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Hello, everyone. We are live. Now. Can everyone hear me if you can hear me loud and clear? Can you just drop a comment in the chat box? Just so I'm sure everyone can hear me drop, drop an EMG or your comments in the chart box to be sure that everyone can hear me loud and clear. Yeah, perfect. Thank you. I deli thank you very much. Um, so welcome everyone to today's session of the General Surgery teaching series. Um, today we'll be talking about small bowel obstruction. And, um, basically this is, um, an event brought to you, um, from surgery interest Group of Africa. That's what CD stands for. And, um, if you are keen to join the association, output the information in the chat box shortly and you can join, it's very, very straightforward. Um, you can join whichever speciality you want to join. Um, we've got over 10 subspecialties in surgery that you can join. Um, that being said we would, um, invited the stage very soon. Our speaker for the day, Doctor Samuel Ammo, a who is a court trainee in um, the West Ex Dery in United Kingdom. He finished from the University of Ghana Medical School. He would be taking us through small bowel obstruction very soon is live with us now. And um you would have the stage in a GP Doctor Samuel. I'm of a, a full, are you there? It is just to double check. Yes, please. I'm here. Yeah. Ok. The stage is years now and um you can always let me know what ever is not working rightly and um I'll try to sort it from this end. Thank you very much. All right. Thank you so much and, um, welcome everyone to, uh, s, um, teaching series today. Um, like has rightly been said, my name is, um, Samuel A a and you can just call me some and I'll be sharing, um, a series of, um, topics which begins today, er, on small bowel obstruction and hopefully next week we would look at large bowel obstruction. Um, I hope that you will be engaged in this lesson and you could just chat, um, on the chat box if you have any question and then we'll address it soon. So we're looking at small bowel obstruction and I'm happy for you to, sorry to, sorry, sorry to interject. Um, could you, do you mind just taking off the app metal showing on your screen if you just click on hide? Yeah, perfect. Thank you. Yeah. So, um, I'm happy. My email is a AO at doctors dot org dot UK. I'm happy for you to chat to me, um, concerning your surgical training, planning and everything. Um, so small bowel obstruction and my, our learning objective today is to know what's basically is intestinal obstruction. And because we're looking at the small bowel today, we will look at a little understanding of the basic anatomy and physiology of the small bowel. We'll look at the major causes of small bowel obstruction and what the presentation and symptoms are, how to investigate the patient who comes in with suspected small bowel obstruction and to follow it up with the management and we'll look at a few clinical cases to try and, um, solidify our understanding of the lesson today. So by way of introduction, uh we know that intestinal obstruction is any partial or complete blockage of the bowel. And in this case, the small bowel and intestinal obstruction is usually classified as either mechanical or functional. And at that time, which is used is either dynamic, which is, um, uh, mechanical or adynamic, which is functional. Mechanical simply means that there is a physical obstruction and adynamic or a functional obstruction means that there is no actual mechanical or physical blockage of the bowel. Um, a little bit of statistics in the UK shows that if you take all the emergency laparotomies done about more than half of it or almost half of it, um, consists of small bowel obstruction which is huge and it's important and any patient coming through the ed door, especially patients who are age 65. Yes. And above, there is a chance of 10 to 12% of these patients who have abdominal pain will present or will come with a diagnosis of a small bowel obstruction in the UK. And in most parts of the world adhesions from previous surgeries are usually the most common cause of the small bowel obstruction. So, a little bit of an anatomy is that we know that um the, the, the intestinal gut or the gastrointestinal that um tract um consists from the mouth all the way to the anus. Um There's a bit of a variation of the length of the small bowel. Um with men having a longer length compared to females. And even, um for the same patient, the research has shown that there is still a lot of variation in the patient intra op in the patient. Um, post mortem, there are a lot of variations and um, it's been estimated to be about 300 to 850 centimeters in length ranging from the dual fla to the valve. So if you take the whole um git tract, you take the, the small and large bowel and you look at the general ture to the IA you have a length of about 308 103 108 50 centimeters in length. And this is way longer than the large bowel. And therefore, the small bowel makes about almost 60% of the bowel. So any obstruction in the small bowel is very significant. One thing to also bear in mind is that in, in, in, in, in principle, there is no real demarcation between the Jegen and the AOM. And so we, we have certain features that we use to try to separate and assist to differentiate what the gen is and the ale. And I've made a, a simple table here to just help um us to remind ourselves about which um bow is the Jeno and which bow is the IOM. And when you look at the Jegen, the ju usually forms or it's usually um correlated around the left upper quadrant while the ileum is around the lower right quadrant. When you, when you in inter, when you look at the bowels, you realize the Jegen is, has a very thick intestinal wall compared to the thinner wall in the, in the ileum. Um The ju has longer Vax Recor, which are the, the um smaller vessels supplying from the me and supplying the bowel and the I don't have, they have a shorter vas recor um because of the longer Barres, um they, they cause a lesser aca or lesser arterial loops where the ilium will have a, a longer or a more arterial loop color wise, not too much of a different uh difference, but the a seems to be more reddish in color was the ali tends to be quite pinkish in color gas supply to both the IUM and the jejunum is by the superior mesenteric artery. And if you can see clearly from this, you have the celiac artery, then you have the superior mesenteric artery which gives branches to your jejunum, which is usually in the left upper quadrant and to your eye lung, which is usually in the right, um upper right, lower quadrant. The lymphatic drainage follows the arterial supply in terms of venous drainage. The venous drainage also goes all the way through from the smaller um Iliac Jejuna ileocolic veins into the small uh mesenteric vein. And this small mesic vein join in to become the port vein, joins with the splenic vein to become the port vein and then empties back into circulation functionally. The seems to be greater insp responsibility with regards to digestion of your carbohydrates, your proteins, absorption of water and electrolytes. But when it comes to vitamin B 12 and bios um absorption, the alum is um very remarkable in this regard. And both of them are also um involved in synthesis of hormones such as the um moulin. Sorry, this is Moline hormone, the GLP one and two and peptide double Y. So what are the causes of small bowel obstructions? We've already said that the bowel obstructions could be dynamic, which is mechanical adynamic, which is functional. But the purpose of our discussion today, we're looking at mechanical and mechanical can be a complete mechanical obstruction or an incomplete, which is a partial or a subacute obstruction. There are several causes of, um, small bowel obstructions, mechanical causes of small bowel obstructions and like I earlier indicated adhesions, um, forms about 60 75% of the causes of small bowel obstruction and adhesions could come from an inflammatory procedure, congenital adhesions or from post surgery. And many years back, especially when I was training as a medical student, um, in my home country and most of the most of the causes or the, the the major cause of small bowel obstruction was from hernias, um inguinal hernias or from femora, he groin hernias. But in, in the west and in many um developed countries because of the increasing advent of surgeries or performing procedures, um and adhesion seems to become the major problem and even in the West African region, um adhesions seems to overtake hea as a major um cause of small bowel obstruction. So, hernia still remains the second um worldwide. Um most common cause in vaginal abdomen. And this is an important thing to bear in mind when you see a patient down at the ed with abdominal pain with signs of obstruction and the patient has no para surgical history. It's important to try to, to put in mind that this could be a hernia and a hernia could be an external one or an internal hernia. And um I remember um as a young um, house officer, uh the patient presented with a small bowel obstruction and out of being um polite and respectful to the patient, I decided not to push down the, the uh pants and look at the groin. And my uh consultant came around and said, oh, what's the cause of the obstruction? I'm like, oh, I, I'm not sure what the obstruction is. It was like, oh, did you look at the groin? I'm like, wow. No, I didn't look at the groin lo and behold, we, we, we pushed down the, the pans and there was an inguinal hernia. So it's always important to consider hernias, especially in patient with no surgical history, no abdominal surgeries. Um The other common causes are, which are quite rare are foreign bodies. Um, gallstone I and tumors and Crohn's disease or inflammatory diseases, intussusception and parasites. So, how do this patient present? And that's where uh we want to spend time on. So these patients will present with the central abdominal pain and they will tell you that this abdominal pain is intermittent or colicky. And uh most of them will present with vomiting and for small bowel obstruction, vomiting is uh uh a most important sign compared to constipation because the higher the level of, of obstruction, the likelihood that you are going to vomit than be constipated. Um So constipation is also an important sign, but most of the these patients may not have what we call an absolute constipation, which is total um um loss of passing feces or absence of, of passing any, um, wind or gas. Um, patient with small bowel obstructions may also come with abdominal distension. However, because the length of the small bowel is closer towards the chest and because of the um, chest wall, restricting the, the abdo the abdomen, abdomen, on the, on the higher level, sometimes these Distentions are a bit difficult to appreciate, but sometimes the patient will tell you that, um, he or she feels that the abdomen is bigger than usual. And um it's important to, to appreciate these things or ask the patient if there is any form of distension. I have mentioned that there is um a central abdominal pain and it's important that because the small bowels usually um congregate within the center of the abdomen. Whilst the large bowels are usually fixed and plastic to the radial parts or the peripheral parts of the bowel. With that said, there are situations where we would look at. Um going forward that we realize that sometimes this pain is not just intermittent or colicky. This pain become a constant severe pain, but initial presentation, initial classical signs or symptoms is intermittent and a colicky abdominal pain. So how do we move on or how do we assess this patient? So we have a patient who is presenting with some days or duration of a history of vomiting. Um What's important you want to characterize this vomiting? Is the vomiting projectile? Is it non projectile? What is the frequency of this vomiting. What is the timing of this vomiting is the, is the vomiting associated with another symptom? Um, is the vomiting below or none bilos? Um, uh, is anything that makes the vomiting worse or, or, or less? You want to ask all these questions about the vomiting? And then we, we, we've, we've asked about abdominal pain, we've asked about abdominal distension. We've asked about constipation and we have an impression in our mind that this might be a bowel obstruction. And, and usually we, we cannot at the E A&E or at the clinic, be able to clearly state that this is a small or large bowel. However, majority of bowel obstructions are small bowels, majority of the bowel obstructions are small bowel. So we move on to trying to assess this patient and our assessment will begin with an A to E assessment. We'll check that the patient is well and stable by doing the airway a quick breathing and a quick circulation, checking for dehydration capillary, full time check that the patient is well oriented and alert and then you do a quick a good exposure. And what I've highlighted these important things, it's about dehydration, dehydration because we in the physiology of the small bowel, we realize that the bowel produces a lot of, um, fluid. There is about nine liters, almost up to about nine liters of fluid contained in the bowel. And you can imagine that when you have an obstruction and fluid is sequester away from circulation. This can cause massive forms of dehydration. Secondly, this patient will come in possibly vomiting days and days away and because of the vomiting, they won't be drinking. So it's important to assess this patient for dehydration and start fluids. Um You have to look out on your examination. Most you have to do a head to toe examination, but most importantly, we, we restrict ourselves abdominal findings. So looking for any distinction, obvious distinctions, you're looking for any scars or surgical incisions. You're looking for any hernias, um, abdominal or groin hernias. Um You have to do a good palpation, palpating for, for tenderness, you have to check whether there is per periton or peritonitis. Typical small bowel obstructions do not necessarily come with peritonitis. And when peritonitis begin to set in, then you are concerned that if there is a complication of the small bowel, which is more of an ischemia or a perforation. Um, um, and that's something we'll discuss very soon. The last thing you want to do is you want to listen for bowel sounds and in, in bowel obstruction, the bowel sounds are, are increased. You hear increased bowel sounds, frequent bowel sounds and because of the activity of pers stasis trying to override the, the obstruction in, in late stages of unrelieved bowel obstructions where peritonitis have set in. Um, the, in the, in that situation, the bowel sounds will be reduced or the bowel sounds will be totally on head and always remember to do, uh, a perect or the gua rectal examination, um, to see whether you have a collapsed rectum, empty, um, rectum, um, any bleeding check for any erectile masses. Um, um, and see if there's any bleeding. This may be a sign of ischemia or an inflammatory process which has been going on. So how will we investigate a patient with small bowel obstruction? And, uh I mean us, our first form of investigation would be doing a supportive investigation and a definitive investigation, supportive investigations will be doing your full blood count, your blacks, doing your full blood count, do your un e checking for dehydration and um electrolytes. Um uh making sure that the kidney functions are good baseline. You want to do a, a liver function test, we do and my list you want to check for for all the uh clotting profile and everything, what the baseline stuff we do for all the patients that come in with an acute surgical abdomen. Now, definitive investigation is in terms of imaging, depends on where you are and the resource available and what your facility can provide um immediately and II I have our face investigation as an abdominal airy and many facilities have er phased out the use of abdominal airy as um initial investigation for any suspected bowel obstruction. And this is because about 60 to 80% of um abdominal air I picked are picked er, for small bowel extractions which, which leaves about 40 to, um, 20% 20 to 40% can be missed. So, if you have a patient with a clinical diagnosis of small bowel obstruction and the only modality, you have to investigate an abdominal history, an abnormal history comes and it's not very positive for, for obstruction because you, it's not very positive for obstruction. You have to bear in mind that there is still um a caveat or there is still a percentage that will be missed. And that is the reason why many have shifted from doing abdomal because the abdominal history come back and they are negative, you will still move on and get a CT scan. And why do we do a CT scan? Because CT scans have a sensitivity and specificity about 95% and this is very good. So it, it is unlikely to miss a bowel obstruction on the CT scan. And um the, the other advantage is that the CT scan will give you a definitive diagnosis and it would also give you the cause of the small bowel obstruction. So when we look at the abdominal xray, usually the abdominal issues, we request 222 films, we request the E and the supine, the ure is to look for air fluid levels. So we have multiple air fluid levels. It gives an idea that there's small, there's a bowel obstruction. Then the supine gives you the, the area of um, bowel obstruction or the area of bowel, which is involved and usually on the x-ray. Um because of the plaque seculars seen in the Jeu, which is what we are seeing in this image, the street lines across the bows. These are, these are positive signs that this is bows showing Jeu, the ilium on the x-ray is featureless and you can actually appreciate it and see it on an x-ray. So when you have a, a CT CT scan, CT scan helps you want to know the, the transition point which you can actually appreciate on an abdominal x-ray. So you see the transition point, um, you're able to appreciate some complications and some of the complications of small bowel obstruction is that the power can become ischemic, you can have a ischemic process going on, you have a per, um, um, going on and, and the CT scan helps us to see this. The CT scan also helps us to know other than the transition, the cost of the small bowel obstruction. So if, if you look at this x-ray, you, you, you, you know that there's a bowel obstruction, but what's the cause? We can't really tell from the x-ray. But if you look at this x-ray and if you can see my case with the eye or feet, this is a, um, a small bowel obstruction and you can see that the air fluid levels, you can see that the bowels are small loops of bowels are distended. And if you look on the up view, you realize that the on, on the left groin, around the left groin, there is a bulging mass um, into the, into the pelvis. And that is um, an in an ob inguinal hernia. So the, the, the ct scan has benefit in helping you find what cause of the small bowel obstruction and it helps you with your surgical planning very well Cause going at it this way, you just do an abdominal history and you go in and it's a tumor and you can't, you didn't really plan for, for two more debulking or a surgery and for the tumor. So that's one of the reasons why we do a CT scan. And, um, I had, I mentioned earlier that one of the complications of a small bowel obstruction is ischemia. And that's one of the things that we can pick from a CT scan. And because of time I won't go through this. But when you look on this slide, it tells you some of the CT finders that can help you with ischemia, it is not 100% but it is better than, um, but than any other modality we have. So, uh, when it comes to bowel ischemia secondary to a small bowel obstruction, um, you're looking at three, criteria. So you're looking at clinical signs, you're looking at CT findings, you're looking at your biochemistry, which is your plaque. So clinically um, you have a patient with a small bowel obstruction that is abdominal distension, vomiting, and constipation. And these three signs are three important signs of intestinal obstruction. Then the features of ischemia in the bowel obstructions will be the intermittent colicky pain becomes a severe constant pain. And usually if you have um, a groin swelling, the groin swelling become, or the hernia becomes very tender. Patient would disallow you from touching it and you can see some reddening um around it. Um The other thing about, um, ischemia clinically is the patient usually go into shock, they go into shock and especially when you resuscitated them, they do not really get better. Because if you look at this picture, this is a segment of bowel that has become ischemic and gangrene. And um um when the process of gangrene and ischemia sets in patient gets refractory shocks and this is something that clinically should pick you up. Most of the bowel obstructions do not present with fever. Most of the bowel obstructions, inflammatory markers will be normal. So, one of the clinical picture is a fever in a patient with a small bowel obstruction. It's an ominous sign that something bad is going. Then with the second criteria is a CT findings. And CT has a lot to tell you um, with regard to ischemia and uh most important is looking at whether you have a close loop obstruction, which means that you have a pros and a distal, um, ends that are obstructed. And that gives you an idea that the bowel will be ischemic. And the other thing is looking at the mesenteric ves vessels, when you look at the mesenteric veins, are they engorged? Is there any Mesenteric venous gas? Um, is there, uh, any Mesenteric edema? Is there fluid in the mesentery or peritoneal cavity? And these are positive signs, something which is very waste of, is seeing a venous gas. And that, that means that the there is too much ischemia and um, gas is gas is leaking off from the ischemic bowel. By chemical, we is by doing a venous blood gas and just do a venous blood gas, which is in 10 minutes can give you or five minutes can give you a results. You check for your lactate, you check for acidosis. Um, usually these patients have a metabolic acidosis and then in your blood CRP and W counts are normally elevated. So we, we have just as a quick, um, rec up, we have a patient with small bowel obstructions. Clinical history is abdominal distension, abdominal pain, vomiting, plus or constipation. Um, right at seeing the patient, you must form a mental picture in your mind. Is this patient on the way spectrum of a small bowel obstruction? That is if the patient have an ischemic bowel is the patient likely to have been, um, per and, and these are complications and this means that your management should kick kick, start quickly and, and move on. Or as the patient on the lesser spectrum, which is a mild presentation, probably some mild vomiting, not much of an abdominal distension, bowel is um is tense but it's not periton. So we come back to managing. So we said that it is very important given the, the a picture of these um situations where there's a lot of dehydration, a lot of electrolyte abnormalities. So you need to do a good A to e you take your bloods. Normally you have to keep this patient. No, by mouth and we have to appreciate that no, by mouth did not, does not mean that the bowel will not produce fluid. And we said that this bowel produce about nine liters of fluid in 24 hours. So it's important to stick in an NG tube. In this patient, you stick in an NG tube, you give them analgesia and some antiemetics. You give IV fluids uh pass in the catheter, make sure you keep a fluid chart to, to correct the input and output um start on antibiotics according to your hospital protocol. And um if the patient is fine, like prot me, you would in, in the UK, you would have to cal with the need last call to see the mortality rate for this patient. And then your definitive management is not a question of whether this patient needs surgery, open surgery or laparoscopic surgery or this patient does not need surgery and this patient must be managed conservatively. And, uh, I'm, I'm happy to tell you that most of small bowel obstructions are managed conservatively. About 65 to 80% of small bowel obstructions are managed conservatively. And what are the indications for a patient to go in for surgery in a small bowel obstruction? So, not, not all small bowel abstractions will go into, into the f immediately. And these are the reasons the patient that will be selected for surgeries are patients that have a complicated small bowel obstruction that is, they have an ischemic process going on. They have a closed loop obstruction. A close loop obstruction is not likely to resolve on its own or the patient has, um, perfusion in the bowel or there are ct findings of bowel necrosis or severe bowel wall thinning. Uh, uh, going on. The other thing is when you have a patient with small bowel obstruction, which is secondary to a hernia, it's, uh, with secondary to an obstructed hernia, it is not likely to resolve on its own unless the incarcerated hernia is, is, is resolved. So this patient will need surgery. If the patient has a ulus, the bowel is twisted on its own. They need a surgery. The patient has a malignancy. They need a surgery. You can't leave the malignancy in even if the obstruction should resolve and it's not likely to resolve. And if a patient has a gallstone, I, if there's a perforation of a stone from the gallstone into the, into the bowel. You'd have to go in, relieve the obstruction and remove the, the gallstone from the bowel. One of the indication for operative surgery is if there's field of conservative management, usually for three days. Um, some, some places you can extend it up to five days. And usually this patient, we just drip and suck. We put in an NG tube, we drain it out. Uh, we, we replace IV fluids, we replace electrolytes and we allow the bowel to rest. And most of them would resolve 65 to 80%. If they don't resolve in three days, or they show signs of complications like ischemia or like perforation or necrosis, then they would need operative surgery. The other thing is the last indication is vagin abdomen. And I put, I put a query in there because when you have a patient with a small bowel obstruction. And um, so most of the bowel obstruction that we treat conservatively are obstruction secondary to adhesions to adhesions. Patient with previous surgery. If a patient has a vagin abdomen, clearly, there's something causing the bowel obstruction. If it's a mechanical obstruction, unless it's a non mechanical obstruction. If there's a mechanical obstruction, there's clearly something which is obstructing and therefore not, not operating or not finding that causes a problem. And, and, and the fear is if this patient has an underlying malignancy, are you going to leave this malignancy to linger on or if this patient has an underlying into INSS or anything, are you going to allow it gone? So, um there is a low threshold of trying to get vagin abdomens, especially into theater um to explore and if these patients are not operated on, they need to be followed up um, post the relief of the obstruction to make sure that there is no underlying malignancy. So, um something I, something of interest I put here. So I'm, I'm not sure how many of you in your, um, trust or in your places they do this, but this is something very wide practice nowadays. So, and there is a lot of research around this and this has been based on a lot of randomized control trials and I'm sure most of you have heard about gastrograph and it used in small bowel obstruction. And, um, what, what, what typically happens is that patient comes in with a small bowel obstruction. Um, they are given ng tubes, given IV fluids, we drain empty the bowels. And then later you give the patient a gas grain solution and gas grain is important. It's a hypotonic solution, um, water based solution. And it's been shown that it helps to predict the resolution of small bowel obstruction. So you want to manage this patient conservatively, but you need to, to have a, a clinical indicator or an objective indicator to, to see that the bowel obstruction is, is relieving clinically. You, you would say, oh, the vomiting is resolved, the patient is open the bowels and that, that makes a lot of clinical sense. But radiologically and objectively, when you give a patient gastrograph, what happens is that it helps to predict post imaging to see whether the small bowel obstruction has been relieved. And then it has been shown in uh research or in studies that it decreased the length of stay. So you will keep the patient conservative for 3 to 5 days before, before intervening. But when you give them ga grain because of the hyper hypertonic solution, what happens is that when you take the gas grain, it, it has a LAZ effect. So it helps the, the bowels open up. And then the second thing is that the hypertonic nature of it cause fluid to draw into the bowel and in and stimulate the Peress and it also reduces the bowel edema. So it's, it's been found to have a, a lot of benefit. And um there's been a comparative studies to show whether there's been any morbidity or mortality following gas gray. And um, there's not been much done and seen or any mortality seen. And um studies have shown that um this is best used in patients with adhesions or bowels or the patients that are tailored for um conservative management. So what they do is usually, um at the in ne sometimes we, we will give it for the patient to go into the, the, the scanner, the CT scanner, it, it's helpful because with the gastro grain, it helps the CT scanner and it helps the interpretation um of the image, you get a very good image output because you have a very um opaque object and you can see the area of obstruction clearly. However, the danger with also giving it too early is that patient is vomiting, patient's um abdomen is full. and if you give any solution, patient may aspirate and vomit. So it's, it's a, it's a risk and benefit analysis and for most people who will drip and suck for almost close to 24 hours and give the gastrograph and then you do a check, imaging CT or x-ray eight hours to check if there's any resolution. So I I that's, that basically brings me to the end of the presentation for small bowel obstruction. And um I, I'm sure that if there are any questions, I'm happy to answer them, but I have these um great scenarios that I want us to go through and I think it will help us, um, remember what we've learned today. So we have a 78 year old man and he presents to the AM E with nausea and vomiting. Um He complains of the right iliac foa. He has a dull pain at the right iliac fossa, which has been going on for five days among his symptoms or relevant symptoms. He's had unintentional weight loss for the last six months. You do abdominal examination and the abdomen is distended. It's not Peric. There's a right iliac fossa mass. You can feel that there is a, there's a fullness or there's a mass in the right iliac fossa and which, which is down on palpation and you do APR and it's normal. I just want to, I don't know if anyone can ha has that a guess. But what comes to mind, what, what would be your phase differentiate in this 78 year old man? II, I can't see the chart. So I'm not sure if there are um, any office on the chart. If someone can help me, if the mod can let me know if there are any office. No, not yet. Ok. So just in you can drop your nsaids or what you think is the likely differential and investigation modality in the chart box. Yeah. Yeah. Someone said small bowel obstruction is the differential. Yeah. So, so, so clearly we have a small bowel obstruction, but small bowel obstruction is always secondary to something. It's always secondary to something. So just someone else said, um, can colonic cancer and someone else? Ok. There are lots of answers popping in. Um Someone said secondary to possible malignancy. Other one said colonic cancer. See couple more small bowel obstruction secondary to query, colon cancer. I've got the minutes. Yeah. Thank you. So, at least I'm, I'm happy with the answers that are coming and it means that we are considering the history of the patient as a whole and we are thinking of malignancy high on our list. Very good. So investigation wise, we will do supportive bloods and um all that. And then most importantly, the def investigation will be a CT scan. So this patient went and we had a CT scan. Um er I just took one film and, and I'm sure that we are not masters. I'm not, I'm not a mastermind. So, but I just took one film of the CT scan to just bring here for you to appreciate it. And I just want you to see something. I don't know if anyone um, is unexpected, but if this is the small bowel and the small bowel is distended. So the small bowel. Um, so there's what we call the rule 369. Um, so, um, you have the distention of the small bowel more than 66 centimeters diameter than then the bowel is um enlarged. We have a sca um, or a colonic distention of more than nine centimeters. And you know that that is also distended. So this is a small bowel and you, you can see that the, the rations are complete, you can see the lar and you see an N fluid level, you see that the bowel is distended. And over here this is the, the bow transition point from the i into the sco and this is where you have as the sco this is where you have a as and this patient was indeed diagnosed with AC A tumor was diagnosed with AC C A two. So unlike a um an abdominal x-ray, which I'm, I'm hoping that after today, many of you will not use as your face modality. We will not probably have appreciated ac a tumor on the abdominal x-ray. But the surgeons were able to appreciate this and plan a A AAA surgery which would be fitting for for a tumor and not just going in without any knowledge. So this patient survived and went back home. Second scenario. So we have an 88 year old female woman and she was living at the care home. She came to our A ne with nausea, vomiting and constipation. And it's been going on for 11 week. And the problem with people who are fail and living in care home is that you may think that oh, constipation is constipation is normal. But this woman had a left groin pain and she's had this left groin swelling, but it was painful for just a day. We examined her, the abdomen was vagin, there was no surgical incision. She was febrile, she had abdominal distension, she was very per Peronei and she was severely dehydrated, which is not surprising. And we did apr and it was normal. The rectum was empty, there was no blood but she was febrile. She was distended. She was very dehydrated. She was perton. Can anyone tell me what complication of small bowel is, do you think is going on in this lady? So she has a small bowel obstruction? But what complication of small bowel obstruction do you think this woman is having? Do you have any office? Yeah, just a few. Yeah, I think one just popped in now and it says, uh I, ok. So all those are coming. So a strangulated hernia. OK. So take her OK, great. So ischemic. Yeah. Yeah. So I'm I'm happy that we are all in class today and we are learning um from sic ischemia. Yeah. So, so I think, I think that all the differentials are important and all the differentials uh need to be in your mind. So this one could have a paralytic. But what will make paralytic is down on the list is that this woman is having peritonitis. You get it. She's having peritonitis in paralytic eyes. They, they typically do not have peritonitis with it. They get it, they can have the dehydration. They can be a be slightly febrile because even from the dehydration, but they, they do not become Peric with it. Um strangulated hernia. Good point, femoral hernias, good point. And we've mentioned that this woman has a left groin swelling and it, it's only been painful the last day. And therefore, on top of our differential will be a small bowel obstruction, likely from a strangulated hernia or the process which is going on in the small bowel is an ischemic process like, right, we said so in this patient investigation, among the things we'll do concerning the plats, one of the important things we will do is we will need to do a VBG for what we're looking for the lactate. If the lactate is very high, it is high like around 4.0 and above, then we are concerned there are other things to be. So this woman, this is what we had from her. When her CRP came back, it was 1 60 that is high. You typically don't have high CRPS like that in normal small bowel obstruction. The obesity count was 22. Her lactate was 4.0. She was severely dehydrated. She was having an ischemic process going on. So how will we manage this? Manage her? And I want to ask you um quickly because of time, I'll just quickly run through. So what, what we did for her right at the A and she was free. She was all those things. The most important thing to think as a junior doctor, as a house officer, um as a young surgeon is not trying to rush the patient into theater because you need to optimize this patient. You need to correct the, the um deficit. So what we did for this woman is that we, we, we, we stick an NG tube down into the stomach which drained a lot of bio content. Um We started IV fluids. We gave her pullo initially about 202 50 mils and we repeated it again. We gave her 500 then we give her a large maintenance fluid to continue. We gave her some antiemetics, we gave her some pain medication and because the hernia was irreducible was I in incarcerated. And if you see it in the caucasian skin, you could actually see a bit of redness around the, the, the hernia. At that time, we were not really keen about whether it was femora or it was inguinal hernia, but this is how we started her out on the A NE and we sent her straight to the scanner. And fortunately, we have a scanner and this is what this is what we, we had. Um, you can't really appreciate it much on the uh corona view. But if you look at the soar view, you realize that we've seen a similar thing before and that is the hea sack here and that is the obstruction, that's the point of obstruction. So, this woman had an, um, an obstructed um femoral hermia. And um, it was, it was really a difficult one because we had to decide whether she was fit for anesthesia or not. But uh eventually, um, she was palliated. Um, she didn't have the surgery, she was palliated because she wouldn't have survived anesthesia. So the diagnosis for this patient was um, a left, um, femoral hernia and we take the last one. so we have a 42 year old. So we seen a two more and we've seen a hernia and let's take the last one. So 42 year old woman normally fits un well, she has nausea, vomiting, constipation for the last two days. She has a history of two previous cesarean section on examination. You see a surgical scar from the CS, she's a fibri, the abdomen is fine. She is just distended. You did Apr Apr and the dre is normal. Who can tell me what is the likely the likely cause for the small bowel obstruction? At least just know that it, it's not a tumor and it's not a hernia because we've already seen it. Yeah. So we've got likely a dec um intestinal obstruction. Um Someone, someone else said the same thing. Addition, small bowel obstruction, small bowel obstruction. So to addition, you know, I think everyone is just great, great. The same answer. Yeah. So which which clearly means that uh we are done for, for this lesson. I do not need to, to, to continue. So excellent, we, the obstruction was secondary to adhesions and how, what I want you to learn from this is how did we manage this woman? So unlike the ones, this woman met the criteria for conservative management, so we did our blas they came back normal and we manage her conservatively conservatively mean means that we just did an NG tube, we drained the, we kept her node by mouth for a day or two. And then we give her gastrograph and she went into the scanner um, again and it showed that the bow was resolved by day five and she was well and home. Um So this is what we did. So we gave a no by mouth NG tube. We gave her fluids analgesia and we gave her oral gas grain 24 hours. Within that machine, we repeated the x-ray in D three which showed that she had resolve obstruction and then she went home by day five, she had open her bowels. So it's important to understand and appreciate the differences and how to manage them. And when the patient has adhesions or you want conservative management, it's important to manage them. Well, even with the conservative, do not ignore the fluids, do not ignore the, the treatment do not ignore the things you have to do because then they would, they would end up becoming surgical candidate to be operated. So, in conclusion, small bowel obstruction is a major cause for acute surgical abdomen. You have to always think whether this patient is a surgical candidate and requires operative management or this patient can be managed conservatively. About 65 to 80% of this patient can do well on conservative management. Always understand that assessment and decompression of the bowel is important. And remember at your level at our level, resuscitation is key and you need to keep that statin. And thank you. And if there are any questions, I think it from you. Awesome. Um Thank you very much, Tom. I was um a very lovely presentation. Not so much enjoyed it and I'm sure every other person enjoyed it as well on a and we've gained one or two things from this presentation today. We've got a couple of questions in the chat box and I'll just start from the very first one. So, um someone is asking, I'm sure you might be able to see the charts box. Now, some are you able to see it? Yeah, I, I can read the questions out for you. OK. Just, just read the first question because I don't know where to start. All right, if you scroll back to the very top. Yeah. Yeah. Um So the first question is by doctor adi adhesive, um adhesive, small bowel obstruction. Could you prevent it surgically by intraluminal splinting with a baker's tube as an alternative to extra laminar methods of nobles plication on child Phillips mesenteric plication. That was the most question. Yeah, that's, this is, this is high level question and yeah, this is high level question. So, um I'm not, I'm not sure if there's anyone who can help with answering it. Um Or if the doctor Ali has an answer to I'm happy to learn from him. Um So yeah, basically, I think um from my own little to experience. This is not a common thing that has been done. Um, now, I mean, at this age and stage it's more or less, um, it's used to be a thing. Um, it's, it's, I think it's, it's not a, er, it's not something in vogue anymore. I would just put it that way. Um, so I think, um, for a big CAS tube, um, historically, they, they tend to use just like a catheter. Like if you imagine a, like a ureter catheter sort of, um, being inserted into the bowel just to bypass the obstruction. And, um, that's, that's that sort of, um, splints the lumen open. Um, majorly it's, it's, it's, it's, um, they, I think they normally use it for, um, recurrent bowel obstruction, especially those that have got lots of add lesions and they are prone to, um, recurrent obstruction. So, but like I said, I don't think it's, it's a regular thing anymore. I stand to be corrected. Same thing with the extra Luminal splint in as well. So big because is for intraluminal and the nobu plication and Charles Phillips is, um, extra Luminal. So you're 10, you're, you're basically just, um, um, like holding the bowel onto the abdominal wall or, or than the bowel loops together just so that's extra luminary at the cirrhosis level just so it doesn't obstruct. Um, again, so both of them are valid. I don't know whether there's still any part of the world where they do that. But from my own little experience, I've, I've never witnessed it. I don't know whether there is any, anyone that has witnessed that um in their center, I'll scroll back to the very end to see whether anyone has put in any contribution regarding that. No, no, I don't think anyone has said anything about it. So that's, that's, that's my li to contribution. OK. And the second question, yeah, is testing serum like this a little better than my lis for pancreatitis diagnosis. Um So I think, I mean, I I'll answer it but uh I'm sure we've already treated acute pancreatitis and, and stuff before. But um honestly, different places have different first line what they want to really do. And the only reason is that lipa seems to to last longer. So when you do lipa, it peaks around 24 hours and it can last for up to 10 to 14 days. So you are likely to still have a positive lipase um um in acute pancreatitis. And whilst Amal lacks a lot behind um compared to uh um la las a lot behind compared to piece. However, in the acute stages of pancreatitis, both of them are diagnostics, both of them are diagnostic and either of them can be done um for the criteria. And with acute pancreatitis, you do not, it, you do, you need a bi chemical criteria, you need a, a radiological criteria and you need AC C. So there are three things that constitute to make that diagnosis. So if you have a raised zone or lipase, you need additional thing. Two out of the three criteria is, is needed to make the diagnosis. So either of them is fine and there's a question, what's the intravenous fluid of choice in managing bowel obstruction? Um So I'm not sure where, where, where you are from, but um different places have different kind of fluids. Um Most, for example, when I was training in my, my country, we, we used to have a ringers lactate uh was quite preferable um as initial fluid of resuscitation. Um The reason with P sodium chloride, the pseudo chloride is also fine, especially even if you need to correct um fluid deficit immediately. But the patient with usually um severe dehydrations usually have a a metabolic acidosis and sometimes the um um too much of sodium chloride can cause hypochloremia or worsen the acidosis um by giving a lot of chloride shift. Um Here in my trust, we, we have a fluid called the pas which is very um personality and very questions are very close to that of plasma and that's what we use. So that's our first line of fluid plasma light. How come and with what risk is acute intestinal pseudo obstruction, secondary to Sjogren's Syndrome in pregnancy. Wow, this is a phd question. So I think that the the spectrum of pseudo obstruction um is a, a whole different topic compared to acute intestinal obstruction. In acute mechanical intestinal obstruction with pseudo obstruction, you do not necessarily have a uh a mechanical obstruction. Um It's an adynamic one and, and in patient with Sjogren's syndrome, they have all these um motility abnormalities. And um it is common to have pseudo obstructions in um Sjogren syndrome. I do not know how comparable it is in pregnancy, but typically they, they can have this form of pseudo obstruction. And I think that's ok. So there's a question on does metoclopramide or promethazine play a role in the management of small bowel. And is there a preference if? Yes. So, so usually if you have a mechanical small bowel obstruction, which is what we are treat, looking at, you want to try and prevent um pro pro kinetics like metoclopramide because metoclopramide will increase per static activity and it's, it's basically worsening your obstruction. Um So we try to avoid metoclopramide. Um Promethazine can be used because it, it, that is not a prokinetic and we, we typically use um Oran um Ondansetron or Cyclizine, um which acts centrally in the brain to prevent the vomiting. Uh Yeah, I think, yeah, I think that's, that's all for now. Um We are right on time. That's um 7 58 to puff it. Um um sort of time management, I would say. Um, thanks a lot. One thing I just wanna chip in is um, I was quite um interested in in. Um, or let me say I was quite, um, I was quite happy when I saw the slide that showed that, um, additional additions generally is the most common cause, um, worldwide because it's one of the research groups in, um, c gap general surgery that be, um, that is lots of work on, um, systematic review and meta analysis of adults, mechanical bowel obstruction. And that should be published any moment from now. And what's, what's the group found? Um was that um prior to now in Africa, hernia was reported as the most common cause of um bowel obstruction, especially in adults. And um but when we searched the literature, we realized it's now addictions in Africa. And that's also tell with what's happening all over the world. So, yeah, I was just going to chip in that. And also um if like still um as a writer to that, if you want to join any research group, there are lots of research projects going on presently in CG generally in all the specialties and also in general surgery, there are quite a lot of um projects going on and if you are happy to coordinates any research projects, just um join, join C A. And um we can take it from there. There is always um room to network and collaborate and all of that. Yeah, I'm not sure there is any more questions. So still trying to see whether anyone will pop up anything. Um, yeah, so, um, the speaker, um, email address is, is now on the in, in the chart box. Rather if anyone have further questions, you can always email email that across. And, um, there will be another session next week which is gonna be large bowel obstruction. I'm sure you wouldn't want to miss that as well. Just to give you a perfect, um, picture of both small and bowel, um, both small and large bowel obstruction. I will drop the feedback form in the chart box now and you can always click the link to fill in the form just so you can get your certificates for this session. And um this would also be sent to your email addresses anyway. Um We need to know what we are doing rightly and um what um we need to improve on for subsequent sessions and you can always suggest which topic you would like to be thought in this series as well. Thanks everyone. Like I said, um CV dot org is the website if you're not yet a member of C gov. And um you can email the speaker, he's got his email address there and um you can join any of the research groups as well if you're interested in research projects. I don't know whether this pica still allows any other thing to. So just thank you to everyone and thank you for mode this. That was a pleasure today. Thank you. Thanks everyone. I've, I've dropped the feedback form now in the chart box so you can provide your feedback and, um, we'll see you next week. Saturday. Thanks a lot. Everyone. Ches.