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just give me a minutes. Just froze for a bit, right? Can you see the screen going out? Just say yes in the chat screen. We can. Yeah. Fat. Okay. So like I mentioned earlier, All right, we'll be having a presentation. Sorry about that. It's just fiddling about. So just just be having a short presentation. I try to make it quick. Um, half an hour, 45 minutes, tops. Uh, we'll make it as interactive as possible. So I'll be asking you guys questions. Um I mean, like, Andrew saying that the audio is muted, so you can just reply on the chat, if that's okay. Um, so I'll be talking about kind of six different topics, uh, including questions so that you guys can get involved. There'll be a pole as well, and you guys can choose the answer, and, uh, we'll go through the explanation of the theory behind it. So we're talking about diabetes and surgery. Acute pancreatitis, John, this colecystitis penectomy and op see, And also pancreatic cancer. Uh, these are all things that you as an f y one later on in one or two years time, uh, will be, um, be tasked to handle with on the wards. So it's just good to know quickly what to do if you know you're on the wards and you get called to to see these patient's either on the acute ward or when you're nights. Okay, so start off with questions. First, I will get the pool started, and then we'll talk about why? Why this the right? Understand what? So forth? Okay, right. So with all of the questions first. So if you read the question 60 old man is to undergo total hip replacement this morning. He has a background of type two diabetes. Well controlled the metformin. He takes local side as well. He's not been started on a sliding scale. So you s a f I one. Uh, What changes do you do? Sorry about that. Just came up too long. Right? I think. Well, you will end it there, give you guys a few seconds, right. We'll end the pole. Okay, so most of you guys just be, um you guys might have been cheeky and saw me giving the answer right before. So Right, So the answer is indeed be. Why is that so? So glipizide, which is a sulfonylurea on the day of surgery, You should admit, um, sulfonylurea on the day of surgery. So, um, the exception is, um, if the patient is, um, taking, um, the tablet twice daily, so B D. So if it's the patient schedule for the morning, you can omit the morning dose. But you can allow the patient to come back and take the afternoon dose once the patient's back from theater, but always omit the morning dose. So before surgery or mitt the morning dose if the patient is scheduled for surgery, Uh, in the afternoon, then you'll meet both altogether. So you, Amit the days' worth of my closet. Okay, so any reason why sulphonylureas in particular that you should be concerned about not metformin? You can put your answer in the chap. Okay. All right. Okay. So yeah. So someone mentioned hypoglycemia risk. So, as you all know, software, the risk and risk can result hypoglycemia. So if, um, the patient, um, is to get the morning dose of your glipizide and the patient is due to go for surgery in the afternoon, and the patient has been on a sliding scale of the patient's beneath by mouth. You would expect the patient to be hypoglycemic on the table in theater. You don't want that to happen because, um or what's going to happen next. I'll tell you why. Okay, so first off, we'll talk about patient's who are being treated on insulin. Um, so patient's who are being treated on insulin? Um, patient's have good glycemia control and who are undergoing minor operations. So daycare surgeries such as, you know, plastics or patient's. We can have day surgery in the morning. You can go home in the afternoon after surgery can continue the regime as usual. But as the F. I one always double check with your registrar, uh, and the anesthetist, because they might think that the patient might need overnight admission just for monitoring, so always check with them. But rule of thumb is patients who are on day case and patient's who have good classmate control on insulin can continue as regime as usual. If in doubt. If in doubt, check with your senior if they don't know most, surgeons don't check with endocrine and check the diabetes Registrar is always good to check with them rather than doing something which will result in harm. Okay. Secondly, surgery requiring prolonged fasting. So big surgeries, major surgeries in general surgery such as hemicolectomy. Or into a big major, intractable surgeries where patient's need to fast for more than a meal or poorly controlled diabetics. They should be started on a sliding scale. Um, when I was an f I one, people mentioned sliding scale right? Right now, they usually mentioned variable rate insulin infusion, so the term differs, but it's almost the same. So start, start them on the on variable rate, there's always a regime. Um, just look up your local, um, protocols that trust guidelines. There's always a regime, and so you can read and write. Follow them word by word. And if in doubt, speak to the diabetes team or speak to S H. O or you're rich, right? So, um, you've talked about metformin and Southland areas, but most diabetic patients' or most complex patient, there are always on one or more or even three medications. So, um, you can see from this table. So I took it from a textbook, Um, so you can see what the changes that that needs to be done. Um, metformin, south main areas are the most common common ones. Now the new kids on the block, the cliff walls in so the the your SGLT two inhibitors. So most diabetics take those nowadays. So look them up. Look at your local trust guidelines. If there's none on your local Internet, speak to S H O. Speak to your registrar. Or if in doubt, contact your diabetes registrar, your diabetes registrar. And they'll always be glad to tell you what to do next. Okay, Alright. Someone asked. Yep, yep, yep, yep, yep, yep. There's a risk of lactic acidosis. Um, so not there's some old guidance. So you should be quite aware of those patients, especially patient's AKI or CKD. Um, if those patients'. I mean, if you look at blood test for your blood test, hence why It's very important to pre your blood test, especially using these, because if the patient has a good baseline use in east, then you don't need to omit metformin. If the patient to arrange using knees and ckd, then you're right. Metformin can cause lactic acidosis because the patient's kept in my mouth. All the patient's on IV fluids Patient can have lactic acidosis, so always speak to your senior. Speak to the diabetic wretch. Speak to the anesthetist. They always make a note when they do their checks before Tater what they want regarding metformin. Um, so do that and then contact them. They'll be happy to tell you what to do. But you're right. You can cause lactic acidosis. Most patient's on the day. Case procedure will have good renal function. But some patient's with, you know, bad renal function. Um, you should be aware that they can cause lactic acidosis, So yeah. Good question. Any other questions about antidiabetic medications? Right, So we'll go to the next slide. Okay, So, big question here. Why? Um well, why? What? So why should you be cautious about antidiabetic agents? Um, inpatient undergoing surgery once mentioned that it's there's a hypoglycemic risk that applies to sulfonylureas. Also applies to your, uh, DPP four inhibitors of the equipments. But why in general, why you as a surgeon, anyone? Anyone. If you want to do surgery, if you're a core training a wretch, why should you be? Um why is this important? You can explain the chat. Yep. Neil by mouth, there's a There's a risk of hypoglycemia good, but you as the good old. Therefore, one you should be able to start them on a sliding scale or variable rate insulin fusion if the patient's has uncontrolled diabetes. But why in general, why are you Why are surgeons quite cautious about diabetes? Um, if you've been to enough clinics, most surgeons, if the patient has uncontrolled diabetes that usually advocate for conservative treatment rather than surgery. Do you know what that is? Okay. Mhm. Yeah. Okay, well done. So, yeah, the the main concern for surgeons is wound healing. And also for the anesthetist. Is the cardiovascular risk on the table? Um, so you as a surgeon, you're talking about wound healing. That's a very that's an important step. It's not only what you do on the table in terms of cutting and tying it also, what happens post opportunity to the patient. So you want your patient to heal after surgery. Hence why you do daily what rounds? And you do POSTOP blood repeatedly after surgery. So, as you know, diabetics are an increased risk of blade wound healing. Hence why optimum? Um, but glucose control is important. So hence why Surgeons always stress Um that should optimization before surgery. Um, the main reason is that it can improve bone healing post operatively. Okay, um, the next thing I was saying that there's an increased cardiovascular risk. So all diabetic patients, regardless of how well controlled your diabetes is, is an increased risk of cardiovascular, um, conditions such as M eyes, strokes, arrhythmias, you name it. So, um, it's quite important for the initiatives, because if the patient is on the table under general anesthesia general anesthesia, as you know, um, agent such as sevoflurane, Halat ane, um, and all that they can pretty supposed to bradycardia, uh, cardiovascular depression. And they can lead to mis and strokes if you lower the heart rate too much. Hence why any cities are quite concerned if patient's have poor glycemia control. Before Tater, someone asked me for which surgeries would you switch Diabetic patient students infusion. So, um, there's no particular set surgeries. I would say in my experience so far, major surgery. So major intraabdominal surgeries, um, like hemicolectomies, gastric surgeries, even vascular surgeries. They require patient to switch to insulin fusion, mainly because, um, insulins you can titrate insulin to your blood sugars, whereas agents such as metformin? Um, Southern. Curious. You're quite. It's quite hard to control them. Um, even orthopedic surgeries currently, um, the irritation that in all surgeries. So all hip surgeries, pelvic surgeries, spine surgeries. We advocate for, um, sliding scale or variable rate infusion, simply because it's better to control. Uh, if things happen, If the patient's hypoglycemic, you can reverse it. Whereas patient's with, you know, if a self injury can give glucose and all that, but you don't want it to happen. But surgeons are mostly old school. They prefer sliding scale. Most of my bosses and consultants they prefer patient's to go straight to variable rate, no questions asked. Um, so it depends on your consultant. Depends on your trust. Uh, if you're unsure, speak to S H o. Speak to your registrar. They have They probably have their own preference. Um, so that would be the answer. It's kind of there's no set. Right? Answer. You just have to speak to your boss. They might prefer different things. Just just just speak to them. Okay? Right. So the next slide for the next question. So, um, it's a different station now. So have you read the question. Um, see what you think. Good. Mhm. Okay, give it about 20 seconds, and then we'll stop the pole. All right, so we'll end the pole just now. Right? So most of you guys are right. Uh, this is basically a spot diagnosis. So if you know, you know, you don't know, then it's good to know. Um, so it's basically a textbook question. I've not seen this on the ward, so the correct answer is great. Turner's two seconds. Right. Some of you guys chose a Cullen sign. Um, so the correct answer is great. Turner's so otherwise known as flank bruising. Um, they signify retroperitoneal hemorrhage. Um, they were first noticed by, uh, an option gynie consultant, Um, one of them named Gray. One of them named Turner. Don't know what their full names are, but they they were initially seen in patients with ruptured ectopic pregnancies. And then, um, you can see them now in patient with hemorrhagic pancreatitis or any other intraabdominal hemorrhage. But basically, the two most common conditions are ruptured ectopic pregnancies and hemorrhagic pancreatitis. I've not seen this in the ward, um, or in real life, but it's good to know as medical students or even as trainees for exams. It's, uh, still comes out in or skis and, um, interior exams. So it's good to know. Um, so some of you chose Cullen sign? We'll talk about Cullen sign and great honor sign. I'll tell you why. How to differentiate between the two. So, first off, we'll talk about acute pancreatitis. Uh, favorite medical school question. Um asked post the medical students on ward rounds, even post the court trainees and juniors like myself. Uh, it's a must know. There's no excuse for not knowing, um, because the risk factor management and as as as the fy one on a surgical ward, you'll see many of these on your ward, and it's important to know how to manage them. Right? So acute pancreatitis definition, uh, anything with itis behind it is basically inflammation. So acute pancreatitis, basically an acute reversible inflammatory process. The pancreas, which can affect multiple organ systems. Okay, the clinical features that you see patient's with pancreatitis when they present epic gastric tenderness or pain ready to the back. Um, do you know why the back Very simple question. You can pull some chat. You can also have fever. And I also have tachycardia. So systemic signs, Um, I guess three tenderness on examination. And, like I mentioned earlier, great Turner and column sign, um, on examination. Quite rare. I've not seen anyone like I mentioned earlier. It's quite common on examination questions, though, so it's good to know. Yep. Increases retroperitoneal. Good. Uh, simple quick question. The causes, um, assume as medical students and people like myself probably have the pneumonic drummed into our into our heads. So I get smashed. Um, if you don't know them already, right. So important to know for your or skis people who are sitting for MRCs and also good for, you know, for life. Basically. So, um, I get smashed. So do you guys want to have a goal? Each one of you can just type what I what g what each alphabet stands for, or you can just I can just go through all of them all together. It's up to you guys. If you guys wanna start, go on your You want me to let you guys know scoping venom? That's not the most common. That's a good one, right? Uh, Yep. Yep. Okay. So the top two most common ones you see in the UK is gallstones and alcohol or ethanol. I've not seen scorpion bites, but it is in the in the pneumonic. Um, Yep. Steroids. Anything else? E ercp. Yep. So keep them coming, so I'll just start it out. Autoimmune. Yep. So I is, um idiopathic G for gallstones. E for ethanol. Tea for trauma. As for, um, steroids M for mom's A for two. Immune s scorpion bites. H Do you know what h is there? Two causes most commonly. So h is hyperlipidemia or hypertriglycerademia and e is ercp. That's the most common intragenic cause of pancreatitis. D for drugs. Do you know what drugs most commonly can cause? Pancreatitis. It's an anti f g GLP agonist. You have not seen them, but, uh, very common anti epileptic drug can cause pancreatic. Do you know what it is? Lamotrigine? Yeah, there's one more more common than lamotrigine. So your b so valproate sodium valproate? Yep, yep. Um ok, verapamil might be, uh, okay, Right. And also, uh, HIV drugs. So, such as? Such as didanosine, um, older HIV drugs can cause, um, pancreatitis. So right now they don't use them anymore, so it's quite rare, but yeah, it's just good to know for exams. Uh, if you tell the surgeons when they ask, you know what round they'll be wondering what drug that is. So surgeons being surgeons, that's good to know. Um, diagnosis. So how do you treat so pancreatitis like appendicitis is a clinical diagnosis. So see the patient, take a good history, examine the patient and use of clinical conundrum use of clinical reasoning to find out what the diagnosis is. All have a differential list. Um, you can also do your basic blood test if you're thinking of, uh, pancreatitis, so the blood test to do is an MLS. You can also do a serum lipase, which is more sensitive and more specific. But labs really do light pace, but it takes time for them to come back. So, um, unless they're usually three times higher than your normal value, Um, if you're thinking about the course, you're thinking if it's a gallstone, you can do an ultrasound abdomen, and most surgeons will want a CT of the abdomen pelvis. Anyway, big surgeons being surgeon, so do your ultrasound, your CT. But before doing your CT, speak to your rich. Speak your senior and ask them what they want. Okay, Uh, in terms of severity, um, there's mild, moderate, severe. You can use your scores. So for pancreatitis, there's the Glasgow Emery score. There also two different scores that you can use for pancreatitis. Do you know what that is? Mhm. You can put in the chat, if you don't know. It's fine. Um, so you have your Glasgow Emery score. You also have your Apache to score, and you also have your ransom criteria. But on the wards, you always use Glasgow Emery. That's the one that, uh, everyone uses. Okay. Management for pancreatitis. Um, s the f y one s h o. It's conservative. Really? Um, so you treat the the etiology and you admit the patient, um, so just treat him conservatively. You give them fluids, you give them painkillers antiemetics for patient's or vomiting. Um, you can give them that you can start them on a diet low fat diet. Um, And if there are signs of necrotizing pancreatitis, inform your senior, um, immediately do a thorough eat. We inform your senior because these patient's are quite sick. They're quite unwell. They usually would be admitted to, um I t u for monitoring. Okay, but the main step for you guys to know for S N f I one. Pancreatitis, bandeau, pancreatitis. Just treat them with fluids. Painkillers, antiemetics. And you'll be grand. Okay. If the patient deteriorates, do your a two e your a b c d e. Do them thoroughly. Speak to your senior, get them involved as quickly as possible. That's the only thing you need to do and document everything. Okay, Right. So that's pancreatitis. We'll talk about Cullens and great earners. So there's a quick picture showing these two. So, like I mentioned, great honor signs usually flank hemorrhage. Usually see them on the flanks. Um, Cullen sign is usually around the, uh, umbilicus of paraumbilical hemorrhage. How I remember them, uh, you might take it on board, but how? I remember what stands for what is C Looks like a sea around the umbilicus, So C stands for paraumbilical hemorrhage. And great tennis is the rest, which is flanked. I'm rich. That's how I remember it if I forget it. But maybe you guys have a different way. Okay? Yeah, right. So complications of pancreatitis. So, um, as the f I one, um, or the fy two. You should be aware of complications that can happen. Um, again, you can divide complications to acute and chronic. Do you know what the acute complications are for pancreatitis or the chronic? You can just put. So you started acute. First, anyone can put in the chat. What the acute complications of, uh, pancreatitis are? Yep. Pseudocyst. Anything else? Mhm. All right. Anyone else? Right. So the two most common acute complications that you can get with pancreatitis is, um, things that probably you should be aware of. Um, Yep. Hemorrhage. You can. Quite rare. Yep. AKI, you can also get a r d s so you can get respiratory distress syndrome. Uh, so adult respiratory distress syndrome or acute respiratory distress syndrome, Or you can get the I see. Um, usually those patient's, uh, they become really unwell and really sick. And you have to call your seniors, get I too involved. Okay, um, achy and diabetes would probably infusion Be a complication. Yes. As part of our d s, you can get political infusions. Um, you can So ARDS otherwise known as non cardiology and pulmonary edema. Taking a pulmonary edema. You can get parole infusion. So if patients are complaining of shortness of breath fever, obviously you're a two e. Uh, but, you know, think of that as a differential. Okay. Chronic ones, chronic complications. Like someone mentioned here. Diabetes. Okay. Why diabetes? Because patient's have chronic pancreatitis. Can can can cause your can cause destruction. If you're langer hand cells so your beta cells would be affected. Um, so you can have reduction insulin secretion and can get diabetes. Uh, pancreatic cancer? Yep. You can get pancreatic cancer as well. Quite rare. But it does happen. Pancreatic cancer and cholangiocarcinoma chronic complications. Um, but the top four most common chronic complications are chronic pancreatitis, diabetes type two or type one diabetes, and, um, pancreatic cancer and cholangiocarcinoma. Okay, so those are the ones to be aware of, but sdf I wanted the ward. Uh, you should be, um you should watch out for D i, c and ARDS developing. I've not seen them. I've only seen one patient which went to I t u for ARDS, but I've not seen them at all before that after that. So it's just good to be aware of. Okay, Right, moving on to the next question. All right, we'll give it 55 to 10 more seconds and move. Give you the answer. Right. We'll end the pool just now. All right? So what do you think is going on with this gentleman? What's the diagnosis? You think Just put in the chat. What do you think it is? Yeah. Yep, yep, yep. So the answer is pancreatic cancer. So the tumor marker would be Yep, yep. Um, over here. The pancreas. Yep. So the tumor marker will obviously be see 99. So let's talk about the different your markers here. So, what's the Alpha fetoprotein for? Yep. Good liberal. Testicular. I'll be and ask. Ask you what kind of testing Look, answers. But it's okay. It's a Saturday night. Uh, what? C A four? Yep. Colorectal? Yep. Was 15, 34. So 15. 3 for anyone knows. So his breast. And what's s 100 for? Right s 100? Um, not long. So S 100 is a It's a skin condition to skin cancer. Really? It's a melanoma. Okay, so I remember how I remember 99 15. 3. it's quite cheeky. Ready? So nine. I mean, I invert the nine, so if you just rotate the nine horizontally, the nine looks like a pancreas. So that's how I remember 99th pancreas 15 3, which is for breast cancer. Um, just inverted three. Um, and it looks like a pair of boobs. Um, really sorry about that. Yeah. So that's how I remember it. And s 100 is a marker for melanoma. Um, so you can just remember it. That's medical school question. Um, that's how I got examined on it. So I still remember until today. Um, but yeah, the answer is, see, 99 right? And we'll talk about John this. We'll talk about pancreatic cancer later on, but talk about John this because it's quite a common surgical question, even in MRCs and also your finals. So they're types of John Day, so that three types, So it's prehepatic hepatic and posthepatic. Okay, So, um, do you know what the causes of a prehepatic cause Jaundice? Do you have a list of causes that you know of? Mhm. So hemolytic anemias. You have Gilbert syndrome as well? Yep. So him a techni mia's g six PD sickle cell anemia and specific Tosis. So all the hemolytic anemia is You can also have Gilbert syndrome. Uh, gilbert syndrome. I mean, it's quite rare, but do you see them as a course in textbooks? Have not seen them. Really? Um, but yeah, all the hemolytic anemia is basically can cause prehepatic jaundice. Okay, all your hepatic causes that you know of I'll just give you the answer. So Yep. Cirrhosis. So, um, viral or time, Your hepatitis drug overdose, paracetamol, uh, inherited disorders. Um, Crigler Nature and Gilbert. Sorry. Gilbert Ages is actually a hepatic former John is not prehepatic my bad. Um, so as fro one, if you're doing an e d rotation, someone who comes in with paracetamol overdose and who comes in slightly yellow looking or slightly jaundice looking, you should be thinking of any liver damage. So, um, the, uh, paracetamol levels the liver function test the your clotting screen co acted. Check if all the synthetic function is affected. Um, viral hepatitis. So you have a hep B and hep C, um, can cause John this, uh, autoimmune hepatitis as well can cause John this, um So it's just good to be aware of those pasta pathic course. One of them information already. Do you Anyone? Yep. Goldstone's pancreatic cancer stricture and also cholangio carcinoma. Okay. All right, so there you go. So it's good to know a course. Just one or two courses for each, Uh, each category is a prediabetic hepatic and postherpetic. Right? So bilirubin cycle. I hated these in biochemistry in medical school. Um, but it's something which would be asked again in MRCS, if you're doing if you're doing MRCs later on, uh, you have four years. So you just have to know this. You have to just memorize this by heart. Um, so I will not talk you through the steps, so the steps are all listed here. So basically the breakdown of red blood cells in your spleen and it gets converted to Billy Burden. Um, it's coming to Billy Ruben and Billy. Ruben is then converted or, uh, kind of combined blue chronic acid and make to make it water soluble. So it becomes, um, your belly. No gyn. Okay. And that's re absorbed in your terminal ileum where it enters the antibiotic circulation. Where? Portal system. And that's how it gets recycled. Hence, patient's with Crohn's disease um, and patient's who have undergone terminal other receptions. They have been given agents of medication to help with the the bile salt recycling. Okay, so it's good to know the cycle, Um, for your exams, in your skis or even in your theory exams. Also, for your MRCS exams. Uh, for my MRCs. These exams, they actually asked me to subscribe the cycle in detail. Um, step by step. So there was quite a media call station for me. Okay. Right. Um, okay, right. Symptoms. We'll just talk to you quickly through symptoms and jaundice. So there are two main agents. When someone comes in, a patient comes in with generalized itching. There are two main agents in your body which can cause itching. One is bilirubin. The other agent. Anyone can tell you what the other agent is. Itching? Yep. Histamine. So histamine. In a mild allergic reaction or anaphylactic reaction, you can get itching as the first sign. Okay, so in john, this because of Billy Ruben, you can get curator's. Okay? You can also get yellowing of this clearer. So uterus changing your color of urine. Dark yellow. It depends on whether, um, if it's obstructive jaundice or whether it's hemolytic jaundice. So patient's with obstructive jaundice can have pale urine. Rest patient with him lytic jaundice or or John ST to hepatic cost. This hepatitis can have dark yellow urine. Okay, pills to a colic otherwise known as a colic. Quite commonly seen in, um, post hepatic john days. So patient with cancer. So, um, cholangiocarcinoma strictures or pancreatic cancer can community pills to as their first presenting symptom. Abdominal pain and fever again commonly, senior autoimmune hepatitis. Have a happy and hep C. All right, So what's the criteria for John This? What is your minimum level of? What's the threshold for Billy Ruben? If you do a blood test, anyone know, put in the trap. Mm. Okay, more than 50. I'll tell you the answer. All right, so it's 35. Um, it's Yeah, it's a very low threshold. So, um, currently present, actually, 35 again. Some patient's You can see them quite. Uh, it's quite visible, but some patient is quite hard. You have to look at in the eyes for uterus before you get generalized on the so patient's who present above 70 micromoles. You get generalized on these patient's presenting about 35 usually see a living at the sclera first. Okay, so it's good to check the eyes first. And also the hands diagnoses, of course. Do your blood tests? LFTs bolivar. Been do a full liver screen. Um, also imaging as well. So the first form of imaging is your ultrasound to look in the liver or the biliary tree and then your CT of the abdomen. Um, most surgeons who want to see t straight away. Um, if you're thinking of, uh, more complex imaging than you think of M r c p for diagnostic if it's diagnostic and both therapeutic, you can think of an ERCP for that, actually, is with your gastroenterology colleagues. Okay, management again, depending on the etiology, Um, initial treatment would be anti histamines or cholestyramine for itching. Uh, if it's a gallstone stuck at the sphincter of oddi or if there are multiple gallstones, you can do an ercp or if it's gallstones, basically in general, then you can book them for a lab coli. All right. Okay. Any questions about John this before we move on? If no, Then we can move onto the next question. We're straightforward, really. Yeah, we'll just end the pool just now, right? So most of you guys have got the right answer. So it is. Um indeed. See, So it's quite a straightforward question. I mean, all the questions in this presentation very easy. So it's not a reflection of what's gonna come out in your finals, or it's not a reflection of what's going to come out. MRCs. They're much more tougher questions. I made these questions quite straightforward. Easy just for a kind of an introduction or tasted to my teaching later on on the that particular topic. Um, but as you guys say, rightfully, the answer is C Um, so, as you can see, look at the history. Patient is worsening, right? Upper quadrant pain. Colicky. Nature typically comes after having heavy mails, So that should kind of ring a bell saying that, uh, you know, it's probably biliary colic and likely acute cholecystitis. Okay, so we'll talk about the tip policy status now again. Definition criteria and tendonitis inflammation. So a kit policy studies means inflammation of P gallbladder. Um, they're different courses. So there's a calculus, a calculus, and also a very rare cost due to infection. Okay, the most common ones are calculus, so different types of stones. So it's good to know what the different agents are, so they have cholesterol, stones, pigment, stones and also mixed stones. Mixed stones mean you can get both cholesterol and pigment stones together. You can get both pigment and also infected stones together. So, uh, patient who have mixed stones tend to present quite unwell, uh, and quite sick, but most commonly cholesterol. Uh, normally seen in patient's having, um, you know, diet rich in fat and carbohydrates Usually, um, patient's with the four f sense. Why in medical school have been drilled on the four fs in college societies? So fat, fertile female in the forties. The first F is being fat because, I mean, presumably they they've been eating, uh, fatty foods or cholesterol laden foods. Okay. Can get pigment stones do to Billy Ruben and again, Mixed owns. Like I mentioned earlier. Um, a calculus causes are again cholesterol deficits, not not stones per se. You get cholesterol deficits in the gallbladder wall so you can get polyps. So basically fatty polyps. So polyps just basically made of fat or cholesterol, basically so, an oil polyp just thinking of an oil polyp. And it's just basically due to cholesterol. You can forget diabetic, close to the gallbladder. So basically, that's out pouching of the gallbladder wall. Do two stones due to infection and do two fibrosis. Okay, that's that. You repeat the inflammation, you can get weakening of the gallbladder wall. You can get out pouching similar to what you see in diabetic close of the large bowel. The colon. Okay, again. Diabetic losis of the gallbladder. I've not seen it before in patient on the ward, but in textbooks, MRCS. It's quite, uh, it's good to know. OK, infection. Like I mentioned earlier, common bacterial agents are your equal. I clap, Stella, your streptococcus faecalis and your salmonella. Okay, so if you mention equal life, any abdominal stuff will get it right. So the top most common infectious causes equal I Okay, um, And for infection and all that, give them antibiotics, started sepsis six, and then speak to your senior if the patient needs to be scheduled for surgery. All right, so So just do your three most common causes. Calculus acalculous infection for college cystitis investigations. Your basic investigations that you should do as an f i one or any s h o on the ward blood test. So after you do a thorough be to eat, you do your blood test. So basic blood test for blood count white cell count liver function test and you use an ease. You do erect chest X ray and abdominal X ray. Do you know why you should do it? Direct chest X ray and abdominal X ray for patient presenting abdominal pain. Yep. Perforation. Yep, yep. Correct. Yep. You would want to see if there's no peritoneum. Um, good. Um, so you do an ultrasound of abdomen, you don't need to do them yourself. You shadow them, uh, request radiology to do it. Or you can ask e d do a bedside ultrasound scan or fast scan to look for a course. Um, you're sitting, so I want to do an MRI cp. Or you can also do a PTC to look for a course and, uh, gallstones. You can do an ercp rather than opening the patient up with a to do a lab collie or an open cholecystectomy. Okay, You can also do a Haider scan, which is quite rare. So Haider scan is basically a radioactive agent that inject. And basically you do an MRI and you look up. Look up on where it lights up. Okay, so PTC is per detainees transhepatic cholangiogram So basically, uh, you do a bedside test. Really? You do it in the CT scan. Er you basically inject an agent, and you do a scan, and you look it's basically cholangiogram you look at the scan of the biliary tree. Um, it's ready. Done. Um, only tertiary hospitals do it. My hospital. I mean, TGH we just do CT scans at m R c P. Okay, so, um, most of your juggle surgery distrusted one a p. T. See, if you're in a tertiary center, big tertiary center, would you do both m. R, c, P and ERCP? Nope. So MRCPI is only diagnostic. So MRCPI has a magnetic retrograde cholangiopancreatography cryptogram. So it's just a diagnostic tool. Whereas e ercp it's endoscopic retrograde cholangiopancreatography panic radiography. So it's both therapeutic and diagnostic, so you can do it. You diagnose there's a stone there you can put a stent in. You can take the stone out rather than doing MRC, P and ercp. Um, so M R C p is being done by the radiology department. E ercp is done by general surgery and your gastroenterological leagues, so it depends on what expertise you have. All right, Any other questions about M R c p R c P and P T C? No. Okay, so management for a quick policy cystitis. So again, conservative do you're a two e initiate. It's up to six. Um, I presume all of you know, it's up to six by hard. So give your fluids, give you antibiotics and put in energy the patient's actively vomiting and also give the patient analgesia and antiemetics. Okay, um, surgical options would be a laproscopic or an open cholecystectomy. Um, speak to a senior about it. Uh, they might schedule them for an interval. Laparoscopic cholecystectomy. So, probably two days or three days after, um, usually, they let the infection market settle. Let the CRP come down with antibiotics and then do a cholecystectomy. Do you know what a hot cholecystectomy is? So a hot cholecystectomy is basically a cholecystectomy done within 12 hours of the patient presenting to hospital. So the patient's acutely unwell is in shock. Then you do the cholecystectomy. Then they're in Tater itself. Um, I mean, research have shown that it's not preferred nowadays because a patient who has a hot cholecystectomy tend to have complications down the line in terms of perforation, the gallbladder in theater and then, you know, converting to an open cholecystectomy. And there'll be further repercussion to the patient on the line. So mortality rate is quite high in patients undergoing a hot cholecystectomy simply because the gallbladder is inflamed, walls are weakened. And you, if you go into the abdomen, the instruments chances are you might perforate the gallbladder and they will lead to a leak in the abdomen. Patient's become more and well, it's a whole lot of, uh, complications for the patient. It's also not good for the surgeon, because you have to open patient. You have to convert to an open surgery and take the gallbladder out. But it used to be done, I think, 34 years ago. But right now nice guidelines have updated saying that you know it's not preferred, so they prefer to just give antibiotics. I admit to I t. If the patient's unwell, let the infection markets come down. When the CRP is below, I think 80 nowadays. Then they go for a cholecystectomy. Okay, right. Exemption of the abdomen. Um, in your in your patient recalls society. So you get your classical Murphy sign. You know what Murphy sign is? Just bring the chat. I expect you guys to know what Muffy Sciences. Yep, yep. So right up the Gordon pain on inspirational inhalation, where the inferior border of the cold weather hits your hand and the patient kind of not jumps. But, you know, there's a big, uh, reaction from the patient because it's an inflamed gallbladder, which is your hand. It's painful. Okay, Anyone know what boa sign is? Also one of those, um, you know, eponymous limbs? No, before that. So boas sign is basically hyperesthesia or hypersensitivity of your your scapular scapular region on the right. And do you know why that is right. So you're inflamed. Gallbladder is basically by innovative. Your t one dermatome. Yep. Preferred nerve irritation. So basically t one. And that is referred pain to your clavicle or your shoulder or your scapula. So I've seen a few patients come in with just shoulder pain. Um, and just mild abdominal pain and When you When you think it's an orthopedic problem, you do a shoulder X ray and all that. When you do a little function test, it's deranged. Liver function test. Okay, um, again, Boys signs. Good to know. For exams. Um, good to know for, you know, when you see patients on E. D. Uh, your boss will be impressed. Or your red should be impressed if you know what it is, and you can pick it up. Okay, Chapter six, Quick. Run through as an f Y one. It should again be drummed in your head, So just remember, gift three. Take three. Okay, So your gift three is your we'll talk about take three. First soldier, take three. Yep. Black tea, blood cultures, blood test. Full account. Yep. Urine output, cancers, rice. Yep. So you're doing a B g for elected or BBg to your full blood count using lft CRP blood cultures and you catheterized to get your output. Okay. And your gift three is oxygen fluids and antibiotics. Okay. There you go. Okay. So, um, rule of thumb as an f. I want anyone presenting with spiking temps in the world. If the nerves call nurse call. See if the patient's spiking temps start your sector six. You won't go wrong. Seniors won't shout at you. If you started Sector six. Just do it. You'll be fine. You'll be safe. I mean, just just hallmark of a safe before I want to save Doctor. And that's fine. Okay, Next question. All right. Any questions? Sorry about Acute called studies by Move on. Hurry. We'll just move again. Mm. All right. Right. We have, I think, um, when was the last question? Really? And then we'll go on to talk about pancreatic cancer, right to end the thing there. Right? So most of you guys are right to strep pneumoniae A or pneumonia. So, um, I'll tell you why that is. We'll talk about topsy. So basically, these patient's postsplenectomy, uh, patient's has been removed. Extremely vulnerable, too overwhelming postsplenectomy infections. And they are caused by encapsulated organisms. Okay, Um, one of them is strep pneumonia. Um, can you tell me or can you just write the chat? Do you don't have any other common encapsulated organisms? Yep. Marvelous. Another one. Their tree that remember, if you guys know more than I'm open to learning from you guys as well. So Haemophilus strep pneumonia clap seller. That's the one, I That's what I remember. Okay, so those three So we'll talk about a BSA quickly and pancreatic cancer. Right? Alright. Spit up to me. And upsy so does stock quickly. Um, again, it's not as an f I one. It's not important for you guys to know it's good for exams. But if you're doing clinics as an F Y two and patient coming in post after it's been actually done, you should be aware of these patients coming in. Okay, so talk about quickly about the spleen. Do you know what the function of spleen is? So I'll put in the first thing is filtration. But do you know any other functions of the spleen? I give you the demonic of fish. Uh, demonic of fish gives you the function to anyone. Know what I as an h sample? Okay, I'll give it to you. So etymological. Yep. Someone mentioned. All right, one more storage and hemato paces. Okay. Good to know what the function of the spleen is. Everyone forgets the spleen. Um, everyone talks about the labor, pancreas and the stomach, but already talks about the spleen. So just good to know what the spleen is and what it does. Okay? Splenectomy. We'll talk quickly about the indications. Most commonly is trauma. Usually after a major traumatic incidents of motor vehicle collision. You patient for hypertensive and have spin, it ruptures. You have to do a splenectomy patient's who have hematological stuff. So, like, hyper span is, um sickle cell crisis cll you do you do a splenectomy? And like I mentioned again, mount and C c l l c m l a m l and e m l You can do a splenectomy. Okay. But you don't need to know if the patient need to go for surgery because you know what the common causes are. The common indications are for surgery. Complications will talk about a bit. Um, early complications are infection bleeding gastric, Stacey's pancreatitis. Um, late complications are pancreatic. Fistula can get trumbull cytosis so high risk of a patient developing portal, vein thrombosis and DVT. Hence the patient should be put on taxi or an extra parent. Delta parent will stop. And last but not least op. See? Okay, We'll talk about topsy for a bit. Symptoms are usually flu like illness. So you get headache, fever, lethargy, vomiting. Uh, they can mimic many other serious, uh, causes of, uh, illness like meningitis or encephalitis or even, um, you know, chest infection. But you should have You should be wary of patient development. I mean, patient with history of splenectomy having an op. See? So you look at the patient's medical background. The patient has had a splenectomy for patient comes in with flu like symptoms. Be aware of that. Developing. Okay, Have a have that as a differential. Investigations again do a two e. Um, anyone presenting with a temperature or, uh, being unwell? Do you six immediately? Um, like I mentioned again your gift free Take three. And you will be right, um, treatment for these broad spectrum antibiotics. So most commonly of beta lactamase antibiotics, penicillin, cephalosporins. Should you do again, refer to your local guidelines your micro guide or antibiotic guidelines, or speak to infectious disease or your microbiology consultant. If you wanna advise, um, speak to your wretch, speak to a consultant. Okay. And, uh, you should also be aware that postsplenectomy patient's should have antibiotic prophylaxis for two years. Postsplenectomy ok. Lifelong with the patient's even suppressed patient has HIV has active cancer. Uh, has had chemotherapy before. It should be lifelong. Okay. And the patient should have annual vaccinations for, uh, organisms. So the g p should make make sure of that, but, you know, as the S h O. You should be aware of, the patient comes into the ward. The patient should have had vaccinations before and again. Regular follow up, Be it with a g p. And also be the general surgery t looking after him. Okay. Sorry for Just run being true, right? Last but not least, we'll talk a bit about pancreatic cancer. And what can just shelter with the respect is our We've talked about it before. Chemicals or chemicals? Yep. Alcohol, pancreatitis. Harry, that tree? Yep. Working with nuclear chemicals. That's a nice one. Not heard of that. OK, right. Let me show you. So, mats? Yep. I'm talking about primary cancer. Okay. Okay. You're always something new every day that I learnt. Okay? Yeah, but the most common cause if you mentioned smoking in any disease as a risk factor, will never go wrong. So Smoking age, chronic pancreatitis, being overweight, patient with diabetes, and also inherited syndromes like your, uh, HNPCC or lynch syndrome. Your, uh, puts Jacob syndrome, your broker one and two mutations. And also your men syndromes. Your men, One not usually men one, but meant to a meant to be. Okay, um, and, uh, I mean, I've heard of two patients who have no risk factors at all and just got pancreatic cancer. They fled a healthy lifestyle, and they're just unlucky. So, yeah. I mean, there are some patients who are just unlucky, and they get, you know, pancreatic cancer. But for exams, these are the most common cause of smoking age diabetes in the narrative syndromes, um, clinical features. You get painless John D's. So you get quality assign. Uh, do you know what qualities signs just mentioned? The question earlier. And what we caught it. Yep. Yep. So quality is rule of cause. It qualities. Law states that a nontender and large gallbladder always almost always rules up gallstone as a course. So you think of other causes such as a stricture cholangiocarcinoma pancreatic cancer. It is nontender. Okay, if it's tender, most likely it's called stones. Okay. But you're right. Um, other symptoms. Systemic science weight loss, dark urine and tail stools. Diabetes can get steatorrhea, which is fatty stools. Stools are quite hard to flush away. And you can also get trophy a sign of milk and say, You know, what does your sign is again? It's for exams. It's not. Doesn't seem before. Yeah, trouser sign. That is for hypocalcaemia. Tetany for hypocalcemia. Yep. Migratory. Tremble. Phlebitis. Okay, again, I'm not seeing in Patient's presenting with pancreatic cancer, but it's in the textbooks for exams. It's good to know. Okay. Yeah, but right. So Sign and Shosteck. Science's for hypocalcemia is tetany and facial spasm. So there's a whole different, uh, pneumonic or course Okay. Diagnoses. Um yep. CT scan is the gold standard. Um, ultrasound is quick sensitive. You can see the classical double duct sign. Um, most surgeons with one m r c p r. A pet scan. And also you can do your blood tests. Race bilirubin, LP, um, and your tumor markers. See, in 1990 c. A. C. A is usually for colorectal cancer, but it's also slightly raised in pancreatic cancer. So most people do. I mean, in my clinic, my boss, like they like to do both C in 99 see a so it depends on what they want, really. But blood tests, imaging and tumor markers. Those are the key tests to do if you're thinking of, uh, pancreatic cancer treatment. Um, so again, it depends on how how early is it stage 123 or four. But most surgeons advocate for a tumor reception or Whipple's um, sometimes patient's. By the time they present with symptoms, it's usually a late sign. So once patient's present with back pain, John Days is usually stage three or four, and by the time it's usually widespread. So most surgeons don't don't advocate for Whipple's, they should just advocate for chemotherapy and radiotherapy. Okay, we can do palliative treatment so you can put a stent in. You can provide chemo radio. You can provide ripples just for reassurance, but most of the time, because pancreatic cancer is quite notorious for micro deficits or micro a maps. So the prognosis for pancreatic cancer is quite poor. Unfortunately, um, so by the time the patient's present to you, it's usually a late sign. Um, so, yeah, so that's a quick trip about pancreatic cancer. I think that's us for the evening. Do you have any questions about any of the topics or pancreatic cancer in general? Please don't chat. I'm sorry for just rambling out for the past few slides, for someone asked me how many questions they are in total. So, yeah. Um, please, throughout the feedback form. Again. Any questions? Please Put on the chat. I'm more than happy to answer them. I think that's best for Andrew to answer. Hello. Hi, everyone. Uh, my name is Maria. I'm just taking over from Andrew. Um, uh so? Well, we advertising very soon for all the other sessions. Make sure that you follow or our our social media accounts. And we advertise on there very often about our next sessions. We have very, very great, um, sessions lined up just as amazing as today's. Uh, so thank you very much. Honestly, it's been a great session. We've got a question question. Right. So you prefer your CPU MRCB? Uh, no. So for consists itis. Um, so the patient is well, the vision is stable. Uh, most suggest just go for a CT scan and the schedule for, uh, a colleague, but MRCB just reserved for patient's who, who are? They're stable, but they're unwell there just to show for I mean, M R C P is usually for, uh, for pre op planning to look at where the stone is to look at the anatomy of the biliary tree. Because MRCB is more accurate than CT. Um, like I mentioned earlier depends on the hospital. If you have E ercp a sessions available, if you have a gastroenterologist, you can do it. Or a surgeon who can do ercp. They'll go for an ERCP straight, but usually you do a CT and the CT shows a stone. If it's in the gallbladder alone, then you could do a lab coli. But if the stone is in the biliary tree, if it's in the, you know, the junction between the right and left hepatic duck, or if it's between, if the sphincter of oddi, then you can do an ercp straight away. But then again, it depends on if you have ercp in our stone. The first place, um, most surgeons would just go for a lab collie. All right, Any other questions? Yeah, I think this is honestly, thank you so much. It's been a really really great session. Well, that's fine. I hope you guys do something fun tonight rather than, you know, revising for general surgery. If the pancreatic cancer is found early, what about Oh, or long transfers along my procedure? So I've not seen them done before. Um, but usually my boss usually just advocate for Whipple's. Um, that's a very cool procedure that I think really done it, like twice in six years or something, because most patient's that when they have pancreatic cancer, they presented when they have symptoms 85 to 90% of the time, it's stage three or stage four because unfortunately, the way the NHS works, I mean not talking bad, but the NHS, But usually if patient presented back pain, they go to the G p. The G P. Things is probably just mechanical back pain or UTI just give antibiotics and then when they come in, unwell or coming, John, this is quite late, but the transfer so long my procedure have not seen that before. But you know, again depends on the expertise of the surgeon, um, the boss that I used to work for before his boss used to do them. But he doesn't know how to do them. He does repost alone. So it depends on whether the surgeon has the expertise. Sad. Well, I've not seen one. I wanted to assist, but everyone was just fighting for to entity this. But good for you. Any other questions? Interesting. Yeah. I mean, the the long my procedures usually reserved for the duct. But sometimes they have done both a Longmire with post procedure where they do both, Um where where the There's two more of the head of the pancreas, and it's really the duct. So I mean, the surgeons have done them both. We both and also along my procedure on the table. All right. Any other questions? All right. I think that's us. Okay, great. Thank you very much. We'll we'll end it there. We took so much of your evening as well, so Thanks. Fine. Fine. Have a good evening. Have a good weekend. Thanks, guys. Very much. You too. Cheers. Bye Bye. Everyone