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Hello, everyone. Um, I'm sa, I am one of the, um, Os CS for my and today I'm gonna be, um, going through some gastro cases and how you should approach these when it comes to your OS exams. Um, so, um, the start of this session today is gonna be slightly different compared to how we've done, um, other oscopy Sunday sessions if anyone's attended them before. Um, so what we're gonna do is, um, we're gonna have three cases as we always do. Um, at this time we'll just work through them all together. Um, so, um, just putting, um, in what questions do you want to know and things in the chat, um, and working through some polls as well, um, to get to the, um, end sort of diagnosis and management panel. And, um, as always as we go through, um, we'll make sure to highlight any key learning points, um, that we want for each presentation, um, everything that you need to know about what you should be asking in these histories. Um, what sort of things you should be considering for your differential diagnosis, um, and how you manage these conditions. Um, and also as always, if anyone has any questions as we go through, feel free to just pop them in the chat or you can always unmute and ask them as well. Ok. So, um, here is sort of a rough list of all of the different gastro presentations that you should try and prepare for in your ays. Um, so, um, uh, it's quite a long list and there's quite a lot of different things that could come up within the gastro station. Um But a lot of them are sort of fairly similar history taking that you need to do. Um So things like diarrhea, constipation, um bleeding melena, um they're all gonna be a very similar history style. Um, nausea and vomiting often also comes along with those things. Um, hematemesis is maybe a bit different and there's a few different things that you want to be focusing on. Um Jaundice um is also a bit different and can be quite complicated ones. We're gonna go through Jaundice station today. Um And then finally, Abdo pain, which again is a massive um sort of differential. Um So just working out different techniques that you need to um sort of narrow that down as quickly as you can, um is a helpful tip that we'll go through as well later on. Um So, um moving on to the first case. Um So Emily, a 30 year old woman has come to see you because she's concerned that her skin has become slightly yellow in color. Um, so the first thing that we're gonna do is go through, um, what you guys want to be asking Emily in your history. Um, and then once we've gone through the history, um, we'll also be discussing, um, how you might investigate her, um, and how you might manage her as well. Um, so, um, starting off, does anyone have any ideas of what sort of conditions they might be thinking about? Um when um you get told um that the case is gonna be a patient with yellowing of their skin. So jaundice. So um for this, I want you to just sort of think about um picture you are standing outside the door ready to go, to go into your and what are you gonna be thinking about in that minute or two minutes um that you have before you go in? What conditions do you want to be um narrowing down on um with Emily? Um If you just pop in the chat, what what you might be thinking? Ok. Yeah. Great Georgia. Any conditions that cause liver cirrhosis? That's a great one. Yeah. Um So prehepatic hepatic and post hepatic causes really nice that you've got a bit of a structure there. So what you're gonna be looking for um and then pancreatic cancer and cholangitis, both great suggestions as well. Um So, um to the next slide. So this is how I would think about it. So, as um a partner, sorry, I'm probably pronounce your name wrong. But as a partner has said, um you wanna have a little bit of a structure, particularly with jaundice because it's such a wide um wide presentation and lots of different things that could cause it. Um So the best one for this would be um to split it into your prehepatic causes. Um So that would be an unconjugated um jaundice. Um And within that, you've again, got the differential of, is it intra versus extravascular hemolysis? Um So, with intravascular hemolysis, you're gonna be considering um anything that causes sort of a breakdown of blood cells within the bloodstream. So that would be something like D IC. Um Also an artificial heart valve could do it just because um the metal of the valve can sort of tear the blood cells that they're traveling through the heart. Um Malaria will also cause it. Um And then also um something like um if you were to give a blood group mismatch. Um So, following a blood transfusion um and then extravascular hemolysis, um you've got your things um like anything where the blood is being taken out by the spleen. Um So that would be um heresy spherocytosis or um G six PD, um deficiency, things like that. Um Then moving on to hepatic causes. So, hepatic can again, be broken down into your own conjugated causes and your conjugated causes. Um So, in your unconjugated causes, you've got things that um cause an issue with the enzyme that conjugates your bilirubin. Uh So the main one to be aware of there is Gilbert's. Um And then there's also um a more rarer um type which is Crigler Nha syndrome, but very rare, very unlikely to come up. Um And then in your conjugated form. So this is things where the hepatocytes within the liver have been damaged. Um And this damage has actually um the first thing to get damaged really is the transporter that removes bilirubin out of the hepatocytes and allows them to be excreted. Um So you've got the conjugation happening, but that bilirubin then gets stuck in cells and isn't able to be excused out. Um So things that cause that is just all of your classical causes of anything that directly causes liver damage. So, anything that causes hepatitis. Um uh So, like your viral hepatitis is um and anything like that, um We'll go through those um a little bit more detail on the next slide, I think. Um And then finally, you've got your post hepatic causes. Um So that's sort of your obstructive form. So, anything after the liver that's stopping that bilirubin from being excreted into the bile tract and out into the gastrointestinal tract. Um So that might be a physical blockage um or it could be because the tracts themselves have um become smaller and stenosed. Um So, in this case, specifically with Emily, so, you know, you've got, um, a 30 year old female. So you can already start to sort of, um, narrow these causes down a little bit in your head before you go into the room of what you think might be causing it. So, when your prehepatic causes, um, so, um, the more likely ones in this case would be something like hellp syndrome. So that's, um, a syndrome of pregnancy. Um, so, um, one of the first things that you want to be working out in the station is could she be pregnant if she's not pregnant, then you can forget about it completely. Um Then um autoimmune hemolysis as we discussed. So, anything that's causing a breakdown of those blood cells um within the blood stream, um less common would be things like D IC. It's quite unlikely she's gonna be coming into the GP in a situation where she's got any of the risk factors for D IC because you're normally very acutely unwell with it. Um Artificial heart valve, quite unlikely in a 30 year old woman. Not impossible though. Um Malaria, again, you're in a GP setting in England. Um So you won't be ruling out that travel history, but again, less likely, um blood group mismatch is gonna happen in a hospital setting most likely. So you're not gonna see it in GP. Um and congenital blood disorders, she's just a bit too older. Um So it's, it's possible but very unlikely to present this later. On. Um, and then the same with Gilbert very unlikely to present this later on. So you can kind of exclude that in your head a little bit before you go into the room. Um, and then your hepatic causes, um, these are probably the most likely ones. So, um, your viral or autoimmune causes of hepatitis. Um, so far while we're talking about, you know, he ABC, all of those ones, um, again, you wanna be thinking about um any recent travel history and things, um which might make that more likely. Um And um ascending cholangitis, um or um we've got down in the obstructive ha as well, um uh gallstones as well. So any condition where um there's an obstruction in the ascending cholangitis type of gonna have inflammation sending off into the liver itself and causing a bit of liver damage. Whereas gallstones, you don't have that, but you do have the physical obstruction, preventing the bilirubin from being excreted. Um And um then PSC PBC, um those kind of causes be a bit more common in someone of this type and then your cancers, um your pancreatic cancer or a cancer of the bi system itself, um would be very unlikely in a young woman. So you couldn't think that that's probably less likely. But again, you still don't wanna um rule this out completely before you go into the room. So, um after you've had that little consideration, you've moved in