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And we can give it a few minutes if you like a couple of minutes if you want for people to join. But sometimes people just join in a bit later. Mm. Think we're like, hello everyone. We're just gonna give it a couple of minutes and just wait for a couple of people to start trickling in and then you can stop. Mhm. Get a minute or two more and then we'll get going. Oh if you just click hide, I think the share screen biz in the way the slides, you just click the hide button. Someone just mentioned on the chart for. Ok. So I, no worries. Ok. I think we should, we got to move on and then we'll see. I'm sure people will join us and win anyway. Yeah, we'll get started. Sure. Ok. So hi everyone. Uh welcome to another teaching front revision session. Um, my name is Judy and I'm writing this session today with me. Um, we're a couple of doctors currently working in the east of England. We both actually graduated just this past summer. Um, and sat the UK Malay pilot as our finals exams. So we have a little bit experience of what comes up. Um Typically. Um So today we're gonna be covering the acute abdomen, which is what we think is quite a common presentation that is likely to come up on your MLA um, whether it be your MC Qs or your Aussies. Um It's kind of a very broad topic and I'm sure you'll encounter it somewhere along the way. Ok. Right. Thank you for that introduction, Judy. So to kick, start things off, I want all of you to start thinking if you haven't already about the abdomen in nine different regions as shown by this diagram. So this is really helpful both for your OS exams as well as MC Qs. Because when they're asking you about, for example, specific symptoms, it's better to know where the organ lies and therefore where you're expecting the pain to be. So as the diagram shows the epigastric is at the very top epi meaning higher up to the gastric. So there's some sort of language clues that you can use in order to figure out exactly where the region is the left hypochondriac and the right, on either side underneath that is the umbilical and on either side is the left and the right lumbar at the very bottom is the hypogastric region and on either side is the left and the right Iliac. So we'll be referring to these pains throughout our presentation as well. Oh, sorry, just stop. So I think they're saying the slide isn't moving but it's moving on my screen. I don't, the chats saying that the slide isn't moving at the moment it's moved on my screen as well. So I'll, I wonder if there's a delay like uh as you came in a slide now, I don't know if it uh can someone just put in the chart if the slide is now on the kind of UK Malay content map or it's still stuck on an intro slide? It's working now. Ok, perfect. Um So just to kind of cover why actually this topic is kind of relevant to your UK ML exams. Um So as you've most likely seen this is the MLA content map. Um It's on the kind of GMC website. Um and it contains quite a few presentations and conditions that are related to the acute abdomen, um mainly within the surgery modules and the gastrointestinal kind of section. Um And if you just flip to the next slide, these ones we'll be covering today. Um So we've picked a number of them, we think that kind of cover most of the presentations, um and kind of regions within the abdomen. Obviously, we won't cover everything, but we think it's kind of a nice overview um and kind of the most high yield topics that we think are most likely to come up. So we'll start off with appendicitis. Um Let me just check. Yeah. Um So we'll start off with appendicitis. So, um this is quite a common one that comes up. So, um kind of definition of appendicitis to start off with. So it's essentially just the inflammation and infection of the appendix. Um and it's usually secondary to kind of a buildup of bacteria within the lumen of the appendix. Um And that usually happens as a result of um obstruction of the actual lumen by either a fecalith. So a fecal stone um or hyperplasia of the lymphoid tissue in the appendix. Um and it presents with that classical kind of migratory pain. So it starts off with the central abdominal pain and then within 24 hours, kind of sort of migrates over to the right iliac fossa um and becomes very, very central, very localized, sorry in that, in that right iliac fossa region. Um patients present with mcburney's sign, um which is basically pain specifically at mcburney's Point, which is a third of the distance between the anterior superior like spine and the umbilicus. Um patients often present with loss of appetite, nausea and vomiting. Um and on actual palpation, kind of abdominal examination, you'll see signs like Rovsing sign as well, um which is pain in the right iliac fossa, on palpation of the left iliac fossa, um and guarding as well. Um And often if, if the appendix is perforated as a result of the appendicitis, they'll present with peritonism. So, signs like rebound tenderness. Um So tenderness on kind of coming off of the ab of the abdomen, um and percussion tenderness or tenderness when you're actually percussing the abdomen itself. Um Now, although obviously appendicitis presents with quite a kind of characteristic pain. Um there's obviously also differentials that can cause similar pain patterns that you have to consider and rule out with patients presenting like this. Um one really important one being ectopic pregnancy. So with any kind of women of childbearing age that present with any sort of acute abdomen, um, acute abdominal pain, it's really important to rule out ectopic pregnancies. Um Other ones include things like mesenteric adenitis, especially in Children and then gynecological issues like ovarian torsion and ruptured cysts as well. And then in kind of younger or teenage males, things like testicular torsion and just brilliant. Um And then we'll cover a bit by investigations and management for each condition as well. Um We try to split it up into kind of bedside blood imaging and like special tests, which is usually quite a useful way to structure answers in acies and things as well. Um We're starting off with bedside investigations for appendicitis. Um It's really useful to do a urine dip and this is kind of done straight when someone's admitted. So usually in the emergency department, they'll have a urine dip. Um, that's not to kind of look for appendicitis, but it's to exclude other causes of similar pain. So uti S kidney stones and again, ectopic pregnancies. So you do a urine H CG test. Um, moving on to blood, you don't want to do your basic blood. So it's your full blood count. You're using these, um, liver function tests, things like that. Um And then you'd also want to be looking at inflammatory markers like CRP as well. Um And it's likely that because it's obviously an infectious inflammatory process, you'd have a raised CRP and a raised white cell count. And then again, with any of the kind of acute abdomen presentations, um you want to be doing your clotting your group and save and your cross match just in preparation for likely surgery. Um in terms of imaging. Now, appendicitis is generally a clinical diagnosis. Um It doesn't really need imaging to confirm it. Um but you can do an ultrasound abdomen to again rule out other pathologies. So, gynecological causes, for example, like cysts and torsion will show up on ultrasound. Um But in some cases with appendicitis, um especially if it's perforated, um you can see inflammation in the abdomen or fluid, build up in the abdomen as well. Um What's kind of become more and more common is that people are now doing ct abdomens to um diagnose appendicitis, which wasn't as common back um kind of a few years ago. Um But on act, if you can see on the right, there's act image on the screen, um where the red arrow is pointing, that's kind of where the appendix normally lies. And if you kind of look closely, you can see that it's quite enlarged and there's a bit of fluid surrounding it and the walls thickened as well. And those are the signs that you look for on a CT abdomen. Um, if you're looking for appendicitis, um and in most cases, the kind of definitive kind of the best investigation to do if you're looking for appendicitis is just a diagnostic laparoscopy, um, which is just kind of a surgery to look for the inflammation. And then obviously, if they find anything, they'll remove the appendix in the same surgery rather than going in twice or anything. Um But yes, those are the main investigations you'd do, uh moving on to management. So again, we've set it out in a, in a kind of kind of a logical way. So you'd go with conservative, then medical, then surgical. Um, so more conservative management you'd start off with, um, always making your patients know by mouth as soon as you're suspecting something like appendicitis just because the likelihood is they will need surgery sometime quite soon after admission. Um So you start off by making them know by mouth and giving them fluids and then treating their symptoms as well. So, analgesia antiemetics because they're usually, you know, quite in pain and also quite nauseous when they come in. Um, medically, you can also, um, you'd give preoperative antibiotics. So, um, with patients who come in with appendicitis, um they'll obviously undergo their, um, laparoscopic procedure and it's really good practice to give preoperative antibiotics just as prophylaxis. Um, because it's quite a, um, it's a procedure that can cause quite a bit of contamination within the, within the abdomen, um, just to prevent infection essentially. And then the definitive, um, treatment for appendicitis, obviously, your laparoscopic appendectomy. Um, but it's actually quite interesting is that sometimes, um, and more so now when patients present with quite mild appendicitis, um and they want to kind of avoid surgery, we can just try and treat it with just antibiotics and in some cases that does work. Um but for some that does end up having to lead to surgery anyway because uh because the antibiotics don't kind of completely um heal the infection and then some complications to be aware of as well, so of appendicitis itself. So, like I mentioned a bit earlier, you can get perforation and peritonitis as a result. Um you can get an abscess forming. So a collection of kind of purulent material around the appendix as well. And that can be a lot harder to treat and a lot harder to kind of resect and then also sepsis. And then um complications of the surgery itself, you can get intraabdominal adhesions, you can get perforation, especially because it's a laparoscopic procedure, there's a higher risk of perforation and then also infection hemorrhages you would get with kind of any surgical procedure. Ok. So now I'm gonna be talking through bowel obstruction and shortly after this, we'll be going through paralytic ileus as well. So, bowel obstruction, it's exactly what it says. It's an obstruction of the passage of food fluid or gas in the intestines. So, the way that I think about this is, first of all, is it a partial obstruction? Which means that fluid and gas is allowed through, or is it a complete obstruction where not even gas is allowed through? And then you'd want to think, is it an obstruction in one site or is it a closed loop bowel obstruction where two sides are occluded? And that's a lot more dangerous because if you have a look at the diagram on the right side of the screen, um, the sort of banana shape of the bowel that you can see that is what a closed loop bowel obstruction would look like where because there's two areas that are preventing the flow of material in the bowel both proximately and distally. It increases the risk of bowel ischemia, bowel perforation, hypovolemic shock. And it can be a lot more dangerous, which is why for a closed loop bowel obstruction, you'd be wanting to act really quickly and get senior help involved, which is definitely something to keep in mind for the AK stations that commonly come up for bowel obstruction too. Um, to mention it's sorry to cut you off. I think your slides frozen again. Are we not on bile obstruction. No, I think the slide hasn't moved. Is it still stuck? Is it stuck on the appendicitis slide? Still, I'll go back and go again because II can see it, but I think it's still stuck for everyone else for some reason. Sorry. I think there may be a lag but if someone can let us know in the comments if we're all good and I'll keep, uh, I think, can someone write in what, what, which slide is on at the moment? Oh, is still on appendicitis? OK. I think for my one it's bowel obstruction. Yeah. And for me, what else is? Mm Maybe if you unsa in this area, would that work? Ok. Thank you everyone. Sorry about this. Thank you guys. We'll try again how we know it is not. We've just unh and then shared again. If someone just let us know if it's still appendicitis or if it's, I think we were saying it's still appendicitis. OK. Let's move it around a bit. I'm hoping it's just the one person, not everyone in the audience that still took an appendicitis appendicitis. I think it's just us. That isn't, we're just probably not the right way around. Um So we try and share it for a bit and then reconnect your internet maybe. Right. Give me a second guys. Let's try this again. I can't believe you're all missing out on the riveting subject of bowel obstruction, but let's try this again. Right. Ok. Right. How are we now? Thick. Yeah, we'll send the slides out as well. Um, I, yeah, we'll send the slides out. If you can put in a free back form at the end of the session, we'll send them out. So you'll have access to them as well. Ok. Amazing. We're on B now. Oh, yes. Ok. Ok. And you take the hide icon again? Yes. Ok. It was updated though, right? Fantastic. Um Please let me know if it starts lagging again. Um So I hope it, what I was saying previously makes a bit more sense now that you can see the slide but yes, quick recap, partial or complete obstruction and either one site or two sites closed loop, bad story. Get the surgeons involved immediately. And another way to think about wild obstruction is where the obstructive substance lies. So, is it within the muscle, is it within the bowel itself or is it extramural? And this table is also a very useful one to have in the back of your mind when you're working through questions related to bowel obstruction. Um in terms of the high yield content for bowel obstruction. So the top three causes are adhesions, hernias and malignancies. Again, bowel obstruction comes up a lot in Aussies. So these are the right questions that you need to be asking. So, for adhesions, you'd, if you've got a suspicion that it's a younger patient or a female patient, you'd want to see if there's any gynecological history of pelvic inflammatory disease or endometriosis or if they've had any surgeries in the past more rare. But you can, you still see it is radiotherapy treatment that can lead to adhesions as well. And then moving on to the slightly more older patient. So around their fifties, you'd be thinking about hernias. So any obvious lumps around the groin, any strangulation when you're doing uh uh palpation of the abdomen as well. And then the third most common cause malignancy that affects the large bowel. And in terms of patient range, we're talking 6070 plus. And in terms of history, you want to ascertain if they ha had any of the b symptoms, if they've had any pr bleed, any weight loss, because that will again allow you to understand what's driving the bowel obstruction because it's always as a result of something else. Ok. And now you should be able to see the next slide. Um, so in terms of the key features of bowel obstruction, the most common feature is green bilious vomiting, there will be abdominal distension, present, diffuse abdominal pain, absolute constipation and lack of flatulence. And that's with a complete bowel obstruction rather than a partial. And you'll also hear tingling bowel sounds, especially in the early stages. In terms of investigations to do. You'd want to be doing an abdominal examination, especially if you want to be ascertaining what the cause of bowel obstruction is. Feeling round for any hernias or any generalized pain. I it's also really important that you do a BBg um that gives you important information, especially if you're thinking about surgery and perforation because they may be presenting with a raised lactate, which is a lot more serious. And if they're actively vomiting, you'll note a metabolic alkalosis in terms of bloods. As Judy's mentioned previously, the surgical bloods are clotting grip and save and cross match memorize that for Os Ks. But alongside that you want to do the standard F PC and E now moving on to imaging and we'll go over this in the next slide as well. But the simplest imaging form you can do is an X ray or oh CT with this is done more than surgeries. Um because it allows you to see where the site of obstruction is, whether you need a stent or whether it needs to be an emergency procedure to temporarily fix it. For example, in the case of um colon cancer. And on the right hand side, you should be able to see a diagram of the pathophysiology of bowel obstruction. I'm not gonna go into it in too much detail, but for me, it's quite helpful to visualize why everything happened. So if any of you are the same, feel free to take a screenshot or it'll be on the slides that we send out. Ok. So as I mentioned imaging earlier, um would anyone be able to tell me in the comments or if you can unmute your mic, share with what abdominal X ray we're looking at and if you could describe it in any detail and if you're sharing it in the comments, um I'll get Judy to relay it to me. We'll give you a minute. There should be an abdominal X ray on the screen. Now, can you guys see an abdominal x-ray with management on the right? I'll go back and for again, no technology is really failing me today. Maybe let's go back and show again. Uh Yes, I think people can see the x um abdominal X ray. Oh OK. They can see it now. I need to go back on it now. So if you if you could get a diagnosis from this, what would you kind of go for from this abdominal X ray? So feel free to describe it. Um If you can unmute great, if not pop your comments in the chat or they can't see it, they can't see the abdominal X ray. Ok. For some reason it seems to be lagging. Ok. Can you see Adomal x-ray now? Ok. Brilliant. Yeah, I don't know what's going on there with the leg, but it should be on the screen now. Ok. So any takers for describing this abdominal X ray, if not, I'm happy to go through it. So, first of all, um it's important to have in mind the dimensions of bowel when you're analyzing an abdominal X ray. So as it says, at the bottom of this slide, small bowel should be less than three centimeters, the colon less than six and the cecum less than nine above that, you know that there's evidence of distension of bowel and you're more concerned of there being an obstruction. So, with this abdominal x-ray, I hope you can all appreciate the lines that are, if you can see my mouse, the lines that are crossing over the width of the bowel here, these are known as the valvula contis and they are the mucosal fold that are found in small bowel. So this abdominal x-ray uh displays a good example of small bowel obstruction. And you can tell that because of the lines that are going across the entire width of the bell moving on, you should be able to see another x-ray now and if anyone can comment on this or provide any insight into what kind of obstruction this is. We've had a large bowel toxic megacolon and coffee bean like the coffee bean sign. Ok. Nice. Thank you very much. At least I know I'm on the right slide as well. Ok. So this is large bowel obstruction. Um First of all, one of the distinct things to know is that there's no lines that are crossing over the width of the bowel. So these are known as Haustra. These are found in the large bowel. So this is consistent with large bowel obstruction, we will go into toxic myo colon shortly and what that also looks like. But abdominal X ray is a good initial test if you are suspecting viral obstruction. Now, moving on to the management. So conservative management, you need to be doing an A to e again, this is more osk based because bowel obstruction comes up very commonly in osk stations. Um It came up for me last year in my finals, oy as well. So it's one to go over what you're doing. You practice, you want to be keeping the patients no by mouth, giving them IV fluids. Since there's a blockage, you want to make sure that everything before that blockage has a root out. So which is why you insert an NG tube with food drainage and that reduces the risk of vomiting and aspiration as well. Ultimately, there will be surgical management involved and this can be in the form of exploratory surgery. If there's a unclear underlying cause, such as a malignancy that hasn't been picked up or if we know that it's something that can be fixed such as a hernia repair, then that will be done and that should reverse the bowel obstruction. Ok. Moving on to acute pancreatitis and I hope everyone can see the slide and Judy can take it away. Yeah, let's hope it's on the screen, hopefully. Um So moving on to acute pancreatitis. Um, so pancreatitis essentially is the inflammation of the pancreatic cells or what's in the chart? Yes. Brilliant. OK. Um So it's inflammation of the pancreatic cells as a result of autodigestion of the cells. So, um pancreas always releases a lot of digestive enzymes. And what can happen sometimes is you can get backflow of those enzymes into the pancreas itself and that causes digestion, inflammation of the, of the cells of its own pancreas essentially. Um So how it presents, it's again quite a classic one. So it presents usually, especially in questions and everything. You get the epigastric pain that radiates to the back. Um And it usually causes quite severe nausea and vomiting, loss of appetite, things like that. Um It can also cause things like abdominal tenderness on palpation. Um the same kind of as most of these presentations and then it also does cause some systemic symptoms as well. So, fever, tachycardia, um rapid breathing or tachypnea as well. Um In rare cases, if it's kind of transformed to hemorrhagic pancreatitis, you've got bleeding in the abdomen and it can also cause these two signs that are on the screen. Um So the one on the left is known as Cullen sign. So it's just bruising around the umbilical area. And then um the one on the right B is gray turn sign and that presents with bruising at the flanks. Um either one or both flanks and that's usually very, a very rare sign, but it's just something to be aware of. Might come up in a question or something. Um, and a quick bit on the main causes of pancreatitis and I'm sure you've all seen the get smashed pneumonic. Uh, the two most common causes are usually gallstones and alcohol. But there are also kind of a number of other things, trauma steroids, um, the classic scorpion sting and then certain drugs as well can increase the risk of pancreatitis, things like azaTHIOprine, certain diuretics and then also um things like GLP one agonists and that's actually becoming a lot more common. Now, pancre relating to GLP one agonists um with kind of the uh increased like popularity, things like Ozempic and Jaro. Um That's kind of probably a lot in the media is why you might have seen it. Ok. And um just to add one of the ways that I used to remember this for my finals in terms of the sign is that Gray Turners, you've got two flanks and it's two different words that form the sign and Collins, the sea Loki looks like the sea if you look at like above the abdomen. So that's the way that I remember it. The Gray Turners two flanks, therefore, two names for it. And Collins is a upside down sea. Ok. Brilliant. Um Moving on to your investigations that you would do for pancreatitis. So at the bedside, um you'd want to do an ABG. So this is for a number of reasons. Uh One is that one of the complications of pancreatitis is odds or acute respiratory distress syndrome. And that um obviously, if you're checking your ABG, you have a look at oxygenation levels and just see if they are in, in respiratory distress. And it's also because we'll come onto the score in a little bit, but one of the scores that we use for severity of pancreatitis, it looks at the po two within that. So you're kind of doing it for um a number of reasons. And then blood same as always, you've got your basic bloods and you're expecting to see your raised inflammatory markers again and your urea might also be raised. And that's again, a sign of um kind of more severe pancreatitis. Uh You're gonna look at your calcium, your album and your liver transaminases as well. And that's again for your scoring system, which we'll come on to and then your kind of typical pancreatitis bloods, you've got amylase and lipase and you're expecting to see these to be raised more than three times the upper limit of normal and lipase is actually more specific and more sensitive than amylase, but it's done kind of less in interest just because it's a bit more expensive. Um But those are both true to be aware of. And then you can also do imaging again, like with appendicitis, it's, it's more of a clinical diagnosis, but you can do ultrasound in the ct abdomen. So with the ultrasound, you can be looking for the underlying cause of the pancreatitis. So you can be checking for signs of gallstones um in the gallbladder or gallstones in the bile duct. And that can kind of give you an indication as to what's caused it. Um And then you can also do a ct abdomen and that checks for complications like necrosis, like abscesses around the pancreas and like pancreatic pseudocysts as well. Um and then covering the Glasgow Emory score as well. So the Glasgow Emory score um for severity of pancreatitis, it's kind of the main score we use. Um and it looks at a number of different things like oxygenation, age, calcium, et cetera. And if you look on the, on the right of the screen, it's actually a kind of a nice way of remembering it. If you look, it says kind of pancreas on the left side and it kind of um matches up to the different um criteria we look at. So P for po two A for age, et cetera. Um and you're looking at kind of po two being low age being above 55 white cells being really high calcium, being low rear, being raised and then enzymes like your LDH and your AST as well being really high albumin being low and um hyperglycemia as well. And then judging on the scoring from that, that's either your mild, moderate or severe pancreatitis and the more severe it is the more at risk you are of complications like necrosis and pseudocyst forming. Um moving on to the management of pancreatitis. So, um so starting off with the conservative management, again, it's your kind of typical fluids, analgesia antiemetics, just kind of keeping patients as comfortable as possible. Um While they're kind of um experiencing symptoms, now you wouldn't make patients um typically know by mouth of pancreatitis, you'd try and encourage oral intake, but if they're unable to tolerate that, then you might go for kind of NG tube. Um because you're unlikely to require surgery for this. Um It has a medical treatment, antibiotics can be given, but it's usually only in very specific cases. Uh for example, if they've got necrosis of the pancreas relating to their pancreatitis, but it's not routine. Um And then surgically. So you wouldn't do any surgery on the pancreas itself, but you might do an E RCP or cholecystectomy if gallstones are the underlying cause. Uh and you could do percutaneous drainage as well for any abscesses that are formed around the pancreas and then complications to be aware of as well. Necrosis as I mentioned and abscesses. So, collections of the pus pseudocysts. So these are kind of collections of fluid blood and enzymatic material around the pancreas or on the pancreas and then also chronic pancreatitis is is one of the more common complications as well. And that can kind of leave patients with, with symptoms, lifelong things like diabetes, um poor absorption ST arteria and things like that can all develop from just this acute infection. Ok. So, moving on to paralytic eyes. So like we discussed briefly when I spoke about bowel obstruction, that's a mechanical obstruction. This is a functional obstruction. So, paralytic eyes is also known as a dynamic. It affects the small bowel and it's a destruction in the actual function of the movement of the food and material down the colon and bowel. Um, so it's a disruption of peristalsis as opposed to something physically obstructing it. The most common causes are injury to the bowel or excessive handling of the bowel during surgery. So, this is a common postoperative complication that you should be expecting in patients 2 to 3 days post surgery, especially if there was inflammation or infection near the bowel. If they were trying to get rid of some abscess or uh peritonitis during the surgery itself, it can also be exacerbated by electrolyte IBA imbalances specifically hypokalemia or hyponatremia because that affects the electrical activity of the smooth muscle in the bowel itself as well as other conditions such as sepsis and M I. In terms of the signs and symptoms, it's similar to bowel obstruction with slight differences. So, yes, you still have the vomiting, abdominal distension, pain and absolute constipation, but the bowel sounds are absent rather than the tingling bowel sounds that you hear in the early stages of mechanical bowel obstruction. Now, moving on to management for all surgical patients as we now know, you have to keep them know by mouth if they have to be vomiting, consider doing an NG tube uh to a, a drainage. And one of the key things in terms of management of paralytic ileus is IV fluids because they are likely to get dehydrated very quickly as a result of the vomiting. And you need to be making sure that you're replenishing all the electrolytes that may have driven them into uh I state in the first place. So if the hyponatremia and hypokalemia gets worse, that's gonna make the paralytic eye is even worse. So you want to be restoring it preferably with Hartmann's, which is the fluid of choice for surgeons. Um You also would be thinking about early mobilization in order to help stimulate prostasis, avoiding opioids because they're constipating and that's gonna be making things worse. And in terms of blood, again, thinking about other electrolytes include a bone profile as well as checking for any evidence of infection. So, doing a full blood count and that will give you the white cell count and adding on a CRP level as well. For gold standard investigations, it's a CT scan and some patients may need TPN whilst their bowel rests and kicks back into action through the um medical management of NG tubes and IV fluids, uh just probably move on to gi perforation. Hopefully, that's on your screen. Now. Um I've noticed a couple of questions in the chart. Uh We can cover questions at the end, maybe if anyone puts any questions they have throughout about any of the conditions, then maybe you can do a bit of AQ and A at the end just to see um any questions you might have. Um OK, so gi perforation, so essentially this is just um a breach in the epithelium or the wall of the gi tract at any point. Uh So that can be anywhere from the upper esophagus all the way down to the anorectal junction. Uh So in terms of kind of causes and precipitating factors, these are has a number of reasons basically, but they kind of differ between upper and gi upper and lower gi perforation. So, with your upper gi perforations, it's most commonly to do with things like peptic ulcer disease, um malignancy. So things like gastric or esophageal cancers, foreign bodies. So, um you might have seen cases of of of Children swallowing button bacter and they often cause perforation quite higher up. Well, esophagus and stomach normally uh and then repeated vomiting. So things like Boh syndrome, which is where you get a tear in the esophageal thelium just because of repeated forceful vomiting. And then it can also be iatrogenic. So it can be secondary to procedures like OG DS endoscopies, things like that in terms of causes of lower gi perforation. It's more commonly pathology linked to kind of the lower um colon. So, diverticulitis for example, uh toxic megacolon which can occur as a result of things like c diff infections and ulcerative colitis. Uh inflammation generally um secondary to IBD malignancy. So kind of cancers of the, of the colon and the rectum appendicitis. And then again, iatrogenic causes like laparoscopy and colonoscopy. Um they can both of course perforation as well. And if you look at the, at the right side of the screen, you've got an abdominal X ray there. Um And does anyone want to pop in the chat? Maybe where they can see on the abdominal X ray? What's the classic sign or what's the diagnosis from the X ray? If no one knows that's OK too. And this one, it's, it's a, it's an abdominal X ray showing toxic megacolon. So if you look at the kind of a more kind of superior aspect of the x-ray, you've got that lead pipe colon sign. So you've got the loss of Hatra coming in through the colon. Um And that's a typical sign of toxic megacolon on a on abdominal X ray. Yeah. Can you guys, oh, we've moved sides now. But could you guys see that. So if I point it out here and if you and the more transverse section as well, you've got that loss of Hatra all through there. Ok. Brilliant. Yeah, perfect. And then going on to kind of how the how perforation actually presents. So obviously, it depends exactly where on where the perforation is in the gi tract, but they have fairly um common signs and symptoms. So things like rapid onset, severe abdominal pain, um, nausea and vomiting, loss of appetite, peritonism. So if you've got perforation, they like you to be quite peritonitic, they'll usually have a rigid abdomen, rebound tenderness, um just generally very tender all over the abdomen rather than it being localized to a certain point. And then they also present with systemic symptoms, lethargy and fever. And commonly, they can also be quite hemodynamically unstable as well, presenting with things like low BP and high heart rate just because you've got um kind of first infectious process beginning as well when you've got perforation, but also just because of kind of the loss of fluids and blood and things like that moving on to investigations that you do in your suspecting perforation, um uh bloods is normal. So you'd have your normal set of bloods, plus your surgical bloods, your clotting group and table and cross match. You'd also want to be looking at doing V VG as well just for some kind of um direct kind of quick results as well. And you're looking for a raised lactate on G just because of kind of ischemia and and things like that going on with the perforation. And then in terms of your imaging, you can do an erect chest X ray first and foremost. Um and that's what's showing kind of in the middle of the screen. Does anyone know what we're kind of trying to show with the, with the chest X ray with a perforation? There's an arrow that kind of helps you out a little bit there. Yeah, exactly. So Neop peritoneum. So typically on the left side of the chest X ray, you're, you're happy with kind of a gastric bubble because that's where the stomach is. But on the right under the right hemidiaphragm, If you ever see air in that region, that's always a bad sign. That's suggestive of pneumoperitoneum or free air in the abdomen. Um likely secondary to a a perforation of some sort, whether that be against stomach bowel, it kind of they will present in a similar way. Uh Another thing you can do is also abdominal X ray, which is what showed on the right side of the screen. And if you look closer, you can see what's called Rigler sign, um which is where both sides of the bowel are visible on the X ray, which is kind of not normal. Um And that again, is suggestive of free air in the abdomen and perforation. Um But the gold standard um imaging for gi perforation is your ct abdomen with contrast. And that is to kind of confirm it for definite and also localize the source of the actual perforation. I like guide your management and things and then going on to management. So again, your conservative measures, fluids making them no by mouth. And it's really important to get surgery involved as soon as possible. So, this requires a very urgent surgical referral because this patient is typically rushed to surgery as soon as they're stable enough for it. Uh medically looking at again, analgesia and antiemetics. And then in terms of your surgical interventions, again, it depends on where about the perforation is which is why the ct abdomen is really important to localize the perforation. But if it's within the stomach or secondary to a peptic ulcer, you're doing a, an open or laparoscopic repair. And surgeons typically will use a patch of the omentum to repair the stomach lining. And then for bowel perforation, it's a bit more, um, it's a little bit more complex, usually a laparotomy and it's usually they'll resect the ischemic, the perforated piece of bowel. And then depending on how much is taken out that might also require a stomal formation. So often patients will, will leave the operation with a stoma in place. Ok. Moving on to gallstones. First and foremost, your average patient that has gallstones can be remembered with the four fs. So female fat fertile and 40. Again in osk, that's something to look out for. If someone's presenting with a history consistent with gallstones, a bit of pathophysiology to start things off gallstones form because there's an imbalance in the bile components. Bile is made up of cholesterol, bilirubin as well as salts. If the cholesterol is super saturated, then it can form crystals and those crystals can eventually form stones, which is why those that are having a high fatty diet that's rich in cholesterol are more likely to have gallstones formed later in life. So, gallstones typically present in three common ways that we're gonna go through. So, that's bilary colic, acute cholecystitis and acute cholangitis. Bilary colic and acute cholestasis have some key differences which I've highlighted in red, look out for S as well as oss. But of no, your average patient will have bad colicky pain. Uh, right, upper quadrant, moving on into the epigastric region, it may radiate to the right shoulder or the back, but it wouldn't last for more than eight hours because the reason why bilary colic is happening is like you can see on the diagram on the bottom, right hand side of the slide, there's a temporary obstruction, but it's not a complete blockage. So once the gallstone is released and either passes into the duodenum or goes back into the gallbladder, that pain will also stop. So the reason why it happens in the first place again, just a bit of pathophysiology. We love that here. Um It's triggered by eating a fatty meal. Your duodenum releases a substance called cholecystokinin and that substance causes the gallbladder to contract. So if there's, I'm not sure if you can see my mouse, but if you look over in the dia the cystic duct, for example, if there's a fairly large stone that's about to obstruct the cystic duct. That contraction of the gallbladder will cause it to become lodged in that area. In terms of the management, initially, you are gonna be recommending uh a low cholesterol diet and encouraging dietary changes and eventually they will need a laparoscopic cholecystectomy moving on to acute cholecystitis, which is slightly more towards the infectious side. So that also presents with right upper quadrant pain. But this time around, it will be lasting more than six hours. They will have fever, abdominal pain, vomiting, they'll also have Murphy sign, which is inspiratory arrest. Basically means they'll catch their breath when you're palpating around the liver gallbladder region. So around the right upper quadrant and there will be a rise in inflammatory markers because this is an infection related to the bilary system and the gallbladder. Um, initially, you'll want to do an ultrasound. You'll note that there's gallbladder wall thickening as well as some fluid collection. You may also consider doing a Hida scan if the ultrasound isn't conclusive. And a Hida scan is basically one where they um, inject a specific dye that gets processed in the biliary system. And if it doesn't show up on the scan, then you know that there's some sort of obstruction. Now, moving on to the management, we're going to be resuscitating these patients. So giving them Harman's ideally, pain relief and broad spectrum antibiotics and ideally, once they are stable, you need to be looking at getting the gallbladder out within three days, moving on to acute cholangitis. So there should be a slight change. Now, um, acute cholangitis is specifically an infection related to the bile ducts and there's two main causes. So either there's an obstruction in the bile duct itself because of the gallstones that are obstructing in this area. So the common bile duct, so where the cystic duct joins onto the common hepatic duct or it's because of infections that have been introduced during an E RCP procedure. Um If you did a blood culture for these patients, you might find evidence of bacteremia which may include enterococcus, cpsa or E coli moving on to investigations. Now you'd note a cholestatic picture. So an obstructive picture in the LFT. So they'd have high alp as well as bilirubin because the bilirubin can't be processed and released through the bilary system. Therefore, more is effectively leaking out of the blood vessels and it sorry, more is leaking out of the bile ducts and into the blood vessels. Now, moving on to imaging modalities, the least sensitive is uh abdominal ultrasound scan because this time around, you're not having a closer look at the gallbladder. You're trying to visualize the actual bilary ducts, uh which are a lot smaller. So it's harder to see on ultrasound. So you may do a CT scan, but ideally you'd be doing an M RCP, which is basically an MRI scan of the bilary system management is similar to acute cholecystitis where you're keeping them in all by mouth. IV fluids, broad spectum, antibiotics and analgesia in order to keep them stable. And you'll find that this management is quite common for the majority of surgical conditions. So, as long as you say those four things, you're pretty good for osk as well. But definitive management would be an E RCP. So it's, that's an endoscopic procedure where they can physically remove the stones or they can insert a stent or ultimately, if there's too many stones there, you can also just get rid of the gallbladder. So a lot coldly on the bottom right hand side of the slide, you'll see uh A tried and AAD, this is very sort of how you will come up and it's a these triad of symptoms that you're looking out for. So, fever, right, upper quadrant pain and jaundice, that's acute cholangitis until proven otherwise. And if they progress and they become septic, you'd see Raynaud's Pentad, which is, they'd also be confused and they'd be in a state of hypovolemic shock. Ok. Lovely. Moving on to the next presentation, which is acute mesenteric ischemia. So this is when there's a sudden interruption of blood flow within the mesenteric blood vessels that supply the intestines, um which then results in ischemia and potential necrosis of the tissue. And the main blood vessels affected in this would be your superior and inferior mesenteric arteries and then also your, uh, celiac kind of arteries or artery, which supplies kind of the, um, summer conen as well. The main causes of this, um, are your thrombi and your emboli. So, with your thrombi, it's when you get a blood clot that forms within the actual vessel itself and remains kind of in situ and that's, um, usually secondary to atherosclerosis in the vessel or coagulopathies and also malignancy as well. We do embolis when you've got a clot that forms elsewhere and then kind of moves and lodges itself within one of these vessels supplying the bowel. And that's usually secondary to af can be post M I as well. And with patients who've got prosthetic heart valves, particularly quite soon after surgery, they are at higher risk of clot formation around the valves because of stasis of blood flow and that can kind of move and lodge itself within one of these blood vessels. Other causes are shock and hypoperfusion. So an actual lack of blood supply to the to the intestines just purely as a result of shock that can happen in um kind of severe sepsis. But it can also happen with heart failure as well where the heart's just struggling to pump enough and it can happen post arrest as well for patients who've had a cardiac arrest and been kind of um hyperperfused for a long period of time during that arrest can suffer from this afterwards as well. Also inflammatory disorders like Takayasu arteritis and polyarthritis, nodosa can also cause disruption and interruption of the blood flow that's supplying the bowel as well. Now, in terms of presentation, this usually presents with quite generalized abdominal pain and it's usually quite severe and disproportionate to what you'd find it on an abdominal examination. So they usually don't present with many signs on examination, just very intense pain. They also can present with signs of shock and hemodynamic instability. Again, nausea and vomiting sepsis if it's kind of infective and then peritonitis as well. So again, your rebound tenderness, precaution, tenderness guarding things like that. And now looking at investigations, um, you got your basic blood plus the surgical bloods as normal. Uh Again, you do a VBG here and that's because you're looking for that high lactate because of the ischemia. You get a build up of lactic acid and that shows up on BVG. And it can also present as a metabolic acidosis because of how acidic the lactate is. So they often drop their Ph as well. And then gold standard imaging for your acute mesenteric ischemia is your contrast CT abdomen with angiogram. So it allows you to look at both the tissue itself of the bowel. But it also allows you to look at the blood vessels that supply the bowel to actually locate the obstruction. And that allows you to kind of guide management as well. And then management, uh conservatively, you need to make your patients know by mouth because they will almost always need surgery and IV fluids, especially if they're hemody unstable, especially if they're septic in shock to bring that BP up and keep them stable enough for surgery medically. Again, you're looking at treating their symptoms. So, analgesia and antiemetics and then also broad spectrum antibiotics are similar to the appendicitis. You're just trying to prevent infection both because of the ischemia but also following surgery and then surgical intervention is usually required as well. And that involves either excision of the necrotic bowel if it's kind of too far past um reversible reversibility, if it's not reversible anymore, or if it's still kind of caught at an early ish stage, then you can do bowel revascularization. Um and that can be in the form of thrombectomy. So, actually removing the thrombus that's formed embolectomy or thrombolysis. So, treating patients with things like alter plays and like trying to dissolve that clot before it causes more damage if you could just have the next slide. Um So with chronic mesenteric ischemia, this is slightly different. It's less of an acute presentation, but it's just one I wanted to include because it links quite nicely to acute mesenteric ischemia. Um It's also known as intestinal angina, uh and it presents very differently. So this one presents more um kind of chronically over a long period of time and patients will usually complain of postprandial pain. So, pain specifically after eating as usually quality So it comes and it goes rather than it being quite a constant pain, uh, they present with weight loss normally just because they eat a lot less than normal. Um because of that pain, they're getting after eating. And if you auscultate their abdomen, you often can also hit abdominal bruit just as a result of, um because with the chronic mesenteric ischemia, the kind of underlying cause of it is a build up of atherosclerosis or atheromas in the actual blood vessel supplying the bowel. So if you listen, you can hear turbulent blood flow because of that build up of of kind of fat and cholesterol. So you hear these bruits when you actually listen and that's why usually when you do an abdominal examination, if you're watching kind of tics ones or whatever you guys watch for your finals, um, often you'll, you'll be listening to the um kind of like renal arteries and arteries in the abdomen. And that's so you're not just looking for bowel sounds, but you're also listing for things like bruits, which suggests that they are at risk of things like intestinal angina or chronic preenter ischemia. Um The main risk factors are the same ones that you'd see with heart disease. Um because like I mentioned, it's a build up of cholesterol. So it's things like increasing age, family history being male as well as one, smoking, obesity and then high BP and cholesterol would all be kind of the risk factors to remember, um, investigations for intestinal angina or, or cm. Um So you do do your basic bloods. And with this way, you'll also be interested in looking at their lipid profile and the HBA1C to check you for signs of um, high cholesterol or glucose intolerance or diabetes. And the gold standard imaging for this one is CT angiography because you're more interested in looking at the specific blood vessels with this one. And you're again just looking for any signs of atherosclerosis. So you'd be looking for kind of narrowing um of the blood flow within the blood vessels or actual blockages within the blood vessels. And then with management conservatively, it'd be kind of about lifestyle changes. So encouraging smoking, cessation, weight loss as well is a big one. And then medically you're looking at more secondary prevention. So things like statins and antiplatelets like clopidogrel and then surgically, you're looking at things like revascularization. So that can involve stenting to keep the blood vessel open. Despite the um blockage with cholesterol, you could do an endarterectomy, which actually involves removing the atheroma itself or if the blood vessels kind of if that sexual blood vessels kind of past the point of saving you can do a bypass surgery. So using a vessel from somewhere else in the body and allowing the blood to kind of bypass that blockage just to relieve symptoms. Ok. So moving on aortic aneurysm. So an aneurysm by definition is a dilation of all layers of an arterial wall. It has to be over three centimeters to count as an aneurysm and the underlying cause of it is normally because of atherosclerotic disease found most commonly in men, which is why as part of the national screening process, men are offered a single abdominal ultrasound at the age of 65 I think. Thank you. I had a long street there. I was bound to happen again. It was peaceful for too long. OK. Let's stop and start again. So it should have moved on to a AAA slide, but I don't think it did. We'll try again. OK. Uh OK. Thank you for letting us know how we're doing now. Is it triple line? Yes AAA AAA for everyone. Yeah, that's fine. OK. Fab let's go. So first of all types of aneurysms, this is more academic than high yield. But again, love pathophysiology. So I'm just going to mention it quickly. Um There's different ways that the layers of the arterial wall can dilate. Um you can have saccular aneurysms, fusiform or pseudoaneurysms. So those are listed in the diagram on the right hand side, it basically just describes the shape of the outpouching. Basically the key most high yield things that will come up again and again in exams and on past med is when you will be taking action. So as I mentioned over three centimeters bad news. So as long as at the age of 65. If a gentleman has his abdominal ultrasound, if it's less than three centimeters, you don't need to do anything else. However, if it's between three and 4.5 no, sorry, three and less than 4.5. So 4.4 you have to rescan every year and it's classified as a small aneurysm over, over four point five U scan every three months and, or if it's growing rapidly, um you have to refer within two weeks. So within an urgent triage straight to the nearest vascular surgery center because we most likely need to intervene in this case. Um It's only a probability of one per 1000 screened patients, but it does have a fairly high mortality rate at 30%. So it's important to get it screened and take action if you find any positive results. So, in terms of the key features, um it is known as a silent killer, but typically they will present with back pain, loin pain. Um they may present with some abdominal pain that actually radiates to the back instead. Once the aneurysm dilates to the point it ruptures, there'll be hypovolemic very quickly because you're losing a large amount of blood quickly. There may also be acute lower limbs. Now, because for example, if you have a look at the saccular aneurysm type, you can visualize how an emboli could get stuck there, especially because if it's quite atherosclerosis, it suss it to having fatty deposits, which means that for the arteries lower down, that are supplying the legs, they may have a reduced supply that they might present with acute l ischemia. And as I mentioned earlier, there is a mortality of 30%. Um Now moving, moving on to imaging these patients once there's a high suspicion of a potential rupture. So if they're presenting to Ed with these symptoms, you need to do act angiogram that allows us to plan management specifically involving either an open repair or an ear, open repair. It's what it says on the tin and they will be repairing it with a synthetic graft. It's more dangerous, high risk of complications. But sometimes that's all we have available to offer for the patients that are really hemodynamically unstable or we can do an er which is less invasive, has less complications associated with it and you insert a graft within the femoral arteries under fake guidance. But this is a very important vascular condition that monitored very carefully because as you can see, it can have catastrophic, catastrophic consequences. No, we are going to be going through some of the triple hammer pass med questions for this part of the presentation. So these are the harder questions. We've also got some polls that will be coming up in the chat. So we'll wait for a short while. You can vote based on each of the Mc Qs and then we can discuss it with the answers. I hope you can all see the MC one mile. There should be a pole that comes up, hopefully. Can we see the pole? Let me know when to switch the slide and we can go through the answers? No problem. Ok. OK. There's no pa if you guys can just put your answer in the chart, so just ABCD or E and we can go through it that way. It's the same thing. Either way we've been let down by technology today. It seems. And then once a few you put it in and we can just discuss the answer and see if we all think the same thing. Oh Po OK. Brilliant. So if you go to the pool and then we can go through together. Oh, I don't think actually, I don't think the the poll matches the question. I'm sorry. Uh It should give us a and vomiting. So it should match the question M CQ one persistent vomiting MC. Oh, sorry, I'm reading it. Sorry. It does. It's my fault. Sorry. It's fine. Can you still see the question on my slide? Yeah, you can see the question in your slide. OK. So I think the majority of people have gone for a uh so abdominal x-ray. So abdominal x-ray is still used in some settings. Um and it's often used kind of earlier on, but the most appropriate one to confirm it is that whole thing with pam me being like, is it definitive as an all definitive. So it's sometimes done as the first investigation kind of in the emergency department. But the definitive gold standard would be the ct abdomen. So actually, it would be d um X rays can show if kind of, there's, there's a kind of loading and and distension of the bowel, which would show kind of signs of um obstruction. But a ct abdomen would be good to just give you a bit more detail and would also show you if the, if the obstructions result in perforation as well of any abdominal viscous. Um and you wouldn't want to kind of double the radiation that the patient is receiving. So you, you could do an abdomen x-ray and then act abdomen. But it's just that just do act abdomen, it won't go. So it's kind of the gold standard definitive investigation. But I can see why you might have put abdominal X ray as well because it's still a useful one to do. It's just not the gold standard. Ok. Perfect. Um Do you want to move on to two and hopefully the pole? There we go. Perfect. Is the screen still stuck on key one? Someone's saying it might be stuck, screen stuck. Yeah. Ok. We'll get there. Eventually guys, we're nearly there, got a couple more left. I'm mindful of the fact that it is just past two, but we won't, there won't be very um many questions more. Now it's like five questions then we could do a quick Q and A and then we'll leave you guys to it. Ok. So M CQ two should be on the screen now, Judy, if you let me know when you've got a few answers in the poll and I'll start going through it. So we've got a couple, um, which we have a couple more. So most I think everyone, actually, that answer has gone for B OK. Nice. So you're exactly right. So it's gallstones that are present in the common bile ducts that can cause ongoing jaundice because that's the bit that's connecting directly onto the duodenum. And if that's blocked, then it's not allowing excretion of the bilirubin. So we'll move on to three. So three should be on the screen. OK. So we can go through three if we've got any pulse, wait for a couple more. OK. Mm. So a as of now we split 5050 between D and E and I can, I can completely understand why um any anymore. OK. So we've got, yes, we've got a couple of so, so between ad and E. So with this one based on just if you isolated the fact that it's 4.4 centimeters, um you'd be looking at yes, three scan in three months. But the fact that it's grown in um 1.4 centimeters in six months, that's worrying. So any aneurysm that grows more than one centimeter in 12 months, you'd be looking at urgent. Er um So in this case, you would be going for urgent two week um endovascular repair. And that's usually if it's over 5.5 enlargement more than one centimeters or if it's symptomatic as well. So, if patients have got pain as a result of it, um then you will be looking at two week um referral for repair. So that's why I see why people went with E as well. Remember, these are the hardest questions around the acute abdomen um on past meds. So it's ok if you're getting me wrong. Ok. You should be able to see MCQ four. Now, are we all good for the pulse? Just got a couple of responses so far, we can give it a bit of time. 12, I think I remember get a few seconds, the majority have gone for e from what I can see. Ok. So e is indeed the right answer. This is a version of acute mesenteric ischemia. Um since the patient is deteriorating further and there's evidence of peritonitis within uh abdominal examination, we have to act quickly, which is why you'd be doing an I immediate laparotomy as opposed to any laparoscopic procedure. And in light of the fact that there's severe abdominal pain, which is disproportionate to the examination findings as Judy's previously explained, it's consistent with the fact that we have to take action quickly and there's most likely gonna be an area of bowel that's necrotic at this point. So you could attempt to revascularize. But most importantly, the necrotic area of bowel has to go and that's via laparotomy. So this should be our last one. Ok. Should we go for? But I think you've got a 10 responses. You've got, uh, just two at the moment. So just give it a couple of minutes, a couple of few seconds. So I think most people have gone for a see. That's correct. So, yeah, so with this one, the best one, from the options that you're given would be your right chest X ray. Um That's because of the kind of s you mentioned earlier, the pneumoperitoneum, it's really quick way of seeing kind of whether there is air under the abdomen or air under the diaphragm. Um and therefore kind of diagnose perforation. I think if they had put a CT abdomen on here, then you'd probably go for the CT abdomen because that would be your kind of best gold standard investigation. But from the options, you're presented a right chest X ray is best abdominal x-ray again. So you could have a look and you'll probably be able to see a regular sign, but the kind of quickest and um easiest way to do it would be your right chest X ultrasound would be unlikely to show um perforation. It might just do some fluid potentially, but it wouldn't actually kind of different to be diagnosed without perforation. Ok. Uh So these are a few resources we used as you saw, the questions were from past med. Um But we thought it might be useful because we know most people probably do use past med um to revise and these are kind of the hardest ones relating to the acute abdomen. Um I know there's been a couple of questions as well whilst you've been presenting so we can go through questions now and if anyone else has any questions at all, from any of the um presentations we went through, please leave them in the, in the chat and we'll answer them now. And while we're kind of doing that, if you guys could just also fill in the feedback form, it would be really great for us, but it also means that you can get a certificate as well um for kind of your attendance. And if you guys want access to the slides, then um I think either there is either a box on the feedback form to leave your emails or if not just leave your emails down in the comments and we can send them to you. Um So you can actually have access to these as well. So I'll just have a look at what questions we've been asked so far. Why does pancreatitis cause respiratory distress? So, um I think it's a quite a complex process to be completely honest, but I think it's something relating to the fact that when you've got the pancreatitis. You've got a lot of inflammatory chemicals that are secreted into your bloodstream, things like your histamine, your cytokines. Um and that can cause an increase in vascular probability. So it causes an increase in the permeability of the vessels in the lungs. Um, increased alveolar probability as well. And it just means you get a lot more fluid moving from the blood vessels into the actual tissue of the lungs, into the alveoli and that can cause fluid build up and that reads the respiratory distress. So patients present with a lot of shortness of breath, increased oxygen requirement, they'll present with um low oxygen sats and they, um, usually kind of in need of really high flow oxygen or even in some cases, things like CPAP and intubation if it gets really bad. And that's why a lot of patients that have pancreatitis with odds um will actually be moved to itu for management. Uh, just because to kind of preemptively to prevent um, the deterioration essentially. But yeah, I think that's potentially the answer to that question. And then we've been asked as well, why does ischemia cause peritonitis as well? Do you wanna cover that or? Yup. Sure. Um So do you mean ischemia of the bowel in terms of when there's bowel perforation or acute mesenteric, if that question could clarify, but I can cover generally mesenteric ischemia? Sorry. So why acute mesenteric ischemia? Yeah. Ok. All right. So in acute mesenteric ischemia where basically as a result of an emboli or a thrombus cutting off supply to a section of the bowel. If that supply is cut off, it means that the bowel has a high susceptibility to undergo a process called third spacing. So that, that means that it's losing fluid and blood. Um, that fluid and blood has nowhere else to go apart from in the surrounding tissues and the area surrounding the bowel, which is why it will basically escape from the bowel wall and cause peritonitis, which is pain on generalized palpation of the bowel. Um It can also be because if the ischemia progresses and there's perforation, that means that more often than not, there's gonna be fecal matter in the bowel and fecal matter especially is quite inflammatory to blood vessels and that will lead to pain and peritonitis. So those are the two most common causes of it. If I don't have any other questions, feel free to use in the chat, um Are we can if not, that's completely fine to you, but please do fill in the feedback forms, um because that's really useful for us as well. So we know what to kind of change for next time as well. Um And also just to know the next week session. So there'll be another session next Saturday as well. It won't be delivered by us. It'll be by one of the guest speakers, a clinical perfusionist. And for all you people who are involved are like interested in cardiology or respiratory. Um is looking at the cardiopulmonary bypass machine, which is really interesting topic. Um But yeah, any other questions, leave it in the chart. But thank you all for listening. Um Please you fill in the feedback forms and we hope to see you next week for another session. Thank you. Thank you guys. We'll stay on for a bit if anyone wants to add in any questions. But yeah, uh someone's has chronic mesenteric management is endovascular. Uh So, so, yeah, if you're going surgical management, if you're past the point of kind of conservative and medical, so your secondary prevention, then um you're looking more at your endovascular management. Yeah. So it's um, things like stenting and bypass. Well, stenting is your endovascular, but then it can become more open surgery with bypass, uh bypass surgery or um, actually removing the atheroma or endarterectomy activists gone past the point of kind of more conservative measures. Hope to answer your question. Ok, brilliant. I think that might be all the questions. So I think we'll leave it there. Thank you again guys. Thank you very much. I'll leave it on the slide it the morning. Yeah. Yeah, I'll just stop now.