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Yeah. All right. Welcome back, everybody. Hopefully, you've all managed to grab yourself some lunch before another, uh, intense, uh, a couple of sessions of talks again, a lot crammed into this afternoon. Um, if you aren't able to pay attention for the whole afternoon, uh, feel free to watch some of it on demand afterwards. Um, so we've got our first speaker of the afternoon, Paul Sutton, who is going to talk to us on the management of bowel obstruction. Thank. Thank you very much and good afternoon to everybody. Delighted to be speaking to you today and kicking off this session on the emergency, colorectal surgery talking about bowel obstruction. Um, and this talk is simply going to cover small bowel obstruction and a large bowel obstruction using a case to highlight some specific points for it for each of these things. So, dealing with small bowel obstruction. First of all, it's a very common surgical presentation. It's certainly much more common than large bowel obstruction characterized by interruption of the flow of intestinal contents. And as we know, patient's often will present with abdominal distention, vomiting and constipation and, but how we manage patient's with small bowel obstruction depends on the etiology of the obstruction. How severe the obstruction is both in terms of the grade of the obstruction and the physiology, the physiological changes that, that results in and, and the location of the obstruction. So we'll move straight into a case. This is a case of a 79 year old gentleman who's had a previous Hartman's procedure and a subsequent reversal for diverticular disease presents with a four day history of abdominal pain, distention and vomiting his tachycardic with a heart rate of 100 and 10 temperature broader iron pyrexia and clinically is dehydrated and his abdomen's distended but with no evidence of peritonitis. Um So that's his uh distended abdomen there. His initial blood work shows him to be a little him a concentrated his white cells raised at 13.7 and he's a bit dehydrated. You can see there on, on his bloods. So the first poll is what would be the next your next test for this gentleman? A blood gas abdominal X ray or a CT. Yeah. Yeah. Mhm Yeah. Okay. So, so looking in the, looking in the chart, there we go. So we've got 14, 14 responses, their blood gas, abdominal X A N C T. So blood gas at 35% but CT was the most popular getting increasingly popular. Uh 64 64%. Um So there's no right answer to these polls. They're just there to sort of help us with help us with the discussion. A blood gas is a very helpful test for somebody. I know this is a talk on bowel obstruction. But from the presentation that I've given you, we don't know this chap's got bowel obstruction. Appreciate it needs diagnostic work. Football. A blood gas is a very simple, straightforward bedside test to help you establish what the changes in this, in the physiology are because the management of this gentleman is going to be dependent on his physiology. Predominantly, his blood gas shows a slight acidemia, basics s of minus four and a lactate that's slightly raised. Your next steps are to pass an N G tube and to decompress the stomach. And when you do so, it immediately returns 1.2 liters of bilious fluid. You secure some Weibo access place a catheter and commence fluid resuscitation and you're still in a and A and a patient's looking a bit and well, the A N E S H O sends the patient for an abdominal X ray without you knowing uh included this here for completeness showing multiples uh centrally placed loops with prominent value, convent ease diameter, measuring 2.53 centimeters, uh something of that nature which is the classic appearances of, of small bowel obstruction. So now you do have a better understanding of the patient's physiology um and the start of a diagnosis. But the next question will be, what's the destination of the patient from here? So, you've got this gentleman in A and E um is he going to theater the critical care unit, search club missions units or CT? Yeah. Okay, good. So, so looking at the polls that's predominantly uh ct, there's 10% for surgical admission's unit and non, for critical care or theater. I mean. Absolutely. So it would be very difficult to get a patient onto the critical care unit without a proper diagnosis. And similarly, we don't have enough information to justify what's, uh, have to manage the patient whether he's going down an operative or a non operative route. Uh So the patient goes off for a CT scan. Uh This is the CT scan which shows a clear transition point. There's both dilated and collapsed, small bowel dilated bowels around 2.5 centimeters. The bowel is, uh, is contrast enhancing and all appears satisfactory on the CT scan in terms of the viability of the bowel, but there was a clear transition point. So you review the patient later on essay, you, the CT has been reported as additional small bowel obstruction. The heart rates come down a bit to 90. The patient's still complaining of abdominal pain. Um, and the N G tube is still draining. It's 5 to 9 at night. So you're about to hand over and it's decision time. But what's the plan for this gentleman? Are we going to operate or are you going to manage them conservatively? Yeah. Yeah. Okay. Yeah. Okay. Really? Okay. So interesting. So that's the vast majority of people want to operate, uh, want to manage conservatively overnight. Very small number of people wanting to operate. And I guess this follows the mantra of patient's with a digital bat. Small bowel obstruction will be managed conservatively initially for a period. But there are a series of people who are not suitable for non operative management. So if we think back to this gentleman, this gentleman's got fever, he's got leukocytosis, he's got pain which hasn't been relieved by putting the end G tube down and he's got a metabolic acidemia, uh accepting, he doesn't have peritonitis and I accept that a lot of the signs uh that, that are presidency. His fever was only mild is leukocytosis was only mild pain is a very, you know, important thing to consider because patient's presenting with additional small bowel obstruction, get colicky abdominal pain, but they don't get persistent energy pain and the pain from additional small bowel obstruction. If there's no compromise to the bowel, we would normally expect to resolve at after a period of analgesia and decompression and initial management. So I'll put it to you that there's a few things in this gentleman story that will make you concerned about managing him uh managing him non operatively. Not as I said, not, not a right or wrong answer, but those are the clinical signs of bowel compromise that we need to be really careful about assessing for and be very, very conscious of when we're making the decision as to which direction we're gonna take the patient in initially. So there are some uh moving on from the case now, just to talk more generally about patient's who are not suitable for conservative management, additional small bowel obstruction. So when there's clear radiological signs of bowel compromise, and some of these are very obvious like free. Obviously, if patient's perforate, that's a different story, pneumatosis and portal venous gas portal, venous gas does tend to be a late sign associated with significant bowel compromise, mural edema and thickening a much more difficult radiological sign to, to pick up. There are some other features which might make you think twice the report of a closed loop bowel obstruction. So closed loop, generally speaking, is unlikely to settle with conservative management. I say generally speaking, because this is something that's often overcalled in radiology reports, you need to be mindful about what you see. And if there's any ever any doubt discussing the scans with the radiologist is, is a helpful thing to do and taking the findings on the scan in conjunction with what you see with the patient, high grade obstruction, very acutely angled transition points will sign suggesting some form of mesenteric twist and potential compromise and significant amounts of free fluid we don't normally see with bowel obstruction. So the hard radiological signs at the top, softer radiological signs at the bottom but really, it's the patient's physiology that's driving your decision here as to whether or not to manage them operatively or non operatively. So the take home points for small bowel obstruction would be that the goals of initial management are to relieve discomfort by placing an N G tube. And if that doesn't significantly improve the situation, in particular, if it doesn't improve the pain, then that should be an alarm bell for you. Uh, restoring fluid volume, acid base balance and electrolytes with resuscitation. Uh, we've talked about early surgery for bowel compromise whether or not that's clinical or radiological evidence of a scheme you necrosis or perforation. There are some surgically correctable causes that no matter how long you wait with conservative management will never, uh, you know, we'll never settle hernia, volvulus and interception being three examples in additional obstruction where there is no clinical physiological or radiological reason to mandate surgery. 60 to 80% of those patients will resolve with conservative management. But that conservative management needs to be initially, it needs to be time limited. Uh, it needs to be nutritionally supported and the patient needs to be kept under regular review. And 48 to 72 hours is about the time period that, you know, most people, I would feel comfortable watching somebody. But clearly, there's a lot of subtlety and nuance is depending on what you think the cause of the obstruction is the patient's fitness wishes, comorbidities and physiology or playing into that. If the bowel obstruction is caused by another pathology and don't be seduced into trying to manage that operatively. So, for example, it's not uncommon to see small bowel dilatation which may even be reported as obstruction secondary to a diverticular perforation or collection. And if you manage the diverticular disease, uh in a sort of non operative way, we're pertain this drainage and antibiotics, then treatment of that will often lead to resolution of the small bowel dilatation and obstruction. So move on to large bowel obstruction. Now, large bowel obstruction is much less common. Approximately 25% percent of patient's presenting acutely with bowel obstruction will be large bowel obstruction, but the vast majority of these are distal to the transverse colon of malignant etiology and most will require operative management. The nine causes include uh stricture which of course may be malignant volvulus and all of the causes of small bowel obstruction can also cause large bowel obstruction as well. So this cases of a 69 year old male who presents with a four day history of abdominal distention and constipation. Again, tachycardic, slightly raised temperature is clinically dehydrated, is abdomen is distended, but there's no evidence of peritonitis. This is a single slice of a CT scan. And what you can see here is a sigmoid tumor with some thickening, a little bit of stranding around it and a cecum there which measures eight centimeters, no evidence of free, no evidence of free fluid. So next question is, what's the optimal management of this 69 year old gentleman with an obstructing sigmoid tumor? Just to comment to everybody. If you click on the right hand side of your screen, you'll see three little circles. If you click on the top one, that's the chat function, you'll be able to get involved in the chat, see messages and see the outcomes of the polls as well. So you got, you're muted for some reason. Uh Sure, I can you hear me now? Ok. Right. So the, so the three options that I think are all appropriate for this gentleman will be resetting the function and stenting bypass is very difficult for the sigmoid colon because there's nothing difficult to uh to anastomose on. But the other three are all good options and choosing those options can be very difficult and requires a little bit of judgment. I've tried to put some thoughts here as to which situations it might be appropriate for each of those, each of those three options. So in order to resect this tumor, that would be appropriate if the tumor was easily receptible in inverted commas, I mean, none of these are ever easy in the emergency setting. And if the physiology allows, so the patient's got to be reasonably well to have this operation because it's going to be a longer operation to resect it and just to defunction the patient. And if you are going to resect it, the oncological principles don't go out of the window. And if you'd be compromising the oncology significantly and then resecting is probably not the right thing to do in that emergency setting, definitely avoid it in the rectum. Um And uh probably not for this gentleman, but if in a different situation, somebody presents sub acutely and you can consider anastomosis and defunction in the in the setting of resecting when you might choose to defunction. So those are the difficult to resect. Tumor's definitely for rectal tumor's any extrinsic compression from other malignancies, non colorectal tumor or peritoneal metastases. D functioning is a, is a safer and easier option. And certainly in the setting where you've got somebody who's physiology is adverse because you're operating on them and they are acutely unwell and then spending the time to resect is probably not the right thing to do and you can do a quicker and an easier operation to relieve the obstruction, which is the primary purpose of why you're there by the functioning and stents uh is a good option and there's some variation in practice and it depends on the service configuration where you might be working, but it will be safe to say that it's not contentious to say that in patients who are surgically unfit, who have got left sided tumor's with unresectable metastatic disease. Those are the obvious patient's who will benefit from stenting where it's a little more contentious is right sided tumor's just because it's difficult to get there, the potential for cure if that's still there. So, if there's not a significant metastatic disease, if you were to have an adverse outcome from a stent, such as a perforation, you've changed a potentially curative setting into a situation to a non curative situation. And closed loop is a bit more challenging. Again, particularly the more proximal around the colon you get, because you have to insufflate air to, to get there. And there's a risk that you're putting extra into the colon that's already compromised. And the quality of the colon in a closed loop, obstruction is unlikely to tolerate or be very forgiving in the event of difficulties placing the stent. So again, a bit of judgment required when you're choosing those options. But if we go back to the uh to the scan, this is a Sigma tumor, you can see a very clear plane there from the, between the psoas, it's free from the abdominal walls. There's a little bit of stranding around it and the cecum is already a little bit dilated. And there may be questions about the viability of the cecum when you do a laparotomy. But this is a tumor that it will probably be appropriate to consider receptive uh upfront. But if there's any difficulty in resecting it or there is um adverse physiology or the patient's not not uh is co morbid or significant metastatic disease, then other options are probably more suitable for that patient. So to summarize early resuscitation and early cross sectional imaging is critical for these patient's small bowel obstruction. Additional obstruction can mostly be managed conservatively initially unless there's adverse features. And we talked about some of the clinical and radiological features that should make you think twice before embarking on a non operative management. Um If the, if there's a surgical cause of small bowel obstruction, for example, in susceptive in hernia, volvulus, those are patient's who should be optimized and generally speaking, operated promptly. Large bowel obstruction is mostly malignant. They will often require some form of surgical intervention. And you're four options in that setting are reset, reset, defunction, bypass and stent. And we've talked about, we talked about three of those bypass tends to be more potentially appropriate for a right sided tremor if you can get a small bowel loop on to the distal onto the transverse colon or the, or the left colon. And, but predominantly, the message will be the treatment decisions in this setting are driven by the patient's physiology and that's informed by our understanding of what happens to the patient's when we do and don't intervene and the context of their fitness and wishes and, but some of these operations can be difficult. So remember why you're there and you're there to relieve the obstruction. That's the primary purpose of the operation. Uh and the cognizant of where the patient's going next in their treatment journey. If I was going to point you in the direction of three papers, uh encourage you to look at the work that's been done by the. Now as BO collaborative, the ACP has got to position statements on the management of large bowel obstruction. And also there's quite a lot of information that will be available on the Kneeler website. Thank you very much. Thank you very much, Paul. Very, very uh excellent talk and, uh up to 20 minutes exactly as well. So, uh, thanks for, for being on time and, uh, I'm sure, you know, it's, it's, it's a large topically in trouble in 20 minutes. But thanks for, for providing as well these guidelines and the statements from, from A C B for people to, to, and if people have questions, please ask them on the chat function and I'm sure Paul would be, uh, happy to answer them there as well. Thank you very much. Thank, thank you, great. Take home messages about how to be safe when you're on call and how not to, uh, with the wrath of the consultant on call when you were, uh, tablet about a closely large bowel obstruction that, uh, presented in the morning. And it's now 10 o'clock in the evening and you're going to have to do something because they're c comes, uh, about to pop. So, thank you Paul. So we're now going to go on to our next talk. We've got Capped Baker talking on lower gi bleeding again because every all of our speakers are busy. NHS clinicians. Uh cat has also uh busy today, so has recorded her talks for us. So hopefully this will play. Thanks so much for the invitation to join you here today on this Great Dukes Club course. I'm Cat Baker. I'm a consultant colorectal surgeon in Oxford. Uh And the Jeep Club is really close to my heart, having been a proud member for many years and then being a past presidente um to really delighted to be involved in one of Duke's clubs, new ventures with the fundamentals of cola proctology course. So I'm gonna talk a bit about now, lower gi bleeding. They will start with a quick case. You're the S D three on call and the patient comes into E D. We'll talk a bit about history, what to ask, examination, what investigations you might do, uh review the management guidelines and then talk about the etiology of lower gi bleed. You've got a 24 year old male who's collapsed at home with a large volume fresh red pr bleed, no past medical history fit and well, 24 year old that brought in by ambulance to E D with a systolic of 90 heart rate of 80 and copious fresh fresh red blood. So I'm gonna start with a brief history and abc assessment just to ascertain how unwell this patient is. Um And if it becomes apparent, this is actually a massive pr bleed, you need to get some help. So from the F one in court or ECG encore with you from a nurse practitioner in E D, perhaps you want to getting some more access. So two large bore cannula, get some IV fluids running cross match four units of blood. You want to take a full complement of bloods, including the calculation. Um think about urinary catheter if they're really unstable, um and continue your assessment, but you know, things going on simultaneously while you're still sort of parking the patient. And importantly, at this point, if it is apparent that having a massive pr bleed need to activate the major hemorrhage protocol. We'll talk a bit about that further in a moment, the history we're going to ask about the duration of bleeding. Is this something insidious over several weeks or is this just an acute episode today? The volume of blood off at this point, patient sort of ask, you know, I've got pictures on my phone, you want to see. Uh I used to shy away from that, but actually can be really helpful because it just puts into context what they mean when they say they're having a pr bleed. And it also helps not just with volume but also color. Uh As far as I'm concerned, pr bleeding is either fresh red, dark red or black and obviously the slight gray areas being nosy, fresh red, dark red or black is it left sided, is it, um, right side colonic or small bowel or is it upper gi and obviously, and as you might see in our case, um, there can be some discrepancies and that, but that's a good ballpark to start with. Have they got an abdominal pain? Have you got any sort of left eyelid, foster crampy abdominal pain? This is perhaps the scheme of colitis picture have had change in bowel habit over recent months. Um Do we need to be thinking about cancer? Albeit cancer doesn't normally present with an acute lower gi bleed? And have they had any prodromal symptoms? So, weight loss, malaise dyspepsia, we need to do a bit more about their history. Um, so have they got a new previous history of gastrointestinal disease, liver disease, alcohol excess and inflammatory bowel disease. And what came abilities do they have that might impact um, their treatment from, from the pr bleed or their risk factors? So, did they have any ischemic heart disease? Af vascular grafts? Are they on anticoagulants? Are they are more foreign on the ondo ax? Any anti platelets, aspirin clopidogrel? Do they take NSAID? So they been taking quite a lot of ibuprofen recently? Do we need to think more about an upper gi bleed? And are they beat a blocks which is important for masking a tachycardia? Is there evidence of significant blood last? So, um, uh they pale sweaty and they tachycardic perhaps more than 100 and 10 BPM. Are they hypertensive? They're becoming confused. Do they fail to respond to initial fluid resource? Any d do they have a low urine output? And are there signs of obvious continuing ongoing bleeding? So you mentioned the major hemorrhage protocol and this is really, really important. You don't need to know the protocol inside out, but you just need to know how to activate it and what it sort of means in your trust. So for us, we call 4444. and it just really rallies the troops from a blood bank point of view from porters. And let's people know that you're worried about this patient. Um and it expedites things happening. You also want to think about doing a TEG which you can normally do with the help of, of I T or their nieces too involved, which helps guide um what clotting factors they might need. Um And effectively the protocol will give you different packs of blood products which are different in different trust that it will involve some combination of red blood cells, FFP, platelets and platelets and cryoprecipitate and also anything about the other factors that will dilute clotting factors. So other controllable, hypothermia, hypocalcemia, and acidosis, examination findings are often quite limited but abdominal examination, is there any tenderness, any masses or enlarged organs is often normal? Um And rectal examination is really important. Um What color is the blood? Are there any powerful masses. And if you can do proctoscopy, particularly, it's an acute bright red bleed or sigmoidoscopy looking for hemorrhoids. Or if there's any suggestion of IBD history looking for proctitis, the views endoscopically are often very obscured by blood. What next you've got bleeding patient? You can't see much pr what are the guidelines? Well, there's extensive guidelines from BSG uh the European Society and the American College of Gastroenterology, but we're going to focus on the BSG guidelines. Um And this is the lower gi bleed UK audit um published in 2017. And this framed uh the, the BSG guidelines for management of acute lower gi bleed. Um And this audit entailed 2.5 1000 patient's from 100 and 40. So the guidelines frame around this algorithm which is really useful. Um And it looks like a busy slide. But what we want to focus on is this. So this is a shock index and this is calculated by um the heart rate divided by the systolic BP. So for our patient that we talked about earlier, his heart rate was 80 and his systolic BP was 90. Um So is his shock index more than one. And so is the unstable, is it less than one? Uh And for him, it was less than one. So he's stable, which is the right hand column. But if we focus here on the left hand column, um this is an unstable patient with a shock index of more than one. The next step in the algorithm would be to do a CT angiogram. And this is our standard of practice CT angiogram always before a colonoscopy. And if we identify a lesion, we uh something amenable to I are, we then want to treat that with I R or if it's very disk also towards the rectum, you can think about clipping it and treating it endoscopically going towards the right hand side of the algorithm. If they're stable, we can then calculate an Oakland risk score, which I'll talk about in a moment and then ascertain whether we're safe to discharge the patient home. If they are having a minor lower gi bleed or if it's a major gi bleed, do we still need to think about um admitting them and getting them on the next available endoscopy list for uh it's certainly a lower uh gi endoscopy but also thinking about an O G D as well. This is the Oakland score and this uses a variety of characteristics to calculate a score and ascertain whether it's safe to discharge a patient. And this validated um score shows that if your score is less than eight, then there's a 98% chance that you can have safe discharge and it's less than 10, there's 96% chance of safe discharge. This just helps you ascertain which patient's are safe to go home. And what about their anti coagulation more? And more. Now, patient's are coming in on Warfarin there on dough ax. Well, there's clear guidelines about what to do. Um, certainly for Warfarin, it depends on risk factors. And if there are low thrombotic risk, you can stop it and restart it seven days after bleeding stopped. And if they're high risk and you might need to bridge them with low molecular weight heparin. Um, if the aspirin is primary prophylaxis, we should probably after a lower gi bleed, stop it and not restart it. But if it's secondary prevention and we shouldn't routinely stop it or if you have stopped it, then recommence it as soon as the bleeding has settled. Um for do ax, we should stop those on admission and consider targeted reversal reversal agents are very costly. So always consult with a hematologist. The CT angiogram is our gold standard investigation here. It's a triple phase. So plain arterial and portal venous phase and gives localization of the bleeding point because the IV contrast given is detected within the bowel lumen. So you don't give gut contrast as well. And this is really valuable to direct ir embolization. But also if our embolization isn't possible and surgical reception required, it informs um that as well with what area needs resecting a few quick images here. This is uh CT angiography showing a hepatic flexure bleed here, we can see a diverticular hemorrhage and on, on an arterial phase. Um and the reformatted image going from the vascular anatomy leading to the lesion, which helps for targeted angiography. Uh The embolization is directed by the CT angiogram. You've done using normally transfemoral approach, but there needs to be active bleeding. So there needs to be at least 0.5 mils per minute um to be able to embolize vessels. Um And the BSG guidelines state that if you've had a positive CT angiogram, then interventional radiology should occur within 60 minutes. And in most units that are major trauma centers or tertiary referral hospitals, particularly vascular service, that's normally achievable. But in some district general hospitals that can be quite hard to achieve. But it's important because if there's a delay of more than 90 minutes from the CT angio to um I R and the success rate is decreased by a factor of eight. There are risk factors associated with doing this. So there's a risk of a scheme you which is quoted as being between seven and 24%. We've certainly had a couple of patient's who've developed a scheme of colitis afterwards. Um There is a higher success rate in diverticular bleeds. What about colonoscopy? Well, the view is often obscured by blood and we try and avoid it in the acute setting. But if the patient's having a less acute bleed is really for follow up after some bowel prep and gives good localization of um the bleeding. Um And it allows the therapeutic potential also in the acute setting even while the patient's actively bleeding, if there hasn't been a scope to do this by I R. Um So for diabetics and disease, we can use um clips or cat mounted clips for angioectasia APC. Um and imposed polypectomy bleeds again, often clipped or hemostatic agents. Um And it's also helpful because they're often dual pathologies and don't forget the upper gi tract. Okay. We're going to get back to our case are 24 year old who came in was stable. And initially, um as he met the Oakland criteria, he was discharged home, but he came back in with the collapse the next day, having a further fresh red pr bleed had a CT angio which was normal, didn't find any cause for the bleed, no active bleeding, seen had ongoing pr blood and dropped his HB 2 60. Um So I think it's doing, it's a hard to uh CT Anjos both were negative. So we then took him to theater. They had an O G D on table which was entirely normal, more fleck of blood and then had a colonoscopy that had blood all the way around fresh red, including this blood um seen here, fresh red blood in the terminal island. So what our options, we can't see anything endoscopically, we can't see anything on ir so surgery really is the last resort. Um Often it's helped by localization by CT angiogram, not in our case. Um And often you can resect the effective segment. But in our case, we didn't know where that was. And the BSG guidelines are very clear that no patient should proceed to an emergency laparotomy unless every effort has been made to localize is also bleeding radiologically and endoscopically. So, what's the etiology? One of the most common causes? Well, usually it's diverticular or undue dysplasia and uh these leads are generally painless, pretty fresh red, pretty brisk, but they're normally self limiting other causes. So, inflammatory bowel disease, radiation, colitis, ischemic colitis cancer, although not commonly is an acute lower gi bleed. But do you think about the bleeding particle, sir? So what about our case? We've got this 24 year old. He's on table now, this was just a few weeks ago for me. Um, still got active fresh red bleeding now, requiring ionotropic support. I've got nothing on CT Angio. I've got nothing on O G D and Carla scopic li I just got fresh red blood all the way around including the T I. Um So at this point, I, I did as a last resort, proceed to surgery. Um and I started by just popping a laparoscope in his abdomen. Uh And what did we find? Well, luckily, uh we found this. So, um, he had a bleeding Meckel's diverticulum which when isolate the small bowel on either side doesn't, well, very quickly briskly filled with blood. Um And I respected the specimen, the segment and um, I didn't do a wedge excision, as you'll see here on the right, because the base of the diabetic team just felt very firm and very thickened. It was actu fine once I open the specimen, but it didn't feel normal, it didn't feel amenable to wedge. Um And the histology confirmed ectopic gastric mucosa in the Meckel's diverticulum. So this is obviously a slightly unusual case. But do you think about alternative diagnosis and those who don't obviously have a diverticula or an angio disclosure bleed? Here are some of those less common causes. Um uh including small intestinal diverticular disease, small bowel ulceration, particularly onset induced angiodysplasia, rarely a also intact distally. Um These are just having the back of your mind if patient's aren't settling in the cause is an immediately apparent. They have talked about the need for a rapid assessment and simultaneous resuscitation of these patient's. Um There are clear guidelines, so don't feel lost, just triage patient's accordingly. Use the open score, use the shock index and follow the protocol. Always try and do a CT angio ahead of any colonoscopy. Um And surgery really only is the last resort, mostly at lower gi bleeds are self limiting. Um and usually to reassure patient's um and safety net. So they represent, if it doesn't settle, do you think about their anti coagulation, anti platelets? Uh And if they're safe to stop. Um And it really is a multidisciplinary team with the gastrologist, Ir and surgeons. I hope you're feeling well equipped after this great calls from the Dukes Club to manage your own calls uh in your S T three year. Um And good luck. Thank you very much cat. So cat was uh was planning to join us live and I think she, she will join us at some point. She just had to be in theaters. Uh So thank you and thank you again for being on time. We are actually emergency teams doing very well. We are ahead of sign. So we'll let you use our next speaker, right? Okay. I'd like to welcome Jonathan Evans who is a colorectal surgeon from Nottingham who is going to talk to us on acute diverticulitis. Thank you, Jonathan. Hi, everybody. I'll share my slide. I hope you can all hear me. Let me know if there's any problems and hopefully you can see those slides now. So, yeah, thanks very much for the introduction. I better go back to the beginning of my talk because it's a bit more useful start at the start. Suppose. Uh That's generally how we do these things. Yeah, thanks for the invitation to speak. Um As, as, as I mentioned, I'm a consultant. Correct, Sergent Nottingham. Um We see a fair amount of emergency work here, busy trust. So I have looked after people with acute diverticulitis in my training as a consultant. So I don't know if that makes me an expert, but I have managed enough of it to be able to say some sensible things. So hopefully this is useful to you guys. Um So what am I going to talk about? Well, I'm just going to talk a bit about what diverticular are and what's diverticulitis and, and sort of nominate can sure around that. We'll talk a bit about how it presents and some differential diagnoses, how we diagnose it, um the complications that can occur as a result of diverticulitis and, and how we manage diverticular disease. And I mean that in the acute setting, but we'll also touch on sort of long term options. Um So you know, what do you do electively or how do you discharge these patient's safely with a plan for follow up? And what sort of things should you be doing when they go home? I'm not really going to talk about diverticular bleeding because we've just had a very lovely talk about um about rectal bleeding and things. So I think probably best left from that side of things, but we'll go through the rest together, right? I thought probably best to do this is sort of case presentations and, and run through some um some presentations and some imaging and things and then talk about how we manage those patients'. I think that's often more useful and helps things stick in our brains a bit. So um let's let's go through this case together and, and see what you guys think. So, this is 72 year old gentleman. He's had a bit of left about fossil pain for about four days. Just gradually getting a bit worse. Bowels have been a bit loose but non specific. He's not had rectal bleeding before all this. He was, he was absolutely fine. He's had no preexisting bowel symptoms. He's not particularly co morbid. Um, and he's got a white cell count 16 and the CRP of 230. So reasonably high influencing markers. Um And you know, the moment I start taking a history from a patient, I won't teach the psychics because you guys have probably seen quite a few patient's now. But, you know, we start with a history and examination and when I'm taking a history, I'm doing it with some differential diagnoses in mind. The moment you hear left out fossil pain, then diverticulitis has got to feature on your list of possibilities. So those questions I'm asking from that point are focused on narrowing down that differential and also um working out whether it's safe to pay to send that patient home or keep them in whether they need imaging or not or whether they need an operation or not. So my, my kind of my history taking focuses on that and that allows the more focused history. So, you know, your list of differentials for someone left out fossil pain is, is pretty large. But, you know, taking this guy's age into account the 72 year old male, he's certainly not gonna have gynecological pathology unless something very unusual is going on. But you know what, if this guy said along with this pain has been fairly, some non set and he had a bloody loose stool, um, perhaps he's a smoker. Um, and he's lost and he's suddenly come on like that. And then your differentials change, don't you? And then you're thinking actually this could be a scheme of colitis. They might say that doesn't make a huge amount of difference in the short term because we're probably gonna do the same thing. But it is really important to keep these things in mind when you're taking a history. So perhaps he had a longer history and some weight loss, um, and a bit of change in bowel habit leading up to this. Well, you might be thinking then that, well, have you got an obstructing cancer? Is there something like that going on? So, it's really important when you're taking these histories, bear things in mind while all this is going on, you've also got to make an assessment of how unwell this patient is because sometimes you can do this things in the traditional way and take a history, examine the patient, investigate them and then come up with the management plan. But if you come and see a patient who's really unwell and you recognize the unwell from the moment you see them, actually, what you need to be doing is resuscitating that patient and improving their physiology. And the rest of it comes as part of that. And that's that thing about, you know, acute sort of uh time, critical diagnoses and those diagnosis that you can take a bit of time over and work things through. But this guy is stable, let's say you're not particularly worried about him, but he is a bit tender in the left their foster, he's got a mild pyrexia and normal observations other than that. So what we often do for our patient's um in surgery is a CT scan and this is no exception. Uh If you come to a surgical ward, you're over the age of about 50 you're likely to walk out there with a CT scan, I guess. Um But there we go. So this is what this CT shows and I'm not expecting you guys to the radiologist, but I do encourage you to look at all your scans yourself. You get quite good at looking at these things. And we also have the benefit of knowing what it looks like real, you know, with our hands in the abdomen or with a laparoscope in. So I really would encourage you to, to look at imaging yourself. And, and if we're going to talk through the CT scans, what I would note is that there is some areas around the colon. So the music colic fat that looks a bit inflamed and a bit gray in color. So that's sort of inflammatory um, stranding in the fat around, around the effective bit about and a bit of bowel. You can see there is the sigmoid colon, uh, sitting in the pelvis that just looks a little bit fuzzy around the edges. And, and that's kind of one of the first things I look for when I look at the CT because actually you can kind of work out where the pathology might be just by looking for that sort of stranding of the fat and that dirty looking fat. So this guy's got some pockets on the wall of his sigmoid and some inflammatory stranding around it. So that's consistent with diverticulitis. Um talking about investigations, not so much as an inpatient, but say you were faced with this gentleman and he was perfectly well and you were going to send him home. Um You'll be thinking, well, what am I going to do next? Does this guy need anything else um, doing in the longer term? And traditionally, there's been this view that we should send everyone who has come in with diverticulitis for endoscopic imaging. Now, interestingly, um when you look at the guidelines for this, it's not actually commonly practiced. Um and I don't know what the groupthink, but how many of the people listening today would send this patient for a six week scope. Um, following this episode of diverticulitis, I'll admit that's what I've traditionally done. But given these guidelines that coming out and you can see this was published in the international journal Color of colorectal disease. This first paper, it's a multi center study and basically the pickup rates for colorectal cancer or unexpected pathology in people having an endoscopy for a CT proven simple diverticulitis was really low and almost as low as the general population at 1.28%. So really can, can we justify sending all these patient's for a scope? Um And I would say probably not. And I've changed my practice recently. If I've got a CT scan that says this is simple diverticulitis with no local perforation, no concerns on it. I actually don't know, send from the scope scope. However, if the CT report comments that there's some bowel thickening, cannot exclude malignancy, I think you're obliged to, I think in those circumstances you'd be rather foolish not to go ahead and do it. Um I would say that that rule or rule or guideline only really applies to those patient's with simple particulates on the CT. If you've got complicated di diverticulitis, iaea, local perforation or something else going on, then actually the cancer rate on or the cancer pick up rate on endoscopy can be as high as 10%. So I think in those circumstances, you've got to send that patient um for a scope after they leave the trust, but I would leave it sort of 6 to 8 weeks. Uh What you want to be doing, escaping someone with acute diverticulitis because when it hurts them to, you might perforate them and three you're unlikely to get through anyway. So, just bear that in mind. So, personally, now, ct scan looks like that 72 year old man who's well, with no other concerns, I wouldn't send him for an endoscopy. So, how are we going to manage this gentleman? Well, if he's on well, and he's poorly, you're gonna give him some IV fluids, you're probably gonna give you some intravenous antibiotics in those circumstances. So you've got evidence of sepsis. Um You probably let him eat and drink is actually the guidelines are, or the, the evidence is, it makes no difference whether they eat or drink or not. I guess the exception is if you think you might take them for an operation, um, in the short term, but certainly with that CT scan, you wouldn't. Um, now the thought around antibiotics, this is another sort of slightly controversial area or not in a patient who is, well, who is not Parexel, who is not septic. There have been a number of randomized control trials. Now, looking at antibiotic treatment versus observation and actually, um a recent meta analysis of all these shows that there is absolutely no difference in outcome, giving antibiotics or not for those patient's who, um, who have got simple diverticulitis, you know, well, with it. Um So it is an interesting one and it's quite a difficult thing, isn't it saying to a patient. Actually, I'm almost going to do nothing for you. I'm just gonna keep an eye on this so it can be uncomfortable. It's all about communicating it to the patient. Explaining actually this is inflammation, inflammation and maybe not an actual infected problem. And therefore we're going to send you on your way without any antibiotics, but it should just get better. And I think the key in managing these patient's is deciding which patients need to stay in. And those are the ones who have evidence of sepsis or unwell. So your sepsis six and all that sort of thing and those that can go home and there's now a whole load of ambulatory pathways. Potentially we've just brought in virtual wards in our trust over the last year or so. And there's ways you can get these patient's observed, that means they don't need to be in hospital provided. You've got a scan that says it's simple diverticulitis in a patient as well. I don't know if the poll came through, but if we can rule a pole, I was going to ask if those who would give antibiotics in this situation or not, but if it's not, if it's not sorted, don't worry about it at all. Uh But just in case we got that, there we go. Let's see what people think. So this is a world patient, 72 mild pyrexia, but otherwise, well, raising punching markers. Would you give antibiotics for that? That looks like a resounding. Yes. So, I think, uh, as usual surgical dogma wins. Um, and I must admit in this gentleman with the CRP of 230 all the rest of it, you might think, um, you might think twice about sending it without antibiotics. Um, but the events is ct simple diverticulitis should be able to go on his way. So, just a little bit of background about diverticular disease and, and some of the, the non it's just surrounding it. So diverticulum. So these are the actual things in the wall of the bowel are out pouchings of the clonic mucosa. The belief is that these occur around areas where blood vessel and blood vessels enter through the cirrhosis submucosa and and potentially high pressures in the loop of the bowels force the mucosa through these as sort of like mini hernia. I guess you'd describe it as um so out pouchings of the wall about and those are diverticular and there is a scope there with a picture of two little diverticulum in it. Now, it's not diverticular disease until you get a problem with it. And it's not diverticulitis till you prove that it's been inflamed. And those I think those are important distinctions that we should bear in mind. Most diverticulum in the UK occur on the left side of the colon. Um interesting in the far east, they get far more right sided disease and perhaps there's a genetic element to that, that we don't fully understand yet. Diverticular are unbelievably common. 50% of people over the age of 60 have them, but only 1 to 4% of these will actually develop diverticulitis. So it, although they're really common, developed a problem from me is actually relatively uncommon and I don't know how many of you guys do endoscopy but you see on most of scopes you do. So, um yes, it is unbelievably common. I've tried to update myself in the literature on this because I go and tell patient. So you need to eat a high fiber diet. It's probably because you got high pressures in your lumen. And there seems to be an association with irritable bowel and diverticular all these things. And so I often will tell patient's about eating high fiber diet and avoiding conservation. That is good advice for anyone, I guess. But actually the role of fiber in diverticular disease is controversial. Um There's no particular evidence that eating season things makes it worse, but we do need to kind of. Um but I think it's reasonable to say to patient's that a high fiber diet potentially reduce your risk of complications, presidential e reduce the risk of developing diverticular. Um just because we have got the evidence that it doesn't necessarily mean it's not true. I guess there may be a genetic component to it. And there have been twin studies and it was more common amongst identical twins and there seems to be some relation to constipation, but again, this is unproven. So what about elective surgery on, on people with recurrent episodes of acute diverticulitis? Say this 72 year old gentleman came back to see you as an inpatient three or four times with the same problem. Should we be operating on these patient's? And, and actually, um Jama published quite a nice quality of life study. Um And I think that was, yeah, that was this year earlier, this year called the Laser Randomized Clinical Trial. And essentially that showed if you had three or more episode of diverticulitis, your quality of life was better if you then went on and had it resected. Now, I guess that's wonderful. As long as you don't get a complication and end up with a leak and end up very poorly in ICU for a while because that tends to set you back a bit. But that is that is what this study found. Um Interestingly, the European Society of Color Proctology have guidelines on the management of diverticular disease that were published in Colorectal Disease. That was about three years ago now. And they felt that surgery to prevent a complication from your diverticulitis or diverticular disease was um was, was not warranted irrelevant to the number of attacks, but they could consider surgical resection to improve quality of life in those people with recurrent diverticulitis. And that was a balance of the risk versus the benefits. So, how many attacks they had, how much impact that was having the quality of life, all decisions individually, they felt there was no evidence to support reception. Symptomatic patient's unless there was radiological or endoscopic signs of ongoing inflammation, narrowing. So, stenosis or fistulas. So, unless you had radiological proof, there's an ongoing problem. There was no evidence support reception of these patient's. So that's in contrast to the later evidence that came out in this laser trial. And the truth is I think if they've got an obvious complication, you'd probably operate on it such as official and we'll talk about that briefly. But if they haven't, it really is a discussion and um case by case kind of decision between you and the patient on how much impact this is having on their quality of life. So just moving on to case too and this is this is a brief, brief a case just talking about some of the complications of diverticular disease now or diverticulitis. Um So, so you have the same story, 72 year old gentleman, same blood, same story, but probably a little bit more unwell swinging fever, night sweats, that kind of thing. And you do a CT scan and you've got this on the imaging and what that is essentially showing that yellow measurement line. The blue measurement line is this, this gentleman is now developed an abscess now interesting is on the right of that foster. So uh that can happen because the sigmoid can be very mobile. So if you do get someone who's older with right at foster pain, do bear in mind, this still could be diverticulitis. Um That's why I tend to see t the older patient's with lower abdominal pain and this patient's got an abscess in there right at foster. And that was caused by a local perforation of the diverticulum of the sigmoid colon. So, how are we going to manage that now? And I don't know if we've got this as a poll as well, but let's try it. So, if not, don't worry. Um I don't know whether, whether the people in the group would just give this patient antibiotics a range of radiological drain or jump straight into an operation. Um, again, don't worry if we haven't got that as a poll, but just be interesting to hear your thoughts and if anyone's got any comments, you can put them in the chat. But essentially there's guidelines on this, there's guidelines for everything really aren't there. But the same guidelines from the E S C P talk about just antibiotics alone will normally do the job if the absence next, less than three centimeters, they suggest putting a drain in it if possible if the absence more than three centimeters and reserving surgery for if those measures fail. So if your patient is continuing to deteriorate or not improve with that CT scan, at that point, you might consider operating and the, and the thinking behind that is if you take the heat out the situation, sometimes that's all I need. But even if you then go on to do an operation, they're less like to look with the stoma, the operations, low risk. Um, and they tend to do better from it. So let's just get the thoughts of the group. Anyone here just, just antibiotics for that who stick a drain in it and who do an operation? Well, I've already kind of told you the answer, I guess. But there we go. Um, and almost unanimously we've gone for a drain and that, that is probably what I would do as well. I'd very rarely jump into an operation on someone with a localized absence like that. So, moving on to our next case, um, another complication of diverticular disease or diverticulitis. So, you've got a 72 year old gentleman again. So similar presentation he comes in to see on stu as the restaurant call. He's got lower abdominal pain, but this, this chats been getting recurrent water infections for a while. Um, and poor stream poor flow. Sometimes he gets dish career, but he says doc sometimes I get little bubbles in my um uh in my urine. It's like there's frothy urine coming out. So he's got a bit pneumaturia going on. Um And what do we think is going on there? Well, this gentleman, we may well have developed a fistula to his bladder so a coal over cycle fistula, another complication and a nasty one of diverticular disease. Basically, what happens is the sigmoid tends to stick itself on something when it's inflamed. And if it's locally perforated, um, stick yourself on the bladder, if it's nearby can stick itself on anything else as well. We've all seen diverticular disease to official it to various places. And as you know, I'm sure, you know, that officials named from the organs it it connects to or from so cold over cycle two bladder, um Kolok cutaneous to the skin. I've seen all sorts of weird fish is coming out of people's thighs and things after really nasty diet type particular disease. But this particular fish is about between the sigmoid colon, the bladder and you can see it circled by that red um circle there and that shows very nicely the sigmoid attaching itself the bladder and in the cross sectional imaging as well, you could see bubbles of air in the bladder. So we had almost 100% confirmation this gentleman that he developed a coal over cycle fistula. So you're the register on call. This is coming while you're on call. But the chaps actually quite well, he's just plagued by these recurrent water infections. So, so what you're going to do, um and I think if the patient's completely well, it's not unreasonable to send them home because if they're relatively well with it, you're unlikely to jump into an operation acutely. Well, we struggle here with our emergency list but potentially would. But I think these things are always or often better than this sort of more planned fashion if you can. Um, because it's going to take time, potentially you need the right personnel available. So I often will send these patient's home. If they're really plagued by water infections, I might give them prophylactic antibiotics to take just to try and stave off any water infections to keep them well. And then I'll make an outpatient plan to manage this longer term. And I don't know what other people's thoughts are here, but these are the sort of things going through my head when I see these patient's, should I do an endoscopy first or be going straight for an operation? I am I gonna try this laparoscopically or is this an open operation? And should I be stenting the ureters? And, and these are all things that you kind of take on a case by case basis. And I wouldn't be nervous about stenting ureters in these cases. It can be really useful sometimes just a wire in there. It can make the ureter much easier to feel. Um And much more, you can be much more confident of where it is can be very nasty trying to find it in these nasty diverticular segments. I would send this gentleman for a scope because this is complicated diverticular disease. I'd want to make sure there's not a cancer there, which would change potentially how much bladder I resect rather than just pinching it off. If it's diverticular, I would try and do this case personally laparoscopically. And the evidence is that um if you've got the expertise, the outcomes are as good, if not slightly better in terms of quicker recovery and things, but you do need to operate within your skill set. And I would, I would say to these patient's the conversion rate, um uh compared with say a box down sigmoid countries quite a lot higher. So consent wise, try laparoscopically but a high chance of conversion. So that's the kind of cycle Fischler, this is the last case we're going to discuss um a bit tight for time. Now we've got a couple of minutes, I think. So we'll run through this one quickly. This is 72 year old gentleman. So same patient say, but with a different story this time, he's had a few days of grumbling pain, but it suddenly got worse in the last 12 hours. He's got generalized tenderness. He's pretty unwell. He looks poorly. He's got the same inflammatory markers though, but he's got a lactic acidosis. Now, uh with low base excess and low ph on his blood gas. Now, this is one of these cases, I was talking about where actually the history and examination and things are part of it. But what you need to be doing for this gentleman is managing him at the same time and his management is, is treating his sepsis. So you give him oxygen is the ABC approach oxygen IV, antibiotics, IV, fluids, all the steps stuff and make sure you go and check for response quickly. So this guy, you can give him a liter of fluids pretty quick if he's not got heart trouble and come and see if he looks a bit better, if his observation approved after that. If he's stable enough, I would this gentleman for a CT scan and on his CT scan, you get this and basically you can see a lot of free air on that. You can see his falciform ligaments swinging in the breeze there with a load of gas around it on the scan, on your left side of your screen and on the right, a lot of free air. And this gentleman is essentially got a free perforation caused by um, diverticulitis or perforated diverticulum and he's gonna need an operation if he's fit enough. The question is, what operation should we be doing for these patient's? And this is a controversial topic. Um I don't think the evidence exists yet to make these decisions. Definitely. And I think really, you'll find most units still are probably doing an open heart comes in these circumstances and that is a safe operation that will save this man's life potentially and get him out of trouble. So it's not the wrong thing to do. But these are things we should be looking at and thinking about for the future. So you're gonna resuscitate this gentleman and take him for surgery. And the thoughts are with an operation. Should we do a laproscopic wash out, which can be considered in certain cases? Should we resect the bit about with a perforation in it? And if we are respecting, are we going to do a heartburns and give this guy an end colostomy? Or could we be thinking about anastomosis? And certainly, I don't know if you guys have heard of the Hinchey classification, I would have thought you probably have, but it's just there on the left of your screen. And if you've got a Hinchey to, um, three or two or three, probably you could consider a laproscopic lavage. Um, certainly if you look at the, we'll, we'll talk about the evidence in the next slide, but you could consider it. I think if you've got lumps of poo in the belly, you're probably gonna be doing a Hartman's because I don't think the whole is going to be small enough that it'll seal itself with a wash out. So I won't read through Hinchey, but that's essentially what it is. And really, if you've got a Hinchey four, I don't think you should even be thinking about a laparscopic lavage and you could consider it in a three and there's quite a lot of evidence. Uh, there's quite a lot of studies that have tried to look at this and the big one that we talked about um in the UK is the Lola trial um that was actually stopped early because of quite a few complications in the li laproscopic lavage group. Um So it was event and that event most commonly was a return to theater a resection. So um it was stopped early, that's still published in the Lancet in 2015. But basically, the, it kind of suggested that the short term problems were very high and actually, we probably shouldn't be doing laproscopic lavage. But if you look at the longer term data, which has now been published, actually longer term, the patient's do better if they get through the short term events and with fewer stones in the long term, the lab arch group and no difference in long term mortality. So, although there were more events and more returns to theater that stop the trial, if you follow the patient's up long enough, really, that didn't make any difference to their long term outcome. So I don't think we can write off laproscopic lavage yet, but I do think it should be used um in very select patient's and in very select circumstances. And certainly, if you've done a laparotomy, I just take that bit out because if you, if you do a laparotomy and wash them out and close them up and then they have a problem, it's a bit of a bit of a pain sorted. Act. The other thing that's been looked at is whether we should be joining these patient's up with the primary anastomosis. And um, the ladies trial looked at this, they're all sort of part the same trial but broken into different arms. And basically, they conclude that if you've got a well patient whose under 85 you can actually do anastomosis and they do just as well. They have to be hemodynamically stable and well. Um and they have to be pretty fit just in case you get a problem. Um Now a lot of units aren't doing this and I must admit I would do it very selectively and I tend to want to wash the colon out before I do it as well, especially in the area of air of bowel preparation. Um Nowadays, so I do this very sparingly and in the right patient's. Um but I must admit most of the patients I've come across with a free perforation. You need a reception, I'm probably too unstable to have this done. So I think a Hartman's is still a very good, get them out of trouble operation and you can come back and fight another day down the line and join them up as they want to, which is a never a nice operation, but doing it on a stable well, patient is always a better idea. Um So that was the the ladies trial. So it's worth knowing these trials when you come up to exams and things. So just some key take home message is if you look at the evidence, not everyone needs antibiotics for simple diverticulitis. And certainly, um if you look at the latest guidelines coming out, not everyone needs a scope either down the line. And I've actually changed my practice now and I don't send all the simple diverticulitis is ct proven for a scope. If your face the sick patient management by the ABC protocols, resuscitate them and then check for responsive, they got better. Uh Don't just leave them languishing in A and E uh and waiting for an operation because they can be there a while and get sicker if you're not on them. Um And I'd say with it, when it comes to laproscopic lavage, the role is uncertain at present. Um and certainly short term outcomes seem to be um worrying, but in the longer term, actually, patient's might do better. Um And certainly, I think this is an area that he's looking at in more detail. Um And I would say once you become a consultant, you do realize that stones do create problems such as um parasternal hernias which you end up having to try and fix. So, you know, maybe we should be looking at avoiding some of these colostomies. But um I think the evidence isn't out there yet. Thank you very much for listening and feel free to ask any questions in that. Thank you very much John there's actually a question on the chat for you, but I'll let you read and answer. Thank you again for a very, um, case based discussion, uh, talk actually. And it's uh, very useful. Uh Thanks again. Thanks Jonathan. So we'll let you answer that question in the chat in the interest of time. We're now going to move on to Katie Adams who is going to talk about surgery in, uh IBD. This is quite a complex area. It can be quite a complex area that I find even quite senior trainees um uh struggle with. So hopefully, Katie will give us a good overview. Thank you. Lovely, thanks, Nikola. Can everyone see my slides? Great. Thank you. So, my name is Katie Adams and thank you to um Nicola and Mohammed for the invite to talk today. Um I think it's a great initiative to get us all thinking about some of the things that maybe makes us feel anxious, particularly with inflammatory bowel disease on the acute take. Um my primary practices inflammatory bowel disease, but as in today, I certainly do deal my days on call. Um So let's think about what sort of patient you might see. We're going to cover three main areas. So we're going to cover a patient with acute colitis, a patient with Luminal crone's disease and a patient with Perianal Crohn's disease. And that will cover about 90% of patient's you might see with inflammatory bowel disease during acute months elected general surgical take. So the first is you're going to get a referral from the ward. So this is a patient you've been asked to see who you've been called up by the Gastroenterology Registrar saying is a patient with acute colitis, we're not sure if they're going to need an operation, please. Can you come and see them so that we can help make a decision. So after quickly looking at the guidelines on your phone, as you walk to see the patient, you're eventually going to get to the Gastroenterology ward and you're going to go over the history again. And what's really useful is to kind of select out where this patient is on their acute pathway and identifying, identifying it by days is really useful. So sort of seeing when their symptoms started and where are they today and what treatments have they had so far? So we've got Arney. Arney is a 24 year old man diagnosed with ulcerative colitis six months ago. And prior to this admission had been started on as a coal and was otherwise doing quite well. Now that started to change about a week ago, they started to get more diarrhea, um and certainly with a lot more blood in it as well. They came to the acute Gastro Clinic and was actually started on steroids at that point and admitted to the Gastro ward. Now, later that day, and they had suddenly a space come up in endoscopy, that patient had a flexible sigmoidoscopy, which did show severe left sided colitis. And there's no real extra benefit to doing a full colonoscopy. Left sided severity is a marker of prediction for full colonic activity. So, they were started on steroids and intravenously and after 72 hours, the patient was no better. So at that point, they started their first dose of loading infliximab. Um So that's gonna start immunosuppressing the patient further on top of their steroids in hope of getting on top of that sort of immune mediated inflammation. By the time you see the patient and we're now today, today is now day six, that patient is still got severe diarrhea. So they're going 14 times a day there crp is increasing and is now 70. They've got a low grade fever and when you examine them, they've got mild abdominal pain throughout all four quadrants. So you now need to start thinking about does this patient need to start going towards surgery? And how do you decide? Well, the first thing you do is you are going to grade the severity. We all still use true love and wits and this is a combined um physiological patient description and biochemical marker of severity. So you can look at number of bowel motions a day. We know ours had 14 a day plus blood. So already puts them in the severe category, they've got a low grade fever. So they've got again a marker of severity, they're pulse rate, which we didn't mention maybe it's around 80 85 90. So, borderline anemia, um the E S are we haven't checked, but the equivalence is doing a CRP and we've already said that this CRP is raised and it is above 30. So this patient definitely goes into that severe criteria. So by all accounts, this patient is heading towards a colectomy. So we need to decide what to do next. Well, what happens to these patient's who come in with this grade of severity. So of the patient's who come in with acute severe ulcerative colitis, if it's their first episode, actually, 20% of those patient's will end up with a colectomy. So that's 1/5 of patient's you'll see referred from the ward will end up having their colon out in that admission. What happened to the ones that get better? Well, as an IBD surgeon, I'll often see them shortly afterwards. So, because within one year, almost a half will have had a colectomy and within three years, the rest of those 40% who end up needing a colectomy will have had their colon removed in more of an elective setting. So we need to take these referrals really seriously. These patient's are on. Well, um they're often within a short period of being diagnosed and quite a lot of the time they're going to end up with a colectomy as well. So what's the risk? So when someone's not acutely unwell. It's really hard on the acute surgical take to say, right, we need now to take quite a few hours out and actually do collect me on this patient. They're not crushing me unwell. Can they wait till tomorrow? Well, maybe the next day and maybe the next day and suddenly your acute surgical takes rolled and it's suddenly Saturday. What's the risk of that? Well, it's massive. So the more risk of mortality doubles from day 32, day six. So if the patient came in and we're already at day six, that patient has already had an increased risk of mortality from any resection and, or even if they don't end up with the resection and by day 11, so if we imagine we see them on a Tuesday and we've rolled them till Saturday, their mortality will have tripled. So we can't afford to wait in the, with these patient's. And that's why patient advocacy is really important that we need to really struggle and fight and advocate for our patient's to get them to theater once we've made a decision for surgery. Now, no decision for surgeries are one person event. We need to decide who's going to operate when he's going to operate. And what does the patient know if you imagine the patient we're talking about? He's 20 he was only diagnosed with ulcerative colitis six months ago. He's just been on tablets and now you're going to do a huge life altering operation that's going to potentially leave him with, if not a permanent stoma, certainly a stone. But for quite a long period of time, you've then got to decide, how are you going to operate? Are you going to do an open operation? Laproscopic robotic. Are you going to do it with your consultant on call? Do they have a specialist interest in inflammatory bowel disease? Are they a colorectal surgeon or are they a really, you know, skilled general surgeon as most of our colleagues are, who have done probably more colectomies than a lot of us who trained in more recently. So, what we do know from that is if a patient can have a laproscopic or minimally invasive approach, they're going to have a lot better outcome in terms of recovery and also they're much more likely to have any subsequent surgery minimally invasive as well. So you're really preserving their abdominal cavity for the future. So if you can a laparoscopic subtotal colectomy or if you have facilities robotic subtotal colectomy is an ideal approach, but it's got to be balanced against the access that you've got the timing that you've got to do it in. And if a patient sick and it's the middle of the night and they've perforated, you do an open colectomy and you leave them with an end ileostomy and a rectal stump. How are we going to get this patient ready for surgery again? Most of this is not us as much as we want it to all be about us. It's not, it's the stoma team. They're going to be the ones who, if they can mark the patient preoperatively, considering that a lot of patient's will have this stone a long term and some forever actually getting a stoma in the right place is key correcting electrolytes. This patient has already been in for almost a week. He's been filled with steroids. He's got third space losses. He may not have been eating a lot and he certainly had a lot of diarrhea. His electrolytes might be all over the place. Blood loss is a significant consideration with this type of surgery as it is with any major resection. So making sure this patient has got a group and save is really important and then you take them to theater. So in theater, you may find that there is time and facilities for uh epidural or a spinal and then general anesthetic. But certainly general anesthetic. You want to cover this patient with antibiotics as per your local guidelines. You want to uh urinary catheter and make sure they're steroids are covered. That's something that's really easy to forget because we haven't physically been giving them steroids. They've been under another team. It's really easy to forget steroid cover. I'd really need a rectal wash out prior to starting the operation and that's just so that when you leave them with a rectal stump, you can help reduce the kind of mucus and fecal burden within that area to reduce their risk of stumped blowout. You're then going to do a sub total colectomy and stapling over the end of the rectosigmoid junction. Now, I routinely bring this up to the to the sheath to the rectus sheath as a contained mucous fistula. So I wouldn't naturally mature it to the skin by making it almost like a second mini stoma. But I certainly would over so it and leave it some cutaneously so that if it does go, then that patient, then it's going to come out through the skin rather intraabdominally, intraabdominal sepsis poster collect me is a really poor indicator of future pouch function if that's what they go for. So you really want to protect the patient from that as much as possible and then you're going to do a standard end ileostomy. Now, thankfully, you did all that. Your consultant was really pleased. You've got to do most of the colectomy. The patient recovers with their ileostomy and they come back and see you now this time in clinic and they want to discuss their next options. So at the moment, the patient's back to college, they're back to normal physical levels of activity and they've kind of got used to the stoma and they want to know what their next options are. You may discuss them at the time of the emergency colectomy, but it was certainly too much to take in for any useful decision making at the time, but they have been reading a bit online. So there's four main options that you've got at this point. First is surveillance. So this is for a patient who not always but sometimes is older, doesn't wish to have any further surgery is very happy with their end ileostomy and doesn't want to undergo a proctectomy or consider a pouch. Now, these patient's need ongoing surveillance of their rectal stump with ongoing initially ulcerative colitis. And then further to that sort of diversion colitis. These patient's got a really high turnover of cells in their rectum and they have got an increased risk of rectal cancer. So usually depending on your local protocol on two yearly or five yearly basis, these patient's need a proctoscopy. So a flexible sigmoidoscopy done into the rectal stump to survey it for any signs of dysplasia. Now, these patient's may go through the rest of their lives just with an end ileostomy and inter intermittent surveillance. But if they start to develop dysplasia, that patient really, that risk benefit is changed, they're going to need a proctectomy. The next option, which is really gaining favor in this country. And I suspect it's as the stigma of having an end ileostomy decreases, patient's go actually, I love having a stoma. I don't need to know where the nearest bathroom is. I don't have to wear a pad, I'm not bleeding, but you know what bothers me. It's the mucus discharge. I have to go to three times a day and I'm just, you know, really fed up with that. Now, a lot of these patient's will decide to have a proctectomy. So this is where you're going to remove the rectum anal canal to an inter sphincteric dissection and seal up the anal skin. And then that patient will keep their end ileostomy long term. They will no longer have any chance to be reversed. And that's them done now for these patient's and any patient wishing to undergo further rectal surgery. Family planning is really important. So having a pelvic procedure will decrease your fertility. So ability to get pregnant and back undetected, e ability to stay pregnant and go to term by 30%. So I have a lot of patient's who will have got over there acute episode and they will be 2025 then we will wait, we will do rectal surveillance until they finish with family planning. And this is men and women, men, you're gonna have that risk of, you know, potentially some impotence. Um and certainly women infertility and fecundity until they've completed their family planning. So I'll often surveil patient's for five years. They'll come to me 10 years post colectomy and then say, right, I'm ready now for a proctectomy, I want to get rid of the discharge and I finished my family planning, the next group, which is not that common in the UK but is really common, particularly in northern Europe and the Scandinavian countries is an aisle, erectile anastomosis. This is really only for patient's who've had rectal sparing. So their colitis was bad, but the rectum wasn't too bad. And actually over time, what they've learned to do is they've learned to do five S A. So Asacol suppositories, mesalazine, suppositories or enemas or steroid enemas to keep any proctitis at bay, they can go undergo a primary anastomosis onto the rectum. It's a great option if you're willing to do long term rectal inflammation management. It's just not that common in the UK. And then the one that we've probably talked about a lot, you know, previously and you thought about more is the pouch in an anastomosis. So this is a J pouch there, rather other configurations. But the most common one we do is a J pouch here. It's important to talk about function. It is not the same as before when they had ulcerative colitis. They are not going back to formed stools, going to the toilet once a day. The average function is 4 to 6 times a day and not to two times at night. And they will often require ongoing support, long term. So, pouchitis management, stenosis, potential fistula ation, inlet problems, outlet problems, most patient's will require something on an ongoing basis. So they need to know that beforehand and counseling for that's really important. And pouch surgery really should be done at high volume centers. So you might find that you see patient's coming through have had a colectomy, but then they get sent on somewhere else for a pouch consideration. So that was quite a quick journey of somebody who's had ulcerative colitis. But I think there are three key main points. The first of which is 1/5 of patient's admitted with ulcerative colitis will have a collect me on that admission. So of the patient's, you see, their first interaction with the surgeon is really important, talking positively about stoma as their way out of trouble interaction with the stoma team. Careful discussion with the patient and gastroenterology is really key. Delaying collect me significantly increases your mortality. These patient's are usually not grossly unwell but delaying has significant ramifications. Patient information and consenting steroid management and early stone stone team input is vital. These patient's are overwhelmed with information because they haven't learned a lot before or if they have, they're really glad to have kind of got away without needing a colectomy before. They may have seen someone with the stoma and didn't like it. And they've suddenly got to make a massive decision with the information that you're giving them. And at the end, I'll show you a really good resource for information to use with these patient's. So let's leave our patient behind and we're now going to be back on call. So you're having a busy day. Your next referral is they're calling up from E D and there's a patient with likely appendicitis. They'd like you to come and see and organize an appendicitis to me. Now, you're not taking that at face value. You're really thorough. You're going down to E D and you're going to take the history again. So you go and see John. John is 20. Um He's had two days of central to our iliac fossa pain is the referral with a low grade fever, white cell count 12 and crp 32. Obviously on a talk with inflammatory bowel disease, that's not the end of the story. So as you delve into it more, you find that actually he's had diarrhea on and off for about six months, he's been feeling really tired. He's no longer got the energy to go to the gym after college. He also feels really full after eating and he's lost some weight over the last 12 months. He thinks it might be just where he's not going to the gym anymore. He's got an uncle with a stoma but doesn't know why. And he's a current smoker. When you examine him, you go great. It's tender in the right alec fossa appendicitis with a possible mass though doesn't feel quite right. But the story is really short. So it's only a two day history of pain, but a mass and tenderness in the right alec fossa. He is a bit tachycardic for him and he's also a bit anemic So your next question is, what are you going to do with this patient? Hopefully, you're going to not immediately take them to theater. You're going to think, could this be something other than appendicitis? Now, it's already at eight o'clock at night. Um, you know, you, you could get an out of hours ct, but you're going to start off by doing the basics, this patient with diarrhea, you're going to do stool cultures, You're also gonna think, could this be the his first presentation of inflammatory bowel disease? You're going to do a fecal calprotectin, which is a nice specific test. Looking at inflammation within the colon, you're going to give him intravenous antibiotics, even if someone says, well, it'll mask appendicitis no matter what. This patient has an intraabdominal pathology with clear signs of developing sepsis with a low grade fever with a high heart rate. And you know, you think something's going on, so you're gonna start antibiotics, you're not going to delay and you're also not going to forget to give ted's and dalteparin or local vte prophylaxis. Now, what imaging you do really depends on where you work and it depends on the patient. You might see a really slender patient who an ultrasound would be ideal. You might work, work somewhere that's got copious access to MRI most of us probably aren't lucky in either of those camps. So, a CT is the most commonly performed acute diagnostic tool in these patient's if you see, pediatric patient's ultrasound is brilliant, but they have to know what they're looking for. An ultrasound that says appendix, appendix not seen a little bit of fluid in the right alec fossa is not going to help you diagnostically. And a lot of these patient's do end up in theater, they do end up thankfully these days laparoscopically having a diagnostic test where you're going to see that actually the terminal ileum is not right. The appendix looks normal and your option at that point is you should just walk away. If there is pus, wash and leave a drain. Don't start trying to take biopsies. But see that there is terminal ideal information. Do nothing, take lots of pictures and close up. Actually, you happen to have been on call somewhere where they can get MRI. And the next day you see that there is the MRI report which says there's an inflamed distal ileum with no abscess, is your fecal calprotectin comes back as 620. So at that point, you pat yourself on the back and you're pretty glad that you picked up somebody with a new diagnosis of likely Crohn's disease. And you refer to uh gastroenterology, colleagues who continue with the IV antibiotics and the patient is discharged home later, a few days later with a plan for an outpatient I leo colonoscopy. So 12 months later. So you're an S T four. Now, you've seen a few more patient's with bowel pathology, inflammatory bowel disease. So you're seeing this patient who comes to clinic, then it's John again. So when he was discharged on hospital, he was then started on Adeline Mama Bernie's a fire print nine months ago. He was told it is a leo colonoscopy that he had an impossible stricture at the terminal ileum and that the biopsies confirmed crones over time, his diarrhea has got better, but he has lost a bit more weight and recently has felt a bit more early satiety and bloating and has sort of self managed himself by, he doesn't eat steaks and salads anymore. He finds that he just naturally prefers soups, um, and sort of Masya foods. But fantastically, he has stopped smoking, he's already had a repeat MRI which shows that he now has got some pre stenotic debilitation. And you can see the corona scan of this patient showing some normal small bowel loops up in the left, upper quadrant and down in the right alec fossa. He's got this really thickened straightened area of small bowel, which is really got a narrower lumen. And upstream from that, you can just start to see the, the pre synaptic debilitation developing. But thankfully, there's no fistula. He's been discussed in your local IBD MDM and his choices at the moment is he, he can either switch medications to see if that will work, but there's doubt that it will or that he can go for surgery. Now, you cancel him on surgery and what that might involve. And you're going to offer him an idea, secret resection. And actually that's what he decides he'd like to go for. He doesn't want to start on a litany of different treatments. He'd rather get rid of this stenosis. Now, get back to a normal diet, get his energy back. So you take him to theater. Now, before you take him to theater you need to think about. Is he ready for theater? He's lost a bit more weight and he already can't eat particularly solid or high fiber foods. So for these patient's, I'd recommend they go on preoperative elemental diet or at least low residue. And you might find that your local teams got a preference. We prefer elemental diet for six weeks preoperatively because it really reduces the amount of pre synaptic diet, ation and inflammation. Stoma marking is vital and operation. You do hopefully a minimally invasive procedure and a primary anastomosis. So again, you've saved John. Now, this is your settings for your elective Eilis seeker reception. You're gonna be Loyd Davis at the operation, you're gonna fully inspect the small bowel. So you're gonna measure it. How much small bowel does he have and actually find another stricture at 200 centimeters from the D J, but 50 centimeters proximal to his disease, terminal ill your segment. So you are going to do an idea seeker reception plus a Strictureplasty. It's loads of options for how you do your primary anastomosis side to side Kano s end to end hands own. It's nice to have options. And obviously, there's ongoing trials at the moment with the Meerkat study to look at which is best postop particularly oral metroNIDAZOLE has been shown to reduce your recurrence that your anastomosis by at least 40%. And you're going to review the biologics with the gastroenterology team. You say actually he's had great disease control. He's going to continue on the add Alimta may Bernays of bio prem. So two years later, you're now on ST five. So you see this patient in the emergency department with an acute abdomen. It's John again, he's been feeling worse last six months. He's lost 5 kg in weight. He's bloated. He's got diarrhea, he's now vomiting. He kind of stopped taking his Adeline um ob and he started smoking. You can now feel a big mass in the right iliac fossa and he's got percussion tenderness and a low grade fever and written flamed inflammatory markers. He gets an emergency CT and you can see now that he's got an incredibly inflamed neo terminal island with thick and small bowel loops and small bowel obstruction. You can manage this the same way you would as when you had the talk on small bowel obstruction, you are going to admit N G tube vte prophylaxis, correct their electrolytes. But you're also going to drain that collection and again, in the acute setting, try not to operate, you'll get a much better long term outcome. If you can downstage this disease rather than trying to get it all out, it will be stuck to everything, particularly in a redo operation, kidney ureters duodenum is all going to be stuck together. So you do hold off operating. Eventually the patient goes home, returns for an elective operation in six weeks with a primary anastomosis and you hope to stop smoking. So the key points for Luminal crone's disease. So your first presentation of Crohn disease can easily mimic appendicitis. You need to exclude other causes of iliitis, usually infective. But during COVID also COVID iliitis and up to 30% of patient's will have a symptomatic and um anastomotic recurrence at 12 months, particularly if they keep smoking. Now, we've got just enough time to talk about the last case, which is a patient who's been handed over to at the end of that original shift. So you're back to being an S T three, I'm afraid. And there's a patient with a periodic abscess that just needs draining. So thankfully, you go see the patient on the ward, preoperatively. Patient's usually, well, they're a nonsmoker. They say, yeah, the G P said they've got I B S, you can see a scar from a previous incision and drainage, but actually, it's on the other side to the current abscess and there's no family history. You feel comfortable saying I can obviously feel an abscess. It does need training. You take them to theater, you see fleshy skin tags and you see a fissure at three o'clock, maybe there's an internal opening at six o'clock, but you're not really sure. Everything's very inflamed. So you do the right thing, you're going to drain the abscess. There's an obvious cavity, not a huge amount of pus, but going going posteriorly maybe towards that six o'clock. Now, in these circumstances, I wouldn't recommend trying to find the fistula unless it's incredibly obvious. And in a lot of these patient's who don't end up having inflammatory bowel disease, even if there is an internal opening, a third will heal up just by draining the abscess. Now, this patient, you haven't really thought about inflammatory bowel disease. You've had too much of it already today. So this patient gets treated like any other patient with a periodical abscess there, discharged home in the morning and they don't have routine follow up nine months later, you're seeing pretty again in the colorectal clinic that external opening at nine o'clock never did heal up. And actually the other side where there was the scar keeps swelling as well. The bowel habits still fluctuating. And when you do an examination, you find they've got a bit of an anal stricture and they're not able to tolerate a proctoscope. So you're going to do the same investigation, staging of these patient's, it's fecal calprotectin Luminal assessment and cross sectional imaging. So you do a colonoscopy which shows tiny bit of tea, eye inflammation and stricturing and the distal five centimeters of their terminal ileum is a bit inflamed. Biopsies are taken. The MRI shows that there's a horseshoe collection in the anal rectal junction. There now is an obvious internal opening high in the anal canal with a stricture just below it. So for these patient's, you want to get Luminal control and that's your gastroenterology colleagues, you want to drain the sepsis and you want to dilate the anal canal and that's all electively but usually urgent elective if they've got undreamed collections. Unfortunately, as with this patient, it's not the end of the story. So a few weeks um of gone, you know, and that, that patient ended up with their incision and drainage. They've ended up with the drainage of sepsis. They had see tons put in and she's back in E D. You can see that the to see tons are there, but she's got a lot of perianal pain. And actually, you can't really feel a collection. It just doesn't feel quite right. These patient's MRI or endo an ultrasound is so useful if they can tolerate it. We got an MRI for this patient and you can see a new collection at that three o'clock position on, on the patient's left. So they get taken to theater. So your priorities in theater are the same with any patient. I think a lot of us get worried about taking patient's to theater, who've got perianal sepsis. If they've got Chrome's the priorities, the same, get the infection out. If you can't feel it, then either call a colleague who's got more experience in treating these patient's or get some imaging to help you. So when you're in theater, careful assessment of the undreamed sepsis, if you can't feel official to, don't make one if the seat on there leave them in And when you're draining the collection, it's usually access through the external opening of the prior seat on or prior abscess. And that kind of guides you into that same area. These patient's have often got recurrence rather than a completely new area of sepsis. So the key points, patient's will often have had multiple abscesses prior to their diagnosis. It's often looking back that we think it's pretty obvious at the time, Crohn's disease patient's with new perianal sepsis is a really common E D presentation and your priorities on the emergency side. Can you feel the sepsis and manage it as you would any abscess you want to drain effectively and then organize IBD surgery or colorectal surgery. Follow up further reading. I think these two resources are great. So there's a really comprehensive set of guidelines from the BSG on the management of inflammatory bowel disease in adults. But often what we need is information for our patient's Crohns and Colitis UK is fantastic. It's got loads of pictures is incredibly balanced. And it's got a great section on surgery. I would say if you were thinking, where would I even start to what to tell a patient? Have a look at this section before you go see the patient? Thank you. Thank you. Thank you very much, Katie. And uh we agree that we can't summarize IBD in 20 minutes. So sorry. Thank you having a good go and, and thank you very much. I know that you're on call today and you thank you for all the effort to, to, to come and join us. Uh There's some questions coming on the chat. So if you, if you have some time to answer them, that would be great as well. But we're going to move to the next talk now. Thank you. Right. So, I'd like to produce our next speaker who is Abby Patel and she's showing two on acute renal pain. Thank you very much Abbie. So, can you just hear me just being sure that great? Okay. So, um ex tight, right? So, um a brief outline of what I'm going to talk about, think Katie's covered some of it in that last bit on Perianal crones, um and how to manage a perianal abscess in the Crohn setting. Um So I'm going to start with a little bit of anatomy of the anal canal. So you have an understanding of, of how some of these things apply. Um a sort of a brief whiz through sort of common anal rectal conditions, some of which are more common for the acute setting. Um a little bit about why history and examination are very important. Um and then um a summary at the end of how to do a knee way, um and the best way to do that. Um And then any further investigations, you may need to think about when you see these patient's. So this is my um drawing of a anal canal. Um So I think that there are a couple of things to sort of remember when you, when you're looking at somebody's bottom and you're doing any you a so it's looking and knowing where the internal sphincter is where the external sphincter is. Uh and some of the sort of anatomy within the anal canal. Um and the things that you're looking for are the dentate line. So anything above the dentate line, the patient won't feel below the dentate line. If you do anything to them, they will potentially feel it. Um And that's probably probably more important sort of in a, in a outpatient setting when they're not under anesthetic. Um And then outside of that, there is the circular muscle. Um And then the long enough to Denel, outer muscle layer, um the elevator muscle holds everything up in place. Uh And then there are two sphincters, their internal sphincter, and then the external sphincter, the external sphincter is made up of three components. So there's the deep component, the superficial component and the subcutaneous component. And that will become a bit more important when we talk about abscesses and the anatomy of abscesses. Um And then the other thing to remember is that the anal glands which are the culprits for anorectal sepsis really reside between the internal and the external sphincter. And that's often the source of where most of these problems arise. So an anal rectal abscess, you will have all seen as an effective cavity caused by blockage by one of these anal glands. Patient usually presents with pain redness and swelling. Uh And most of you will have done an incision and drainage. It's the bread and butter. Uh Most S H O training, I think, um if the abscess is extensive, you may consider covering the patient with antibiotics post operatively, the most patient's will be able to go home once the abscess has been drained. Um The other things to sort of bear in mind is not all abscesses are the same and not all patient's with an abscess are the same. So, patient's who have diabetes have preexisting inflammatory bowel disease or a suggestion of inflammatory bowel disease when you're doing, uh the eu A are more likely to have ongoing infection and are more likely therefore to require prolonged antibiotics or even a second eu A. Uh and then the other things to look out for our patient's on immuno suppressants. And if they've had previous radiation, it'll affect their ability to heal in this area. So what happens once you've drained an abscess? So you've all drained the abscess. Not many of these patient's will come back to you, particularly in an acute setting. Uh They may present later on in an outpatient clinic with ongoing symptoms. So this is a study that was done on heads data. Uh And it showed that the overall incidence of having a perianal abscess was about 20 per 100,000. Uh and a subsequent proportion of patient's went on to develop or present with a fistula. And this was 15% for idiopathic patient's and 40% for patient's with inflammatory bowel disease. And two thirds of this patient's presented within the 1st 12 months. So if they are going to present with ongoing symptoms, they're going to present quite early on. Um And some of the things they looked at at risk factors for patient's coming back with fistula was obviously crones um female gender age. Uh and then the location of the abscess. So, was it interstim Terek or issue erectile? They're all more likely to present with the fistula after their primary abscess restrained? Uh if it was perianal, uh then they were less likely. So an anal fistula um is less likely to be something that you see in an acute setting. But like Katie mentioned in a previous talk, quite a lot of patients with Crohn's disease and then officially will present with ongoing sepsis and have abscesses that develop on top of having seat on. So it's important that you have an understanding of what anal officially look like. And and this is a common slide that's shown for parks classification. Um an abnormal communication between the anal canal and the perianal skin. Um The steps this usually starts in that interstim terek space between the internal, external sphincter and then goes in any matter of direction. Um The main thing to realize is that if you find official a at the time of an abscess, um and you treat that fistula with most likely most of the time of fistula. To me, it reduces the risk of developing subsequent infective um complications and presenting with official uh subsequently. So there's quite a good lot amount of evidence to support this both in terms of meta analysis and a Cochrane systematic review. But 40% of patient's who have got bacteria in their perianal abscess do not develop a fistula uh and do not present with a fistula after their abscess has been drained. Uh And there was an RCT where they looked at patients' only with internal openings at the time of abscess, drainage and a significant proportion of those patient's. Um if you drain their abscess, they didn't have ongoing infective set complications with the fistula. So I think the take home message is if it's blatantly obvious, then you might want to be to treat the fistula. But in most circumstances, given that most of these procedures are carried out by often more junior members of the team, the priorities to drain the infection. Even if you see a fistula don't go chasing it because there is a good chance that that fistula will heal if you get time for the infection to be cleared. So, moving on to other things that you may encounter with a patient who has an acute anal pain, uh an anal fissure which as we know is a tear in the lining of the anal canal. It's commonly at six o'clock. Quite often, it's very difficult to see. Uh and most patient's if they have an acute anal fish will not tolerate a pr. So you may be able to see it. You may not be, if you feel that there is no no other abnormality that you can see on the examination, then it would be reasonable to treat it as an anal fissure based on the history and the examination which are going to details a bit later on. Um patient's present with sharp pain occasionally. If it becomes more chronic, they have burning and itching. Um and sometimes they go on to develop rectal bleeding. Uh the pain is quite classical. Most patients will describe it as a passing glass or something sharp going through. Uh and it can last for several hours after they've opened their bowels. If it's acute, sometimes they just healed spontaneously, you don't need to do anything managing the pain and making sure the patient doesn't become constipated as a priority. Uh And if they become chronic, they usually present to the outpatient colorectal clinic, uh, and either managed conservatively with diet lifestyle laxatives, occasionally with medical treatments, 2% dilTIAZem or rectal Jezek. And it's important we give it for the entire six weeks. Um, but if there's any doubt of diagnosis or that you suspect there may be another disease process going on, then this is not just an idiopathic unofficial. I you're worried that they may have crones, then you do need to do any you a and make sure there isn't anything else there. Um And in the really, really difficult fissures which do not heal, you would consider having Botox injection or even a sphincterotomy. So the other thing that you will see is hemorrhoids most commonly uh when they prolapse down and patient's present with acute anal pain, uh and a swelling which has become very, very tender. Um If it's chronic, they present with pain itching and bleeding uh and occasionally prolapse. So the acute management is conservative, it's with ice packs, analgesia and soft stool softeners. Um I will often send the patient home with the glove with several gloves and tell them to put water in the glove, put it in the freezer and then it creates a little finger that can go into that area much easier and provides good pain relief. Um Acute intervention, I taking them to theater and removing that from those hemorrhoid may seem an attractive thing to do, but the whole area can be quite swollen and therefore the risk of damaging the sphincter uh and do and having morbidity with the procedure is much higher. Um So generally speaking, in most circumstances, acute intervention is not advised. Um and again, hemorrhoids, I think is a diagnosis of exclusion. So look for associated red flag symptoms and make sure the patient does not have an underlying cancer. Uh And that's really the key message, you know, don't label them as having hemorrhoids unless you've really excluded any other abnormalities. So, perianal hematoma is another one that can be quite difficult to differentiate sometimes from a, from Bose hemorrhoid. Um It's actually very different. It's rupture of a small vein at the anal verge. It usually presents with this swelling which is bluish, has a bluish tinge to it. It's quite, you can't reduce it because it's in the actual anal verge. And often it's proceeded by forceful evacuation or coughing or straining or lifting. So again, the, the detail is in the history, um they can be variable in size. If they picked up fairly acutely, then you can simply pierce it and drain it under local anesthetic. But if they're patient has had it for a long time, it becomes more congealed. It's therefore then quite difficult to drain. Uh and you will treat it conservatively with analgesia and simple measures as before. So some of the other anorectal conditions that you might want to consider, um, are sexually transmitted infections, um, anal warts. Um, it's important that you exclude an underlying anal cancer, um, and any coexisting disease such as inflammatory bowel disease. Uh, and then some functional things that can present with anal pain, such as levator, a nice syndrome and pelvic floor dysfunction. So I'm going to move on to the first poll, the pole in the in the uh talk. So quite often you there will be a lot of patient's on the emergency list who are waiting for an abscess drainage. Uh And so I've listed five patient's here. Um And I would like you to prioritize them in the poll. Uh And I think I'll ask motor set up to release the pole, okay. Um We can close it, okay. Um So, uh we'll keep it there for, for the time being that uh put up the slide with who I think should go first. Um So I think most patient, most people have gone for patient to which is the 54 year old gentleman with the diabetes. And then there's been uh one person has gone for the Koreans patient. So, uh we'll, we'll reveal shortly. So as I said, history is very important. Um I think if you're going to look at these patient's, it's worth working out whether they're presenting with pain on its own. Are they presenting with a lump on its own or are they presenting with bleeding? And these are some of the common differential diagnosis you can associate with any one of these symptoms in isolations. Um It's important that you look at the whole patient so important to look at what their past medical history is, but also any impact of any coexisting disease, um such as diabetes and immuno suppression and, and uh inflammatory bowel disease. If they're presenting with more than one symptom, um uh pain and a lump is often one of these three things, a perianal hematoma from those hemorrhoid or an abscess. If it's pain and bleeding, then it could be an anal fissure or proctitis and, and if it's lump and a bleeding, then it's hemorrhoids very important to rule out cancer. And if they present with all three, then that could be with hemorrhoids or a perianal hematoma. So it's important to sort of start thinking about which of these symptoms collection do the patient present with? Now, examination is very important. Um And I would stress that anybody who is going to go to drain an abscess in theater goes and sees the patient themselves. Rather than relying on a colleague, you may have seen the patient and listed them for an eye and d uh of an abscess. And that's because often you need the patient to be awake to actually examine their bottom properly. When they're asleep, you will have no idea what site was more tender uh and what anything felt like. So it is important you go and examine them before you take them to theater and inspection is key. Um Look for any fissures if you can see them. Um You may not be able to feel them. As I said, the patient may not tolerate the pr um look for any lumps, any skin tags, any abscesses, any fistula openings, um be very detailed and thorough in her, how you go about looking for these things. Um How patient obviously to exclude any cancer but also to locate the site of an abscess. So sometimes patient's may complain of acute anal pain and there may be nothing to see around the perineum and they may present with an abscess that's hiding inside like a submucosal abscess or even no swelling whatsoever. And it's an interesting Terek abscess. So it really depends on where the abscesses and you may get nothing more from the patient when they're awake, then pinpoint tenderness at five o'clock. But that gives you a clue when you're going to go and do the eu A as to where the most likely source of sepsis is going to be. So it's very important that you look for, for that clue before the patient's asleep and that applies mostly in patient's who have other reasons to have sepsis. So that's patient's who are immunosuppressed. Those patient's who are having treatment for hematological malignancy like chemotherapy uh and patient's with Crohn's disease who already have draining see tons in, um, you know, it's important you look for these things when they're awake. Um, he thing to look for is necrotic skin. Any patches of necrosis are very concerning for um sort of synergistic infect and obviously necrotizing fasciitis. And if you do suspect that somebody has necrotizing fasciitis, it really does bump them up the list and you go in that clinical suspicion, you do not wait to feel the crepitus or gas gangrene. You know, you take them to theater and you explore it most of the time. It won't be necrotizing fasciitis, but you will have saved the one patient out of the many that you see who may have necrotizing fasciitis if it's too painful to examine them. Think about why, why is it too painful? Is it that they have a fissure? Is it that there's an abscess hiding somewhere or is it something more sinister? Is it some form of inflammatory or inflict infiltrated process that has infiltrated their sphincter? Uh And that's why they're presenting with pain. So it's to look at the whole thing. The other reason to, to examine them very carefully is to consider whether you want to do an eu a first, whether you want to send them for an MRI scan. And in patient's where you are suspicious that there may be a hidden bit of infection hiding somewhere in the depths between those sphincters or above the pelvic floor, you will send them for an MRI because it will give you an idea of where to go for. You may not find that when you do uh any you a on its own and then any additional test, is there a different disease process going on here? Do I need to look for a cancer? Do I need to look for inflammatory bowel disease? So those are some of the things that should be going through your head as you're examining the patient. So I put the patient's in this order. Um So the first patient, I think the 54 year old with the type two diabetes whose feverish. So he's systemically unwell and has a necrotic skin. I'd be very concerned that he's going on to develop necrotizing fasciitis. And if not, he has got some form of synergistic infection that is spreading. So he would be at the top of the top of the list. Patient five, who's the 32 year old lady with a recurrent abscess, small opening that straining past obviously has got ongoing uh infection uh and that needs exploring. Um and it's looking and seeing and making sure that there is no reason why um she wouldn't be developing um or sort of profuse infection behind the small opening. So really do look around the whole area, particularly looking for any horseshoe extension. So extension around uh the anal canal to to the other side uh and making sure that there's no other reason why the abscess hasn't drained completely. The first time, the 21 year old chat with a tender rectal examination, but nothing physical to see you would be concerned he had either interest enteric um infection or infection that's being masked. Um and his super elevator. Um So you would potentially arrange for him to have an MRI scan and also medically optimize him before you took him to theater to explore him. The 26 year old lady with Crohn's disease who's already got a seat on but has a tender bulge near her vagina is most likely to have an abscess there and it may communicate with that seat on. So she's more likely to have horseshoe abscess is going around to the other side. Um And that needs exploring. Um And then the last patient who's presented with the first abscess um can probably wait um whilst all the other patient's are being treated. So, how do you do any? You a so I think it's a part of the sort of thinking behind it is you've gone and you've examined the patient yourself. So, you know where the infection is, the patient who's at the top of this photo. Um It's very obvious where the infection is, there's a bulge there, the cellulitis and there's a patch of necrotic looking skin behind the skin that hasn't broken down completely. Now, that patient is easy to do and you wouldn't miss much if you didn't see them beforehand, except for the fact that there might be a bit of necrosis there and they may put you, you may put them at the top of your list. The patient's where there is no bulge are the more difficult ones to, to find the infection. And like I said, if you've been and examine them at the beginning, you will have a suspicion of around where that infection may reside, but you may not. And if you do not, then the next thing to do is to probe with a white needle. So go for the area where you think it's most likely to be um container, an abscess. And if you're not sure, then you can just go around the clock face uh and look and see if you can find the, the infection. Um It's important you do a registered more endoscopy, I think. Um it's important that you rule out any um proctitis. Um And um if you can look in, then by all means do. Um and the main thing to think about when you can't see anything on the outside, is there a sub mucosal abscess hiding inside the anal canal or is there an interstim terry confection? Uh And the best way to find the interstim terek spaces to put an ice and hammer in um stretch the ice and hammer and you will actually stretch the internal uh sphincter and you'll be able to feel a groove a bit like how you would do a lateral sphincterotomy. And you can prove that space with a needle to see if you get any infection. If the patient has any coexisting comorbidities like diabetes or immuno suppression or anything like that, then look for horseshoe extension, um, and make sure that there isn't an abscess on the other side that's communicating with this primary cavity if you're uncertain and you haven't found anything but the patient presents with a good history, suggestive of some form of anal rectal abscess or fistula, then ask for help. Um I think that it's the wrong assumption to say it's just an eu a uh and I can't ask for her, you can ask for help because the difference will, it will make to the patient can be quite massive. If you loo if you don't find that source of sepsis in somebody who's immuno suppress or somebody who's developing florid inflammatory bowel disease, then it will have a significant impact on their subsequent journey. So please do put your hand up and say, I don't know, I can't find it. Can you come and help another person coming into theater who can help? You will be, may be able to find the source of infection. Um And the picture of the is from the chap that I showed a couple of slides before where you've seen somebody with some Coronas disease. This chat presented for the first time um with a watering can perineum that he developed over four or five years, but he was too ashamed to show it to anybody. Um And it shows a whole remit of drainage procedures. So there is a bit of the abscess that's been opened up. All of the openings have been probed and opened up. See tons have been inserted to an internal opening. Uh And the corrugated drain has been put to the to the super elevator collection that he presented with. The thing to bear in mind is in this position, we thought we had done a very good job. A few days later, he had ongoing discharge of pass. And um we're still showing signs of sepsis. And actually what he had was an abscess. Uh an official attract tracking from his Parini um all the way up to his natal cleft which have been missed on the first eu a so again, examination is key, his subsequent eu a required to position changes. He was done on his side and then lithotomy. So position the patient based on what your findings are preoperatively, don't wait to find that out a few days later, document your findings. Now, this is the ST Mark's pictures that are used commonly for fistula um uh to describe the anatomical position of the fistula. I think it's a good guide for you to understand some of the anatomy around this area. And if you can get in the habit of thinking about the anal canal and every you where you do in this way, it will help you to not only document your findings but also plan how you're going to treat the patient. So it's important that you look and you document was the abscess, interstim Terek issue rectal super elevator or just Perianal. Did I? If you look and you find a fistula, where was the fistula internal opening? Where was the external opening? What communication is there with the muscles around the anal canal? Um and particularly for something like secondary tracks. So sometimes you can have an abscess, you can have a fish dealer with the abscess, but then there can be a blind track that goes off in a different direction. And it's really for, for documenting those blind tracks is very important because none of it will heal until you've drained those blind tracks. Uh And it can also help with subsequent management of the patient and follow up particularly if you think that there's a reason they're going to have ongoing need for recurrent the US. So just to conclude, it's not just another eu a uh an eu A is actually a very important operation if it's done very well. And I think the key things to that are, you know, pre operative review of the patient. Really, what am I looking for? You should have an idea of that before you take them for an examination, anaesthetic, look for the pitfalls. So the pitfalls are patient's with diabetes immuno suppression are my suspicious. There's necrotizing fasciitis here. Is there another source of sepsis that has not been drained? Uh, and particularly somebody who's presenting after they've had an abscess drained and then they come back with an infection. Why have they come back with an infection? And what went wrong with the first? Eu a don't be afraid to ask for help. Um, particularly if you find nothing. Um, it is more important that you have that diagnosis of nothing done properly uh than actually finding something. And if you find something, it's often easier when you don't find something, it's actually more difficult to ask for help. So actually don't be afraid to ask for help because what usually happens when you don't ask for help is that the patient has ongoing infection and they come back for anyway, a few days later, if you're lucky, if they, if you're not lucky, they get spreading infection and they have significant morbidity, arrange imaging if necessary. So, really think, do I need to do an MRI before I send them forever before I do? Anyway, am I really looking for some hidden pockets that I'm not going to see easily on an eu A? And when you do your, you a be quite systematic and thorough with it? So look in the anal. Can I look in the vaginal canal? Look at everything and examine everything before you put your knife to the patient because once you've drained the abscess, everything collapses and often you lose that opportunity to get more infection and more information. Uh And the main thing is drained widely. I think there's a, there's a sort of hesitation to make um a big incision and people want to make a small incision and drain the abscess, but it doesn't drain the abscess properly. And often then has more infection. Uh And patient's have to then come back. So drain widely. If you, if you're going to make a big incision, and you think you're going to have to go around. So say if you make a decision at three o'clock and then there's a horseshoe going around 229 o'clock, you might not want to, you won't do an entire 3 to 9 o'clock incision. You do two stabs on three and nine and you can put in corrugated drains on either side to, to get rid of the horseshoe. So there may be other ways in which you can drain better without having to make big incisions. But generally speaking, if you have an abscess on one side, drain it to it's entirety and make a decision as necessary in most patient's, if it's the first time they're presenting, they will heal, it may take a little bit longer, but they won't come back with another infection. So it's important that you drain it appropriately and that's it. Thank you very much. All right. Thank you very much Abby for, for another interesting and excellent talk. And uh we will be looking for some questions on the chat again if you, if you don't mind just to monitor that and, and uh respond accordingly. Um We are obviously running behind our schedule and uh we will have a short break just for five minutes for uh five minutes break, uh comfort and then we will uh start again. Uh We've got kind now who has managed to join us and he will be giving his, his colon cancer, uh, talk. And then we will carry on after that with the schedule as a band for the, uh, for the ward around, uh, talks. So we'll see you, uh, 3 35 minutes.