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So let me just introduce myself and my fellow colleagues here tonight. Um My name is Lock. I'm a third year medical student from the University of Buckingham. I'm currently in place at uh Warwick Hospital and uh my colleague, Amin is also here with me and uh he might not be this. Uh he might not be free at the moment, but he's 1/4 year medical student at Central Lancashire University. Um We're very happy to uh invite uh senior here. Uh She's a graduate from the University of Buckingham and currently she is um fy one F Swansea. And um um if we don't have uh any questions beforehand, I'll hand the stage over to a senior and I'll monitor the chat and uh yeah, feel free to tap into the chat. Uh Any questions that you might have uh during the lecture or after the lecture. And um yeah, that's all for me. I'll handle further stage to you then. Hello. My name is as I was introduced with Kind before. So I'm one of the firms who's currently working at Swansea Bay Hospital. Uh And I'm here to talk about the lower gi presentations. Really And if you have any questions at all, do, let me know for the moment. I think I'll switch off my camera as well. Uh And I'll try my best to answer any questions you have. So most importantly, I think since lower gi is a primary surgical, primary, a surgical topic can be a surgical topic as well. I'd like to touch on a really helpful structure that was introduced to me by in med school called Vitamin C and D. So when, when you are taking a history at maybe an osk station or even in an exam where you, you have to think through what can be potentially causing some symptoms. I find this structure to be a really useful structure to think about what causes it, what, what are the causes of uh what potential causes it could be. So we're gonna start off with any vascular causes. So, and then you can move on to any, whether it could be infection, whether is it, whether it's traumatic autoimmune metabolic, whether it's a neoplasm, it could be congenital or whether it's a degenerative. So that's a really nice little s um um structure to start working on when you're doing your ay and history stations, et cetera. So now I'll, the way this presentation is structured is I have given around three case studies and they are very simple case studies and we can then talk about the diagnosis and then you can just talk through a bit more of the questions you guys have as well. All right. So your first patient is a 23 year old male who presents to his GP with a three month history of diarrhea and intermittent abdominal pain on the left lower abdomen. And sometimes he notices some fresh blood in his stool, but occasionally it's darker looking as well, which can be quite worrying. He has been feeling quite tired all the time as well despite not having any additional work, stresses and adequate sleep. So what can it be anyone got any ideas so far? Well, so in this patient, you, you have to first think about the age because pretty much depending on the age, our differential diagnosis of blood in stool can be different if it's in the younger, in the younger populations. IBD is always a big question. If it's in the older population, you start mixing bowel cancer into the mix as well. Yes, you're absolutely right. I was going at ulcerative colitis. Um So it's also I think a noteworthy point in most exams. Now, younger males, younger males or females, then they, then you get a history like this. What they want you to say is inflammatory bowel disease, ulcerative colitis Crohn's et cetera. But it is no noteworthy to mention that bowel cancer is getting a bit more prevalent in the younger populations now as well. Is it something for us to keep our minds open about when we are taking a history in a clinical setting, especially if it's accompanied with any of the other red flag symptoms such as weight loss. All right. So, inflammatory bowel disease, just a, a quick run through of everything. Quite simply it is inflammation in the gastrointestinal tract. You have the two main types of Crohn's disease and ulcerative colitis. This is an exam favorite. You have common symptoms of diarrhea, sometimes accompanied with some rectal bleeding, associated abdominal pain. Your f you get fatigue and weight loss as well. You have some common associations which I think uh exam buzzwords, uh which is like erythema nodosum, which is basically tender red lumps, which are usually found out the shins, pyoderma gangrenosum, which is basically large, painful. So and then enteropathic arthritis is swelling and pain in the joints and uveitis and scleritis. It's basically inflammation of the uveal sclera dissolve. Come on. Um common associations. All right. So in exam, sometimes in short answer questions, they can easily ask on give four differences between Crohn's disease and ulcerative colitis. So, in Crohn's disease, rectal bleeding is far less common because the lesion can be from anywhere between the mouth and the anus. So it can, the lesion could be anywhere along the gastrointestinal tract. Whereas ulcerative colitis is usually very limited to the colon or the rectum. So, finding blood and mucus in the stool is a lot more common in Crohn's disease. You can find skipped lesions on endoscopy with full thickness inflammation, which you can find when they take biopsies. In ulcerative colitis, only the superficial mucosa is affected. And by no way, you should be encouraging your patients to smoke. But in ulcerative colitis, smoking is a protective factor. Whereas smoking is a risk factor in um Crohn's disease. And Crohn's disease is also associated with strictures and fistulas. And this is because so basically, when the gut, because it's transmural inflammation, the gut inflammation can be spread throughout all the layers of the bowel. So this can cause small leaks, little fistulas, little abscessus to form, which causes uh which is why it is associated with strictures and fistulas. All right. Moving on to investigations. One of my personal favorite ways to approach investigations in an osk station or in a short answer question is to take or even in real life. And you're taking a history with a patient and you're now you've moved away and you're thinking, ok, what investigations that need to be done? It is really helpful and you get more points for this case, I believe if you structure the way you think. So, start with bedside, what can be done to um this patient by its bedside. So, taking a stool sample, we can send the stool for fecal calprotectin, which is basically to check for inflamma inflammation markers in the feces. You can check for stool microscopy and culture to rule out any infectious causes of the diarrhea. And then moving on to bloods, starting off with the full, um, full blood count. Thinking about if there's a why the patients being more tired. Is there an anemia associated with this tiredness? Is there bleeding? Then uh moving on to check the CRP to check for any signs of inflammation. Check for renal function, check for thyroid function test because hypothyroidism can be a cause of diarrhea. And um then moving on checking for anti ttg as well because uh to check for celiac disease, I haven't particularly covered celiac disease, but celiac disease is pretty much an allergy to gluten. And the treatment for celiac disease is pretty much staying away from gluten and for the rest of your life to prevent any inflammation. All right. And then moving on to imaging you depending on some, for most patients. The the first line would be a sigmoidoscopy or a colonoscopy. A sigmoidoscopy is um easier thing to tolerate because it only goes, it only checks for any lesions in your rectum or rectum and um sigmoid colon if there's any, there's any inflammation et cetera. And um a colonoscopy is given if that doesn't prove anything and the patient has any worsening symptoms. The symptoms aren't, are still unexplained and you need to visualize the location of the lesions for biopsies. All right. So, um ulcerative colitis management, you start off with an for mild to moderate acute exacerbations. You start off with um and a minus salicylate which can help reduce the inflammation. Uh The exact mechanism of this, I read about this before this um presentation is not particularly known, but it's thought to reduce the inflammation by reducing the amount of cytokines released in the gastro uh gastrointestinal tract. And it also inhibits the production of inflammatory mediators from the cot and the lipooxygenase pathways as well. Just know that it's you for mild to moderate exacerbations. You can get MS and some corticosteroids. For acute exacerbations, you give IV corticosteroids, IV cyclo cycloSPORINE to reduce the production and the release of some lymphocin. And infliximab is a TNF alpha blocker. Again to um help with the inflammation and with ulcerative colitis, you have, taking all the anti colon usually kills the disease because the disease is limited to the colon and the rectum that is a very last resort um option for most of the patients. And usually it does help people as well, but it depends on the exacerbations. And usually a lot of the medications are tried before we restart the surgery and to maintain the remission, it's a minus salicylate, azaTHIOprine and Metacine for Crohn's to induce remissions. It steroids if there are any nutritional deficiencies. To think about dietician reviews, giving any supplements, dietary supplements, et cetera. And to consider medications like methotrexate, adalimumab, azaTHIOprine metacine, you maintain remission with azathiopurine and metap and you have the surgical options of resecting the part that's affected if it's possible. And to treat the strictures and the fistulas for any os gestation. Another helpful way to thought when you are asked about how you will be managing a patient is to think about what is your conservative management, which in this case is, there isn't really a conservative management as far as I'm aware, at least, what's the medical management, which are the medications as listed on the screen? And what are the surgical options? It's a very nice way to structure your answers if you are, um, ever so stuck sometimes in ay and your mind like words just blank out. Just think conservative medical surgical and your examiner would be really thankful that you are at least thinking out loud options. So, yeah. All right. So your second patient of the day, it's a bowel related day for you and the GP practice. You have a 70 year old woman who was presenting to the GP with a six month history of weight loss. She's been passing loose stools more frequently when you ask a bit more about her family history. Her mother passed away from cancer. They couldn't remember what it is, but her mother apparently suffered similar symptoms for the last years of her life. So off the top of your head, what could be the glaring thing that you should all be worried about with this patient at the moment? Uh So yeah. Um, we had a couple of bowel cancers as the answer. Um, we also have a question here. Would you like to answer it now or would you prefer to? Um, so I have got some, a slide on IBS later on which I will cover. That's fine. Yeah. So, uh yeah, bowel cancer is what people are saying right now. Yes. Pretty much. These are really case studies. I was going to come up with some weird and wonderful cases today. So bowel cancer, we're starting off with the risk factors. You have a glaring history. If there's a family history of bowel cancer, always suspect bowel cancer. You also have a familial adenomatous polyposis, which is basically an autosomal dominant condition. So it might be a nice question that might be linked up. Um It basically leads to lots and lots of little polyps in your colon and there's a high chance of these polyps turning into cancerous lesions. Um You have here hereditary nonpolyposis, colorectal cancer, which is also dominant, autosomal dominant. And it could be associated with a bunch of cancers such as colon cancer, endometrial cancer, ovary, stomach small intestine, upper urinary tract, brain skin cancer. So a lot of can you had a lot of cancers if you are positive for that one gene as well. IBD is one of the risk factors as well. Increased age, obesity, diet and sedentary lifestyle can be risk factors as well. So your main presenting complaints that you need to be aware of is a change in bowel habit. If you have some unexplained weight loss, rectal bleeding, unexplained iron deficiency anemia is a big, big red flag depending on the age as well. Checking if there's an abdominal or rectal mass on examination as well. It can come present with bowel obstruction if the tumor completely blocks the passage. And this is a surgical emergency and you present with vomiting, abdo pain and absolute constipation. What what I mean by absolute constipation is you are not passing bowels off late at all. And the patient is basically distended as well sometimes, you know, but the red flags are pretty much not passing any bowel, not opening their bowels, not opening, not having any flater either. So again, you can do the investigations, sorry, starting off with something called a fit test, which is fecal immunochemical tests. It basically assesses the amount of hemo human hemoglobin in the stool. There used to be another test which I can't remember what it was called. I think it's fob I think which was less sensitive because it tested for any hemoglobin in your stool. So if you had like a diet rich in meat, red meat and whatnot, it used to test positive as well from what I remember. But a fit test is a far more sensitive tool because it tests for human hemoglobin in your stool. After a particular age, everyone is offered a fit test because it's literally, I think from what my patients have described to me is a card that comes in your card and a pack, a test pack that comes in your, in the, through the pulse and the patient puts a bit of poo on it and you send it off and it comes back with the fit test and your GP gets the results and refer you to the, to the um specialists via the two week path. It's high. If it's high, the primary bloods you need to do is a full, full blood count to check if there's any drop in your anemia. You can do other blood tests such as, you know, use the knees, you can do a baseline set of bloods in real life. That's what happens. Uh You do use any CRP liver function because why not. But that's not the way the most important test that you should be checking for is the full blood count for imaging. Your first priorities would be a colonoscopy in most of these patients to and it's to visualize the entire large bowel. This is usually done on the sedation because a lot of patients can't tolerate this. A colonoscopy means that you have to the bowel prep for colonoscopy is a far longer, uh takes far longer because it takes, I think you have to drink two days with a bowel prep, has a clear fluid diet, et cetera. So it's a lot for a patient to take it and you should be able, you need to be a certain level of fit. Like if you're well and active to take, to do a colonoscopy to go through that bowel prep, et cetera. A sigmoidoscopy. Usually you don't get anything or you just do it on gas and air, it just checks again, just the rectum and the sigmoid colon and its to visualize any lumps on the rectum and sigmoid. And if there are any of any lesions or any tumors, usually a biopsy is taken as well. And if the patient supposedly can't tolerate, uh is less likely to tolerate a colonoscopy or sigmoidoscopy. A CD colonography is done as well. All right. So another exam favorite question, the nice two week referral pathway for colon cancer for bowel cancer. If you have an abdominal mass, if you have a change in your bowel habit, iron deficiency anemia, you pretty much get referred and it depends on the age as well. If you're aged 40 over with unexplained weight loss and abdominal pain, you're referred 50. And if you're under 50 with rectal bleeding, abdo pain, weight loss, you're referred, if you're 50 over with pretty much rectal bleeding or abdominal pain or weight loss, you are referred. And if, if you're 60 over with anemia and even in the absence, absence of iron deficiency, it's a cri criteria for referral. And this, this is because the thinking behind iron deficiency anemia or even anemia for bowel cancer is um, if it's bleeding, you're bleeding into your, into your gut, even in small amounts, which can cause over time, which can cause an anemia, which is why it is always really important if you can't explain an anemia. To always think is this a malignancy in the gi tract? If so it is a, is a colonoscopy indicated. It's a sigmoidoscopy indicated is an O GD indicated, et cetera, always offer fit test in the community if you, even if the patient has had a negative fit test through an NHS bowel screening program and you know, a no, no positive fit test is, has usually more than 10 mcg of hemoglobin per gram of feces. Uh Another classic for exams is a, the dukes classification of colon cancer. Duxa is pretty much confined to the mucosa and part of the muscle wall dukes B. It extends through the muscle of the bowel wall dukes C. You got your lymph nodes involved now and DX D you have metastatic disease. Um This is just over in M DTs. You take a lot more of the factors into consideration. You figure out how many lymph nodes are involved. How widespread, how really widespread is the disease? If it's metastasis, you do a pet scan if needed and just check where the disease has metastasized into. You go through a whole MDT as well to discuss the uh to discuss the exact treatment that you require depending on your classifications as such. All right, this moves on to my management really, which is again, your main options are surgery, chemotherapy and radiation. And these are made of the, the the options of offering these are made of to carefully assisting the patient's clinical condition, the patient's general health, the stage of the cancer, what the histologist says, will it respond to chemotherapy? Will it respond to irradiation and also the patient's wishes? Really? Um So it is really important to look at the patient in a holistic manner. See if sometimes whether the patient will actually benefit from benefit from the treatment. If the patient and you always offer the options that you of options that are the outcomes of the MDT to the patient? Often they'll say, well, you can proceed with treatment. But I personally believe that it would significantly impact your quality of life for some patients. Quality of life is a lot more important than aggressively treating a cancer. And they would choose a more conservative option. Uh palliate for relieving of the symptoms, prioritizing the comfort care. Some patients would want the cancer to be treated aggressively. So it's all very patient dependent as well. All right. So the potential complications of um basic, the types of different colectomies. So, a right hemicolectomy is you remove the cecum and the ascending colon and part of the trans, the proximal transverse colon. Um A right left hemicolectomy, you remove the distal transfers and the descending colon. You have the sigmoid Colectomy, which is basically a resection of the sigmoid colon and the sub total or total colectomy is most of your bowel is removed. Some of the potential complications of this you have with any procedure, bleeding, pain infection. You also have the risk of, you do not remove the tumor completely. That is also a risk. You have damage too. You can damage your nerves. You could have a bladder bowel ureter, you could have a dam damage to those structures. You could have postoperative values. You could have leakage or failure of the anastomosis. You could have a VTE, you could have a de form, you could have an incisional hernia. Um and there's always anesthetics risks and also change your bowel habits as well. All right, your third patient of the day, first change. Now, you decided to go into the emergency room and you decide you got another bowel patient. So you have a 65 year old male that listens to the emergency room with severe abdominal pain, uh, which has been present for the last 24 hours. He mentioned that he has not opened his bowels for the last two days and he's unable to pass, pass any flights as well. His past medical history includes a cholecystectomy done about 10 years ago, hypertension and type two diabetes on examination. He had quite a distended abdomen and was quite tender and tense all over his abdomen. What should be the first thing you need to think about in this patient. Yeah. Yeah. So, yeah, we have bowel obstruction. That, yeah, that's the correct. Uh, that's what I was looking for. Um, so bowel obstruction, the definition is you, this complete blockage of food fluid, gas. So, the gastrointestinal tracts as the intestines become blocked. It's a surgical emergency. Your cau big causes that you need to think about are adhesions, malignancy, hernias. Yeah. The causes are volvulus. You could have diabetic disease causing it as well as strictures and in pediatrics, I think interception. So these patients pre are present with vomiting depending on how far up the obstruction can be. It could be bullous, vomiting and bullous. Vomiting usually looks like the bright. Yeah, it's very bright yellow and usually I just, uh, because I was in pediatrics, the patient, my, the patients parents or the patients themselves would just point to the bright, um, yellow tubing of the, it's the suction tubes and say, well, I vomit my vomit was that color and I immediately start thinking, oh, gosh, is it, was it be vomiting? You have abdominal distension, widespread abdominal pain, like I said before, absolute constipation and lack of flatulence and in early obstruction, it's tingling, bowel sounds. Your initial investigations are you're due for blood count. EC RP take around two hours to take back. So your best bet for first, first, the most quick thing that you can get back is a VBG. You can just run it while you're taking the bloods, you can quickly take a VBG run into the machine and you can get the patient's acid balance status. It should be, it gives a bunch of really useful information as well. Do an ABDO X ray, but I did do a bit of reading about this and sometimes depending on clinical picture if it's very apparent bowel obstruction that sent straight to CTA to get a CD abdomen, ct abdomen. Something to notice it is vital that you involve your seniors from a very early stage with these patients because the you need to do your, they need to be reviewed by the surgical reg or surgeon as soon as possible as well. So some x rays that can come up in, you know, exams in small bowel obstruction, you have dilation of the small bowel. The fancy word for these uh prominent valvular cortes. Basically, if it looks like a coil spring, the potential causes are adhesions, abdominal hernias and tumors, adhesions are caused by surgery by the way. So my case, the case I used the patient had a CEC cholecystectomy. I didn't mention whether it was a la laparoscopic or of open. But by the way, any, any amount, any surgery to your abdomen causes the risk of adhesions forming and that can down the line cause obstruction. All right, you have large bowel obstruction. Your classic by volvulus is your classic coffee bean appearance. And in large bowel obstruction, it apparently looks like a fetus which I can't personally appreciate. Um One of the important things you have to think about is the regular sign. It is when you can see, I think somewhere here, both sides of the bowel wall start becoming apparent. You can start to see a like you can see the borders really quick really nicely and that could be caused due to aid. Common causes for this are colorectal carcinomas, diverticular strictures, hernias and Bulus. Your initial management is affectionate, knows known as DRS. So you keep the patient nil by mouth, you give IV fluids for hydration. And if you correct any electrolyte imbalances, you put an NG tube in with free drainage to allow the stomach continues to freely drain. And so that there's a reduce risk of aspiration and vomiting your definitive management. II, I've nicely split it again into you're conservative. If it's in stable patients, you can, I'm not really sure. I think it's just watchful waiting really. Um But your surgical options are exploratory surgery. You do a giant incision and you just go looking for the cause of the obstruction. You can remove the adhesions, repair hernias or emergency resection of whatever tumor it is. So this from here on, I haven't included any slides for this. So diverticular disease starting off simple. I appreciate this side. Its are now a bit text heavy. A diverticula pretty much means a pouch or a pocket in a bubble wall. These are formed as the basically the circular muscle in the colon, they get penetrated by blood vessels over time, creating areas of weakness and over time, it creates pressure in the colon and there could be gaps forming. And then it allows the mucos penetrate and form little pouches. Diverticulosis is the presence of this diverticuli without inflammation or infection. They're quite common in increase with increasing age, increased use of nsaids, low fiber diets or obesity. It's often an incidental finding it can cause some abdominal pain, some constipation, rectal bleeding. And the management for that is conservative, high fiber diets and weight loss if appropriate and bulk forming laxatives and diverticulitis is the inflammation and in infection of these diverticula. All right. Now, diverticulitis concerns with typically pain in the left iliac fossa or left lower abdomen. It could, so it could be in any part of from what I've listened to from surgeons. As far as I'm aware, it can be painful anywhere else as well. But it's most prominently present in the left left fossa, not left, lower abdomen. Usually you get accompanied fever, diarrhea, some nausea and vomiting, raised inflammatory markers, rectal bleeding and sometimes a palpable abdominal mass. Your management for complicated diverticulitis in primary care is a five day course of oral amoxi amoxiclav and you give some analgesia ideally, you would avoid nsaids because NSAIDS can be a cause of diverticulitis. Um I'm not really sure why. Um You only take clear fluids for 2 to 3 days and 3% if the symptoms worsen or persist or usually a review with the GP in a couple of days to check how they're getting on is also advised that's been nice. If you have severe pain, complicated diverticulitis, you send them straight to the emergency room, kneel by mouth, give them IV, antibiotics, IV, fluids, analgesia and think about surgery. The complications of acute diverticulitis. You have perforation, peritonitis, per diverticular abscesses, hemorrhages, fistula, skin foremen and obstruction pretty much. And, um, I appreciate the fact that I have talked about lots of complications in this lecture today. All right. So, brushing over the concept of stoma, um, you have a colostomy, which is basically a creation of the opening from the large intestine. You bring it up to the skin, an ileostomy. Basically, you bring a part of the small intestine up to the skin surface and you collect, put colostomy alloy bags. A urostomy is when you connect the irritus and you have a little bag creating um, and collecting all the urine. Usually it's seen and I think I've seen a patient with a urostomy with basically she had an atonic bladder and had basically a bladder wasn't doing what it was supposed to do. So they created a urostomy for her and you have a peg feeding tube as well. This is for patients who have an on safe swallow. Um, and you know, there are lots of other indications for a peg that I haven't really gone through, but pretty much it goes through the skin, you connect it, you directly to the stomach and you can give feeds through that special feeds. The potential complications of this is you can, it has a psychosocial impact as well. Having a stroma or a colostomy bag can the, you know, can come with its own stigma. Sometimes local skin irritations, a peristomal hernia, which is basically a bowel or swelling created under the stoma. It can lead to issues with the stoma function. You could also get loss of the bowel length leading to high output dehydration, malnutrition. Because if you think about it, part of the gi practice now, not functional constipation, stenosis obstruction, you could have a prolapse, um bleeding and you could have some granulomas as well talking a little bit about hemorrhoids. So basically, these are the concept of anal vascular cushions. Basically that tissue that are really well vasculated. They have a lot of good blood supply with rectal arteries. They help control anal um continence and in hemorrhoids or piles as some patients would put it as they're enlarged and they often associated with constipation and straining. They're often common in pregnancy, obesity, increased age. So you have the different stages, grade one breathing without the prolapse. Grade two, it's protruding a bit, but it's spontaneously reduces. Stage three, you are able to push it back manually. And stage four, you cannot push it back manually anymore. And the treatment for this is usually banding, which is basically just slip a tiny band. This is done on the endoscopy by the way through the well, and it just squeeze on it, squeezes it off and it just falls off. Um So yeah, it's also a cause of rectal bleeding that you need to think about with patients often how these patients present is. Um one of the differentiating questions you can ask is, is the blood mixed? Do you think that the blood is mixed in with the stool or is it on the surface of the stool? Is it fresh blood or is it um more darker blood? If it's fresh bloods, it could be hemorrhoids and keep in mind any patient who comes in with presents with rectal bleeding, you have to always think about um the other causes as well. You need to give them a, a rectal exam, a digital rectal exam. I have seen the question of, is it true to say that people with hemorrhoids have portal hypertension? The honest answer is I'm not really sure of that association. Um But yeah, I can have a look at that for you, but I'm not really sure. I haven't heard of that yet. But yeah, so moving on to irritable bowel syndrome. So quite simply. But IBS is a diagnosis you reach after you have excluded everything else as per answering. I think, I think someone else asked how IBS can present differently. And it is quite difficult to say because IBS also presents with change in bowel habit. You have abdominal pain bloating, it's worse after eating, it's pain is relieved. After opening your bowels, you have stool habit, anomalies and be rush to the toilet or they can be constipated for weeks at times and the symptoms can be triggered with certain foods, anxiety, stress, illness, sleep disturbances, caffeine, et cetera. The list is endless. But with, before you give them the diagnosis of IBS, it is quite important to always, even though deep down, you know, this is likely the patient has IBS. It is quite important to rule out things like inflammatory bowel disease because that also presents with for some patients like Crohn's with abdominal pain, bloating, change in bowel habit, et cetera. And you always have to be uh thinking of other causes like bowel cancer, think about celiac disease, even ovarian cancer and pancreatic cancer presents in its weird and wonderful ways. So always think about excluding the medical, the other actual medical treatable causes. Before thinking about giving the patient the diagnosis of irritable bowel syndrome, which means that you have to do investigations on these patients as well such as so basically the investigations you would do with IBD or even bowel cancer depending on the age. So FBC LFT S, you can do AC A 1 to 5 CRP and TD G. You definitely ask for a fecal calprotectin. What I haven't put here is they often ask for a stool microscopy as well, especially if it's a more diarrhea like symptoms. Um The nice guidance is that I have just copy pasted this from D I. Pretty much before I started this. You need at least six months of abdominal pain or discomfort with pain and discomfort, relieved with opening bubbles, bowel habit, anomalies and stool abnormalities. And they also need straining and urgent need or incomplete, emptying, bloating, worse after eating or passing mucus. And I think, um, if these patients still come to you with saying, oh, I can't find any identifiable trigger for my symptoms. It feels like IBS but I don't think it is IBS. You always have the option of referring them to Gastro. It may not be the two week rate. It might be the standard weight, wait time for uh to be seen by gastro. But if you can't, don't, you're not quite persuaded by the fact that it's IBS and you still think this patient has had some negative fecal calprotectin, but I still want them to be seen by a specialist. It is always very important to refer them because there are other diagnosis that cause um, similar symptoms which I haven't really gone to. But it's, um, what was it called small bowel bacterial overgrowth, which can be treated with? I think four or five day course of metroNIDAZOLE, I think 3 to 4 times a year you could have bile acid malabsorption, which has its own type. So, basically, bile acid malabsorption is when your gallbladder does not absorb bile acids as effectively anymore, which can also come with abdominal pain, bloating, worsening on eating, diarrhea or con diarrhea, constipation, et cetera. And you have no identifiable triggers. And so those are, there are scans you do for those for. So you have for small bowel bacterial overgrowth. You send stool microscopy or stool cultures for bile acid bowel absorption. You do ac a test if I remember, right. So yeah, you have a lot of other causes as well. So IBS is truly a diagnosis you give if there, there's nothing else ca nothing, nothing medical actually causing the symptoms. Well, basically, nothing actually treatable. So for IBS your lifestyle, conservative management is you maintain a food diary at first for a couple of weeks to identify your potential triggers. Although fod map diet, you don't need to exactly know what the fod map diet entails because this is very dietician l but just to be aware of it, you can adjust your fiber intake according to your symptoms. So if you're having diarrhea like symptoms, you can increase your fiber. If you're having constipation like symptoms, you ask the patient to reduce their fiber intake, et cetera, sometimes not particularly doable thing to reduce stress and to limit your alcohol, caffeine fatty foods, et cetera medications, you can prescribe some of these are available over the counter mebeverine, highosin butyl bromide, other think that's known as paco and peppermint oil. You can give out antidiarrhea medications like leam or bulk forming laxatives like this, like cusk and yes, that's it. That's my long rant about lower gi symptoms. Does anyone have any questions? I'll try my best to answer them. Yeah. Feel free to pop, uh, your questions in the chat. Um, yeah. Uh, I guess we'll, we'll get a few minutes for people to talk to questions. But uh in the meantime, thank you very much, Doctor Senior for uh um teaching us about lower gi conditions today. And um if people, you can fill up the feedback form that I've just sent out. Uh Yeah, I if you can fill out the feedback form, that would be really appreciated.