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Hi, everyone. Welcome to part two of the Gastro crash course. Hopefully you found part one useful. Um Just to let you know we will be uploading the recordings and the slides after this so you can go back and watch them as well and if there are any questions in here, please try and interact because it will be really helpful for your own learning as well. Um But yeah, so whenever you're ready, just ok. Yeah. Um Hi everyone. I'm Soran here. So I'm 1/5 year medical student and um I'm gonna be teaching you about digestion. So just going through the cases that we're going to kind of cover today. So, um the first one's about type two diabetes. The second one's about gourd. Um Case three is about lactose intolerance. Um Case four is obstructive sleep apnea. So the first case, um it's a 56 year old male. The height is 100 and 76 centimeters and the weight is 100 and 23 kg. Um So they've tried lifestyle measures to decrease their weight. Um but they haven't really noticed any changes since they were diagnosed last year. Um They aren't as thirsty. So in terms of like the diabetes symptoms, the polydipsia has improved and they don't have blurred vision anymore. So improvement. Sorry, sorry, your slides are like not on, it's like showing up and then not showing up for some reason. Ok. Uh Do you want me to just share it again? Yes, please. Thank you. Ok. Um, let me um, is that better? Yeah, that's fine. Ok. Um, so we'll just go to. Ok. So this one. So um the first case is um Mr T so 56 year old male um height is 100 and 76 centimeters, weight, 100 and 23 kg. So, like I said, not as thirsty as before. So polydipsia has improved um doesn't have any blurred vision anymore. So also improvement in diabetic retinopathy. Um and what you do see is that he has an HBA1C card. So obviously that's pointing towards you towards a diagnosis of type two diabetes. So, what is it? Um So you guys will know this from your endo lectures as well. Um But basically, it's caused by abnormally raised levels of glucose and especially in the case of type two. it's relative to a deficiency of insulin which is normally due to an excess of adipose tissue. So you'll normally see it in people who are quite obese overweight. Um So typical symptoms, it might be incidental. So a lot of people just come to the GP practice, they have an HBA1C as a routine and they notice it's a bit high or they might have symptoms. So, polyps or polyuria. So this kind of diagram just shows you um the pathogenesis of type two diabetes. So you've obviously got your factors that affect how much insulin you're secreting and the action of insulin. So these are things like body weight, physical activity, smoking alcohol, you also have things like a genetic predis predisposition and um epigenetics. So, environmental factors as well. So if these are all like good control, well controlled and then they're not really in the negatives, you get a positive risk profile. And so you're normoglycemic. So you don't have hyperglycemia. But obviously, if in the case of people who are quite overweight, lack of physical activity is that puts you in a negative risk profile and you get the dysfunction of your beat cells and eventual insulin resistance. So, insulin affects mainly your liver, your adipose tissue in your skeletal muscle. So if these aren't working as well, obviously, um the insulin mediated glucose uptake in your skeletal muscle will decrease. Um same goes to your adipose tissue and the liver becomes resistant to the action of insulin. So normally insulin should inhibit your glucose production by your liver. But because the liver cells are now resistant to insulin, you get um hyperglycemia. So with diabetes, what investigations do you need to do? So there's four main ways to check for your blood glucose. So, you've got the finger prick. Um blood glucose monitors. Um you can do a one off blood glucose so it can be fasting or nonfasting. Um The HBA1C again, just remember this measures the amount of glyco glycosylated hemoglobin for the past 2 to 3 months. So it gives you more of a long term kind of prognosis and your oral glucose tolerance test. So this is where you ingest 75 g of glucose and you take a reading two hours later. So normal people, you shouldn't be hyperglycemic because your insulin should be working enough to detect that you've ingested glucose and it decreases the amount of glucose in your body. But obviously, if you're um type two diabetic that isn't working as well. So in terms of diagnosis, um you can have an HBA1C is normally the cut off is 48 million miles more and then that's going to be 6.5. Um So that's just a rough level of 6.5%. So some countries do percentage. Um you can have a fasting plasma glucose of seven or above and your random plasma glucose. So the oral glucose tolerance test. So after you ingest your um glucose load, it should be 11.1 or above. Um So if the patient is asymptomatic, though the same criteria apply, but you need to demonstrate it on two separate occasions um to diagnose type two diabetes, um just go through the complications. So the three main kind of things to remember is you can have diabetic retinopathy. So um you get these things called block hemorrhages accident. So, lipids in your retina and eventually it can lead to blindness, diabetic nephropathy. So, diabetes is one of the like main causes of chronic kidney disease and eventual um renal transplantation. So it really damages your kidneys. And the other thing is diabetic neuropathy. Um so it causes damages to your nerves and you get tingling loss, loss of sensation. So just remember these three main complications of diabetic um diabetes. So if we go through the management, so obviously you start with lifestyle measures. Um So you want to encourage a high fiber and low glycemic index source of carbohydrates. So these are your um carbohydrates which take longer to kind of digest. So you're not getting a spike in your blood glucose levels. Um So these include things like low fat dairy products, oily fish, um control the intake of foods containing saturated fats. Um And if you're overweight, one of the main things is you need weight loss basically. So you want to target a weight loss of roughly around 5 to 10% of their body weight, um oral medications. So you just need to remember Metformin basically um at this stage and that's your most commonly used first line medication. But other ones that you've got are like sulfonylureas, gliptin pioglitazone. And if you can't control it on oral medication, you just go on to insulin. Um So that's basically your end goal of um diabetes management. So, just a quick question. So which of the following thresholds are correct for a diagnosis of type two diabetes? So, I don't know if you can put it in the chart or just have a think um I'll give you a couple of seconds and then we'll go through the answer. OK. So it's um b so it's an oral glucose tolerance test over 11.1. So the A B A1C should be more than 48 and your fasting plasma glucose um should be more than seven. OK. Um So that was diabetes. So, going on to the next case. So it's a 45 year old male suffers from episodic central chest pain. So the pain doesn't really radiate um down the left arm. So it's kind of pointing you away from an M I um by saying it doesn't really go down your left arm and it's not associated with rest breathlessness and the pain does not disappear at rest. So he has a throaty cough but no, not other cold like symptoms. So, in the kind of stem of the question they're already telling you, um it's not a cardiac cause of chest pain or it's not an M I because it's not radiating down the left arm. And the fact that it's not associated with breath breathlessness, it's telling you is probably not to do with a lung cause. So, um the other cause of chest pain, which you kind of need to remember is it can be gastric causes of chest pain. So this case is kind of referring to go or gastroesophageal reflux disease. So what happens in it? So it's basically where the gastric contents from your stomach which are acidic, leak up into the esophagus. So the risk factors for gourd are obesity, smoking, alcohol, pregnancy, and male gender. So, um a lot of these are obesity in pregnancy, for example, you're just increasing the pressure on your lower esophageal sphincter. Um And so that's causing it to become lax. And that's why you get this reflux of your stomach contents up into your esophagus. So this is just um a dia I'm showing you how it works really. So it's the lowest offshore sphincter, like I said, and you do get this episodic relaxation and that's normal in people. So it can kind of relax sometimes. But in go, what happens is it relaxes more often. And so you get the reflux of your um really acidic H plus ion content, heavy contents of your stomach. And that goes up into your esophagus.