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Ok, then should we start? Yeah, we could. Mm Yeah, good morning. Hi. My name is Pha. I'm one of the s working in Fur General Hospital. We have Mister Raman today discussing about acute abdominal emergencies and surgery. So I'll just um move away from the screen and ask you because you to take hold of it. Yeah, no worries. Ok. Can you guys all see the fi my presentation? Yeah. Can you results see me? Hear me and see my presentation? Ok. But so hello guys, welcome today to um this lovely session arranged by Doctor Fabia. Um Today's session is on acute abdominal emergencies mainly in general surgery. So, um without delaying anything, let's just get into it fine. So we all know from our med school. What are the common surgical, acute abdominal causes? Um The common subdivisions could be various infections anywhere in the tummy. Most commonly appendicitis, cholecystitis. Um It can be colitis. Um um it can be any infection anywhere else. Um, diverticulitis is also very common in the UK um perforation, perforated, duodenal ulcer, perforated, um ileum colon, any perforation is a surgical emergency, any obstructed bowel due to any reason. Um in small bowels. It is very common to have obstruction due to additions. Um, large bowels can have additions due to, uh, cancers. There can be volvulus, there can be, um, obstruction due to constipation as well. And hernias can cause obstruction, um, bowel ischemia. This is something that is very, um, uh, a very significant cause of surgical emergencies. It's very, um, um, it's not very, but it's quite difficult to diagnose if you don't know what you're looking for. So you always have, have to be aware of mesenteric ischemia and uh any strangulated hernias or any bowel obstruction, all these things will eventually lead to bowel ischemia anyways and any hemorrhage. So upper G I bleed, lower G A bleed, um inside the abdomen, ruptured ectopic pregnancy usually goes to gyne sometimes, uh it's presented to general surgeons first. Um, any ruptured aortic aneurysm and after any trauma, there can be intraperitoneal hemorrhage. And obviously, we all know causes of upper and lower G I bleeds, right? So we'll try to go through all these things um in, in short, just to give you an idea about how we deal with these sort of surgical abdominal conditions um in the UK and just a few bits and pieces here and there. Uh this session is not for any medical advice. So, um this don't take whatever we discuss here as medical advice if you are unwell, obviously go to the hospital, but this is just for our discussion, right? So, one of the most common um presentations in general surgery um is for appendicitis. So we all know appendicitis is um one of the most common surgical problems and it is sometimes quite difficult to diagnose clinically. So we have to use some investigations, some blood reports, some scans and all these things to diagnose appendicitis. Um So what are the common signs and symptoms of appendicitis? Um, firstly, we can we all know right, um central to uh right iliac fossa pain, uh or migratory pain. That is one of the most common um presentations, classical presentations of appendicitis. So, pain, which would be um sta it starts around the umbilicus, moves to right area fossa, then um associated with loss of appetite, nausea, vomiting, um temperatures, um usually more diarrhea than constipation. Um All these things you have, you have to suspect appendicitis. Um The problem with appendicitis is uh especially in Children and especially in females uh who are very prone to getting urinary tract infections. The uh they can have gynecological issues in fe uh females. Um in Children, they can have a viral illness which um is um um reactive uh lymphadenopathy in the tummy, which mimics appendicitis. So sometimes it's difficult to diagnose it clinically. So we have to do some um investigations, for example, just the routine bloods can give you an idea um to a urine dip or urine. Um uh MC which shows if someone has UTI or not pregnancy test to rule rule out gyne causes, excuse me. And obviously we have ultrasound to rule out these other causes like any urinary problems. Um And then ultimately, the best gold standard is ct Act of Pelvis with IV contrast. Um, if someone is confirmed to have appendicitis or highly suspicious of appendicitis, uh, then the gold standard treatment is surgery. You have to take the appendix out, either you can do it laparoscopically or you could do it as an open surgery. Obviously, you have to give them supportive treatment as well. Um, some, uh, bit of antibiotics, analgesia as per the guidelines. Ok. Another very common, uh, cause of surgical admissions is cholecystitis, which is an infection of the gallbladder, as we all know. Um, sometimes, uh, patients present to us with right upper quadrant pain and that would be, uh, then we start thinking about acute cholecystitis. Um So what happens is that it's sometimes a bit difficult to diagnose uh acute cholecystitis from biliary colic or other issues. Um, mostly in cholecystitis because it's an infection, the pain keeps getting worse. Whereas in biliary colic, it's a colicky pain which comes and goes. Um, um, sometimes it al even like reduces it in intensity of it. Um, but it comes and goes. So that's how you can somewhat differentiate cholecystitis, uh, from biliary colic pain. Um, obviously, when you examine, um, a patient with cholecystitis, they would have right upper quadrant tenderness, then they would have, um, what we call, um, Murphy sign might be positive, which is, uh, the tip of the right ninth costal cartilage. Uh, if you press them, then it would be very painful. The patient would catch their breath if you ask them to take a deep breath. Um, so there, um, and also with this cholecystitis, patients can have jaundice, but it's uncommon with just acute cholecystitis to have jaundice. Uh, but they could still have, they'll have nausea, vomiting, they would have loss of appetite. Um, abdominal bloating, all these things could. Um, you have, you, you have to think about cholecystitis. How do we diagnose or how do we confirm our diagnosis? Ultrasound with any hepatobiliary problems if you're thinking of any hepatobiliary disease or hepatobiliary problemss. Ultrasound is the first gold standard to go for. So, I if you do an ultrasound, you can rule out if, if the gallbladder wall is thick, if there is infection, if there are stones in the gallbladder or sometimes even in the duct. Um, ultrasound is uh very important and how do we treat cholecystitis? We can give them antibiotics. Um We can give them antibiotics to treat the infection and then after maybe six weeks, at least 6 to 8 weeks and then we bring them back for an um elective um laparoscopic cholecystectomy. Um But sometimes if the cholecystitis um is very acute, uh within 72 hours or something, the patient is in the hospital and everything else is ok. Then, um, it within 3 to 5 days, if, uh, from the start of the pain, if the pain patient presents, then sometimes we can offer them, um, as an emergency, laparoscopic cholecyst, uh cholecystectomy in that admission, if not, uh, then treat them with antibiotics, send them home, then just bring them back after 6 to 8 weeks to do an elective lab colon. This is a setup for how you do an elective laparoscopic cholecystectomy. Um You put in four ports and then usually uh this elective uh laparoscopic cholecystectomy has become the gold standard. Nowadays in the UK, it's very common uh for people to have diverticulitis. It's um um diverticulitis is basically when they're small outpouchings from the site of the colon. Um It is um an acquired disease usually due to the diet and like prolonged constipation and all these things. Um, the bowel wall gets weakened and there are small out pouchings coming out and sometimes these things bleeded. Sometimes there is um infection. Sometimes they form um small perforations in the diverticulitis. They form abscess so they can cause all sorts of problems if you, um see a patient with left iliac fossa pain, especially uh elderly patient, um elderly by elderly. I mean, like anyone above 40 or 50 with um left iliac fossa pain, uh maybe sometimes they have blood in their stool as well. Pr bleed. Um, they might have fever, there might be vomiting um, abdomen might be tender. Um, then you are suspecting diverticulitis. Um Well, how do, how do we diagnose diverticulitis again? Uh The surgeon's best friend CT of the pelvis with IV contrast, do a CT and they would show this all sort of um fat stranding wall thickening around the diverticula. Um How can we treat diverticulitis? We can, if it's just an infection, just diverticulitis, no problems, no other problems, then we can give them antibiotics. We give them antibiotics. We ask them to modify their diet and we send them home um when they're stable and they get a colonoscopy after 6 to 8 weeks to rule out other causes of any, any other problems to visualize the diverticula. Um Sometimes there might be rupture or perforation of this diverticula. There might be localized abscess. Then the patient needs to go to theater for um sigmoid resection or heart men or something like that. Uh Perforation again, perforation is uh something that is almost um very um urgent. It's a um a very um urgent surgical problem. So what any uh there can be different sorts of perforation anywhere in the abdomen. It can be due to peptic ulcer disease in the stomach and do to them. It can be due to uh in the small bowels due to different causes. It can be in the large bowels due to different causes um from obstruction from ischemia, it can lead to perforation or um if someone ingests foreign bodies, it can lead to perforation. Uh if someone has typhoid, they can have perforation. So, perforation can be due to many different things. Um What would be the classical sign in perforation? Uh So if you examine the patient, the patient uh abdomen would be Peronei. So what I mean by Paton is um it would be a rigid abdomen, um all over, it would be severely tender and the patient would not be moving around, moving at all. They would lie still because any movement increases their pain. Um Then if after you have examined, if you see the bloods, the bloods would be um the patient would, might be septic lactate would be high. And um if you do a chest x-ray, you can see a sliver of cosentyx shaped air under the diaphragm on the right side, but obviously, sometimes even chest x-rays um miss perforations. So ac T is the best way to go forward. If you do ac t of the pelvis, then you can correctly identify where the perforation is. Um how much soiling is there in the abdomen? How much air is the perforation localized or has it spread all these things? Uh It's very accurate and it helps our management tremendously. So what happens if someone has a perforation? Obviously, they need surgical management to repair it, bowel resection, anastomosis. If it's duodenal ulcer, then we do a Grayhound patch with um we suture the um perforation, we put some momentum on it. So there are different modalities but surgery is the mainstay of treatment. Sometimes if the perforation is very small, very localized, uh, the patient is otherwise symptomatically. Well, we sometimes might treat them with antibiotics. But usually if someone's, um, has perforation, they should, um, the ideal way is to treat it surgically. The definitive way is to treat the perforation. Surgically, you can see a little bit of free air under the diaphragm on the right side. Yeah. And you, you see, um, there's the small bowel with a bit of a gap in it. That's the perforation. Ok. Again, another common, uh, surgical emergency bowel obstruction. Uh, as you can see bowel obstruction, we all know about these air fluid levels in the abdominal x-ray. Uh, if it's in the lateral zones, it's, uh, probably large cut. If it's in the central zone, this sort of fluid, air fluid levels, it's probably small cut. You can try to differentiate between the large gut and small gut, uh, by the aust administrations and, um, the circular lines. But again, Abdo x-ray is sometimes in many trusts, they wouldn't do an Abdo x-ray as well. They say it's not very sensitive specific. So, um, patient should get AC T scan. Um, in Abdo, uh, the bowel obstructions usually, uh, present with four things. Um, pain distention, vomiting, diarrhea. So the patients get, uh, pain first because they're not passing anything. Then the abdomen started to distend because nothing is moving down. Uh, and all the secretions are there. Third, space loss. Uh, if it's a small bowel obstruction because it's higher up, vomiting comes first, constipation comes second. If it's a large bowel obstruction, people get con complain of constipation first and then vomiting, but pain and distention would always be there. Uh, there can be many causes of bowel obstruction. Um, one very common cause here in the UK, we see in elderly patients is, um, severe constipation, um, that can cause bowel obstruction. Uh, there can be and due to cancers due to other growths due to, um, additions, small bowel obstruction is more likely if, if there are previous scars, uh, previous abdominal operations because of additions, there is, uh, it's common to have small bowel obstructions, um, uh, obstruction, you have to, again, uh, if you have done an abdo x-ray and a chest x-ray and it shows obstruction if it's, um, uh, depending on the type of obstruction, the patient, uh, requires surgery. So, if it's a large bowel obstruction, usually in most of the cases, the patient requires surgery. Um, if it's a small bowel obstruction, if it's due to additions, then the, sometimes we try to manage them conservatively with NG tube, catheter IV tubes, all these things. But, um, if it's due to any other cause, then probably the patient needs surgery. Ay ischemia, as I said, mesenteric ischemia is, um, something that can be easily missed. So, the main thing to uh remember is pain out of proportion. Uh again, which is like if you are not sure that this uh not, nothing fits with how with the patient the blood are um the white cells and everything is more or less. OK. The chest x-ray is more or less. Ok. Abdo x-ray more or less. Ok. Uh no other history. Um but the pain is out of proportion and the abdomen does not feel very um um Right. Um I have a question at this. We'll discuss all the questions in the question, a question answer session. I think that would be easier for us to have a discussion. Um Yeah. So ischemia like if you feel like the abdomen is not very um paton, but the pain is out of proportion, then you have to suspect mesenteric ischemia. Um pre um if the patient has predisposing factors, um any heart conditions, fibrillations and all these things, then you have to um discuss this um high lactate lactate um is uh very easily and commonly done in, in the uh here in the UK. So if a, a very high lactate uh raises a high suspicion of mesenteric ischemia again, we confirm with CT of the pelvis and uh usually if it's mesenteric ischemia, we um have to treat it um uh surgically. Sometimes we heparinize them to see how it goes. But if there's any sign of bowel compromise, then we have to take the patient to theater. Um Again, this is uh upper, any gastrointestinal bleeding, um can present in two ways. It can be either upper G I bleed or lower G A bleed. Uh So upper G I bleed is anything from J GM and above almost to um stomach to uum. So bleeding, peptic ulcers, eso facial tears, uh eso facial viruses. So the patient usually um vomits out with hematosis. Um sometimes the these upper G I bleed patients present with black tarry stool, which we all know is melena because the blood gets digested when it travels through the um through the intestines. Um sometimes very rarely. If someone has a massive upper G I bleed, you can have fr uh almost um fresh or like bright colored blood uh coming out um from the rectum as well, but usually lower G I bleeds. These are uh we can, again, uh can be due to different causes. But um we, things that we have to keep in mind is any cancers. Um any ischemic colitis diverticulitis and any anorectal cause like polyps or uh hemorrhoids or fissures, all these things. Um It can be painless and painful. So if it's painful, then maybe it's fissures. If it's painless, then it's um probably something else we can differentiate according to color as well. If it's bright red, then probably it's coming from anorectal region. If it's um dark red or mixed, then probably from the colon or from the left colon and if it's very dark blood or almost melena then higher up. Um So mainly upper G I bleeds, um go to gastro people because they can do um urgent uh upper G A endoscopy. They can inject adrenaline. If there are bleeding ulcers, they can put balloons, they can um cauterize, they can do all sorts of upper G bleeds. Most upper G A bleeds nowadays, um treated successfully by endoscopist. Lower G I bleeds usually comes to surgeons. Uh And after you've examined the patient, you always have to do ad RD, you sometimes do um proctoscopy. Sometimes we can even do a rigid sigmoidoscopy. If you think uh it's applicable just on the bedside, you can do a rigid sigmoidoscopy. Um rule out any uh anorectal causes like hemorrhoids or any fissures or all these things. Um Most lower G I bleeds um just go away on their own. Um It might be due to some uh some patients might be on anticoagulants so that exacerbates these things. Um sometimes they have other causes but it um most of the time it stops on its own, we just have to give them supportive treatment and after everything is settled down, then we can take the patient for um a colonoscopy or flexi sick um to see what's going on if the bleeding is not stopping, then we have options of CT of the Pelvis or CT angio, um the arterial phase to see if there is any active bleeding going on. And then we can sometimes ask uh interventional radiology to coagulate those vessels, uh or thrombo tho those things. Uh If nothing works, then obviously surgical management is always there. Yes. So any upper allergy bleeds, we can do emergency setting. It's easier to get an abdominal ct scan or CT angio. Um But if it's non urgent, then we have to get an endoscopy as well. And obviously, it treatment according to call, but we always have to resuscitate with fluid and keep the patient hemodynamically stable. Thank you everyone. Um This is just a very short, it's very difficult to uh compile everything and um in details in uh in just one session for all surgical uh emergencies. Um So if you have um any specific questions about anything, then um I'll give you guys a few minutes to ask in the group and then we can um discuss um one of the questions uh from doctor A is regarding adhesive small bowel obstruction. Um Can you prevent it surgically by intraluminal splinting with a Baker's tube? He has asked uh as an alternative to extra Luminal methods of nobles plication and child phillips me plication. Um I actually don't know, I'll be honest. Um I, I have not come across the these uh methods in my um short career. So I don't know. Um I'll try to get back to doctor Aie, I'll ask around, I'll ask my seniors in the department and I'll, I'll, I'll try to get back if we do, we have his, um, email and we can get back to him. Yes. If you, if you provide us with your email address in the chat, we can come back to you any other questions. Ok. Uh, if we don't have any other questions, what you can do is, uh, you can fill up the feedback form to get your certificates, um, which will be available immediately after you've filled it up. And if you want us to go through other surgical topics, you can, uh, add it here in the chat box. Um, thank you, Mister Raman. I know you're very busy and, um, this was really nice of you that you have come up with being such a sport because I know, um, like it's a Saturday and you've, you've agreed to it. I'm very grateful that you took the, it's, it's completely fine. Thank you for arranging all this. Um, it's, um, it's difficult with, um, going through all the things, all the basic things, um, within one hour. But, um, I mean, we try to do it, you try to do it and you are arranging all these sessions. These are really good. Keep it up. I'm always here to help. Ok. If thank you so much and if anyone wants us to come up with something else, any other topic, please let us know and we'll go ahead with them. Ok. So should we end our session now. Yup. So if you don't have any questions, uh Doctor Aie has asked another question. Um So he asks, can mesic ischemia be likely in PV D uh patients with chronic abdominal pain, uh postprandial dyspnea plus history of anemia, peptic ulcer LV. Um What, what do you mean by PV D it peripheral vascular disease, do you mean? I think so if it's peripheral vascular disease with someone with chronic capital pain, definitely the uh there ca can be some sort of uh mesenteric ischemia. Um because um we as surgeons, we only deal with um basically acute mesenteric ischemia where there is sudden, um almost definitely there is uh bowel ischemia, bowel, um going to gangrene and going to death. Um But um me uh mesenteric ischemia, people can have chronic mesenteric ischemia. Uh But um my experience with chronic mesenteric ischemia uh or subacute is um limited because usually the these uh patients are dis not discuss like dealt with by gastroenterologist. Um I have I mostly work with Genser. So um um I deal with the acute ones more but um giving this patient's background with peripheral vascular disease, left ventricular failure, uh anemia um with chronic abdo pain in chronic mesenteric ischemia would be a very likely cause. Um Definitely, yes, I would say yes. Ok. Hi, doctor a answers your question and you've provided his um yes, he meant peripheral vascular disease. Uh So he's provided his email address. Um here if you, if you have the answer to this question, Mister Man, you can. Yeah, I'll, I'll discuss this because I've not come across uh this method much. So I'll just ask around, I'll get experts consultants and then I'll get back to him. Ok. Thank you so much. Um So I'll end the session um if you can give the feedback and get your certificate and this will continue like we, I'm trying to put up surgical topics on alternate weekends as well as um how to enrich your portfolio for a different surgical uh training course. Um Keep an eye out in this, this particular part of the website and you get updated. Ok. Thank you so much again. Thanks. Thank you for being help, take care. Thank you, everyone for joining. Bye.