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So our first talk uh is gonna be by Mr uh Samuel. Oh Sam. Uh Bipolar is a consultant surgeon at Colchester. And uh he would be talking to us about history uh taking an investigation in the Collective Clinic. Thank you very much Sam for your time and for your help with this. Uh Thank you very much, Mona, I shall take that back to the starting slide. Um Yes. So my topic is history taking in investigations in color proctology. Uh and Samuel Addict Bowler has most kindly mentioned. Um currently working newly appointed that cultures to hospital or East Suffolk and North Essex uh NHS Trust. Um I did my postgraduate research at ST Mark's um and Imperial. So, um the objective of this talk, I'm not going to try very hard not to teach you how to suck eggs. So, um it's very clear that all of you have a good understanding how to take a colorectal history. Um But what I thought I'd bring in was slight nuances that have learnt towards more senior training um that sort of refines uh the history that we take. Um this is more to set the theme as it were. Um And we'll come back to this right at the end. Um So this is a perfectly um, you know, common scenario, new registrar and clinic. It's three year old gentleman with a two week wait referral. Uh It's from the plastic surgeons. It's actually a real case. Um Chaps recently undergone excision of subcutaneous mcglynn malignant melanoma from his right thigh earlier this year. Um And he had a follow up imaging which demonstrated to avid lesions in his colon. Uh And you're, you're doing a telephone consultation, come back to that at the end. But this is more to talk about the thoughts that we go through when we assess. So the objectives I'm going to hopefully try and cover um start obviously with a structure um from medical school days, we all know about history of presenting complaint, past medical history, etcetera, etcetera. Um And then talk a bit about colorectal symptoms. Um touch and communication history taking is virtually that uh and then examination investigations, which is the other aspect of the talk and hopefully uh leave you with a few conclusions or take home. So, um why is their structure required for a history? Um I guess this facilitates um routine, we can get lost by the situation and having something to fall back on allows you to carry on in all sorts of environments as it were. And it ensures that important stages and information is not overlooked. And so what do I mean, we all know this, we do it instinctively. So we read the referral letter, we look up the previous clinic letters and old notes. You determine the purpose before you actually start the consultation. Hopefully. And then there's key aspects within the consultation that that one's working on. You, introduce yourself, you're trying to develop rapport, you're hoping to put the patient and the family at ease that they're present, that you want to explain the process of the consultation and then go on to take the history, perform a relevant exam. You want to come up with a decision, um or an action plan. You discussed investigations and potential treatment, alternatives and complication, consenting. If required, you want to allow time to answer queries to ensure that that the patient's ideas concerns and expectations have been met. And then, you know, you conclude in some way and there's some entry in the notes and it is important to remember that all this is done often in about 20 minutes and the complexity of the case can also change the nature of how one finds this these various steps. We we are very much in a new era, the alternatives to face to face consultations which have to be born in mind because they then change the the way that the consultation is and and this is a busy slide. Um but it's mainly to highlight that the the key different platforms. Um so telephone text, email online portals, um the sort of virtual consultations and, and the fact that that there's advantages and disadvantages of, of these new platforms and, and they can be seen very much from the perspective of the patient and the family and indeed from the services. But the fact is that they certainly bring a lot of um improved means of assessing patients' and, and they certainly appear here to stay. Um a common um uh thought about these newer platforms of assessing patients' is that a lot about body language, which um is crucial in communication is potentially lost. And there have been some concerns as to whether or not these platforms may affect good consultation, which then instinctively leads one to, to try and understand what determines a good consultation. Uh And various studies have looked into this and, and in summary, essentially, um the patient's perception of being taken seriously is important, giving an understandable explanation of the symptom, applying a patient centered care. We all know about shared decision making um offering some degree of reassurance and, and offering an idea of what can be done. And you can see on the right side of that slide that these are all readily achievable in remote consultations with an appropriate structure that essentially mirrors the one that I spoke about earlier. And so when we look at history taking, um there's the technical versus the nontechnical and um we will all be very versed with the technical which are the aspects that we've learned all through med school and junior training, um which is the relevant questions uh related to the symptom. Um But understanding the nontechnical skills and how to personalize this to the patient becomes the journey of learning that we often embark on in higher surgical training. This element of effective learning sort of understanding what's form surgeon you become, how you managed to do all those things we described in the structure within the time allocated and still develop rapport and leave the patient feeling like they got what they had hoped for from the consultation, which then leads us to this refined understanding of history taking versus report building and personalized medicine, sort of understanding the impacts and goals of treatment and decision making, what patient's are willing to trade and what risks they're willing to take on. And then it starts to help us understand that the history taking. Actually, it's more of an art rather than the sort of technical list of queries that we ask. And most of those actually will be addressed in this very well designed course, which goes through a lot of breath of colorectal disorders and some of these outline here. So the specific symptoms, the technical we know about the gi system's abdominal symptoms, pain, I won't sort of, you know, go into Socrates because I know we all know that alterations in bowel habit, it's very important to understand what the patient actually means by constipation or indeed, diarrhea, understanding what normal is and how their, their habits varies and the impact on their quality of life as a result. Um, rectal bleeding, the, the context with which you're, you're discussing rectal bleeding. Is this a young patient? Is it bright red? Is it after defecation which comes with its own sort of diagnostic potentials or is this, you know, you're sort of more elderly patient, you know, where you're thinking malignancy obviously, and the need to exclude that. And then there's the more sort of anal and perineals symptoms which require a fair degree of experience, um an understanding of the different disorders because remember a famous quote that the mind only the the I only sees what the mind nose and and so unless one is actually um carefully trying to discern the various disorders, um the questions can sometimes not necessarily yield um the underlying problem, um prolapse um is obviously another symptom were aware about evacuate ori symptoms, which can be quite difficult to define um or ascertain when, when, when conversing with the patient. Um the importance of delving back to obstetric history and understanding the length of duration of labor as well as potential injuries also potentially have an effect on the pelvic for all later on in life are all key factors in the so called technical that were talked about and uh pretty much available in every textbook. And I'm sure a lot of uh lectures will will go into some of these when they're discussing the specific disorders. Um but then there's the non technical and the so called para technical that some people like to define it as and, and the key roles of communication um in understanding how to ascertain these key elements that are required uh to establish a diagnosis, the decision making your situational awareness. When are you doing this clinic? How are you doing this clinic? Um Is it you're covering for someone? Are you aware of practice? Is that the consultant does, what is the infrastructure? These are all things that come into your your decision making us to do more investigation, you're going to order. Uh and also in trying to actually elicit the histories and arrive at a differential diagnosis. Um And we talked about performing performance shaping factors as it were that that can be um related to the individual um the system. So are you doing a telephone clinic? Is that a virtual clinic? And that the case I discussed at the beginning becomes pertinent at the end? Because having a heightened awareness for, for various sorts of pitfalls potentially um can put you at a better position um to make sure that you, you get the right um uh story as it were and the impact on the patient. And so communication uh approved pretty crucial as one of these non technical skills, you're trying to elicit information, you're trying to develop rapport, you're aiming to put the patient to the ease. And you also crucially um communicating with other members of professionals when, when you're writing your letter, um you know, collating the findings that you've discerned. Um and, and that information is to oneself so that you can look back at your clinic letter and understand to the G P the next outpatient doctor or the physician caring for the patient. And indeed our responsibilities um you know, as part of the hospital and indeed in law, so when things reach the the sort of complaint or medical legal aspect, then one's record um proves quite crucial. Um And then moving on to examination, communication again, pretty crucial um for the colorectal examination, why these are intimate exams and much like the the stories. Um people don't often volunteer some of these sort of personal um histories is easily unless that key aspect of communication and letting people at ease such that the guards can be done and they can actually volunteer that the crucial concerns they have. Um they often abbreviated your exams in clinic, but one should be fully um cognizant of the complete and full extent. And when one needs to um you know, employ this uh in clinic if not routine, um there's also specialist examination, so your your proctologic aled disorders, um sometimes you're needing to do a proctology or um rigid sigmoidoscopy. And there's sort of more novel techniques which I'll discuss in a letter slide. Okay, um, your investigations are then based around your infrastructure, uh, the resources you have available and your knowledge of the information you've been given. Um, and then also, um, bringing into factor the patient that you're dealing with it, they able to, to undergo the investigations that you're suggesting. Clearly this is less pertinent for some more routine hematological investigations. We need to bear in mind various other conditions that might be associated with, with symptoms that patient's presidente with. So things like diarrhea, important to think about celiac screens, thyroid function tests calcium. Um and with anemia, getting iron studies, etcetera. Uh And then with the stool studies, as we know, um you know, fit is um pretty much revolution allies um uh cancer pathways, um fecal or less stays, um fecal calprotectin are also useful in trying to delineate um colorectal disorders. Um And then we come to the more invasive form of imaging, the Luminal form which assesses um the colorectal organ as it were. And we're fortunate that over time, we're getting more and more advanced in the ability to do this. And with the advent of digital and A I, um some of these systems are even becoming more automated um to allow these disorders to be discerned almost without a clinician input. Radiological um Imaging is also coming along um pretty well in, in line with the digital revolution. So we see thi it's usually used for abdominal assessment staging. Um We have MRI which can be used for the abdomen as well. Um And indeed, the pelvic floor and the perineum um and do anal ultrasounds very commonly used in Europe and increasing traction. Um Here in the U K, although MRI tends to be the preferred gold standard and then we've also got your contrast studies, propped a grams, um various um use in discerning um functional disorders. Um as indeed as the colonic transit study um in erectile physiology, I think Annabelle will probably touch a bit on this um as she goes through some of the functional disorders talk, but it's often a more specialist investigation. It's not always available in all trusts. Um but it gives a good understanding of some the function. Um The evidence is to how uh reproducible or indeed how these correlate with treatments um is variable um and can be its own talk in itself. Um And then we have examinations under anesthesia. So either your laproscopy for abdominal evaluation or more commonly um uh for evaluating the Parini. Um We it's not uncommon that the patient might have to have an in the examination on the anesthesia. Um either due to restrict examination, secondary to pain or body has habitants or just not being able to tolerate um the examination in an outpatient setting, um which brings me to my sort of take home and, and this was something that initially came on as more of a chore. Um while I was doing my fellowship. Um I know she won't mind. But MS Vaizey, a pelvic floor surgeon who I work with as part of the firm would, would ensure that the registrar would always have a full clinic prep for all the patient's um that we're going to be seen in that clinic and as tedious as that potentially may have been initially, um it's completely revolutionized my initial practice because I, I almost cannot attend the clinic now without doing the prep, just because of all the different informations that one cannot ascertain before starting the clinic. And I have certainly recommended to those who don't already do this. Um which brings me back to the case that we started with. Uh you're seeing this 83 year old gentleman, we've been referred by the plastic surgeons and clearly, you know, everyone's thoughts here would be a scope, you know, discern what these um uh lesions are. But then on further uh going down into his history, which was done prior to the clinic. Um and none of it available really on the referral letter and a bit of digging. Um it was understood that actually this gentleman is a bit um more co morbid than the referral letter gave the impression of his bed bound. Um uh Then the consultation completely changed from one where you're just asking a series of questions to try and get a colonoscopy to one where you're trying to actually work out what the performance status is what goals of treatments are assessment burden and the morbidity of the investigations. One might uh do a gentleman with these symptoms or with this presentation. And it also dealing with an emotional trauma that he developed uh secondary to colonoscopy because his wife had passed away following a diagnosis of cancer on, on a colonoscopy. And so I thought that was a good snapshot which hopefully helped encompass all the various um skill sets um that we develop as higher surgical trainees such that we're not the stereotype that people might assume um in terms of looking for um the organ in question that we need to cut out, but more facilitators of patient's true choice. Thank you very much for listening. Thank you Sam. That's a great overview. And I think it is important to remember that history taking is absolutely more of an art than a science and it is so important to understand all of the different pathologies to now you to allow you to focus your history taking. Thank you Sam. Um for the interest of time. We'll move for the next talk, but we have some questions uh coming on the chat, Sam, if you would like to answer them as well. Um So our next speaker is Mr uh he's a consultant collective surgeon. Um uh He will talk to us today about managing uh colorectal cancer in the clinic. Obviously, it's a very big topic, but I'm sure uh summarized in a very good way. Uh You can join us now, the only into some technical issues with uh connection. Thank you. If we have any issues with the connection, whilst Chi is getting things set up, we can always move on to the next tour. All right. So remove it and uh we'll, we'll try and sort out the connection with. Uh our next speaker will be um Miss Annabelle Williams and uh thank you for joining us today. Uh We will uh have a talk about the uh management of uh function disorder constipation audience and fecal incontinence. Thank you very much Annabelle. Sneak, sneak preview. Sorry. Hello, everyone. Uh Sorry for the informal surroundings. I am in my old bedroom because I'm at my parents because I'm on maternity leave. Still don't have an office. So, um I just thought hopefully this will be a useful but very quick dash through of a very, very large subject. And I will apologize now for all the worthiness of my slides. I find trying to jazz these types of talks up quite difficult sometimes. And I think sometimes you just have to suck it up a little bit and learn, learn something and remember some things rather than look at pictures and things. So especially when you're starting out. And you know, if you're based with these sort of complex patient's uh in clinic for the first time when you're often the first person that they've seen when they were sort of referred 10 months ago and you're, they're finally seeing someone and then they walk in the room. They're like, oh, you're the register are not the consultant. At least you can get a very good grounding of where to start before you go and Harang your boss about what to do next. So very quick run through. So I was given two topics. They are grouped under sort of what we call functional bowel disorders. So, basically disorders of the gut brain interaction without any real detectable biomechanical abnormalities, often due to motility disturbance, a visceral hypersensitivity, alter mucosal, an immune function, altered gut microbiota and also altered central nervous system processing all sounds very medical and a lot of the treatment is conservative in its first approach, but that doesn't mean that it is not active. A lot of the references and a lot of this is um found in the Rome. Uh If you Google the Rome criteria or room for, it's a consortium of uh specialist and experts, you come together periods of time to try and come to an expert consensus about treatment for these complex disease uh disorders. And there's a lot of extra information. Uh uh so quick case. So we've got a 65 year old lady complaining of hard stools, they're very hard to pass. She's not going as often as she used to uh lots of lethargy, bloating fullness and all sorts of other overlying symptoms that she's contributing to her bowels, doctor and constipated, tell me why and fix it and she wants an answer now. So as with all things in medicine, we sort of start off with the definition. However, the definition of conservation is actually quite difficult as it's quite subjective. But the room for criteria try to come together with a sensible definition, which includes the following isn't limited who is usually difficulties of defecation, infrequent bowel movements less than three per week. And at least 25% of the time hard or lumpy stools, excessive straining, difficulties with a sort of evacuation strip blockage and often the use of an annual maneuvers to facilitate evacuation timing is important. Acute versus chronic. The acute symptoms often last very short time and they usually precipitated by sort of a big life event and but systems that persist for more than three months and you're approaching chronic territory, which unfortunately is very common. 15% of the general population with prevalent GI condition that GPS and one of the most common things we see in hospital and it's really common in elderly females who are hospitalized with psychiatric disorders from low socioeconomic groups obviously could be all of those things or just one of those things and has multiple causes and presentations. The most important thing is the history with the sort of pelvic floor slash functional disorder patients'. You have to listen to them, you have to give them time. Registrar clinics are usually quite good for them because you have less people booked in. So you have more people per um you have sorry, you have more time per patient so often you are the best resource of getting a really good history and really honing down into what their problems are and their expectations are and what they're trying to get out of the interaction. So most things you need to know is what do they mean by constipation? So you have to establish what they're normal. Was, was it last week or six months ago or a year ago or was it 10 years ago when they thought their bowel habit was normal versus what it is currently? Um Always ask about childhood constipation. That's got a really high correlation with guts function later on in life, especially in females. You need to really delve into their defect, a Torrey pattern. So do they actually get an urge to go? How often do they go? What do they pass? I regularly get out pictures on Google, images of stool types, the Bristol stool chart. Everyone giggles. Everyone thinks it's silly but it helps um to really sort of hone in exactly what they're trying to say because everyone uses euphemisms, everyone's embarrassed and ultimately, you just need to try and put people at ease and make it as easy as possible. You want to know about the number of successful visits. Like, do they go to the toilet every time they want to go to the toilet clustering. So this is where they go back and forth to the toilet and really short time. So passing small amounts of stool, um, sort of in succession in should of, you know, sort of five trips to the toilet within an hour instead of just sitting there and emptying in one go incomplete, emptying. Straining. How long do they actually sit there for? Do they get what we call post Epic A Torrey soiling? So they'll go to the toilet, they'll stand up, they'll go make a cup of tea an hour later and then they'll noticed um soiling in their underwear and also other forms of fecal incontinence. There's a lot of overlap between the various funk of various functional disorders and you need to cover all of them because you need to try and ensure that you're treating the right thing associated symptoms really important. So, bloating, crane nausea, vomiting, bleeding, because weight loss and appetite loss, dragging sort of pelvic, heavy sensations and feelings down below lumps, bumps or masses that they may be complaining of issues with alternating diarrhea and also consider other systems that are involved in the pelvis, especially. So urinary symptoms to ask about urinary incontinence frequency pretension recurrent UTIs and also um in in women, obviously, Gynie concerns such as feelings of prolapse, Volvo irritation, uh also covering us. Um this priority uh sorry, pain during sex. I can never say that word. I'm afraid and also how it's affecting their sex life and also what, how it's affecting them on a day to day basis along with sort of activities of daily living and how they function on a day to day basis need to ask about a junks use. So, digit ation. What they put, where, which hole and when, uh, splinting of the peritoneum, how they do this? Do they use tools do they use, especially design devices that you can buy on Amazon rocking maneuvers, different acrobatics on the toilet. Believe me, I've heard everything. Uh positioning uses of squatty potty and other things that used to help them go. So and then there's the other bits which really help nail down what the causes are. So past medical history, specifically looking at other medical conditions like diabetes, neurological disorders, like Parkinson's and psychiatric disorders, including eating disorders as a teenager or young female, especially affecting mainly young females. Um Any previous operations, drug history is really key here. You'd be amazed what can cause constipation. And the list is as long as my arm, most common ones we hear about our obviously opioids, anticholinergics, um iron supplementation and various types of antidepressants. Obstetric history is always important, especially just looking at instrumentation and injury. So you can assess for sort of possible neurological impairment and obviously social history is really key to all of this. So what's their employment status? What do they do? A living situation that they supported. Do they have family? Do they have friends there? Smoking and alcohol and diet, sexual abuse is really important to try and elicit if they feel comfortable enough to, um, inform you of that and you can explore that from there. Uh, if you're not, if you're the first person that they've ever told, there are things that you can discuss with them about going through safeguarding in your local hospital and the policies that surrounding it's worth contacting your local adult safeguarding um specialist. If you are dealt with that situation, you've not dealt with it before. That's a whole topic on itself. But it, there are useful resources within the hospital and obviously family history is really important about cancer. And IBD as two examples moving on to the examination because that's also very key. So you look at their behavior, their B M I who come with uh assess for global lymphadenopathy and their fitness of surgery, look at their abdomen that you were doing an exam, you know, distention, pain, scars and masses examination of the perineum. I have a chaperone with me for all examinations, be the male, female left, right or whatever. And that's to protect me, I think more so than anything, um, complex, uh frustrated, angry, uh upset pelvic floor patient's have a notorious, unfortunately, sort of a notorious um shadow that can give them of sort of high litigation rates. You know, if the management expectations on or if expectations aren't managed appropriately. I think it just helps keep everything professional, keeps, help everyone protected. And I always documented in my letters as well that there was a chaperone present. Um, and right on my computer notes too, just to make sure that everything is covered. So that patient is happy and then I'm happy. And when you're looking at perineum, you look for skin changes, excoriation, dermatitis, like the skin tags, look how the pelvic floor lies. Look at the anatomy doesn't look normal. Is there a in escaping open? Do they have any evidence prolapses masses? Make sure you look in the vagina as well for women. I'm not suggesting you necessarily do a by manual or a vaginal exam or a speculum exam depends how comfortable you are, what your expertise are and what your um your, I suppose your consultants expertise are. I do occasionally do vaginal exam chaperoned. Um just uh and it's mainly to assess for rectoceles, etcetera. And that's obviously with explicit consent from the patient. And also I liaise my gynecological colleagues quite closely. So I feel I'm covered from that point of view. I'm obviously not looking for specific gynecological diagnosis, but if I was concerned or so something I wasn't happy about, I would obviously refer on urgently. I always do um uh rigid sig plus minus proctor and proctoscopy, which is often actually the more useful one, rigid cigna mainly for looking further up in to look at the health mucosa of the rectum and see if there's anything obvious at the upper record. Um But proctoscopy is very useful for looking for prolapsing mucosa and interceptions, um, as well as hemorroidal assessment. So, investigations, key take home message here is you have to prove they don't have cancer. Basically, hopefully, if the system's worked well and a lot of these patient's have probably come through well, it doesn't necessarily mean it's worked well. They've come through the two week wait pathway. They perhaps have some form of investigation to exclude cancer, but they have ongoing problems with constipation or they're not settling with simple measures that GPS settles, uh often they then get referred back in and it'll sort of say this patient who went through the two week trial pathway and had a normal colonoscopy two months ago, then you can be fairly happy that there's nothing going on in their colon. I wouldn't re investigate them if I didn't have to, you need to try and use some sort of nuance about, uh you know, test resources and what you're going to put the patient through as well. Is there really any need to put them through another test which is unlikely to have changed in two months time with a lot of the investigations in the history, you're trying to find out if they're constipation is due to a motility problem. So what we classically cause sort of a slow transit type constipation or is it actually evacuated. Evacuate ori problem. Are they, is there colon working fine? But they just can't empty so they can't get the stool out. So, is there an outlet problem? And also trying to look if there's a treatable or manageable sort of reversible cause where if you manage that separately, their constipation would improve and even if you have to treat them for their constipation, while you manage that to get their symptoms under control, hopefully, in the long term, they're constipation will resolve and they won't need treatment for that specifically if they manage their condition well. So there are various tests listed here and it sort of depends on what your suspicion of other problems are and what they've had done in the past and what's been done recently. So I have put fit and fecal calprotectin on there. Um, Luminal reviews and biopsies, I think it depends on what you're trying to exclude specifically and what the age of the patient is as well. I'm a great believer in a flexible sigmoidoscopy in a simple CT scan in the frail, sort of 80 year olds who come to see me, but don't think necessarily putting them through colonoscopy, bowel prep and A C T C and all the maneuvers on a CT scan, er, it's necessarily in their best interests. But if you're trying to demonstrate that there's nothing organic wrong with them, they're two quite, there's quite a nice combination test too. Give you a good overview of what my or may, may or may not be wrong with them. Um Imaging, as I said, standard CT scans with contrast or a C T C. So, CT colonography, very good test. Um uh True constipators won't have good bowel prep for a colonoscopy, which of course is key in order to get a decent colonoscopy for an exclusion purposes to prove that they don't have any minute polyps and if they don't have good clearance and if they have a lot of pain as well, a colonoscopy is really not an ideal test to put someone through so often. Um uh The CT colonography is a good, good option for that. Uh We can talk about specific things, specific tests for constipation outlet obstruction. So colonic transit studies, which are sort of the X rays shape tests that do you have a look in Google and each hospital have its own protocol, but usually patient's have to swallow some sort of capital with some, with some plastic shapes in and they'll have either a series of x rays done on day one day, three and day five or they'll just have one on day five. And you can look where the X ray markers were and where, whether they've passed out. Now, purists would say that that is actually a marker of whole gut transit, not colonic transit. And there's a whole debate about their usefulness and whether actually they sensible investigation or not I think there's sometimes useful for exclusionary purpose is to try and prove it's definitely not slow transit. Um But I think that's nuanced depending on the history, uh photography, having word problems today um is a nuclear medicine test which is a much more accurate uh than a clonic transit study. They're, they're fantastic tests, but they take days to perform and patient's get scanned regularly over sort of, you know, 72 plus hours. So they're usually only used in research capacities or it really big centers um where they can do them. So big tertiary referral centers and university hospitals where they've got big nuclear medicine departments, uh defecation, propped, agar. A fee is really important to the defecating Proctor gram, really good for looking for outlet obstruction type patterns or trying to decipher whether there's any anatomical issue is why the patient cannot, who basically and what their mechanism is and how their pelvic floor works. And in conjunction with them looking for small bowel descent, perennial descent, the interaction of the, the anterior in the middle and the posterior compartment, looking at bladder vagina and uterus in women, obviously. And then the rectum and seeing how that all works as one or not in most of the cases, um they can be done in various ways. So some people have access to MRI proctoscopy where the patient lies down and has gel, put up their bottoms and they're asked to bear down which of course, is quite difficult. I think trying to pool lying down is quite difficult person. They not that I've tried. Um And some people would argue that it's not the best test because it's not very, it's not representative what we would do on a daily basis, but it is very good at giving you views of all three compartments in one go. The classic uh sort of fluoroscopic uh propped a gram where you have sort of a barium type porridge paste, put up your bottom. You also have some contrast put into the vagina often and you can also have some contrast to swallow. So you can see the small bowel too, so you can get really good views. They sit on the commode and basically have x rays taken. You have to have very good, very tactful regula gee stuff you very experienced with this because of course, this is probably one of the most embarrassing test patient's can have done. They're often quite grateful to have something done. Those, they're usually willing to put themselves through it mainly because they want answers. And if you've been at the bottom of the waiting list for almost two years or some ridiculous waiting list, time for benign conditions, most patient's will do anything. And which is a sad reflection on the waiting list times currently. But there you go. Um Last testing thing that we would probably consider is an erectile physiology. I'm afraid I do not have time in a 20 minute talk to go through this. But um there's um if anyone wants more information, I can give you some references for it, which I haven't included this talk, but I'm happy to be contacted. Uh It's basically um wart cath balloon that is put up into the anus and will give any rectal uh physiology will give squeeze pressures, resting pressures. You can also do other tests, like look at rectal sensitivity. So you can fill the balloon up and see at what point the patient gets the urge to pu if they, if they get the urge period of really low volume, they've obviously got very sensitive rectum. And actually, you can train patient's out of that bit like building muscle. You can build a rectal reservoir with time and very good biofeedback nurse and the right equipment. And um we can also do something called the balloon expulsion test, which is a useful tool at looking for something called an is mus, which is an outlet obstruction disorder where you get this in a genic movements of the pelvic floor in the anal sphincter, things don't relax and contract in the right pattern to allow expulsion of stool. And therefore, if you have an abnormal balloon expulsion test, that is a very useful tool. So they're the investigations. This slide is horrible and I'm just gonna leave it there, but it just shows the myriad of secondary causes of constipation that you need to exclude before you label someone as a constipated patient's as a sort of an idiopathic primary constipated patient with no cause that we all know identifiable cause in the current understanding of the literature and the body and anatomy as we know now. So it's a very long list, just the medication list is really long. So these are just things to be aware of and why it's really important. Uh So primary chronic constipation, which I think is where this sort of the functional bowel stuff was going for. So last three months with onset at least six months prior know, organic gastro court, gastroenterological pathology or secondary cause uh using this room uh for criteria is then sub classified into four different types. So functional constipation, which has the main definition of those things we discussed at the beginning. So hard, still difficult, evacuating, digit ation, etcetera, etcetera. Um IBSC is the I B S constipation type where they have those symptoms, but they also have the overlying of I B S type problems. So, bloating and pain, functional constipation is not painful. So they are two distinct things. Opioid induced constipation obviously is secondary is caused by opioids. And that's a whole separate thing because there are different medications and different treatment strategies for that individual and then functional defecation disorders of the things I briefly spoke about. So things are like and um this discogenic um movement of the pelvic floor that doesn't allow ex ex doesn't allow stool to come out. Um So n is Mas's the classic one that people see most commonly. So treatment very briefly treat or reversible causes because that makes sense, lifestyle advice and behavior change. This is the key. A lot of toilet ing habits become very ingrained in people and then it becomes almost like a very learned behavior which you then have to unlearn and because toilet NG is so integral to who we are as human beings because everyone eats, everyone has to pu regardless of what people say, everyone fart, you know, everyone has these metabolic actions that have to occur. They can become very sensitive, habitual ingrained. Um almost a bit sort of OCD like behaviors that people then get stuck in sort of cycles which they can't get out of because they've done one thing one day and that works. So then I must do that the next day to make me put 11 o'clock every day on a Tuesday because that's when I have to pu and unlearning. That behavior takes a lot of time and is very difficult. And unfortunately, in this day and age with the NHS, a lot of it has to be self directed and patient led because we don't have all the facilities. Not everyone has a wonderful biofeedback nurse who can help patients' with all of this um laxatives. There are many. So the standard osmotic stimulant, softeners, uh secreta dogs and things like that. Uh Bactine Allied, which I can't pronounce either. Oh, gosh, sorry. Um, the, um, but they work, uh, there's sort of, there's sort of the next stage up of laxative treatment. Uh, the five ht four agonists are Prue Cala Pride, which is licensed for both men and women. So, if you've tried two or more different types of laxatives is, I think the three months, um, and it's not worked, you can then have a 28 day trial of callup, right? To see if that works. All a stat. Uh the weight loss drug is shown very good use in patient's with BMS of over 35 constipated because they can have it for weight loss. And it's main side effect is for sort of fat malabsorption and diarrhea. So it gets them going so that um I know some marks have had some good um results with that peripherally acting uh new opioid receptor antagonist. All these Paramore A Z are these new drugs on the block called uh an example of which is Naloxegol. And they're specifically for patient's who use opioids regularly and they help prevent the constipating side effects of the drugs that they need for their pain requirements. Suppositories and enemas, trans anal irrigation, biofeedback. As I said, this is sort of a usually a nurse lead a therapy. You have a series of sessions they go through um progress with you. There's often also some counseling involved and you have a uh you do diaries, they do reflections, they do other forms of training with using the anorexia physiology monitors. And it has a very good um evidence base and success. It's just very resource intensive if you need a very qualified senior nurse, usually to run it. So unfortunately not every center has one. Surgery is way down the list as you can see right at the bottom. Um, surgery for constipation is, is going out of favor. But primary constipation, if there is a prolapse there that needs fixing, you fix the products and treat the constipation as well. Um You can have uh intramuscular Botox into the puborectalis for an isthmus to try and help relax that and get your sphincter coordination better. Uh sacred nerve stimulation unfortunately, is no longer licensed and no longer funded for uh constipation. Although there are some centers in the UK that still do it due to whatever regulations they have set up in there trusts. So you can have submental colonic surgery. It colectomy with an ira stoma formation and ace formation is where you have a appendiceal stoma and then they can put anti grade enemas down there. And that's your sort of bound management system a bit like a high or you can put high volume irrigation through it. More common in Children. They do not work well in adults and they're not very common, but surgery is very low down the list for conservation. There's whole um There's a wonderful series by Charlie Knowles. All about surgery constipation. It's all free access. One of the references I think is at the end and if it's not, I can, I can provide it if people want it. Sorry. Moving on as quickly as I can to case. Two and a 55 year old female complaining of the following, uh, fecal accidents once or twice per week. She got caught short at the supermarket and had to run home. Highly embarrassing. She now never wants to leave the house and she's missing out on all her social activities. Absolutely horrendous. And I can't live like this doctor fix it. So as with all things, she's describing what we call as fecal incontinence is the involuntary uncontrolled passage of fecal material chronic is debilitating, leads to a lot of anxiety and depression, social withdrawal and isolations and especially in the younger female population, you have had fecal incontinence secondary to a traumatic birth. Our birth rate is quite low already. So, you know, it's, it's reducing the babies being born. Um, it has a very large economic burden, very common in female and the elderly's and it's one of the main reasons for nursing home admission. So again, what do they mean by incontinence? You have to really drill down to what they're having. So how many accidents, what they're passing day night? Do they wake up with it? Try and drill down to the type of incontinence is the passive or is it urged? Can they hold flatus or not? Again? Looking at urgency frequency, what are they actually passing cause that's really important? Um Do they have this normal successful toilet visit? And then incontinence later on? Do they get these clustering episodes as well? Do they ever feel empty? Do they have to strain sometimes as well? How long do they sit there again? Post Africa, Torrey soiling. Do they have constipation type of structure of dedication symptoms? We also look at all the associated symptoms, especially um urinary issues are really key as well as the prolapse type symptoms. So, dragging feelings heavy in the pelvis, vaginal problems, uh female patient's and obviously what adjunct do they do? So what do they wear pads? Do they carry clothes everywhere? How they had to change their day? Have they had to give up work? Do they now have to work from home? Uh Can they carry on their social life? Can she pick up her child without soiling herself from the floor because bending down and gravity and not her friends. So these things are really important again, past medical history, looking at neurological diseases, um diabetes, um operations previously really important that random hemorrhoidectomy that someone had when they were 22 they then have a birth injury at 34 then all of a sudden at the age of 55 there. Now incontinent, all these things are sort of mounting pressures on their anal sphincter and it kind of starts to make sense when it doesn't start working properly. So these things are really important to know. Uh cholecystectomy is really important to know because bile salt malabsorption obviously affects your stool consistency and it is treatable uh drug history. So specific drugs can cause diarrhea, uh obstetric history as you're well aware, one of the main causes fecal incontinence and young females is uh anal sphincter injury. Uh social history. Would you discussed very important and obviously family history to exclude um uh sort of inheritable causes examination is exactly the same. You have to do everything. What's really important is the digital rectal examination, especially for this because you're looking at perennial sensation, anal tone. Is there a defect in the sphincter, perennial descent? Um Can they squeeze really important? Can you squeeze my finger the number of women? Especially because that's the majority who you see? I do not know whether anal sphincter is by the time they get to 55 is quite impressive. Um You need to know where your muscles are in order to use them properly and often a lot of education and retraining is required. Um Do they have paradoxical amusements to death? Does their pelvic floor move as one in a coordinated fashion or not? Again, prolapse is really important. There's lots of evidence out there to say that if you can fix someone's prolapse, you can improve their continents. So they go hand in hand again, investigations you've got to exclude IBD and cancer. Look through what tests they've had done for. Do you need to do a simple test in order to sort that out first and then try to establish if there's an evacuate ori component? So as I said, do they have an obvious prolapse that's causing their anus to be splintered open and therefore they're incontinent, excuse me. Um, obviously fixing that evacuate ori problem will help fix their continents. And obviously, is there any treatable or reversible causes? I actually had a young female who was thyrotoxic in clinic and we got her, got her TFTs, um, done. Uh, she started on correct medication and actually everything got better along with a few other conservative measures over time. And eventually she was able to stop those once her thyroid function was under control. Um, Luminal investigations and biopsies, especially to help exclude a sort of a colitis like collagenous colitis, uh, that may be causing profuse diarrhea and problems. And then imaging, you may consider colonic transit studies because if you think that this, they're, they're loose stool and their incontinence is actually due to them being impacted, you need to maybe treat the constipation first before you treat anything else. Again, a director physiology is important and endo anal ultrasounds ready for, um, looking at sphincters, um, whether they're intact and which bits are affected. Again, I don't really apologize for this, this slide because causes are myriad and often overlap. So you often have to treat one bit as well as other bits in order to try and help the patient. And it's worth just having a look through this. This is just taken from the nice guidelines from 2022 treatment. If you take nothing from this talk, the best thing to be is to go look at this website, which is the mass ick. It's a charitable organization set up for women who have suffered from birth injuries. The nurse led coping advice and the download of all guides will get you through any pelvic floor clinic you need. And it's a really good resource and I refer all patient's that be the men, women, old women, young women, women who haven't had um obstetric injuries because actually the advice is mainly the same. Lots of conservative therapies, mainly focusing on lifestyle advice, positive behavior change, useful para mide um things to help empty things to help firm up stools, pelvic floor physio therapy is a key um irrigation to help empty biofeedback we already discussed. And there's various other things like PTNS surgery. I've already mentioned correcting prolapses, rectoceles and mucosal prolapse. One of the main surgical interventions now called nerve modulation or say called nerve stimulation. Secondary sphincter repair is not done very commonly and it's on a very selective patient basis. And injectable bulking agents can only be used in research settings. And unfortunately, stoma formations is still one of the main surgical things that people go for. But it can be a great break in quality of life and lots of women are actually very thankful for it. So take home message is sorry, I probably massively overrun and I apologize but you need to define the symptoms. Listen to the patient be empathetic and thorough, avoid prejudging, manage expectations, prevent the cause is if you can. So don't let the really small lady have a really large baby via protracted long birth and then she won't have an obstetric injury. Um maximize all conservative medical treatment and be very and careful selection of surgical intervention and always discuss that pelvic floor MDT. It's key. There are some references there and I can also provide you some more if you want. Thank you, Annabelle. Thank you very much for joining us from maternity leave. The benefits of having a virtual event is that uh increases uh participation. So uh we're now going to uh move on to hopefully Kyle Young talk. Apologies were running a little bit behind time. We will overspill into lunch a little bit. But as you can see, our speakers have been asked to cram so much into their short talk so we can get everything done in a day and they're all very passionate about their their topic areas. So apologies for, for running behind slightly. Thank. Thank you. Just you hear me, we can hear you as well. So that's great. Oh Thank you very much for asking me to do the talk. Uh It is a bit of a poisoned chalice. I've say uh particular mention is there's so much you can spend an entire day, do any topics, try to pick it like it is a challenge. I've agreed to take it on and I heard I'll do this, uh talk Jersey so I can ask to talk about bowel cancer in the rectal clinic, uh consultant colorectal surgeon at country. Um So let's crack on then. It's too 12. No, it isn't though. So, uh I we might uh might turn your camera off while you're given the talk just to improve the wifi signal. Okay. We can use the slides running or uh okay. So I thought the best way to do is before we actually see the patient, it's worth just understanding how the patient can come to the clinic. So the most one way is via the bowel cancer screening program. Uh And you know, all of us need to know a little bit about this uh 64 test. Uh The chest is planning inclusion. Uh uh any uh well, like four months fear. Yeah. Uh It went rift. Yeah. Don't taste like good morning quite. Uh Yeah, I think the thing that is not, is not great. Um So we will uh we will have to, to move to a note to the next talk and then I'll see what we can do. To, to get this done. Uh If we can't get it done, like now we can record it and then put it on the recording. It's stations because we, we can't hear you now. Okay. Apologize for for that. If it's okay, we will move on to Henry Ferguson's talk which will be on interpreting colonoscopy results. Um And we will try and get the talk recorded and added to the website to be available afterwards if we can't get it. Uh, running smoothly today. Thanks Henry. Okay. Hopefully, my uh, wifi is working a bit better than the stuff in Coventry. Let me just share everything here. No pressure. It's all on you now, Henry. Exactly. I got to make it work now, haven't I? Is that working is yet? We can see that. It's excellent. Thank you. And thank you very much for the invitation to talk again. Massive topic. I'm going to try and cram it into less than 20 minutes if I can. So, I'm Henry Ferguson. I'm a consultant colorectal surgeon in Warwick Hospital just down the road from Coventry where we have better, wifi. Um I'll try to cover polyps, bit of microscopic colitis radiation proctitis. And if we've got time solitary rectal answer, these are the things which sort of minor points in the curriculum, but you'd be surprised how much they turn up in clinic. So, most of the cases are pretty similar and I'm sure you'll recognize them. So, a 55 year old chap. So yeah, we lost your screen. So do you want to share it again? One more time? I lost my screen. Right. Let's try again. Why has that happened? Just stop showing and start showing again. It's not chairing again. Sure, perfect. We can see that now. Is that work? We're still there? That's working there. Lovely. Sorry. I don't know what happened there. So, yes, two week wait referrals, loose stools, positive fit test. So I went straight to test with colonoscopy. Had to eight millimeter polyps. Doesn't really matter where they are and helpful gastroenterologist said follow up with histology. Um So a month later we get this back cheaper Latino hmas with low grade dysplasia, completely excised and now they're seeing you in clinic. So what do you do? So I'll draw your attention to this document. I'm aware that we've got a lot of attendees from outside the UK and this is very much a UK recommendation in terms of surveillance. But um it's very much our Bible in terms of what we ascribe to here in the UK. So if you just Google BSG guidelines, Polypectomy, um it will come up. So just drilling down a little bit more trying to make it less tiny font. So you want a good quality colonoscopy. So that goes down into the same as Bells talk. Don't be putting people with chronic constipation through a colonoscopy without extra prep because you want to get the whole way around, see everything and clear everything and really what we're interested in at the time of the uh can I click hide on the pop up on screen? I don't think. And we lost your share ing screen. Was that, was that video footage Henry? Yeah, we can see it. Now if, if you press hide that that you know, not stop sharing, you just press the hide, you know that little. yeah, just press the height so that we can see your full slides. That's perfect. Henry, we've now lost your audio any better. Yes, perfect. Yeah, good. We clearly can't have all three. We can either have video presentation or sound but never mind will persist. Sorry. Um So we're looking at premalignant polyps, okay. So this is everything excluding little rectal hyperplastic polyps basically. Okay. So if we take this forward for that case, we've had to eight millimeter polyps with no high risk findings. So really, despite the fact that you'd look at the patient and say actually, well, you've had a couple of polyps there going to be a bit concerned. Actually, the evidence is they don't require colonoscopic surveillance and that particularly the patient at this age of 55 they're coming up on the bowel cancer screening age. So they should really just participate in the bowel cancer screening program. The little symbol there just after the invited is a little footnote in the guidance which says if the patient's particularly young. So in their forties, maybe and well below the age where uh screening would be indicated that you may wish to organize a colonoscopy in either five or 10 years depending on how you feel. So it's a little bit willie at that point, but as a minority of patients that you're going to encounter, so same case, slightly different pit pattern if you like that kind of thing and the histology for the exact same story, this time has high grade dysplasia. So very very subtle difference, slightly worse prognosis polyp, but again, completely X iced. So taking us back to our diagram, okay, do the same. So high risk findings, we do now have some high risk findings. So this is the type of patient who should have a one off surveillance colonoscopy in three years. Okay. This is quite a change from our previous guidelines where essentially if you had a polyp, you were getting a follow up completely overloaded our endoscopy services. So this is much more evidence based and much less likely to leave you uh floundering in doing normal colonoscopies which everyone likes from a from a training point of view but not really in a service utilization point of view. So move on more exciting polyps, same case, but this time we got a 20 millimeter ascending colon polyp okay, as you can see much larger polyp bigger surface area. And again, Gastro have suggested that I would like to follow this up with histology, which of course I would. Now this is achieved A I don't own with high grade dysplasia, which is completely excited. And actually the gastroenterologist did an excellent job, did it and took it all out in one piece. Okay. So we're moving over from the higher risk findings. Questions to the L N PCP, which sounds for a large nonproductive elated colorectal polyp. And then you can see with histological Arnaut on block excision. Now, this is very significant because what you'll mostly find is that big polyps are taken off in little bits. And therefore, the certainty about having all of it taken out is often not there. So you need to be careful when interpreting this particular type of polypectomy. So for this patient, they've had an R naught on block excision. So they're back down into the surveillance colonoscopy after three years, even though they didn't have uh that even though they had a large high grade dysplastic polyps that really is down to the quality of your endoscopist and the quality of the polypectomy. If we've been in a situation where we'd uh not have an on auto section or it'll come out piecemeal. So the histology just couldn't comment then really you're going to be wanting to have a look in, in a couple of months time to check that it's all out and then keep a much closer eye on the patient. And I would say that in this situation where you've either got piecemeal or something that is genuinely incompletely excised. You're into complex polyp territory. Okay. And I don't know how all of your hospitals work, but certainly within our hospital, we have a significant polyp and early colorectal cancer MDT. Um and these polyps particularly where there might be bits of polyp left behind or any reattempted polypectomy is going to be challenging. We like to discuss them at the spec MDT and it's not just uh cancers that require a colorectal resection, some incompletely tackled polyps or polyps which have been approached in the wrong way, ultimately require reception, which I'm sure you can all agree if you didn't have to have a colorectal reception, you really wouldn't. So even if you find one of these, when you're doing your independent colonoscopy lists, rather than having a crack at it, you're probably better off discussing it with someone who knows what they're talking about either at the spec MDT or at least with uh an experienced colonoscopist. So we don't put patient's through unnecessary surgical procedures. So that's a whistle stop tour of polyps. The other thing that you'll get a lot of is microscopic colitis. Now, I haven't really heard of this and almost until I was a senior trainee. Now, um if you do a colonoscopy and it looks normal, it's normal. Right? Well, apparently not. So there's guidance from, from the BSG that if a patient's referred with loose stools and they have a colonoscopy that they should have right and left sided clonic biopsies to look for microscopic changes, consistent with inflammatory disease. Okay. So this situation, while the patient did not have a significantly raised fit um patient and patient was young and otherwise. Well. So we went for a colonoscopy but random biopsies were taken to exclude microscopic colitis. And of course, Mr Ferguson will be in touch with the histology results as I spend most of my afternoons doing so, what do we look for? We look for two specific types of microscopic colitis. Now, obviously the clues in the name, the bowel looks normal. But when the histopathologist get hold of it, they analyze it and primarily what they're looking for is increased number of inflammatory cells in the submucosa most often limited sites. In addition to that, there can also be a collagenous variant where there's a thick layer of collagen and this tends to be the more persistent of the two. Um They can happen de novo as an also immune phenomenon or they can happen as a result of either excess smoking or certain drugs. So if you get a patient who's histology is suggestive of microscopic colitis, it's a good idea to revisit that symptomatology as sometimes this can just be a transient phenomenon and settle without treatment if however, they're still troubled. And some patient with microscopic colitis can have quite dramatic symptoms. There are some simple conservative measures. You can pursue So, asking them to stop smoking, asking them to consider stopping any non steroidal anti inflammatory drugs that they may be taking. And also interestingly asking them to consider stopping proton pump inhibitors is both of these can be underlying causes reasons for microscopic colitis. If after those simple measures or if those meds are present, you may wish to consider uh steroid treatment. My personal preference is to go for a more gastrointestinal specific steroids such as be desonide rather than prednisoLONE. And really, if you're starting to uh if you're going to start people on a on steroids for an inflammatory bowel disease, you really ought to be referring this patient on to gastroenterology. This isn't something we should be um continually managing in surgical care. There's there's no operation for it. So the thing which is slightly more amenable to surgical input is radiation proctitis. And while in the books, this tends to be a condition that affects men who had prostate cancer, radiotherapy. Let's not forget women who have been through a pelvic oncology as well. So this case is a 50 year old lady with a two week wait, referral for rectal bleeding if it was very strongly positive at greater than 400. So I had a colonoscopy. She had this past surgical history of cervical cancer for which he's had radical pelvic radiotherapy. So on colonoscopy, everything else was normal. Aside from, as you can see here, these areas of attenuated uh mucosa but with significant neovascularization and Thailand ectasia is very typical of the findings of radiation proctitis. Now, a lot of patient's will actually be happy but they don't have cancer and that will be enough. And really any intervention for anything, but particularly for radiation proctitis is based upon, first of all how bad it looks and secondarily and actually, most importantly how much trouble the patient's in. So as you can see this grading, um system ranges from really no symptoms through to occasional bleeding. Uh, that isn't really bothering them through to having to alter their lifestyle and then all the way through into significant affecting symptoms and ultimately problems with life threatening hemorrhage, the bottom level, great grade four and five, really acute toxic reactions so often. Um if you really fry someone's rectum, you can uh precipitate acute symptoms and a very small proportion of those patients will have trouble with acute necrosis of the bowel. But that's obviously, well beyond the scope of an outpatient clinic. So taking these forward, if you have a grade zero, if it's not really bothering, you don't mess with it. Be aware that you've got radiation change in your rectum and try and avoid constipation, try and avoid straining, but you don't really require any active input, minor impact in lifestyle and majority of patient's that you will see. So you can certainly try things like uh MS Alazine rectally to try and take away some of the inflammatory nature. Um And if that doesn't succeed, then you may wish to move on to other uh chelate ing enemas such as uh Sucralfate or short chain fatty acids. And if again, if you work in a nice uh tertiary center research center, you might want to consider hyperbaric oxygen, all of which have uh evidence behind them. But beyond that, um major invasive treatment needs to be reserved for those patients who are either becoming anemic or their bleeding is so significant that uh that they cannot cope with their activities of daily living. And beyond that, you may wish to think about yag laser or a PCR gone plasma coagulation, both of which are done endoscopically with the patient awake or failing that installation of rectal formal in which really is nothing more clever than getting a formal in potter histology pot putting a gauze into it and popping it inside the bottom for around 10 seconds, then studiously washing out the anus thereafter and it really just coagulates everything in the bottom. It's not very nice, but it is very effective. Finally, just like to touch on solitary rectal ulcer syndrome. And this very much fits in with what Bell Williams was saying with the functional side of things. So the vast majority of people we get through the two week wait system won't have cancer. The yield is about 2 to 3% but there will be a significant amount of pathology that isn't cancer. And a solitary rectal ulcer. As you can see from the picture looks quite alarming, but fortunately isn't malignant. So this lady similar history but chronic constipation, very strongly positive fit and been struggling with opening our bowels and bleeding. So, colonoscopy was normal aside from this finding where histology was taken eight samples as the endoscopist als mildly concerned about cancer and this showed inflammation, fibrosis and smooth muscle hyperplasia. All of which uh pathognomonic really of a solitary rectal ulcer, interestingly solitary rectal ulcer is not a brilliant name because not all of them, the solitary, not all of them happen just in the rectum and not all of them are ulcers. They can cause polypoid lesions as well. But it's worth bearing in mind if you continually biopsy something that looks weird and you keep getting back these histological findings. Now they represent a complex functional bowel issue. And as Bell touched on requires a significant multidisciplinary approach and discussion discussion via the pelvic floor M D T. The evidence based for treatment is sparse and really the only thing with any proven benefit is biofeedback. And as belts said, the availability of specialist pelvic floor nurses or pelvic floor physiotherapists, it's variable. So if you happen to see a patient in clinic with this and you want something to be getting on with easy things to offer a bulk forming laxative such as fiber gel, which is also known as this Pegula Husk. And again, the squatty potty position, which I find horrendous is a term and infantilizing, but it basically just means put your feet on the step and you can see it changes the anorectal angle changes the angle of the puborectalis muscle. And actually just by simply raising your feet, you can create a much straighter, root out for stools and a lot of patients will respond to that. So that is a whistle stop tour of the three or four things that you probably don't know how to manage. But now hopefully you do so from my point of view, that can be done. Sorry about the uh silly to the beginning. Thank you very much Henry. That was a great talk. Thanks again for, for coming today and uh joining us and I'm sure there'll be questions coming through the chat and just in the interest of time, we will move to the next talk. Thanks. Thanks Henry. Um And it gives me great pleasure to introduce our next speaker, Ashes Senopati. And this is where the fundamentals of color proctology course all started. Really Asher uh was running a basic color proctology course for uh for many years and the fundamentals course is the sort of latest iteration of it. Thank you very much, Asher. Good morning, everyone. I hope you can hear me. All right. And I'm really delighted that A C P G B I has taken on this course and it looks to be an amazing course. So I'm very glad to be part of it. Thank you very much. I'm going to have a goat presenting my share in my screen has that now worked. It has. Yes. If we have any problems with the wifi, perhaps you could let me know and I'll turn my camera off. So, the proctology clinic, there are some units around the country that actually run these clinics specifically named in this way. But when patient's come to these clinics, they come with symptoms, they don't come with the diagnosis and many of them uh won't even know what proctology means and the sort of symptoms that you have heard about already. I've listed on this slide, you've already heard from Sam about how you can run these clinics and how you can take a proper history. And I'm not going to go into that at this point because I'm sure you all know how to do that. Now, you will then examine the patient and the general examination and also an abdominal examination and then specifically have a look at the anal canal because sometimes at the perineum and the external aspect of the anal canal because you can sometimes make a diagnosis, you'll do a rectal examination. Um And uh this needs to be done in a, in a structured way rather than uh rather just sticking your finger in the anal canal. You may then do a sigmoidoscopy, either a rigid or a flexible sigmoidoscopy. Different units have different policies about this and then you would probably do a proctoscopy. Traditionally, we do the proctoscopy after the Sigmoidoscopy. Now, one of the jobs in a proctology clinic is to make sure that the patient doesn't have cancer. Here are two pictures that you'll recognize Deborah James who died recently at the age of 40. And it has said that for two years, she was told she had irritable bowel syndrome and here is Bobby Moore who died at the age of 51 he had symptoms for four years and been told it was irritable bowel syndrome. You don't want to be the doctor or healthcare professional uh with this outcome, but I'm not going to talk in this. Tell you in this talk about how you rule out cancer. That is a subject for a different talk. As far as diagnoses are concerned, there are many, many causes of the symptoms that you will have heard from the patient earlier on. And it can be very confusing. The best way to work it out is to actually try and figure out from the patient. What they're prominent symptom is if it's bleeding, it's more likely to be hemorrhoids or perhaps a fissure. But if it's pain, it's very unlikely to be hemorrhoids, much more likely to be a fissure. They may have itching. In which case you can think of worms or dermatitis. And if the prominent symptom is discharge, then think about a fistula or pilonidal disease. They may say they have a lump at the anal verge in which case, think about prolapse and the different causes of prolapse or perhaps anal cancer. I can't talk about every single condition in a 20 minute talk, but I'm going to concentrate on the ones listed in this slide here. And so let's start with hemorrhoids. Everyone has a collection of blood vessels just around the dentate line which probably has some role in preserving continents and it's normal. But in some people, these get larger, they bleed and they sometimes get so larger that large that they prolapse out through the anal canal. It's likely that most people will have some bleeding from hemorrhoids in their lifetime. In fact, many of you listening to this talk may have had symptoms and it's self limiting needs no treatment at all and it usually stops and in some people, it gets sufficiently large that they want treatment. Um And as I've already mentioned, they also want to be sure that they haven't got anything else. So, hemorrhoids when they get large can look a bit like this picture in the middle here. Um It won't surprise you to hear is actually done in sticking theater because there are clips on the skin which you wouldn't do in the clinic, but they can become quite large, really important to make sure that there isn't a full thickness rectal prolapse. This is often confused. It seems a bit strange. To think of that, looking at these pictures that it can be confusing. And there are ways of distinguishing prolapse hemorrhoids from full thickness rectal prolapse. And of course, they're completely different conditions and are treated in a different way. Hemorrhoids are traditionally divided into different grades or degrees as they're sometimes called grade one over first degree hemorrhoids is where they simply bleed. And then there's nothing to see on the outside. Nothing comes out through the anal canal. Grade two or second degree, the hammer prolapses but reduces as soon as the patient stops trailing in third degree, it prolapses and then is required to be pushed back manually by the patient and the fourth degree it won't go back even when it's when attempt is made to push it back. So how do we treat hemorrhoids? Vast majority of them are treated conservatively have already mentioned how you may not need to do anything at all because it may, the symptoms may just resolve spontaneously. But if not then treating causes of straining, treating constipation, perhaps changing the defect A Torrey habits. There are topical applications, many, many topical applications available in pharmacies up and down the country and some countries particularly use flavonoids. We don't use them too much in the UK. If none of these methods work, then we're talking about more invasive treatments for hemorrhoids. And there are many and this simply tells you that none of them are 100% effective. The most effective one is a hemorrhoidectomy, but you certainly wouldn't be doing a hemorrhoidectomy as the first line of treatment. Um Initially, I'm going to discuss the four listed on this slide because these are the more commonly invasive methods of treatment for hemorrhoids used in, in, in the UK. But as I said, there are many others, but most importantly is that we treat the symptoms of hemorrhoids rather than their appearance. Really doesn't matter what they look like. You'd be amazed at how, how some patient's are quite happy with the, with their hemorrhoids, very large hemorrhoids because they're not causing him any trouble. So treat the symptoms. So, injections, sclerotherapy, this uh is the injection of fennel in Iraqi soil. 5% fill on Iraqi soil. Really important that you check the percentage of fennel if you're going to do this because there's some other uh conditions that are treated with tunnel that are of a higher percentage and would be dangerous. You can do rubber band ligations. This is a treatment which sucks the hemorrhoid or the not exactly the hemorrhoid, but the mucosa just above it into the gadget that you can see on this slide and then by pressing the trigger will release a very tight little rubber band on to it. This then gradually slough. So over the next few days and separate spontaneously and the vast majority of patients are completely unaware that this has happened. But occasionally there is a heavy secondary hemorrhage when this happens. And in some people, it's painful when this is applied usually because it's put too low in the anal canal. If none of these conservative methods work, then surgeries sometimes needed. And hemorrhoid artery ligation has become popular. Uh This is a method by which the arteries supplying with the blood vessels, supplying the hemorrhoid are sutured, using a special gadget and often under ultrasound guidance. And then the prolapsed mucosa of the hemorrhoid is plicated as shown in the slide. Don't let anybody tell you uh particularly if the patient's have been reading on the internet that this is a pain free operation. It certainly isn't. All you can say is that it's less painful. Then a full hemorrhoidectomy shown in this slide. And here the hemorrhoids are actually excised. It's important to leave skin bridges between the three hemorrhoids, usually three that are excised. Otherwise, there's a risk of getting an anal stenosis. This is a very effective way of treating hemorrhoids. It has about a 90% effectiveness with very low recurrence rate. However, as won't surprise you to see from these pictures that it can be very painful, is very painful afterwards and may last as long as about two or three months before the pain eventually subsides. Here's a diagrammatic picture of what the operation should look like afterwards with the skin bridges preserved. I'll just say a word about thrombose prolapse hemorrhoids. This is a an emergency patient's come in through the a any department with very painful prolapsed hemorrhoid that won't reduce. There's often necrosis over the surface. It is controversial as to whether they should be treated surgically or conservatively and they're different schools of thought which I won't go into here. But if you do nothing, it will get better. It'll take a couple of weeks not to be confused with a perianal hemato ba seen on the right hand side. Um and is often referred in in a similar way. But this condition is a blood clot just underneath the skin of the anal verge and it is self limiting. By the time you see it, it's often been there for a couple of days. In which case, it's probably best to treat it conservatively. It will resolve without any securely. If you see it in the first a few hours of it developing, then you can make an incision over the surface and a bit of local anesthetic and the blood clot will be removed, but they are then left with an open wound that then has to heal. And actually the the outcome is probably very similar. What about a fissure? The fissure? And they know most particularly is a very painful condition of the anal canal. Typically, it has pay the patient's have pain on defecation which often last for some hours after defecation is over, they may bleed, they may even be discharged. But the prominent symptom is pain. It is unusual to have a fissure without pain. The causes of fish is, is probably not quite clear, it said to occur from hard stools. But you often see it when patient's have had a bout of diarrhea, many patient's probably get many, many people and many of us would probably get acute fissures from time to time. And the vast majority of these heal without any problem. But in some people, it doesn't heal. And the staff as um that's caused by the pain, reduces the blood supply of the anal canal particularly posteriorly or anteriorly. And this probably reduces the ability of the anal canal to heal and results in a chronic fissure. Just to be aware that if officials are not in the midline, either anteriorly or posteriorly or indeed are multiple, there may be other causes of the fisher such as Crohn's disease that we need to keep that in mind. Officials diagnosed clinically by parting the anal canal gently before you put any jelly on your gloved finger. Because otherwise, if you just slide away and you will then see the fissure has seen in these two slides here, often in the base of the fisher, perhaps not so well seen in these slides, you'll, you'll be able to see the fibers, horizontal fibers of the internal sector is often an associated skin tag. So how do we treat fishers? Well, as I said, they are very painful and painkillers certainly are needed in uh in many patient's and sometimes topical local anesthetic. But this won't actually get the fisher to heal. If it's an acute fisher, you can sometimes treat them symptomatically, as I mentioned and change the consistency of the stool and that will help unhealed them. But if it's a chronic fisher, you often need to do something else. All forms of treatment are geared towards reducing the pressure in the anal canal. And this reduction in pressure will then allow the increased and increased blood supply to the fissure and will very often allow them to heal medically. This can be done using glyceryl trinitrate. This is available commercially is Recta Jezek dilTIAZem, which which I'll tell you about the moment and Botox and if they need surgery, then there are three alternatives here. I'll just go through them. G T N is available as a 0.0 point 4% appointment as recto jas sick. It's available commercially. It's applied externally and it reduces the pressure within the anal canal, but it also causes headaches in the number of patient's and this, the headaches can sometimes be so severe as to be able to have to stop using the treatment. DilTIAZem is available commercially as a know heal, but it is unlicensed for this use. And so you often have to get it through a hospital pharmacy or have to order it especially through a chemist. These twos works in a similar way by reducing pressure in the anal canal but it sometimes causes skin irritation. If neither of these two work, then you could consider injecting center with Botox, somewhere between 10 and 100 units is used by different people. And it is pretty effective and he pretty effective in healing fishes. It can be done in outpatients. Many people would do it under a general anesthetic. Disporting is a different uh form of, of uh botulinum toxin. Um And just to be aware that the dosage is different. Um And it's you have to know exactly what this is before injecting. If none of these work and the patient still needs treatment, then you can excise the fissure under an anesthetic and freshen up the edges. And if you then combine this with Botox to reduce the pressure, it sometimes allows the fisher to heal and avoids the risk of a sphincterotomy, which is this operation here in which the internal sphincter is actually divided surgically divided. This is very effective in healing. The fissure healing rates of over 90% are reported in in series, but it does have a permanent effect of reducing the pressure within the anal canal. And in some people, particularly in women, um the risk of incontinence tends to be significant and so many people would reserve a lateral sphincterotomy for when other methods have failed and probably only in men. Some fissures are associated with low increase low pressures within the anal canal, particularly in post obstetric trauma. When patient's have had, who have had previous anal surgery or a failed lateral sphincterotomy, an advancement flap can be used to heal the fissure. So then in treatment of fish is there's a sort of algorithm that develops out of what I just said, where you try one. And if that didn't work, try something else and if that didn't work, try something else. And if you don't want to do a lateral sphincterotomy, as I've mentioned already, you can then go back to the beginning and try them all again. The majority of patient's will manage their symptoms and be able to control their symptoms from a fissure. But they are prone to getting recurrent fish is over the years. What about a fistula? And a no, this is uh tracked from the intern from the inside of the anal canal to the perianal skin. And here are two pictures of patient's who've got a fistula and patient's will often present with discharge through a little lump sum distance away from the anal canal and, and maybe sometimes unaware that this has anything to do with the anal canal itself. Fistula has been classified typically and most popularly by parts classification. Um And this describes the route that the fissure fistula takes from the anal canal to the skin. The two common ones that you will see are interesting Terek and trans linked Eric. And if you remember the anatomy in an earlier talk today, there's the internal sphincter around the anal canal and to the external sphincter on the outside of that, an interstim enteric fistula travels between the two centers and a transfer enteric sphincter across both of them. It won't surprise you to hear that when they present as an emergency, an interesting Terek fistula would present as a perianal fistula and a trance think Terek as an ischiorectal or in ischial anal. Um So abscess interesting Terek perianal abscesses or uh erectile issue, anal abscess, the diagnosis the fistula is usually made clinically. In the first instance, as I've already mentioned, either by both examining the perianal skin and by doing a rectal examination, but sometimes investigations are required and an anal ultrasound is often helpful. But the gold standard is an MRI examination which will give you the anatomy of a fistula in great detail. This can be augmented by an you a examination under an anesthetic has shown here. It's worth mentioning. Good Saul's law. Most people have heard about this and some people are not quite sure whether it really is that reliable, but on the whole fistula is that are anterior to the anal in the anal canal, anterior between three o'clock and nine o'clock tend to enter the anal canal in a straight line. Whereas fistulas that are seen with their external opening, post area to this line tend to have their internal opening in the midline posteriorly at six o'clock. When we come to treating fistulas, there are competing options here, you can treat all fistulas by dividing them along the tracks and they will all heal. But in doing so, you will divide the sphincter through which they pass and therefore there will be a degree of incontinence. And so you have to balance between division of sphincter and preservationists inked and the preservation of sync to buy whether you want to cure the fistula with a more unreliable continents or preserve distinctive with the more unreliable cure. And all treatments for fistulas are with this balance in mind. Let's take the interesting Tariq fistula. This can pretty well only be treated effectively by laying it open. And as I said already, it is the best way of achieving a cure. There are variations on a theme. There is marsupialization of the tract that can be done to make the rooms smaller and cutting see tons or snug seat owns can be inserted that will divide the internal sphincter in a slower manner and perhaps preserve a degree of continence. Most of the difficulties arise in the transfer enteric fistula, there is more muscle involved and we're generally less keen to divide this. And so there are many treatments that have come about and here are some of them is the fistula plug that can be inserted along the track and suited in place. This fill AC which is a laser that will obliterate the tracked by using laser is the draft which stands for the video assisted anal fistula tract, you know, fistula treatment in which you can insert an endoscope along the tract, clean out the tract and die a firm it attract. There's the lift operation in which, which stands for ligation of the interstim terek fistula tract. You find the fistula tract in the interesting toed space, divide it and repair the fist alone. This way, the fistula can be made open and this muscle so divided can be repaired. Primarily, you can do an advanced flap by which you core out. The fistula tract mobilize and the mucosa and possibly the muscle of the anal canal and overlap the fistula to repair it. Or if you don't want to do any of these things or they have failed, you can leave the patient with a permanent seat on this, of course, won't cure the fistula but it should prevent them from getting recurrent infections. Having said that each of these procedures apart from course, the Seton has about a 50 66 60% success at best. And it's sometimes quite hard to get transferred to fistulas to here. Not to be confused with Pilonidal disease and it is sometimes confused. Unfortunately, Palan Idol disease has nothing to do with the anal canal. But because of its proximity, it often these patient's often end up in a proctology clinic and indeed are mostly treated by colorectal surgeons. We'll present acute, please, an acute abscess and many of you will have seen and treated. Please they may present in an a symptomatic way with just pits and the natal cleft not causing any trouble at all. And they should be left well alone if this is the case. But these pits may then start to discharge. They may get a chronic abscess which discharges through a lateral sinus like this. And very unfortunately, they all too often present with failure of medical treatment, surgical treatment like this with a big unhealed, well, that just will not heal. There are many procedures for treatment of pollen ibis disease which even more so than fistulas tell you that none of them work out 100%. And I've classified them on this side in this way, I just want to say at the outside outset that wide excision, which is actually done sadly, all too commonly with or without midline skin closure has been shown in the number of series now, really not to be as good as lateral closure and so should not be done. There are many alternatives that work much better. I'm going to describe a few of them here. They tend to be the ones that I do the tra fine operation that refined with a lateral incision, a cleft closure or cleft, lift a Limberg flap. Here's that you're fine, you cut out all the little holes and clean the cavity underneath through these holes. Sometimes that doesn't work very well. And you make a lateral incision to make it a bit easier or you can do an excision and close the wound laterally, such as with the cleft closure or cleft lift or a more complex flap, such as the Limburg flap seen here. But perhaps the most important thing is to direct your treatment according to the severity of the disease. So that you aren't using complex operation like a Limberg flat when somebody just has a single pit in the midline. And so, for example, you can drain just an abscess. You can do a simple operation. If it's a simple pit, if it's an unhealed wound, you have to do something more complicated. I need to say a word about anal cancer. This will often present to a proctology clinic because the ulcer that exists or a lump that exists tends to be at the anal verge. It is a rare cancer. It's a squamous cell carcinoma that has already been mentioned earlier on and it affects about 1400 people a year in the UK compared to 35,000 bowel cancers. I don't know costs. And then this, of course, if the cancer is suspected and you'll see here that there are rolled edges to the ulcer on the left. And um there's a lump on an irregular lump at the angle. Virgin. If you feel it, it will be firm to distinguish it from the hemorrhoid. If you suspect it, then it needs a biopsy. This may be done in theater as an you a but the diagnosis of squamous cell carcinoma needs to be made before any further treatment is done. Of course, if it's a cancer, it would need to be worked up in the usual way. But I thought I'd just say a couple of things about anal cancer. One is that it is usually treated by chemo radiotherapy and not by surgery unless it is a very localized small squamous carcinoma mostly on the skin. And this chemo radiotherapy will last for several weeks. And it is very effective early cancers, more than 90% will be treated without the need for surgery. But if surgery is required, it's usually when there's either residual or recurrent cancer. And this may be a salvage abdominoperineal on accentuation. So pretty major surgery with a permanent colostomy, it may also be necessary for complications of the radio therapy such as radio necrosis or a fistula or incontinence. So, in conclusion, then in the proctology clinic.