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Hello, good evening and welcome to our second IBD MDT as part of our three part webinar series. And tonight we are hosting the Crohn's MDT um webinar. We've got a fantastic set of speakers. I'm gonna hand over to Orestis and he's going to introduce our panel over to you. Hi. Hello, good evening. Uh Thank you very much, everyone for joining and apologies for the very slight delay. Um So, yeah, it's our pleasure today to tonight to have the, the Crohn's MDT. Uh we have prepared a wonderful panel and chair. Um So let me start by introducing our chair, uh who is Prof uh Austin Nixon consultant, colorectal and IBD surgeon and associate professor at the University of Nottingham as well as a member of the CPG B IBD subcommittee. Uh Thank you, prof thank you. Yeah. And then um with what is kind of becoming a routine structure for those uh webinars, we have um three consultants, uh gastroenterologist, radiologist, and surgeon. Uh So I'll start uh with uh doctor Katie Devlin who is a consultant radiologist um at S Mark. Thank you, Katie for joining. OK. Um Doctor James Alexander, who is the consultant gastroenterologist at Saint Mark's and Saint Mary's uh at Imperial, as well as an honorary senior lecturer at Imperial. Um Thank you James. Yeah. Yeah. And last, but not least we have uh mister to, to who is a consultant uh for surgeon at ST Mars uh honorary in lecture at Imperial uh as well as a member of the A CPG B proctology uh subcommittee. Thank you, Phil. Thank you. Hi, everyone. Sorry to be uh struggling with tech issues, my fault. No, no problems at all. Uh So yeah, I'll uh pass on to prof to start the webinar. Thank you very much, everyone. OK. Thank you Duke's Club for the, the kind invite. Um So if we're gonna, what we're going to do today is just talk through 33 cases and we've got an expert, expert panel here and I'm going to sort of direct the, the questions towards them. So I think without much ado we should get started. So if we can have the first slide, please. OK. So as as we go along, there's gonna be various poles which um arrest us is going to um lead on. And also there will be chats. So if you have anything in the chart, put it in and arrest us will also look at that. But first la first patient is a lady. Year old lady has come in on the emergency t with some right eye elect foci in for three weeks. Pretty fit and well as you can see there, she's very tender in the right iliac fossa. When you examine her, she got a quite sale of 13 C RP of 45 and a hemoglobin of 100 and nine. So you get a phone call, Phil from the, the Registrar Friday night. You're at home enjoying your dinner and the registrar phone says I've got this lady with appendicitis. I wanna take her to theater to take her appendix out. What are you gonna do? Uh First I, I'm gonna check them on call and they're not just chanting their arm, but assuming I am, uh then I'm gonna ask for a bit more of a story. Um I'm anxious about anyone over 50 probably anyone over 40 with an appendicitis diagnosis, um particularly about the risk of a malignancy in the cecum. So I'm going to push back and suggest that if she's not crashingly unwell and she doesn't sound like she is that I want more story from them and then probably that they ought to undertake act scan to confirm the diagnosis and look for other causes. Brilliant. So, yes, luckily, um he hadn't taken the patient to theater and did act scan. So next, next slide. So this is the first pole. Ok. So if, if we can just check the pole is working. Um There we go. What is the most likely diagnosis on this scan? Is it cancer? Is it appendicitis is it ti inflammation or diverticulitis? Ok. Is everyone familiar with the poles? And is that working? Ok. Arrest us. We're getting some responses. Yeah. Uh We can see the pulse. Um So, so far we've got an 86% of T inflammation. Uh 87 8% of diverticulitis and 4% for cancer. OK. Katie, are you going to talk us through this? Um It's a single slice. So it's a, it's, you know, what can you, what can you comment on this? Um So you've got a single axial ct slice. So there's contrast enhancement and within the central pelvis, you've got quite a long segment of um small bowel wall thickening. Uh And you see sort of the, the gray attenuation suggests that there's edema as well so that there's an acute component to this. And the other thing I'd say is that there's expansion of the fat along the small bowel, which would lead me to think about a, a more specific diagnosis in this case, which II won't say. Um And you can also see the increase mesenteric engorgement and in terms of the differentials, you can see that there's the, the rectum and the co you see there's some diverticular changes there as well, but that does not look like there's any cut inflammation. Um So searching summary, there's a uh a longer segment of um active en enteritis. OK. So what would you commit and confirm that this is diagnostic for Crohn's disease on the scan or not. Um So there'd be a couple of things I want to, to look, look forward to see if there's any other sort of skipped segments of active information, which may again make me favor Crohn's diagnosis and you don't want to also understand if the patients had any sort of prior history. So has a patient had any, for example, radiotherapy, for example, to the, to the pelvis or any other things that may make it seem uh make it more likely to be something else, you know, whether it could be an infective cause. Is there any sort of relevant history? Um but particularly the expansion of the fat and something we look for is like creep or fr which makes us sort of head towards a diagnosis? Ok. Excellent. So Phil, this, this pre registrar, I actually forgot to phone you actually, you know, he thought it was appendicitis and um he didn't do the scan, he took this patient to theater and he's now phoning you. And he's saying, well, now I find this long segment. So, you know, 20 centimeters of terminal inflammation looks like Crohn's. What do you want me to do? I'm in there now. And what am I going to today? It's not append IDE staples. Yeah. And so there's no be because there's no background of Crohn's, there's been no attempt at medical treatment. I I'm interested in whether there is an absolute indication for resection or sta formation. For example, if the patient can get absolutely obstructed or if there's any evidence of ischemia or anything else upstream, because of substantial obstruction and dilatation. But in the absence of one of those absolute indications, er I would back off uh because this patient has an opportunity to be medically treated in the first instance, um without needing a resection, particularly if the segment of disease is long. Um But in any case, I would back off. Ok. And what would you, uh treatment wise? What would you instigate or would you hand straight over to James? I'd certainly be giving him a call and complaining about the registrar, but then handing over the patient and asking whether he'd be kind enough to um to consider treatment. And actually, if we're in the theater, I'll also ask him whether he wants me to take any tissue at the time. Although I'd be hesitant from doing so. I certainly would if he, if he wanted me to. Yeah. Ok. So you do nothing. He comes out, it's documented. He's found some Crohn's. You phoned James James. What are you going to do? He's given them some antibiotics. That's all the treatment. Yeah, thanks. Um So I guess to follow on from Katie's thoughts, I mean, being a medic, we'd probably come and take one of those internally interminably long histories that we like to take, um asking about joints and eyes and all sorts of weird stuff that you probably think is a load, a waste of time. Um II think also being a, being a physician, I'd probably be inherently a little bit cautious here about um being, keep calling it Crohn's um with, with the relatively short history. Um So my preference, uh assuming the patient is stable enough would be to proceed to get a colonoscopy and look at the ilium and take some biopsies, I think. Um I definitely take Katie's advice about skip lesions and things like that. And it, you know, if really pushed, we could go for steroids before uh you know, endoscopic and tissue diagnosis, particularly if we're using antibiotics alongside. But my preference would be to um to sort of secure the.