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Hello. Hi, we got you. Ok. Is it can suit two? Ok. Shall I press present now? Yeah, make sure you share the whole screen. Mm Should I press present now? Bye. I think we can see the sides. Are we lie? Yeah. Yeah, I think we are guys. Can anyone just tell us if you can hear and see us? If you can just pop a message in the chat? That would be great. Sure. Thank you. Um start you when you're ready to start. Ok, perfect. OK. So uh welcome guys to the first lecture of the year from Leonard. Um So today we'll be spending um around 45 minutes to an hour just on acute abdomen and the related conditions and presentations. Um So we'll cover quite a few conditions and their associated presentations. Um And just so you understand um the start means uh gold standard um and then the lightning indicates high yield so to start off with an SBA. Um so there's a 17 year old female who presents to Ed with periumbilical pain. The pain is sharp in nature, exacerbated by coughing and came on gradually over the past 12 hours on examination, the patient is unable to stand on one leg comfortably and experiences pain on hip extension. There is no rebound tenderness or guarding a urine pregnancy test is negative and her temperature is 37.7 bloods reveal a leukocytosis that's predominantly what is the diagnosis. Um So if you can, you can have just have a think to yourself about what you think it may be or you can pop it in the chat. Um oh give me 10 seconds. Um So relating to this b we'll talk about the first condition. So which is appendicitis. So, appendicitis is inflammation of the appendix. So it's often caused by a blockage to the appendix. So either via a theca or commonly in Children due to infiltration of lymphoid tissue. Um and a common cause in the developing world, in particular is a helminth infection. So the appendix essentially gets inflamed and swollen which irritates the visceral pleura um that causes umbilical pain, um which is due to the mid gut, the embryological midgut origin of the appendix. Therefore, it's umbilical. Um but then the um parietal, then the visceral pleura then irritates the parietal pleura which causes a more localized right iliac fossa pain. So that's why you get the migration of pa pain from the umbilical area to the right iliac fossa. Um But I think commonly, um you should pay attention to the epidemiology, epidemiology in question stems. I think that's a very easy way to figure out what condition it's more likely to be. So, for appendicitis in particular, look at the age. So it's more common in younger patients. So 10 to 30 year olds, um, also it is a very common condition. So, like if you're seeing a more rare condition as an answer, um, you can always just put appendicitis if you, it's a complete guess. So, um, a key thing that's very easy to spot in question stems and er like very obviously put three, the three symptoms in the stem is the Matthews triad. So this consists of abdominal pain. So this is pain from the, that travels from the umbilicus to the right iliac fost, as previously discussed, nausea and vomiting and finally a low grade fever. So you can see that in the question stem, we end up seeing all three of these features. Um Other signs that um are often described are rings sign. So this is when you press on the left hand side and pain occurs on the right hand side and that's obviously due to the contact with the pleura. Um, yeah, the obturator sign, um which is the one on the right hand side. So you flex the knee and internally rotate the hip and it causes pain to the patient. And then so a sign which is passive extension at the hip and that causes pain to the patient. Um So you can be careful though in reading the stem um because often they don't make it obvious which sign is being described, cos they'll explain the actual clinical maneuvers they're doing on the patients. So you have to kind of deduce which sign are they hinting at. Um, so also for the appendicitis, um it's pretty straightforward with the management. Um, not that many complicated guidelines. So you essentially make the patient nail by mouth logically, this is because they might need surgery. Um You give fluids if there are signs of shock and you give antibiotics to treat any, to treat the infection. Um Things to be aware of in complications wise, in particular is that there may be a rupture which may cause peritonitis. So you may then see a patient with generalized tenderness rather than more localized by iliac fossa. Um So you could probably tell from SBA one that the condition would be acute appendicitis. So, moving on to S pe two. Um So there's a 65 year old man who comes into Ed because of blood in his stools for the last few days. Um He says he doesn't have fever, he doesn't have chills, nausea or vomiting. Um and says his bleeding is painless. His last colonoscopy was five years ago and showed several colonic diverticula but no colonic polyps or cancer. His temperature is 37 degrees pulses, 80 rest is 15 per minute and BP is 100 and 20/80 rectal examination does not show any abnormalities. What is the diagnosis. Um So once again, you can have 10 seconds to think about it and that brings us on to our next condition which is diverticular disease. Um So, diverticular disease is defined as a herniation of mucosa or and submucosa through the muscle layer of the colonic wall. Um And there are technically two etiology. So there's pseudo um outpouching. So the muscle layer does not actually outpouch um and then true is when the muscle layer does outpouch. Um And it's actually a very common disease. Um around 60% of people in industrialized countries will develop an outpouching of some kind. Um So the key thing here is that terminology can be a bit confusing. So, diverticulosis and diverticulitis are slightly different. So, diverticulosis is the presence of out patching, but the patients actually asymptomatic. So the way I remember this is like diverticulosis. So the low sounds like a no. So I think of no symptoms. Um and then by elimination, diverticulitis has to have symptoms. So, diverticulitis is when you have inflammation and infection of the outpouching. Um so that can often cause pain to the patient. Um So, in diverticular disease, um the reason you get these outpouchings is because the there's herniation of the mucosa in between the bands of taenia coli. So there's weaknesses where the outpouching can occur. Um in the western side of the world, it is common on the left side of the colon. So the descending colon and the sigmoid colon, colon. Um But interestingly, in the Asian population, you often get right sided diverticular disease. Um And that's thought to be associated with more meat consumption. Um But generally, if your the question stands here will reflect left, like left sided um pain and outpouching findings. Um So risk factors to know are low fiber diet. So obviously, this increases the intraluminal pressure um to move stools. So there's more strain and then there's more chance of outpouching. Um.