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Hello. Everyone hope everyone can hear me. I'm just gonna give it a couple more minutes just to see, uh if anyone else is joining, I'll just give it to 35 past and see if anyone else joins and then we'll start from there. It's Yeah. Yeah, right. Yeah. Yeah. Okay. Okay. Okay. It seems pretty steady at the moment, so we'll start from now. Um, So my name is Thomas, and I'm one of the doctors in a wig in hospital at the moment one of the FY to, um and I just finished my rotation in pediatrics. So there's teaching questions about pediatric abdominal conditions. So I'm just gonna go through an overview of some common conditions that I've seen. And, um, you just want to It's not going to be an in depth look into every single conditions, but just an overview of most commonly, things that you've seen a lot of it is surgical just for the abdominal conditions, Neonatal, Uh, pediatrics is something that will cover in sort of future teaching sessions. Right. So the topic that we're going to discuss, um, is Hirschprung's disease, intussusception, pyloric, stenosis, appendicitis and constipation. So we'll start off with hash browns disease. So Hirschprung's disease, also known as congenital aganglionic Mega Colon, is a condition where you have the absence, um, of ganglionic cells for the part of the colon, which makes it either partially or complete of, um, dysfunction within the within the colon itself. This occurs in about 1 to 5000 live births, and it's more predominant in males. So the path of physiology, like I said, is there's a defect in so the gangland formation. So a defect in the migration of neuroblast during embryology, embryology, ical, um, development, uh, usually the distal colon, which renders the segment of the colon aganglionic and therefore leads to abnormal motor function and abnormal Paracelsus as well. So there are various types of Hirschprung's disease. There's a short segment, which is the most common. This is where the nerve cells are missing from the rectum and occasionally the sigmoid colon. There's a long segment, which is the nerve cells are missing from the rectum and large portion of the large intestine and total clonic, which is essentially affecting the whole large, Um, column, and this occurs in about 10% of all cases small intestines. Similarly so just moving along the colon. And so the small intestinal nerve cells are missing from the rectum, the colon and then at the end of the small intestine. And total intestinal is where there is absence of nerve cells in the rectum. Color nearly all of the small intestines. But this is extremely rare. The most common cause, sort of the types is the short segment, so risk factors. Um, like I said, it's more predominant males. There are some chromosome or abnormalities that are associated with this condition, especially down syndrome and family history as well clinical features. So these are the kind of questions that you want to ask, um, clocking in this kind of patient in any, um so things like abdominal distension, bilious vomiting, uh, abdominal pain, those kind of things that are very common fairly to pass meconium within the 48 hours of birth. Sir Meconium is is the first stool that child produces. Usually they passed within 48 hours of birth, but if there has been delay in that, that's a bit of a red flag. But read some of the research that have been into sort of Hirschprung's disease is it indicates that this is only present in about 26% of cases, so not a large proportion. But the classical triad of Hirschprung's disease is failed to pass meconium within the 1st 48 hours bilious vomiting and abdominal distension. But this is again only present 25% of the cases. A lot of the time there is vomiting and abdominal pain. Um, there may be distention as well, but this might be difficult to note, but there's also sometimes explosive stools. So you have a history of a parent telling you, um, they weren't able to pass meconium. They've got some abdominal pain, and every time they open their bowels, they are opening the bowels. But every time they open the bowels is quite explosive. So the initial investigation you want to do is, um, an abdominal X ray. Um, this might show distended bowel loops to show an obstruction, but the gold standard for investigating Hirschprung's disease is erectile section biopsy. So essentially, you take a biopsy of the rectum and then you stay, stay in it, and you essentially seeing if there are any getting chronic cells present in that section of the rectum. There is, um, some guidelines, uh, that have been produced by nice guidelines and of when to do the rectal section biopsy and then to avoid it. And they should be avoided unless the symptoms that I've mentioned are present as well. So if they've had the red flags such as delayed pathogen, meconium, constipation, family history of Hirschprung's disease or any sort of faltering growth growth, growth, failure to thrive, symptoms management is usually surgical. But initially you want to do an 18, um, sort of examination. Start them on IV antibiotics potentially if they look potentially quite unwell with it, Um n g tube and body compression. So if they have evidence of obstruction at that point, so you want you want to acutely manage them In that scenario, the mainstay, however, for this condition is surgery. And, um, this is the reception of the aganglionic section essentially, and this is known as a pull through surgical procedure. So I'm not going to go into this The in depth of how you do these surgical procedures throughout the teaching session, just an overview. So essentially you remove the disease part of the bowel, connect the bowel to the a N s, and they have a normal functioning call on from there on. If they are particularly unwell, they might put, uh, they might prefer to do an ostomy surgery. So, essentially, where there is the former stoma to bring out the bowel to the surface, Uh, do you have a stoma for a while and then reverse the stoma and we join it at the end? In the meantime, there are some management techniques that parents can do at home, so saline but bowel wash out. Essentially, this is a procedure where parents that have taught how to essentially do a bowel rush out. You're just using saline simple saline to ensure that they don't have Stasis of stool within the rectum whilst they're waiting for surgery. So Stasis of stools can lead to further complications of Hirschprung's disease, which I'll get onto in a second, Um, and that can be life threatening. So the complication, the most common and the sort of life threatening complication is Hirschprung's Associated Antara colitis. So this is where you get the status of the stalls and overgrowth of the bacterias within, within the normal floor of the gut, especially cdiff and staph aureus, Um, and that can lead to diarrhea with explosive diarrhea, foul smelling bloody stool and a fever. Um, sort of peripheral signs of peripheral shock. Um, and the Children can be quite and well with it. So that's why the surgeons and may present may prefer you to do sort of saline bar washouts while they're waiting for surgery if it's not going to happen immediately. Other complications. I mega colon and bowel perforation as well. If there's been, um, if there's been delayed presentation. There's been a status of stool for a while, um, and follow up for hash browns disease. So there's a guidelines called the ER Nika guidelines, um, that advise so follow up into adolescence or into adulthood at least, um, and possibly just point to sort of point past adulthood, um, in transition of care, just to see how essentially they're getting on and how the bowel function is doing as a getting older. So the next topic I want to talk about is intussusception, and this is a condition in which the about invaginated or telescopes within itself, um, that leads to narrowing of the Lumen and therefore can lead to obstruction as well. Most commonly occurs in Children six months to two years and, most common more common in boys than it is in females. Path of physiology is essentially. What I said is where the bowel telescopes into itself. Um, this most commonly happens around the Ileo colic region. So that's where the distal ileum passes into the cecum through the ileocecal valve. But it can happen in other areas of the bowel as well. But this is where it's most common risk factors. So what actually causes the risk factors in etiology? Essentially, most of the causes are idiopathic. Um, but there is some research that shows the virus is so potentially roto virus. So that's a very common virus that causes gastroenteritis and Children. It's been linked to development of interception. Meckel's are particular polyps to Muslim. Oh, sorry. Can you hear me now? Yeah. Okay. Um, yes. So brilliant. Thank you. So, um, clinical features, like I said so sort of non. So I don't know whether my quite often but sudden onset, severe, colicky pain, and they look quite unwell, like I said, and they can be drawing up their knees to their chest. The buzzwords for examinations usually is red current jelly jelly stools, and that's pointing towards interception red. Current jelly stools essentially means that you have, um, stools mixing with blood and mucus. Um, another buzzword for exams are is a sausage shaped mass in the right upper quadrant. Um, that can be palpated as well and vomiting. See all the clinical features that you'll be seen for. Interception. So examination wise you'll see you can see abdominal distension that's not always present. But you can do, uh and, uh, possible associate mass and abdominal sort of right upper quadrant region that I've said, and they can also have signs of puritanism and, um, gardening, depending on how severe the condition is. So if that's led to the sort of the interception has led to bowel perforation and obstruction, then you might be seeing signs of puritanism and guarding as well. So when you're examining them, if they if you pop that your hand on the abdomen, they'll be in a lot of pain. Extreme pain, uh, trying to keep still not to move much the signs of purchasing that you'd be looking for Yeah, in terms of investigation, radiological investigations, the ideal investigation is an abdominal ultrasound in which you'll find a target sign. So that's another buzzword for exams. Target sign on the right hand side, you can see, um, the sort of the sign that you might see an A abdominal ultrasound. Um, if how available an abdominal ultrasound is depends on where you work. Essentially. Um, but that's the most ideal goal. Standard investigation for it. You can also use a contrast enema. So this is a therapeutic and diagnostic. Um, can we both both investigation? Um, so essentially, this is where you give the enema, take an abdominal x ray and see how far the the contrast has passed, or we can the other way around to see if you're putting it through the NMO way, and you can see how far the contrast essentially gone up to see the point where the imagination has happened. Um, that can also relieve the interception as well. So management, like I said so initially, 80 e see the signs of shock and dehydration. You might want to give them fluid resuscitation if they've got signs of obstruction. Put an n g tube down. Um, but the mainstay management is a therapeutic enema. So this can be either air or contrast. Like I mention, this usually sort of pulls out the the bowel so that the imagination is the telescoping, essentially pulled out. So you have the other co on as normal. Um, if it's become, if there's been any sort of contra indication to animus, so if we go back, there are some contraindications as well. So if there's any evidence of parroting is, um, or perforation, there's severe guarding, and you suspect that there's been an obstruction or possibly a perforation. Um, that's the contraindications for a contrast enema. Um, so if there's any Contra indication to either air or or contrast animals you want might consider a surgical reduction of the bow complications so obstruction and perforation bone necrosis, depending on how long the president's how delay the presentation has been and dehydration and shock. So those are things initially acutely. You want to, um, so and then also get in touch with surgeons can see how it can be reduced from there, um, moving on to pyloric stenosis. If anyone has any questions, just please put them in the chat. I'm happy to answer as we go along. So pyloric stenosis is essentially the thickening of the pyloric sphincter. So you have the esophagus that goes down to the stomach, and then the pylori is that, uh, through the, uh, sphincter, um, passage of food into the duodenum and the small intestine. So, in pyloric stenosis, what you have is the hyper trophy of the sphincter itself, which leads to stenosis and therefore can lead to abnormal passage of food. Um, a substances through the through the gut occurs in about 1 to 502,000 live births, and it's more common in men as well. What causes the hyper trophy of the pyloric muscle itself is still unknown. There are various. There's lots of research going on around it at the moment. And there's lots of, um, sort of theories as to what causes is causes. Um, the hyper trophy. There's the theory that maybe erythromycin neutro so then pregnancy can lead to hyper trophy. But all of this has not been confirmed, So there's an actual etiology still remains unknown. Risk factors, a male gender and family history is the most common ones. Um, again, because we don't know what exactly causes this This is just the risk. Factors that has been seen has been studied and has been seen in conditions of in associations or pyloric stenosis. So mostly happens to men and can run in families clinical features so usually presents around 4 to 6 weeks of age. Uh, and you can get non bilious vomiting after every feed, but this is usually projectile vomiting. So, um, you get a lot of Children coming in with vomiting is very, very, very common. Um, the what? What sort of differentiates what between just normal sort of spit up or gusta a saw for your reflux disease in Children versus pyloric stenosis is that the vomiting will be project on, and it'll be after every single feed. There will be some risk factors associated, Um, but they can also be failure to thrive, so typically a child will still want to feed, and they'll actively be hungry. They'll actively sort of asked for food or indicate that they are hungry and they want food. Um, but they will vomit after every feed as well. Um, and they'll look quite thin and pale and they'll be losing weight or those kind of things put together kind of a point was pyloric stenosis as opposed to other differentials with examination as well. So you might if they're they're quite thin, uh, quite wasted away. You might be able to see visible Paracelsus, and you might be able to palpate in olive size sort of a mass, um, that you be able to palpate with during a feed. So usually what happens is you can try, um, n g feeding or enteral feeding the child, um, and palpating the abdomen while the feed is going on. And that's when that's the best time to actually palpate the pyloric mass. Um, bloods is a very good sort of investigation for pyloric stenosis. So usually a blood gas will show hypokalemic hipaa, klor emmick, metabolic Arkle OSIs. So, because of the repeat projectile vomiting, you get the loss of hydrochloric acid. So you become hypoglycemic. Um, the kidneys will retain protons to buffer this, um and that will lead to hypokalemia as well. So the loss of chloric acid, um, hydrochloric acid would lead to hypokalemic metabolic alkalosis and as a result of the buffering system from the kidneys, will lead to hypochelemia as well. Um, in terms of radiological examination. You can do an abdominal ultrasound, which can visualize a thickened calories as well. So management again straight away. So you want to do an 80 examination? Uh, manage them acutely. Give them fluids. They might look very dehydrated to some things that you want to look out for. If they're dehydrated, if they've got some confronting ALS if they've got sunken, Um, that's all right. Some can so eyes, if they're completely refill, time is prolonged. If they don't have good skin. Turgor uh, not passing urine. So essentially all of those things would point towards dehydration. So you want to give them fluid bolus and then put them on maintenance fluids as well. Um, start them on energy feeding with aspiration every four hours. But the mainstay is surgical intervention. So this is a surgical procedure known as Ramstad Pilo pyloromyotomy. Essentially, that's where you make an incision to the smooth muscle so the essentially the canal can widen so the food past can continue as well. So complications with that. So hypervolemia lost lots of fluid, projectile vomiting, pretty self explanatory and at please as well. So you have to be careful with them. Um, This can be secondary to metabolic alkalosis, so keep an eye on and keep them observed and try and get emergency. Um, advice from specialists as well, and obviously treat them acutely with the fluid bolus is all right. Moving on to appendicitis. This is again a very common presentation in pediatric. Any so definition, um, is information of the appendix, Um, and there is a lifetime risk about 7 to 8%. And it's one of the most common, uh, causes of the abdominal pain in young Children. This is usually caused by direct Luminal obstruction. It can be either secondary to a fecalith, a lymph nodes, a tumor. Um, and this essentially means that there is an obstruction to the passage within the appendix, at least to commence or bacteria sort of overgrowing, um, and that can lead to acute information and abdominal pain. The difference between an adult or older child presenting to hospital with appendicitis and a younger child is that the signs and symptoms is slightly different. Um, I'll talk about that in a second risk factors of family history, and it's more common in Caucasians, um, and clinical feature. So this is what we'll be looking out for, so you get abdominal pain. So the standard is periumbilical pain generalized periumbilical pain, which led to migrate to the right like foster and as well, localized and sharp. At that point, we can get vomiting and anorexia nausea. The difference is, in Children you can get a lot of diarrhea and urinary symptoms as well. Um, and because they'll find it very difficult. A lot of the times they find it very difficult to localize the pain. That might just be saying General abdominal pain. They'll be, um, change in bowel habits. And what's the one thing we have to be like? The main thing that we have to be careful with Children compared to adults is that they can present a lot later, Um, and that can lead to further complications such as perforation and sort of sepsis as well. So that's the main thing. That's kind of the difference between adults and, um, younger people investigation. So, um, appendicitis is very much a clinical diagnosis. Uh, examination. Why? So you see a rebound, tenderness and percussion of the McBurney's point. I put that in the little post at the bottom there, uh, Rosing sign. So that's when you get right. Elect Foster pain on palpation of the left Elect Foster. So a sign and right let foster pain with the extension of the right hip. Now, all of these might not be present in Children a lot of the time. It's just abdominal pain. Um however, with with the other kind of, um symptoms that they have presented with the kind of put the clinical picture together. From there on, you can do routine bloods and a lot of places do routine bloods, so that will include inflammatory markets. So looking at the full blood count, especially the white blood cells and looking the inflammatory markers such as, uh, CRP, um, it's important to also do a urine dip in pregnancy test. Draw any differential. So if there's any ovarian pain, uh, in females or and also to examine the male genitalia to rule out torsion and any testicular pain in young to earn young males, imaging is not essential to diagnose. Um, you can do an abdominal ultrasound. You can do a CT of the abdomen. It's very dependent on where you work and what's available At that time. I think most places would ideally, like each do an abdominal ultrasound due to the lower risk of radiation. But then how available that is during out of hours or nights or on the weekends is very, very sort of different and different places that you work. So a lot of places will just go with CT up to pelvis, but shouldn't cause you can avoid radiation. That way, management is usually surgical intervention. So laparoscopic appendectomy or an open appendectomy. There is some school of thought that you can treat it conservatively with IV antibiotics and sort of observation. But because your outcomes of a surgical intervention to appendectomy is so good that that's usually the mainstay of management, depending on how unwell they are, they can believes it can be a sort of day kay. So they might leave the state 24 hours and leave, but depends on how unwell they have been and how delay the presentation are so it can lead to things like like I said, perforation and abscesses, Um, which may involve sort of drain placements and IV antibiotics for a while after they've had their surgical intervention as well. So I when I was on surgery. We actually had quite a lot of this young sort of young Children, uh, presenting to any with very delayed onset of them, uh, delayed presentation of their appendicitis at this point that also already had perforation that had sort of pursed formation within the abdomen. So I had to have drains put in. So that's the one thing that you do have to look at for. How long has the pain been going on for and how and well do they seem as well, So inflammatory markers will be very useful for that as well. And finally, we moved on to the most common thing you'll see in pediatrics is constipation is one of the most common abdominal conditions. Um, in young Children, you'll see it on a day to day basis on a outpatient clinics and pediatrics, and you'll see it quite common in in the Indian Hospital settings as well. To be fair. So constipation, um, definition, it's just decreased frequency or bowel movements passing hardened stools that may be large and associated with straining and pain. Um, epidemiology. Like I said, it's extremely, extremely common in pediatrics. Um, and then in terms of sort of the causes of it most. Most of the cases ideopathic and functional. It's usually either behavioral problems or their diet or fluid intake. But there are some secondary causes that can lead to constipation as well. That will go on to in a second. So normal, um, stool frequency ranges a lot in Children as it does in adults. Um, in Children cannot range from four per day in the first week of life to two per day in the first year of life. But then, this also varies in breast fed Children. So it's best just to ask their parents' health and then normally go all the kids. If they're a bit older, how often they're normally again. What's the normal stool pattern? And then the best thing that I've found is, um, if we can just bring up the Bristol stool chart, um, so and I'm show them. Show that to the kids, Um, and just say point towards what? What your stool looks like. And they'll they'll better at sort the visual aspect of them conservation rather than just saying like, Oh, very difficult or whatever, so risk factors. So, um, have actually not opening bowels? Um, This can be common in Children with awesome spec spectrum traits, um, learning difficulties, low fiber diet and poor fluid intake. That's the most common, with picky eaters and Children not eating very diet to not taking in a lot of fluid. Uh, and they can be psychosocial problems as well. So they're having any problems in school or any safeguarding issues as well. They have to kind of keep in, uh, keep in mind as, well clinical features. So, like I said, how often someone opens up Alsbury, especially in breast fed Children as well. But typical features would be less than three stores a week or hard stools or difficult to pass rabbit droppings so stretching, straining and painful and abdominal pain. And you can also get overflow, soiling as well. So, um, sometimes incontinence as well. So incorporate is just can be associated just because they've got overflow soiling. So some of the secondary causes, um, that are it comes from sort of a history taking and what kind of questions you've asked is it if the if you ask them what kind of what kind of diet they have, what kind of food they do, They get fluid. If they're saying no to that, you're thinking what? Idiopathic. But if you're asking the questions, um, some questions such as, you know, like, yes, Hirshman disease. Are you asking? Have you? Have they passed meconium within the 1st 48 hours of the live? Do they have abdominal pain without vomiting? Those are kind of things that will point towards secondary causes. So So some of the secondary causes the Hirshman disease, cystic fibrosis, hyper thought thyroids and spinal cord problems. Um, anal stenosis and cow's milk, protein, cow's milk, intolerance and protein allergy as well. That can cause, um, diarrhea. Sorry, constipation and, um, sexual abuse as well. So that's one of the things if the stories sort of are inconsistent and not matching up, think of sort of safeguarding issues as well with constipation. But like I said, most of it is very idiopathic and very functional. So there are red flags to constipation as well. Um, so some of the things I've already mentioned so not pattern a meconium that can be hutch brings or cystic fibrosis related if they've got neurological signs. So some things like, um lower limb bilateral lower limb. Um so weakness and muscle wastage that can be indicative of cerebral palsy. Spinal cord lesion If they've got vomiting as well associated with abdominal pain or opening the bowels were thinking obstruction and Hirschprung's disease. If they're having ribbon stools, Um, so that's just very sort of thin ribbon like looking stool. Um, that can be pointing towards anal stenosis. Um, if they've got some abnormal back or buttocks, have they got Tufts of hair? Um, that can be pointing towards spina bifida. And if they're having failure to thrive as well, so if they're not gaining weight, they look quite pale. They're very lethargic, very tired. Are we thinking it? It's celiac. Disease is a hypothyroidism. Is there any safeguarding aspect to it? Is their neglect going on? Um, and if they're having accused of the abdominal pain as well, that's a red flag. So we're thinking, obstruction, intussusception, all the things I mentioned already. So the nice guidelines actually have red and amber flags to look out for. So in primary care, you'll see constipation quite a lot as well. You'll see in pediatric outpatient clinics you'll see in a any so these are the kind of red flags to be keeping an eye on two things I've already mentioned. Um, if they start having these red flags or if they've got some amber flags as further investigations to do, it's not just a matter of just giving them laxatives and sending them home. It's, um, sort of further specialist advice. I'll speak to its investigations. Like I said, so no specific investigations are required. If you think it was just idiopathic constipation, you can do blood. Some routine bloods, including thyroid function tests and brain profile, to check if there's any underlying causes going on. But if there are some red flowers going on, it's a matter of silver. Urgent referral to an appropriate specialist, whether that be general pediatrics or pediatric surgeons, Um, and similar with amber flags that's taken into account the whole picture and the how well the child looks to as to whether it needs further specialist referrals management. So again, management, if it's if underlying causes have been excluded, or the history that you've taken is pretty indicative of idiopathic constipation. The main thing is reassurance. Um, a lot of parents sort of that young, younger, younger babies, a lot of parents can be quite worried about. It's a reassurance is the mainstay. Um, obviously with older Children as well, you want to kind of assure them that this is just it's just constipation. Why would you check bone profile? Um, so you can get hypercalcemia hypercalcemia that can cause, um, constipation as well. And if you have those abnormal blood tests, then you want to do further investigations. Why do they have abnormal calcium that will do their vitamin D etcetera, etcetera? I hope that answers your question. Um, so yeah, so just reassurances initial, um, mainstream management and then laxatives for idiopathic constipation. So it's most commonly uses medical in pediatrics, and then you can move on to some stimulus just center latch, aloes, Um, and if they seem quite impacted, So when you examine the child and they seem this seems sort of quite full of stool, so there's no palpable stools that you can see if you're unsure. And if you've done an abdominal X ray and you can see freak a loading in the abdominal X ray, you might consider dis impaction regiment. Essentially, what this is is that you give them some laxatives for that's increasing in frequency over the first few weeks until the impaction. Um, until they've been completely disimpacted. Um, And then you can taper down the laxatives and put them on a maintenance dose and see how often they're going on, how often they're opening the bowels and also behavioral interventions as well. That's very important. So things such has very simple things. So asking them to wake up 10 minutes earlier in the morning and just having a seat on the toilet just sitting there even if they're not able to open their bowels. Fine. Just kind of getting the behavior every morning trying to do that to see if that will help, um, as well tip in the valves. I think I'm just going to show you the the dis impaction regimen as well. And the nice guidelines. There's a whole host of doses that I didn't put on here, but I'll just if I can share my, uh, if you just give me one second yeah, and that correct says you want to see calcium levels. That's the main thing you want to look for hypocalcemia that will result in further investigations. Like I said, doing vitamin D and um, checking for okay. I mean, if I need to share. Thanks, Craig. There we go. So here, you can see. So this is the nice guidelines for the disinfection and a titration of laxatives. So, like I said, you normally give more vehicle, and usually I hope you can see that. Thank you. And yeah, um and so it depends on their age initially. So how much you can give. So if you want to start this impaction regimes to start So for 1 to 5 year olds, you want to give them medical start to sachets on day 14 sachets on day 26 sachets on day, um, for further two days and then eight sachets daily until, um, the impaction resource. So it's quite a lot of laxatives, and they don't taste particularly great either. So trying to get Children to take them can itself be a bit of a struggle. But once it's going, I think you can get different flavours and things. So some Children seem to like a little bit more. You can, if magical is something that they do not prefer. You can also use lactulose a little bit as well. Ideally From what I've seen from my experience in pediatrics most of the time, they like to use medical if there is a serious um so the Children really don't like the Mobic opposite. And I said, Don't place where you can try lactulose as well, and for you can go into further certain picosulfate biisacodyl center, um, and then moving on to even animals and trialing very different, um, accent IBS in hospital. This is can be very, very common in Children, especially Children with learning difficulties. If they don't like, um, some of the behavioral aspect of opening their vows can be quite difficult for them. So essentially, I think that's the end of my presentation. This is just It was just an overview of various abdominal conditions in pediatrics. There are some more. Obviously, there are a lot more abdominal conditions. There are a few things, um, that are more common in the neonatal period, such as necrotizing and entero colitis, gastro cases, um, m for seals. All of those things I will cover in the neonatal teaching session that I'll do. But this is kind of things that you might see in, uh, any with a bit of older Children. Does anyone have any questions? You got some time lit. Okay, um, that's okay to view, so I think devious. Just put a a feedback link in the chat. If you can kindly fill that out for me, that'll be lovely. But if you have any questions, just pop them away in the chat about any of the conditions that we've spoken about. Like I said, a lot of the conditions I've spoken about have been surgical based. Um, so I've not gone into in depth of the surgical aspect of how to actually perform the surgery, etcetera. Um, it's just an overview of the conditions that gone through today. I think differentiating between the different abdominal conditions main comes from, um um, the history taken in itself and the symptoms that have used a lot of the times. Like I said, it can be constipation. Quite simple constipation. Um, but ensure that you've ruled out the red flags of abdominal pain before. You can just rule it as idiopathic constipation. A lot of the surgical conditions that I've spoken about pyloric stenosis Hirschprung's, um they all need Could you please go back to the clinical signs Yes. For constipation. Yep. So clinical features Do you want the red flags or just the clinical features So you can get abdominal pain again with that? And, um, sometimes you can get a little bit of vomiting as well if they're in pain. Um, but it's not very common to get vomiting alongside constipation. That's something that you'd also want to be a bit of an amber flag to see what else is going on. The best way to do it with a lot of Children is just, um if you can. If you have access to the Bristol stool chart, I'm sure a lot of you have seen it. If not, I can just bring it up here. Let's get uh, uh, I mean, I'm sure you must have all have seen it, but it's just the Bristol store chart, and I think that's the sort. The best way to actually, um, you communicate it with sort of older Children who are able to point out to you what they're still looks like. Sometimes even with parents. Just say, if you've seen some of the your child store, what does it kind of? What type doesn't look like um, that can be quite handy, too. So I've categorized. Kind of what? Still how constipated There actually are. Um, and it's good. Document that as well. So if that changes if they come in the future, if that changes, you have a bit of a baseline of what they've pointed out to you. And that's in that presentation. Uh, so the next, um, teaching session will be covering pediatric common pediatric cardiological, um, cardiology and sort of the various different cardiology, um, disorders that you'll see in pediatrics again. It'll just be an overview similar to this one. Okay, okay. If there aren't any more. Any more questions? All right. Okay. Well, thank you so much for attending. I hope it was useful. Um, yeah, so I will.