide, talk about the uh clinical features. So just uh just briefly um classically, one of the things you'll find on examination is a um those tingling bowel sounds. So why do they sound like that? Because if you imagine the bowels all stretched out, it's all dilated as a bit like a drum. So you get that kind of tympanic tingling sound. Um And if you do start to get those features of guarding rebound tenderness. Um, those are kind of worrying signs and make you think about, um, a bowel that's getting quite ischemic, um, you know, ready to perforate. And if they do have generalized rigidity then you, you're sort of worried that it's already happened and they have a peritonitis. So in terms of the surgical management for obstruction, it really sort of depends on the cause and there's lots of causes as we already talked about, it could be um removing adhesions from previous surgery. It could be surgery for a hernia, you know, a strangulated or obstructed hernia. It could be removing uh an obstructing tumor, putting in a stent, uh resecting, you know, some necrotic tissue if it's become quite ischemic and necrotic. Um it, it really, it really kind of depends um in involvulus, you know, you use a flexi sig to detort it uh an interception. You might use, you know, the, the air enemas to try and un telescope that bow. Um So yeah, basically, things to really look out for is if there's any suspicion of ischemia um or perforation and you, you know, those are, those are things you can pick up on clinically. Um And then also with um other tests, like we've talked about imaging as well. So just got a few slides now on some imaging just to have a look at a bit of a break from all the text. So on the left here, we have, well, we've got two abdominal x rays. But on the left, if you can see, this is actually a small bowel obstruction, you can see the, um, there are some white lines going across the entire bowel. Those are the valvulae conniventes. Um, that's something you'll see in the small bowel and not the large bowel. Whereas on the right, y that's a large bowl. You can't see, um, you can't say the valvulae conta, but you might be able to see the house. And then again, on this one, you can see a gastrograph and enema on the left. So you can see uh no enema, um gastrograph and oral contrast study. So you can see the contrast there just highlighting the stomach and the small intestine. And on the right there, you can see the classic uh coffee bean sign. Um And so it looks like a coffee bean and that's um um what is it? Volvulus? Yeah, sigmoid volvulus usually, uh I think I had that my finals exam and then on CT S, if you get a cet, then you might be able to find a transition point. Um So generally, what you'll find is uh the proximal part of the bar will be quite big and dilated and then suddenly it'll get quite narrow and that's the transition point. Uh CT is also quite a good way of trying to investigate what's actually causing it. Um Some, some interesting causes. You can sometimes get a gallstone ileus So that's, um, so if you have a gallstone, which makes its way from the gallbladder, um, through a fistula, from the gallbladder into the small bowel and it usually gets stuck somewhere. So, complications, I think we will probably alluded to all of these. But, um, you know, you, you get obstructed long enough, um, it causes the bowel to just kind of blow up and it gets ischemic, it gets necrotic and eventually perforates, especially with those closed loop obstructions that you want to, um, always be looking out for. And that obviously leads on to peritonitis can also cause things like AK I and uh a bunch of other stuff. Um And then just, just a quick word on pseudo obstruction as well. Um So as we talked about, it's usually not caused by a physical blockage, a mechanical blockage of the bowel. So things you're gonna want to look at include, um, electrolyte imbalances, any metabolic disturbances they have, um, try and treat that. Um And if that doesn't work, then um, you can take them for a colonoscopy to decompress the bowel or sometimes neostigmine is used. Uh I don't really know why, but so the same lady, uh, who we've just talked about suddenly develops worsening abdominal pain. She'll looks septic and has a rigid abdomen. So, and we're talking about perforation. So, perforation can happen anywhere along the gi tract. It's one long continuous tube, isn't it? From the esophagus and the stomach um, small bowel, large bowel. Um, so, uh, I probably won't go through all of these, but, um, one of the most common ones you might see are the peptic ulcers. So, ulcers either in the stomach or the duodenum. Um, you know, you associated with things like h pylori smoking alcohol. Um, you wanna, you wanna consider, you know, things like esophageal rupture behave syndrome if someone's presenting with chest, you know, chest pain and it's, you know, it's not quite, it's not like an M I. Um If you can, if you can rule that out, um There's this thing called the Mackler triad, uh which is chest pain, vomiting and subcu subcutaneous emphysema. So, if you, if you see that, then you can think about esophageal um perforation. Um And then also it can be iatrogenic. So E RCP as well as it, you know, it can cause pancreatitis. It can also cause an iatrogenic perforation of the gi tract. Um Obviously, trauma is always something you want to think about or look out for. Um And as we've already talked about obstruction and ischemia um in the lower gi tract, I'd say probably the most common ones you're gonna wanna think about are diverticulitis, cancer. Um And appendicitis, they're probably probably the most um high yield topics to think about. But um obviously, it can, it can be caused by lots of other stuff as well. Uh So just quickly on peritonitis and peritonism. Um We've already alluded to this. But peritonism is it more, it refers more to a localized inflammation of the peritoneum. And so that, uh you know, on, on examination that might be, um you might see some guarding, uh maybe a little bit or, or not the generalized rigidity, but you'll see some guarding and tenderness, maybe some rebound tenderness. Um Whereas peritonitis refers to that in generalized inflammation of the peritoneum, uh it can be caused by lots of things. So, perforation, obviously, bacterial infection translocation, um spontaneous bacterial peritonitis in people with alcoholic liver disease can be caused by blood. So, if someone's bleeding into the peritoneum, uh it can irritate the peritoneum and cause peritonitis if you get biliary leaks, bile leaks, um that can also irritate it as well as pancreatitis. Um and the signs and symptoms, you can probably guess abdominal pain are up there. Um But it will also really depend on the underlying cause. Um And then the management really depends on uh what's causing it. But um tho those general principles of um fluid resuscitation, analgesia, just the kind of simple things. Um you know, they, they work every time. So and as an f one, that's probably what you're gonna be involved in most of those uh simple things um with the conservative management. So when we still on perforation, so investigations again, never forget the, the basic bedside investigations. Um, blood's pretty much the same as for all of them and to rule out pancreatitis, uh inflammation. So FP CCR P uh organ dysfunction. So you're looking at the U RT S. Um and then imaging CT is probably the one you're gonna go for. It's quick and it's comprehensive. You might also do an erect chest X ray. If you're worried as well, it's quite quick to do. Um It's not totally sensitive though, I think right chest X ray, it's got like a 70% sensitivity. Um So you, you know, you won't always see that quite obvious uh under the diaphragm, but it's a good one to get anyway. Um, management. So again, the early resuscitation, probably the most important, most important part to know about is an F one doing all those basic things. I know it kind of seems quite repetitive but um maybe that's a good thing. So, um you know, you know, you know, you know what you're gonna be doing, um or trying to consider doing when you see these patients. Um and then definitive treatment. So if you're worried about a perforation, a lot of them probably will go to theater, um especially if they've got kind of gross contamination. Um And they really need that wash out. Um Again, it, you know, if it's caused by a necrotic bowel, you might get some resection. Um If it's caused by a perforated ulcer, you, you might get surgical repair of the ulcer. Um Sometimes they, they patch it up um with omentum So, in gastric ulcers, I think sometimes, um, they stick on a bit of a men over the defect. Um, and then in large bowel perforations, you know, you're sort of thinking about resections and poss, possibly stomas as well. So, if it's like a perforated diverticulitis, um, some of them will get what's called a Hartmann procedure. So, um, where they basically take out the sigmoid colon and give them, um, an end colostomy. Um but not all perforations are treated with surgery if it's just like a limited localized perforation, for example, um you know, in a, in a diverticular perforation, sometimes you can treat those conservatively um just with antibiotics, conservative management, you know, fluids, analgesia, et cetera. Um And especially, you know, if they're not a good surgical candidate either. So again, some more imaging just to take a break from all of the text. So here are, here are some of the common signs you might see on plain radiographs. So on the left, we can see that clear air under the right diaphragm. Um And also the left diaphragm. So, um that's some something you always wanna consider getting in a right chest X ray and then on the right side, we can see Wriggler's sign. So that's when you can clearly see both sides of the bowel. Um That's because you've got air on, on both sides, both within the lumen and outside of the lumen, you tend to only really see this with large pneumoperitoneum. So more than a liter generally, um, and it can, it can be a bit of a tough one to sort of see, especially if you're not. Um, used to it cos you, you sort of see the same thing when just two walls, two bowel walls are pressed together. It kind of looks like a similar thing. So not the easiest thing to spot, but, uh, you know, a good one for exams. Um, reckless. So, ok, so moving on to the next one, 68 year old man with a history of af uh presents with sudden onset and severe pain, bloody, diarrhea, nausea, and vomiting. Um So I guess the, the key clue here is the history of af um So we're thinking about intestinal ischemia here. So mesenteric ischemia, um I guess this is slightly different from the ischemia. We were talking about earlier, the localized ischemia you get from um like bowel obstruction, this is more uh a disease of the blood vessels. Um You know, supplying the smaller large bar. Uh So the small bowel is supplied by the SMA A, the superior mesenteric artery. Uh large barrel supplied by both the S MA and the I MA. So ascending codon, first, two thirds of the transverse codon are supplied by the S MA and then the descending colon splenic flexure from the I MA. Um And we're gonna talk about a few different ways that mesenteric ischemia mite, um or a few different causes. So, um acute mesenteric embolus is probably the most common one and one that you're gonna wanna know about. So as in as in the case of uh the vignette, um usually in people with af um but then there's also um thrombosis. So, like in atherosclerosis in the coronary arteries, uh you have enough atherosclerosis eventually, you might also get a thrombosis causing an acute event and that tends to be an acute event on a background of worsening symptoms over time. Um It's not always caused by an obstruction. It can also a bit like a type two M I, it can be caused by things like anemia, hypovolemia. Um y you know, hemodynamic instability, sepsis and things like that. Um And then vein thrombosis uh that's slightly more subacute um presentation generally, it's usually in people on the C OCP or people with hemophilia, um not hemophilia, um coagulopathies, thrombophilia, I'm sorry. Um So yeah, we'll come onto these in a bit more detail in the next slide. So, um here are just those four different causes uh of acute mesenteric ischemia. I've just talked about. So, in, in the embolus, the, the, the acute arterial embolus is probably the most common one that you're gonna find on an exam. Um The key things to look out for are, you know, have they got any, any reason to have an embolus? So have they, have they got af have they had a recent M I, um, because sometimes you can get, um, that, that wall thrombus in the heart if you've just had an M I that can throw off emboli um in vein thrombosis, you know, I wanna look out for C ACP um longer presentation. So the history is over weeks generally. Um, so I with thrombophilia and the pill, um the, the thrombus as we've talked about is generally um an acute event on a more chronic history. So you might get people with mesenteric angina. So uh people when, after they eat, they get typically get um abdominal pain. Um And that's, yeah, yeah, it's, it's similar to angina of your heart really. Um And then as we've talked about the, the non occlusive mesenteric ischemia as well. So looking, looking out for those sort of type two, similar, similar to type two M I. So things like, um you know, uh hypokalemia shock arrhythmias, anything that's going to decrease the perfusion without an actual mechanical blockage. Um Investigation is pretty much the same as what we talked about earlier. Um Except the key thing is probably gonna be a CT angiogram. So that's when you put the inject the dye. So you get the dye going through the arteries. So you can see whether there's an obstruction or not. And then management again, resuscitation is all the same as we've talked about earlier. Um probably want to get early itu input because um these patients are generally quite sick, uh, probably gonna want, wanna start some antibiotics as well. And then the surgical treatment is, is a bit of a crossover with vascular surgery, I guess. Um, if there's an embolus there, they can do an embolectomy. So there's a thrombus, they can do a thrombectomy. Um, sometimes, you know, you can get interventional radiology as well, um, with all the intra arterial sort of gadgets. Um, and I think probably also the key thing is if, if there is any areas of an ische ischemia or necrosis, um it's gonna need to come out, get chopped out venous with, with the venous ischemia. It's a bit different. Um um in terms of treating them with anticoagulants uh as well. Um But again, if, if there's areas of ischemia uh a necrosis, they're probably gonna want to get cut out. Um ok. So that's Mesenteric angina uh as in TCA me, sorry. Um Next scenario, an elderly woman. So she's 84 she's got painless bright, bright reading per rectum. Uh She's hemodynamically stable and has a history of constipation. So older patient history of constipation bleeding makes you think of. Well, I was gonna say diverticular bleed, but we're, we're moving on to gastrointestinal hemorrhage. So, um again, it's, it's a similar slide to earlier. It can happen pretty much anywhere in the gi tract generally split into upper gi and then lower gi bleeding. Um upper gi the the ones you, you're gonna wanna sort of think about mainly are the, um, peptic ulcers. Uh, so the, the gastric ulcers and the duodenal ulcers, looking at those risk factors like h pylori smoking alcohol. Um, we've talked a bit about esophageal, um, perforation, but that's obviously a bit rarer. Um, and then again, a couple of other things which, you know, you might see mallory weiss tears associated with vomiting, you know, cancers, malignancies, foreign bodies, uh, aortoenteric fistulas or something that are quite interesting. So when the aorta forms a connection uh with the gut, um and you can lose, as you can imagine quite a lot of blood through there. Um and then uh angiodysplasias, uh lower gi probably the most common one is that diverticular bleed. So, elderly patient constipated has a painless lower gi bleed. I think diverticular bleed. Um common things are common. So, hemorrhoids fissures. Um the key difference being fissure are painful. Hemorrhoids generally aren't. Um colorectal cancer is obviously one you're gonna wanna have in the back of your mind. Um Meckel diverticulum that can also bleed, sometimes they have gastric ectopic gastric mucosa which can cause irritation and bleeding. Uh Crohn's and ulcerative colitis um are another thing you need to think about as well. Um ok. So clinical features appreciate it's a bit of a list there. But um you know, it, it, it, it kind of makes sense, doesn't it? So, hematemesis, if it's upper gi um Melina as well, if it's upper gi the blood in your gut tends to get digested a bit if it starts up earlier. So that's why it ends up um black like Melina, if it's bright red, that kind of implies it's starting a bit lower down. Um Or else it's just a lot of blood coming through from slightly higher up. Uh depending on the cause you can get abdominal pain. You might get hemodynamic instability if they're bleeding a lot. So, tachycardia and hypotension, uh they might be cool clammy peripherally shutting down again, if they're losing a lot of blood. Uh and then also those neurological symptoms, confusion, dizziness, syncope. Um And again, you, you're gonna wanna look at um signs of liver disease if you're thinking about viruses. Um So as as with all these things, a good approach is an A two E particularly for um you know, if someone is acutely bleeding, then you're gonna wanna dive straight into that uh examination and management pathway. Um Remember to do ad re before l lower gi bleed and upper gi bleed. I'd say I know I've put a lower gi bleed there. But um for Melina, if it's upper gi and um obviously, if it's bright red blood for lower gi uh stool cultures, something you always wanna do to rule out an effective cause um calprotectin as well helps you differentiate from uh IBD. Uh all the usual bloods things we've already talked about right? Chest X ray. If you think there's a perforation. Um And then the um if you're thinking about an upper gi bleed, uh Glasgow Blatchford and Rockall scores are really good ones to learn for the exams. Um And also in real life cos um Glasgow Blatchford before you have the O GD Rock afterwards, um gives you a good indicator of how urgent someone needs to get scoped uh and then their prognosis afterwards. Um So O GD is, is a key investigation in upper gi bleed. Um and colonoscopy in, in lower, in lower gi bleeds. A lot of them are actually investigated as outpatients. So you might see people come in with a, a lower gi bleed, but it itself resolves and a lot of time and they can, they can go home and uh come back for a colonoscopy in clinic later on. But um I think upper gi bleed is more, you know, you'll get the O GD either depending on, you know, how, how serious it is. Um same day, next day in hospital. Um And then sometimes you can do a CT angiogram if, if you can't really find an obvious source of bleeding, right? So management again, going with that a to a approach. Um So, so supplementary oxygen is often often used. Um you wanna put two wide ball cannulas in give some stat fluids, particularly if they're hemodynamically unstable. Uh You're gonna wanna act to the, the major hemorrhage protocol which you should have in in the hospital dialing, uh, quadruple two, um, get a group and save cross match, um, start the blood transfusion pathway. Um, in upper gi bleeds, you can also use high dose PPI S in some cases. And if you're thinking it's seal bleed, go ahead with some terlipressin and um PTAs antibiotics. Um, that this, I actually had pretty much this case on my first weekend as an F one. Um, just a guy on the gastro wall, vomited up about a liter of blood. And um, yeah, that was fun, but it, it was, it was basically all of all of this stuff. Um that was done. So, um if it does happen to you just escalate it basically immediately call your sho activate the major hemorrhage protocol. Um And all, all of this stuff will basically end up being done. Um, definitive. It depends on the cause. So if it's, if it's viruses then uh band ligation, um sometimes the depth procedure, if it's hemorrhaging, massively, they might put a tube in called the same stack and Blakemore tube. But I think that's uh not very common really anymore. Uh If it's non variceal or if it's something like uh an ulcer, they'll go in with the scope, they might inject some adrenaline to constrict the blood vessels. Um They might use clips or thermal coagulation sometimes in interventional radiology or embolize an artery. Um And as we've already talked about and lower gi bleeds a lot of the time it's, it's outpatient investigation and management unless it's, you know, a pretty serious hemorrhage. Um, so, yeah, they'll have a colonoscopy. They might have an ir embolization, but, you know, the management will depend on what's causing the bleeding. Ok. And then I know it's seven o'clock now. But, um, I, we've just got 11 more kind of thing to go through and that's hernias. Um, sorry to ruin this scenario. But um, so, uh I if you do need to get off, feel free to go, but um I will, I'll just put in the um feedback link just if anyone does need to go and I'll crack on with the hernia section. Um Just a second. So, uh that's just the feedback length there. But uh I'm just gonna crack on with the hernias. So 76 year old woman comes into s au with a painful groin lump, she's been vomiting, not able to eat. Uh There's an irreducible mass below and lateral to the pubic tubercle. Ok. So hernias, um probably the most important ones to know about are inguinal hernias and femoral hernias. So, inguinal ones are the most common hernias. Um A hernia is basically just defined as the protrusion of part or hole of an organ through a tissue um through, through the wall of the cavity that normally contains it. So in most cases, it's a bit of a small bowel intestine, sometimes fat, that kind of just protrudes through uh the abdominal wall in a lot of cases. So, inguinal are the most common uh tend to be seen in men. Um They can be seen in as Children. They can be seen when you get older. Um And they're classified as either indirect or direct inguinal hernias. So, indirect is the most common, 80% of them. And that's when the hernia sac goes through the deep, um the deep ring of the inguinal canal. So it actually goes through the deep ring and goes through alongside um through the canal. Whereas direct uh it just protrudes straight through the abdominal wall. Um And I really like this diagram here on the slide because it, it kind of shows you exactly where each of them. Um you know how, how you can really visualize it. So a key, a key landmark to the in inferior epigastric arteries. So direct hernias tend to go medial to the inferior epigastric arteries. And um indirect ones are lateral cos the deep ring is lateral to the epigastric arteries and the ends. Um generally they, I mean, they sometimes get strangulated and obstructed, but in a lot of cases, they're fine if you see one in a neonate. Um or in a very young child, usually you wanna get those sorted quite quickly. But in a lot of other cases, if they're asymptomatic, um you can just manage them conservatively with surveillance um or, or an elective surgery if they're causing symptoms. Femoral ones are slightly different though. They're, um, they're seen a lot more in women because they have a wider pelvis. Um, and they're a lot more likely to strangulate. So, um, you'll, you'll get, you'll get a bowel herniating through the femoral canal which again, you can see on, on the picture. Um, and it's a, it's a very narrow space and it's between a lot of, um, ligaments which don't stretch very much. So, it's a lot more likely to strangulate the bowel and obstruct it. Um And on examination, a key way to differentiate between inguinal and femoral hernias is its relation to the pubic tubercle. So the pubic tubercle, um I don't know if you can see it on the picture, but um it's, it's just the front um section of the pubic bone just lateral to the symphysis, femoral hernias tend to be below and later to the pubic tubercle. Inguinal hernias tend to be above and medial to it. Um And that's, that's quite a common exam question as well. So, clinical features as in the vignette, uh a groin lump, there's a lot of things that can cause groin lumps. Um you can get lymphadenopathy. So, lymph nodes, aneurysms, abscesses, lipomas. But um you always wanna consider um hernias in that differential list. They can be painless, they can be asymptomatic. Um and it can range from that to some mild discomfort, especially on standing or coughing, anything that increases the abdominal um pressure and then if, if, if they present with quite a lot of pain, um Is it, then, then you're gonna want to think, you know, is, is this an incarcerated strangulated? Ow uh how are you? Um So some of the things you can, you can ask for, you can look for on examination. Do they have a cough impulse? Uh So that, that, you know, if they cough, they increase the, the pressure in, in the abdomen and you can feel, feel that transmitted through the hernia. Again, we've talked about the location. Um So in relation to the pubic tubercle and then you, you always wanna see if you can actually reduce it. So if you want to, you know, you gently try to push it back in to the cavity. Um And then, so there's some kind of key terms which I just want to um dig into a bit. So, incarceration. So an incarcerated hernia means that you can't reduce it, which is why it's so important to try and reduce it because um that might impact your management plan. Um Obstruction means that, you know, the bowel is compressed in the hernia and that the bowel contents can't get passed. So, you know, you might get those classic colicky um abdominal pain, uh constipation, you know, nausea, vomiting, all those obstruction symptoms we talked about earlier and then strangulation refers to when the blood supply is cut off. Um So that will that will be very painful, uh, and requires urgent surgery. Oh, because it's at risk of ischemia, um, investigations. Well, i it's typically a clinical diagnosis. You can often see it pretty clearly. Um, but if you're on, you know, in cases of uncertainty you can sometimes do an ultrasound. Um, if there are those features of obstruction or strangulation, you're probably gonna wanna get a CT as well. Um, you know, planning for surgery. Uh and then all those labs, bedside tests and acute presentations as we've talked about. So management, you, you're gonna wanna do urgent surgery. If there's any suspicion of strangulation or obstruction, um in a femoral hernia, even if it's not, you're gonna want to get it repaired pretty promptly because it's at high risk of those complications. Um, as we mentioned earlier, inguinal hernias, it kind of depends. Um in pediatrics again, as I said earlier, if, if they're born, you know, if you, if you see one in a neonate or uh a very young child, you're probably gonna want to get it. Um, looked at getting surgically repaired because they're higher risk. Um But in everyone else, if it's not causing very many symptoms, then you can, you know, you can look at surveillance options or elective surgery. So just to finish off, there's a bit of a flow chart though, which I made any suspicion of strangulation or obstruction, urgent surgery. If it's femoral, you're gonna wanna get it repaired within two weeks if it's inguinal, it depends if it's symptomatic or not. Um, you can get an elective repair or you can just watch and wait. Um, ok. And then just a few of the resources I think quite useful. Uh, teach me surgery is a really good one. especially for the level of finals. Pulse notes is also really good. Um, and then, uh, pass test and, um, post med, I always say really good. Uh So that's the, um that's the session done. Um Feedback links there just in the chat. Um I'd be really grateful if you could fill that out. Um And be honest, you know, was the session too long? Was there too much text? Um Was I just, is there anything that I can improve on myself waffling too much or taking too much time? Um Yeah, any feedback would be really appreciated. Um, and then, uh I think if you, once you do the feedback, you'll get the certificate of um attendance and I think you can also get the slides, um, if you, if you'd like some. So, yeah, thanks for coming and um, I'll just hang around for a few minutes in case anyone's got any questions, but, uh, feel free to go after you've got the feedback.