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Well, maybe it's because I didn't have permission to. Yes, I think people can see that now. Yeah, I don't think we have permission to, um, go live because usually it's like the organization that can, um, hi. So I've, I've started broadcasting so I think everyone should be able to see everything now. I'm just checking. Yes, I think we can. I think my only worry is that because, you know, a lot of people obviously left because they thought it wasn't going on. Should we postpone this or? I'm not sure. Do you think we should just start from the beginning or do you think we should postpone it for a different date? Um, hi. So I think what we could do is, um, how many people are joined previously? About 67? And then I can guess because no one saw it go live. So it's just different people joining and leaving. Okay. So what, what we could do if you want to, if you're ready to present now, um, is we could present the session and because we're broadcasting, we can record the session, um, and then we'll make it available to everyone after and post it for everyone to see and you'll still get feedback for that session from the people who view the video after. Okay. Yeah, I don't mind doing that if you're happy to do that. Yeah. Yeah, perfect. So we'll just go from the start then. Um So is there a separate option to record it or? I think it's automatically being recorded? Right. Yeah. Okay. Let's just start. Um senna do you want to take over? Yes, I do. Yes. Right. Um uh um just, I'm still not sure if this is being recorded or not. I'm, I think so. Um, again, I don't see any options for recording here. Uh I can only see my own settings, so I'm just gonna, uh I'm just going to go on the assumption that it is being recorded and just start. Um So, hello everyone. Uh My name is Sena and today we will be presenting a uh presenting the clinical conditions, uh the G I system. Uh We are both medical student, me and faith. Uh third year medical students from the University of Buckingham and we are basic in ST Mandible Hospital in case uh you want to come and have a chat with just anytime. Um So today we're going to discuss some of the common conditions that people present with in uh with regard to G I, we're not going to go into a lot of detail about the anatomy because we, there has already been a lecture uh on that by James. Um, faith because you just go to the next slide. This. Yes. So, um, I'm just going to start with small bowel conditions. Um, some of the conditions that we are going to talk about today are inguinal hernias, femoral hernia, hiatus, hernia and the gastroenteritis. It's nice Practicals. So, um, the first condition we're going to discuss tonight, um, is in Glendale hernia. It is the most common type of presentation. Uh Most common type of hernia people present with, uh it is effectively herniation of small, intense in into the inguinal canal. And the um signs and symptoms include a bold on the side of the pubic bone with a burning paint and all discomfort, uh unable to be a lot worse when coughing or lifting heavy items. With regards to um investigations, we have abdominal examinations, CT scans and MRI to confirm our diagnosis. Um There are two different types of inguinal hernia. Um And uh as you can see in the picture, it is direct and indirect and a direct inguinal hernia shows a bold from the posterial of the inguinal canal. Uh whereas the indirect hernia is uh passes through the inguinal canal or the groin as it's more commonly known in the indirect hernias. It is more difficult to um palp ache. Uh The, the bold in a in an abdominal examination because of the because the defect is behind the external oblique muscle. Um Other differences with regards to that is um an indirect hernia can develop in young people and uh even in plants in Children. Uh and uh it is um usually when the abdominal um sorry, the inguinal brings, fails, fail to close. Uh but the direct uh occurs in adulthood, uh mostly with, it comes with age. Uh it is mostly due to the weakness of the abdominal wall muscles. Um Some differential diagnosis to consider for inguinal hernias are um lipomas, hemotomas or tumor's and also in Children undefended testing or in young adults. Um, uh let's uh, move on to uh femoral hernias. Now, uh they are quite rare compared to inguinal hernia. Again, it's going to be a painful lump in the uh upper part of the thigh or uh abdomen or lower part of the abdomen. Uh, and it passes through the, it passes below and lateral to the pubic tubercle. Um, signs and symptoms are going to be quite similar. It's going to be a pain and also a, a lump in the stomach. Um, and investigations are going to be quite similar as well. It's going to be MRI CT scan. Uh and also an abnormal examination to confirm the diagnosis. Treatment for femoral hernia is also quite similar to um uh abdominal uh inguinal hernias, uh is going to be surgical mostly to strength to push the hernia back and also strengthen the pelvic floor muscles. Uh There are different options for surgeries. It could be an open surgery or microscopic that is decided by, on a case basis, uh, depending on, on the situation. Um, I quite like this diagram because it shows where the different hernias are. You can see A B and the indirect, direct and femoral hernias and it, it is quite a good picture in terms of anatomically understand what's going on. Um Can you go back to that slide, please? Another hernia that we're going to go through is height is hernia. Now, this is not in uh the um uh this is mostly to do with the stomach. Um As you can see the picture on left, it is uh in the stomach, protrusion into the chest, uh through weakness in the diaphragm. Signs and symptoms include heartburn, dysphagia and um chest or abdominal pain. And again, the treatment is going to be the same uh surgery to push the hernia back and strength and the die from the two different types. Uh sliding, hiatal hernias and Pareles of the deal. Uh sliding uh goes up, the protrusion is up. The esophagus and Paris visual is uh sort of next studio outside the esophagus but into the diaphragm mostly. But and um gastroenteritis is another condition that is quite common. It's quite a common presentation. Uh It is the inflammation of the stomach and intestines. It is often caused by infection, uh sometimes bacterial, sometimes viral, could be simpler factor of food poisoning or roto virus is um norovirus is or some other uh, organisms that could cause gastroenteritis. It's most more common in Children and, uh, symptoms and signs are diarrhea and vomiting and it's also abdominal pain. With regards to treatment. If it's bacterial, we can give them antibiotics. If it's viral, then they're not going to be any good. Uh, just rehydrate rest, uh with them and, uh, complications, dehydration, chronic diarrhea, if the infection is prolonged and also accepted, um, uh, substance is quite important in that matter. Uh Because uh it could be, we could be fatal. And um what, what we sort of um want uh to prevent and a ballistics is what the acronym that we have for some of the actions we need to take if we suspect that uh I would advise everyone to know this because it's a very common exam question and also very important in practice. Uh back slight, please. Um So let's now move on to large bowel conditions. Uh Faith going to talk you through these. So I'm just gonna let her start, I'll just end mute. Okay. So large bowel conditions, um these are the common presentations you see with large bowel conditions like the ones that are most common in hospital and also most commonly come up in your examinations um to start with acute appendicitis, colorectal cancer, inflammatory bowel disease, and diverticular disease. The reason that I mentioned the diagram on the side is because I commonly find that um it's really important to know where the splenic flexure is, the hepatic flexure is. Um, and just the anatomy in general, I won't go too much in detail, but it's just a diagram to remind you of the same thing because it is quite a common question in the exams and moving on to the next slide. Okay, acute appendicitis. Um This is one of the most common presentations I've personally seen in a hospital. Um It's the inflammation of the appendix. Early presentation starts with peri umbilical pain and that often later on radiates to the right iliac fossa. Um somewhere close to mcburney's point. Um mcburney, Bernie's point is basically the distance. If you measure the distance from your umbilicus to the right ASIS, it's two thirds of that distance and that's where you can palpate it. Um And usually with people who have acute appendicitis, they'd be quite sore on that area and quite tender to feel it would cause cause them pain if you palpated there. Um Treatment for acute appendicitis is surgery. So, appendicectomy is where you'd remove the appendix. Um, clinical signs that are very specific to appendicitis um is rough sing sign. And so a sign. So rough sing sign is like in the diagram where you can see if you palpate the left iliac force that you get pain in the right Iliac four cells on the side. And so a sign is pain in the right iliac fossa when you extend the hip. Um some other things you would see is guarding and also rebound tenderness. So when you palpate the abdomen, you must have seen in your clinicals where you palpate the abdomen and then when you release. So when you press down and then you release pain on release, so the patient's would have that. Um, and some complications of acute appendicitis are perforation. You could get pelvic abscess is where you have post filling up and it could be quite nasty. And, um, you get sepsis infection of the bloodstream and that's quite deadly as well. So, it's good to treat this early on to prevent all those complications from happening. Some investigations you do is basically ruling out ectopic pregnancy. So you do a pregnancy test like beta HCG, you do a urine dip test and just blood tests to help you with the diagnosis. Um, moving on to the next side, colorectal cancer. So, malignancy is always an important thing to think about when you think about anything regarding a patient's presentation because you don't want to miss it out. Um, some signs and symptoms include any changes in bowel habits that's been persisting for quite a long time and, um, rectal bleeding. So, if you're not sure what the cause of the bleeders, that is quite concerning, you can get abdominal pain, you could get unplanned, weight loss and weight loss is one of the most important things when it comes to malignancy. It's always, um, one of the most important symptoms to diagnose it and how some causes of colorectal cancer. So it could be inherited or it could be non inherited. Inherited causes are usually um familial adenomatous polyposis disease. So, it's basically when you have a mutation in this humor suppressor gene called APC, and then you're more likely to develop polyps and stuff like that. And that usually causes colorectal cancer further on. So it has low prognosis. Another differential for what causes colorectal cancer. Itch is HNPCC um its heritage Torrey Nonpolyposis, Colorectal cancer. And that's usually when you have a mutation in the D N A mismatch repair gene. Um I won't go into more detail on that you'd usually. So the diagnosis for colorectal cancer is usually a colonoscopy with biopsy. And um you also have blood tests and the C E A carcino embryonic antigen tumor marker. It's quite important. Um The staging for Duke's uh staging for colorectal cancer is Duke staging. Um And it's staged in alphabet. So A B C D where is when it's confined beneath the mucosa uh mucosa vascularies and then be is when it's extended through it and see lymph node involvement of any kind these when you have distant metastases. Um But yeah, so most of the time to correct colorectal cancer, you'd have surgeries and there's different types of surgeries like you could, it depends on what part of the colon. And in fact, uh it affects and um most of the time this is done with alongside chemotherapy and radiotherapy to improve prognosis and complications would include bowel obstruction and metastases if not treated early on. Moving on to the next slide, inflammatory bowel disease. Um, this is another thing that I see coming up a lot in exams and, um, you can classify it into two. So there's Crohn's disease and there's ulcerative colitis there quite different from each other microscopically and microscopically. So let's go through that together. Um Crohn's disease, it affects the whole of um, so it affects everything from the gi tracts, soma to anus. Um and it usually causes vomiting, bloating in those um, symptoms you see down there and alternative colitis, it mainly affects the colon and it's very rare to see it anywhere else. Um It's basically you, it presents with like mucus in stool blood and frequent are. So there's similar presentation symptoms wise, but when I show you the microscopic differences, it's pretty easy to tell when you're like when you send for a colonoscopy and then you send for fecal calprotectin. So, fecal calprotectin is a good marker to tell whether it's IBD or not. And that should be one of the main diagnostic things that you put um to find out. And um common a scope would help you like microscopically and microscopically to tell whether it's Crohn's or ulcerative colitis treatments include NSAID. So, reducing inflammation and you have surgery and also maintenance therapy to prevent remission to the disease again. So you have azaTHIOprine, which is an important one that a lot of people usually take complications, fissula structures, colorectal cancer. I'll speak a little more about IBD in the next slide. Okay. So here you can see what I mentioned. So, Crohn's has basically Crohn's usually have skipped lesions. So it's not continuously um affects the gi tract. Whereas in alternative colitis, you'd see continuous but only in the colon instead of the whole gi tract. Um Crohn's disease, um if you have, if you're a smoker, you're more at risk of developing cones where as an alternative colitis, smoking is actually a protective factor. Um interestingly, but um macroscopically, the difference between cones and alternative colitis um is the whole continue. So in cones, you'd have transmural inflammation. So all around and then in all the layers and in alternative colitis, you'd have only mucosal inflammation. Um and then also in Cohen's, you have cobblestone appearance, which is most commonly known for and um you'd have fistulous fishers, all those kind of things where as an alternative colitis, you mainly get pseudo polyps and ulcers, not really fistulas. Um Oh yeah. So Crohn's is also associated with noncaseating granuloma bus, whereas alternative colitis is not associated with granulomas at all. It's associated with crypt abscess is instead moving on to the next diverticular disease. So, a common thing that I see people get confused with is what is diverticula osis versus diverticulitis. Now, diverticula osis is when you have pouches. Like if you can see in the diagram, there's patches being created in the colon. And um these are called the diverticular and diverticulitis is when those pouch or diverticula get inflamed. And in fact, what causes diverticula isis or inflammation of the diverticular um, symptoms are very, it's not very specific. You have change in bowel habit, nausea, flat abdomen, you probably get. So the abdominal pain is usually worse after eating. So that's a little bit that helps you get that diagnosis. Investigations mainly rely on excluding other things. So again, do investigations for B D I B S celiac colorectal cancer. But the day you'd rely on the CT scan and colonoscopy to confirm that diagnosis of the diverticulosis or diverticulitis um treatment. So usually many people wouldn't even know they had diverticula osis unless it becomes infected and unless it comes to diverticulitis. So you'd only treat it then after it proceeds to that um pathway and it's mainly antibiotics to cure the infection and then pain relief like paracetamol, um and surgery if it gets quite bad. And if you to prevent complications like peritonitis or like fistulas, um okay. So moving onto in erectile conditions, uh you have hemorrhoids, pill, annoyed all sinus, anal fischelis, anal fissures and anorectal abscess is. So the last one is in a rectal abscess is if I um are and then if you can see the most important thing for hemorrhoids for the first case is you need to see the dentate line. So let me just switch to the next side and you'll see what I'm talking about. Um, when you have hemorrhoids above the dentate line. So, like in internal hemorrhoids, they're classified as internal. Whereas if it's below the dentate line, it's classified as external and um, external hemorrhoids are usually the ones that are quite painful and, um, they're the ones that would get term boast and would bleed quite, quite, quite frequently as internal would not. And, um, what a hemorrhoid basically is, is it swollen winds inside the rectum around the anal canal. Um, and the most common presentation you'll get. So it's completely like, it's a unique presentation. It's painless, bright red rectal meeting. So funny enough, they don't really have pain unless it's treme boast. And that's very rare that it would come to that part. Like they probably already feel it beforehand and come to the doctor. And, um, again, management diet changes to prevent constipation. So, increasing your fiber intake and surgical, um, surgical, um, like maintain surgical treatment where you'd um, basically clamp the veins or you prevent the bleeding or you'd sort the trumbo's is and moving on to the next one is pill annoyed all sinus. Now, what a sinus is, is it's basically a perforation or a hole at the back and pill annoyed Elice, just the perforation or whole when it's at the back on top of the buttocks. Um and treatment is usually infection. So treatment for infection. So you give antibiotics, fluid therapy, pain relief, your, your classics and often these sinuses are filled with pus and inflammatory material and stuff like that. So you want to drain the pus and then close the sinus with surgery. Um moving on to the next one. So in erectile abscess is um so again, abscess is similar to what the sinuses. So there's like a collection of pus and, but the cause is a bit different. So the cause for an abscess is when you have blockage of like anal ducks, ducks or anal glands, um symptoms, you would have severe like really bad anal pain, perianal pain, you have fatigue, night sweats, it gives you a similar sepsis presentation. So that's something to think about. So, when someone presents something similar to sepsis, you're, you're thinking um is it open infection or is there something else going on that you can't actually see um on examination, you find a mass and that usually helps you if that diagnosis. Um and it could have discharge. It could not, it depends treatments again, antibiotics, ified infection and then draining the abscess. Um Okay. So next one is an official asses and official is basically a connection between um anything. So an a an official is a connection between the bowel and um the anal canal or the anus and it's usually caused post multiple in a rectal abscess. Is. So when you have a lot of, in a rectal abscess is a complication of that is an official, is developing. Um, symptoms include skin irritation. So you'd have pruritis and stuff like that and, um, it's usually worse pain when you sit down. And, um, you also have smelly discharge and stuff like that. Risk factors to develop anal fistula, which I found quite interesting. It mainly affects caucasian males. Um, age 16 to 30 I think it's because it's more common in people who have to sit down for a prolonged period of time. So, like drivers like lorry drivers and stuff like that. And apparently it starts as an infected hair follicle and then it forms a pit, it fills with serious fluid and then that's how it presents. Uh Oh, wait, sorry. That's my bad. Um So treatment treatment is usually um thigh Brynn blue and it's the only nonsurgical option. And if it was really bad, if the fistula was quite dangerous, they do a fish a lot to me, which is the surgical management for it. And complications would have would include bleeding, fecal incontinence and infections as you would presume, um moving on to anal fissures. Now, it's exactly what you think it is. So, it's a terror in the mucosal lining of the anal canal and it can be quite painful as you can imagine. So, um the pain will be worse post defecation. So when you're trying excreting faeces, that's when you feel the pain the most, it's more like a sharp pain. And most cases, unless the pain is affecting the per person's daily living, there will be no medical intervention and you just try to reduce the cause for what's causing the anal fissure. So if it's trauma to the anal canal, you try to prevent that trauma or if it's um, let's say constipation, you give, um you'd improve diet control to prevent constipation or you have also these queens and like emollients you can apply and um also Botox injections which help um relax the sphincter. So help for easy emptying of the bowel and contents and surgery can also be used to close the fissure and facilitate repair post, you know, conservative management. Okay. Now I'll be passing it on to senna. We'll be having a discussion on common general surgery presentations. Yes. Thank you fe. Um So, um, here is a list of some of the common general surgery representation. So power obstruction actually have done and so on. Uh, what we were thinking of doing is to have a more interactive session. So, um, if, if anyone wanted to put anything in the chat, you're more than welcome. And, and in fact, please do, uh, it will help us learn as well as you, uh and also make it more, more interactive for everyone. Um So next slide, please. Um, so with regards to bowel obstructions, uh, we would like you to consider some of these items. So, um, treatments, uh, either surgical or non surgical and also, um, just have a quick discussion or put something in the chat about how it could reduce the incident. Um, in the, in the meantime, what I'm going to do is to speak about some of the risk factors, uh, bowel obstruction. So, um, for example, a recent abdominal surgery could, it could increase, increase the chances of obstructions, uh, due to the scar tissue, uh, growth, uh, expose a narrowing or obstruction of the bowel. Uh, divert director closest, as famous as speaking about is another risk factors for having that could increase, uh, irritates the lining of the intestine and could, uh, could lead to, uh, a bowel obstructions, uh, cancer or malignancies of different kinds could also increase that chance. Um, as well as IBD, which, uh, they went through in a lot more detail, um, especially in young Children. Um, swallowing foreign objects is quite a common, uh, presentation for bowel obstructions, uh, um, as well as other dangers it might have. Um, uh, and another one is a chronic constipation, um, if it's been going on for quite a long time and it has not been able to, uh, if it's not managed, it could lead to, it could lead to bowel obstruction, uh, which, which then brings us, uh, to, uh, a lot of lifestyle and, um, uh, diet, uh, requirements or connection to, uh, these presentations, uh, for example, with regards of constipation, having active, active lifestyle, exercising and eating, uh for example, vegetables or fibers and avoiding high fat diet could, could prevent, uh, could prevent conservation, which in, uh, in turn would, would prevent uh bowel obstruction from occurring in the first place. Uh And that's is sort of important to consider in, in most patient's and in, in a lot of patient's, in fact, uh, that the, the, the reason, uh that the condition can also be managed uh in a lot, in a lot of different fact, in a lot of different ways other than giving the medication or just uh surgical intervention for, for example, uh huh. Next slide please. Another presentation uh that we do see quite commonly is a acute abdomen and uh it could be due to different reasons, for example, appendicitis, which they also spoke about perforated public ulcers, uh pancreatitis and um erupted aortic aneurysms and so on. Um some other conditions that could, could present or could cause acute abdomen if publicist diabetes. Um um some of the risk factors for that is uh females around 46 40 years old. And also um obesity could increases the chances of uh closest diocese and if that is not treated, then it could lead to pancreatitis. For example, as we can see, and uh if pain practices are not treated, uh it could, you could have devastating consequences. Um um for example, it could, it could damage the liver or it could lead to pancreatectomy, which would um put the patient requiring instead of them having type two diabetes effectively for the rest of their life. So it's, it's quite important to have early medical intervention and also um bear these in mind and see how easily could these be treated or recognize or even prevented, uh rather than leading to, to do something, something so horrible for, for patient's, um, some of the other conditions, as you can see here, hepatitis. For example, again, there are different types of hepatitis. It could be perfect from, we've got to immune and viral with the different types. Um vaccination again, again, against hepatitis could prevent that, which again, uh could prevent the uh this, this presentation could reduce uh this sort of presentation. So it is important to then again, go back to primary care and think about these options um for, for patient, especially those who are uh at high risk of developing these conditions to make sure that we uh we do our best in preventing these uh from happening rather than rather than, you know, trying to treat them. Um Also another one that you can also see in the picture of pneumonia. And TB again, uh important to know about travel history, uh vaccinations and also uh being quite detailed in the history, taking part of thing and considering differential uh different diagnosis before landing on one and also being able to treat the underlying cause uh rather than just the current victim. Another one to consider uh for acute abdomen is gynecological um pregnancies. Again, this is something not, I'm not going to go into too much detail. But for example, um a pain in the abdomen could be from um an ectopic pregnancy. And again, this is important for, for, for medics to be able to get a detailed history, do the correct investigations to be able to um, pick, uh, these, these sort of dangerous conditions at the right time. Thanks a lot. Basically, when you cough up blood and this could either be bright red worm, it or it could be coffee ground color, um, like really dark. Um, it mainly depends on, um, if the blood. So if, where it's originating from. So if it's post gastric, uh, post stomach, you probably get the gastric acid secretions and stuff making it darker color. So you get coffee ground if the bleed is from there. Whereas if the bleed is higher up, um, you'd get bright red and, um, hematomas is, is a common presentation for our gi bleeds. Um, I'll just talk about some conditions that could cause this, um, presentation treatment. So, one of the conditions which you would see is mallory weiss tear and I'm not sure if I'm pronouncing that right. But it's basically when you have forceful vomiting or recurrent vomiting for long periods of time, you get a tear and your, um, esophagus and that's what I would call the cause of bleed. Um, and you present with bright red, um, hematoma sis, um, how you treat that is, it's usually it heals on its own. But if it doesn't, if it keeps happening again and again, and the terror gets worse, you'd have an endoscopic injection and, or heat and it will basically repair the tear or it would at least stop the bleeding if not repair the tear. And um some other conditions that would cause hematomas is s official viruses. Um So viruses are like enlarged veins that become tortuous and they start bleeding. And um usually it's post someone having high portal tension, high portal hypertension. So if they have like a high BP and eventually that's what causes it. And um treatment, you give beta blockers or you try to lower their BP and also something called marshall band ligation. So it's similar to the rubber band ligation that you do for a hemorrhoid. Um And, but it's just for the esophagus. So it's, that's quite interesting to think about and you also have shunting. So you just cut across that terror. Basically, the shunt would help across the terror and you know, still like prevent dysphasia and all that. Um cancer again is an important thing. Always with any presentation that's always a differential to think about. Especially gi um you'd have pancreatic cancer or lung cancer is gas. Your cancer's all causing hematoma sis um cubicle osis can also cause hematoma sis. And that's why you have to ask the question, travel to a tuberculosis country or have been been in contact with someone who has a similar presentation, like who's been coughing up blood or has been really unwell. You have to think about that. And um another thing that could cause hematoma sis is if you had inflammation of the esophagus and that usually happens with people who have good. So, reflux disease, um you'd have again, the standard treatment for good is PPI so proton pump inhibitors like omeprazole and then pain relief, conservative management, stuff like that. Um Sometimes funny enough, hematemesis has nothing to do with an actual disease and is to do with medications um and nsaids or aspirin or blood thinners like that and they can cause these uh this presentation. So you have to think about that. Sometimes it's not really a malignancy or disease, it's actually just medications or overuse of those medications. Um I'll be moving on to the next one. So, dysphasia is another common presentation. Dysphasia is when you have difficulty swallowing or patient's come in saying, oh, I can't, I can't eat anything because I can't take it down like it doesn't go down and sometimes um it can be a symptom of self visual cancer. So you have to think about that in your mind when you're thinking of your differential diagnosis is and um um dysplasia is usually, it can be categorized in two types. If you're thinking about what's causing the dysphasia, so it could be mechanical. So there's like an obstruction or there's foreign body there, if the thyroid is enlarged because if you think about it and, uh, anatomically, the thyroid can compress the Africans and that's what can cause. Again, um, the dysplasia, you could have structures and how you deal with all of these things is you deal with the cause of the problem. So if it's a stricture, you have stents or you have dilators or you just do surgery to open it up where it's like if it's the thyroid that's causing it, you treat the goiter. So you have steroids to reduce the inflammation for the goiter. And if it's just a foreign body, like in most kids that present with dysphasia, you just remove the foreign body and um in cases where so it's mechanical or mortality, right? That's causing dysphasia. So, in cases where it's the motility and the problem with the muscles, um like in my senior gravis, you'd give cholinesterase inhibitors. So the standard treatment for that disease that's causing it. A common cholinesterase inhibitor is pyridostigmine. Um I'm not sure if you'd be able to remember that, but it's just good to know. Pyridostigmine is one of the common ones and it increases. So, colonise trees is an enzyme that breaks down acetylcholine in the synoptic junction to be more specific. And um it basically colonise trees inhibitors like pyridostigmine, increase the amount of a acetylcholine and it just helps with the muscle contraction and stuff like that overall. And you give steroids again um to just help with the inflammation. Um moving on to the next one, giving it to see. No. Um, yes. So, um next one we're going to talk about is uh bowel perforation. Uh, common causes of this, uh either trauma but it could be due to information infection, malignancies, uh, or even obstruction. So, bowel obstruction could, could lead to preparation, um, treatment. In this case is most often, uh, emergency surgery to, to repair, repair, the perforation, uh, sometimes, uh, more part of the intestine has to be removed and, um, then, then connected back together. That is if it necrosis, this happens, for example. Um, and again, it is quite important to, to be able to pick that up, uh, to make sure that the patient's do get the candid they, they need, um, in this sort of emergency situation. And, um, the next condition that we're going to talk about is, uh, Alina rectal bleeding. I've been actually, yeah. Um, so again, Molina could be due to liver damage. Again, we talked about hepatitis, that could be a very late, uh, late stages of that. They're also different, er, different reasons for liver failure, uh, either from alcohol or again, autoimmune or malignancies. Um, with regard to, um, rectal bleeding, it is also very important to consider malignancies. So, just collecting cancer or anal cancer. Um I know we discussed this quite a lot. Uh, but it's surprising how often they go missed and, um, signs are not picked up early enough. Uh So this is, it, this is always important to uh as a, as a clinician to have that have that in my mind and be able to, um, sort of uh investigate that if the patient's present with any of these symptoms that could be related to malignancies. And it's important to, uh, dig in quite deep to make sure patient's do open up and tell us about all these uh for us to be able to help them. Um I believe that uh end of our flight, uh, if I'm correct, uh references, uh sorry, what we can do here is I'm more than happy to stay nickel and answer any questions anyone might have. Uh If you can a Newton speak, that would be ideal. But if the app doesn't allow or if you don't want that, then please do put your questions in the chat and you're more than happy to answer. And, um, if anyone wants the slides as well, I'll be uploading them onto the chat or I'll be trying to send it through the organizers, so you can have a look in your own time. And then if you have any questions, obviously you can be chat to us and we're more than happy to answer. I'll just keep an eye on the messages to see if anyone has any questions, but if not, um thank you so much for attending this. I'm so sorry about all the technical difficulties that we've had. Um Hopefully this won't be the case next time. And um if you could fill in the feedback form for us, that would be amazing because then we can improve and then give better sessions. Um And also you probably you'll get a certificate if I'm not wrong, if you're feeling in the feedback form. So that's really helpful. Um That's all I have to see. Yeah. Yes, same here again. Um I believe you have our email address is I'm also more than happy to um uh any questions you might have later on. Um It's going to be seen a lot better for me and, and it's just not next. Um Please do get in touch uh always here to help any questions you might have. Uh And yes, please do provide us with any feedback so that we can improve uh for, for the future. And I also apologize for technical difficulties went through. Uh If the organizers can just um so if soup to can put that on the chat as well for people to access the feedback form, I guess that would be really helpful, but that's it from us. Thank you so much. Okay, I don't think there are any questions. So let's log out by. Bye, everyone.